The future of psychotherapy will turn less on which branded method wins than on whether the field keeps a working idea of the self. Insurance rules and treatment manuals push therapy toward counting symptoms. Decades of outcome research point the other way, toward the relationship, the particular therapist and how the patient experiences both. Depth and somatic therapies matter because they keep that person in the room.

My argument is simple. Every therapy runs on a theory of the self, including the ones that claim not to have one. Manualized, insurance-shaped care treats the patient as a bundle of scorable symptoms and never says so out loud. That unstated theory is where the field is stuck, and the research it cites does not back it up. The way forward is not to throw out measurement or science. It is to say plainly what we think a self is, and to build treatment around the subjective person who walks in rather than the diagnosis that gets billed.

Every therapy carries a theory of the self

Each model and conception of psychotherapy has a self-concept at its heart. Past models of therapy are sometimes overly complicated, philosophical or intellectually abstract, but most historic models had their place for some group of patients or some type of problem. Remember that all therapists engaging with the psyche honestly and non-avoidantly are describing the same fundamental, perennial phenomenon, but through their own biases and around their own blind spots. We need to integrate, as a profession, multiple voices to avoid the inevitable blind spots of each.

The theories are usually stated. Carl Rogers, writing in 1959, defined the self-concept as an organized, consistent pattern of perceptions of “I” or “me” and of how that “I” relates to others and to life, available to awareness though not always in it, and fluid rather than fixed.¹ Psychoanalysis has its layered unconscious, Jung his ego in relation to a larger Self. Even behaviorism has a position. B. F. Skinner did not deny inner life. In a 1945 paper he argued that private events, which only the person having them can observe, still belong inside a science of behavior.² That is a theory of the self too: the self is behavior and the conditions that shape it.

The trouble starts when a treatment system adopts a theory without admitting it has one. If we want to keep the concept of self in therapy, then we must keep debating what the word means. I have long argued that anthropology and philosophy are not things that can be removed from psychotherapy, and I have written elsewhere about why therapy cannot avoid moral questions either. A therapy that says it is neutral about the self has simply hidden its answer.

ABA: the clearest case of a self reduced to behavior

Behavioral models like ABA have stripped everything out of the definition of the self except how clinicians can objectively measure a client’s behavior. This idea of a psychotherapy with no self, where we are only how a clinician interprets our behavior, is horrifying to me as a depth and somatic therapist. Instead of changing the world or advocating for the authentic self, it changes the self to fit the conditions of modernity.

Applied behavior analysis is the applied branch of Skinner’s science, built largely on operant conditioning. In autism care its best-known form is early intensive behavioral intervention, which Cochrane reviewers describe as ABA-based treatment delivered 20 to 40 hours a week, often for years. ABA’s history includes Ivar Lovaas’s early programs, which used aversives such as slaps and electric shock. Most current practice has moved away from aversive punishment, and its defenders argue that critics paint the whole field with that history. What does the evidence show? The 2018 Cochrane review found only five controlled studies, one of them randomized, covering 219 children. It rated the evidence for gains in adaptive behavior and IQ as low quality and concluded that the support for the approach is weak.³ Project AIM, a 2020 meta-analysis covering 130 samples and 6,240 children, found that once the analysis was limited to randomized trials, positive effects held only for developmental and naturalistic developmental-behavioral approaches. When it was further limited to outcomes free of detection bias, no intervention type showed a significant effect.⁴ The 2023 update, covering 252 studies, found that randomized trials did support behavioral interventions for social-emotional and challenging-behavior outcomes, largely as caregivers perceived them. Once caregiver and teacher reports were set aside, significant effects remained only for developmental and naturalistic developmental-behavioral approaches, and the authors noted that adverse events were poorly monitored but possibly common.⁵

What gets lost in a compliance-first model is harder to count. Autistic adults describe camouflaging, the work of hiding autistic traits to pass socially, and report exhaustion and threats to their sense of self.⁶ In a 2018 survey of 164 autistic adults, camouflaging was one of the factors that predicted suicidality.⁷ No good study has shown that ABA causes camouflaging, and I will not claim one has. But a treatment that rewards looking typical teaches the same lesson camouflaging does. Patients are taught to scream on the inside instead of the outside. They are driven into an inner world where the outer world does not have to listen to, or look at, the evidence of their suffering. Families looking for an approach that starts from the person’s own experience can read about how we work with autistic adults and children.

How “evidence-based” was narrowed into “manualized”

The original idea of evidence-based practice was not a cookbook. David Sackett and colleagues defined evidence-based medicine in 1996 as the integration of a clinician’s individual expertise with the best available external evidence.⁸ When the American Psychological Association adopted its own policy in 2005, published in 2006, it named three ingredients: research, clinical expertise, and the patient’s characteristics, culture and preferences.⁹ The patient’s own view of their life was written into the definition.

In practice, a narrower standard that predated the APA policy did more to shape care. In 1998 Dianne Chambless and Steven Hollon had proposed criteria for calling a treatment “established in efficacy,” giving the greatest weight to replicated efficacy trials.¹⁰ Trials need manuals so that the treatment is the same from one patient to the next, so lists of empirically supported treatments became lists of manuals for specific diagnoses. To bill insurance, a therapist attaches a diagnosis code and documents medical necessity, and the patient in the chart becomes the diagnosis. The result is a field fixated on credentials and billing codes, where therapy is more and more seen as a delivery system for standardized interventions. I have argued that this is less science than science-flavored capitalism, and that the diagnostic categories underneath it are shakier than they look, a case I make in The Insecure Science.

Max Weber had a phrase for this kind of drift. In his 1917 Munich lecture “Science as a Vocation” he described the modern West as marked by rationalization and the “disenchantment of the world”: the sense that everything can, in principle, be mastered by calculation.¹¹ Clinical culture took on the surface of medical science, with its checklists and randomized trials, while the relationship that does much of the work became an afterthought. In 2018 John Norcross and Michael Lambert, introducing the findings of an interdivisional American Psychological Association task force on therapy relationships, traced how contemporary treatment guidelines had devalued the relationship itself.¹²

What the outcome research actually says

The irony is that the evidence the system cites does not support a self-free therapy. In 1936 Saul Rosenzweig suggested that very different therapies might work through factors they share, and subtitled his paper with the Dodo’s verdict from Alice in Wonderland: everybody has won and all must have prizes.¹³ Bruce Wampold’s 2015 review of the meta-analyses found that when meta-analyses do find differences between types of therapy, they are typically no larger than about d = 0.20. How closely a therapist sticks to the manual barely predicts outcome (d = 0.04), and there is evidence that rigid adherence can weaken the alliance.¹⁴ A meta-analysis of 295 studies covering more than 30,000 patients found a steady association between the alliance and outcome (r = .28) across treatment types.¹⁵ These are correlations, a point critics press, though Wampold reports that better-designed studies find the alliance predicts later symptom change after controlling for earlier improvement.¹⁴ Who the therapist is matters as well. A 2019 systematic review found that therapists accounted for about 5% of the variation in outcomes on average, ranging up to 29% in some studies.¹⁶ I go through this literature in more detail in The Map Is Not the Medicine.

None of this crowns depth therapy. A 2017 equivalence meta-analysis of 23 randomized trials with 2,751 patients found manual-guided psychodynamic therapy as effective as established treatments, not better.¹⁷ A 2021 scoping review of Somatic Experiencing found preliminary evidence for effects on post-traumatic symptoms but mixed study quality, and called for better randomized trials.¹⁸ Equivalence for psychodynamic therapy, and only preliminary evidence for Somatic Experiencing, are reasons for depth and somatic therapists to be modest. Equivalence is also a reason the system cannot justify narrowing care to one family of manuals.

The bigger picture is uncomfortable for everyone. A review of data from 1990 to 2015 in Australia, Canada, England and the United States found that the prevalence of mood and anxiety disorders had not fallen despite large increases in treatment, especially antidepressants. The authors’ best-supported explanation was that much of the treatment delivered did not meet minimal guideline standards.¹⁹ A 2022 analysis of this “treatment-prevalence paradox” in depression concluded that the published literature overestimates how well treatments work and how long the benefits last, and that treatments work considerably less well in real-world settings.²⁰ A 2015 meta-analysis reported that the effects of CBT for depression had been falling since the 1970s.²¹ That finding did not hold up: two re-analyses found the decline was confined to early studies or was not a reliable effect at all.^22,23 The honest reading is not that evidence-based practice made people sicker. It is that decades of expanding treatment, much of it medication, have not lowered population rates of depression and anxiety the way closing the treatment gap was expected to.

Many people have nodded and smiled at these arguments for decades while American health care became more “evidence-based.” They have patted existential therapists, and those who called for an embodied or holistic therapy, on the head and said that they are “asking important questions.” This is deflection through pseudo-contemplation. The industry either has the collective will to admit this reality or it doesn’t. If you are squatting on a lever of power in this system, pull the lever or leave.

Holding inner and outer reality at once

If the self is not a list of symptoms, what is it? The depth tradition’s answer is that it lives at the meeting point of an inner world and an outer one, and gets distorted when either is denied. In my work as a therapist, I often find myself redirecting subjectivity and objectivity back to the domains where they are most effective. Politics and healthcare, for instance, are material realities best approached through an objective lens. Yoga and magic, on the other hand, are subjective practices aimed at generating inner meaning. Both spheres are real, but one cannot directly control the other, much as we might sometimes wish otherwise. Both the purely objective scientific materialists and those who literalize spirituality and believe in magic through projected and unconscious intuition are avoiding a part of the self and over-identifying with another.

Every act is either an engagement with the real self or a deflection from it. When we deflect, we don’t call these deflections what they are. We label them as our self, our values, our identity or things we must do. “I didn’t do it.” “I did it, but you did something worse.” “No one can understand how hard I have it.” Institutions deflect the same way, recasting harm as policy and calling anyone who is hurt oversensitive.

The tradition has good language for staying in that tension instead of collapsing it. In a December 1817 letter to his brothers, John Keats described “Negative Capability,” the capacity to be “in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.” The psychoanalyst Wilfred Bion, who in Attention and Interpretation asked analysts to set aside memory and desire in the session, took Keats’s phrase as a name for tolerating the pain of not knowing.²⁴ Jung’s essay “The Transcendent Function” describes something similar from the other side: when conscious attitude and unconscious material are both given a voice and held in tension, a third position can emerge that neither side could have produced alone.²⁵

Ritual works at this boundary. Ritual involves taking symbols from our inner world and enacting them in the outer world, creating a feedback loop of objective and subjective reference points. The goal is to generate a “spicier” cognition that better integrates thought with the non-cognitive parts of human experience. Ritual does this; somatic and parts-based therapy does this. I trace that lineage in The Rituals of Healing. The same is true of the built environment. Our podcast began with conversations about architecture as a form of depth psychology, in that it externalizes inborn archetypes; one episode, with Will Selman, takes up the spirituality of urban design. The more timeless forms of architecture tap into our latent potentials, while the worst forms try to cut us off from our inner experience.

The wider culture is circling the same problem. In a 2010 essay, Timotheus Vermeulen and Robin van den Akker described the metamodern sensibility as an oscillation between a modern enthusiasm and a postmodern irony.²⁶ Two years earlier, Jürgen Habermas had written about a “post-secular” society in which religious belief had outlasted modernization and secular citizens had to stay open to it.²⁷ Patients bring both of these into the room: a hunger for meaning that irony cannot satisfy, and a suspicion of any meaning that arrives too neatly. The serpent in this garden is not in the grass. It is in the belief that the self can be mastered or solved by “figuring it out.” Intellectualization is a deflection from the real work, and there is no means of logical preparation for it.

What this looks like in therapy

Taking the self seriously does not mean refusing to measure. Routine outcome monitoring, where clients fill out a short questionnaire each session and the therapist sees the trend, has reasonable research support, mostly for clients who are going off track. A 2018 meta-analysis of 24 studies found that feedback reduced deterioration and nearly doubled the rate of reliable improvement among clients who were predicted to do poorly.²⁸ The difference is what the number is for. Used well, a score opens a conversation (“your sleep is worse and your mood is better; what changed?”) instead of closing one.

The rest of the work is about the person behind the score. In Jungian and depth therapy, that means asking what a symptom is doing, whom it protects and what it is trying to say, and listening for dreams, images and the patterns Christopher Bollas called the “unthought known,” things a person knows through how they live without ever having thought them in words.²⁹ In somatic therapy, it means noticing where a feeling lives in the body and staying with it long enough for it to move. In trauma therapy I conceptualize much of this as emotional arcs: emotions that we are either enmeshed with or avoidant of. We must develop a comfort with all of our emotions to function as adults. Parts work does something similar by giving the conflicting sides of a person their own voices instead of forcing a single verdict.

This is not passive work. As a therapist, I try to provoke patients. I push them into their most repressed experiences so they can know that alienated part of themselves. Please do not come to therapy with me if you do not want change. Ready yourself to be different after therapy, or do not come at all. That push happens inside a relationship the patient has agreed to, at a pace the nervous system can tolerate, and with the patient able to slow it down. The aim is contact with what has been avoided, not flooding.

Where the future of psychotherapy goes from here

I for one am all in favor of actual science guiding the parts of the profession that it can. Academic and medical psychology have made a reflection of reality that has fundamentally failed to reflect it; they have forgotten the original and chase the simulacra. Let’s study effective systems and models that we might learn from and stop digging the hole we are in.

Training should treat the relationship and the therapist’s own development as core skills, because the research above finds more of the difference between good and poor outcomes there than in the choice of brand. Research should study therapists and processes, not just brands. Measurement should serve the session rather than the claims department. And every model should have to state its theory of the self in public, so that patients can choose one that fits them. Manualized care will survive, and for some problems it is the right tool. What it cannot do is replace the subjective person it was built to treat.

If you are looking for therapy that starts from your own experience rather than a billing code, you can read about our depth-oriented approach or contact Taproot Therapy Collective to ask whether one of our therapists is a good fit.

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