Comparative conclusions and the future

The comparative conclusion is not that all therapies are the same, and not that one is best. It is that general factors carry most of the variance for most presentations, specific factors matter decisively for a minority, therapist effects exceed treatment effects, and the differences between therapists are larger than the differences between the things they were trained in.

Forces shaping the next twenty years

• Process-based therapy: intervention selected by targeted process rather than by diagnosis or by school
• Measurement-based care becoming standard rather than optional
• Digital and low-intensity delivery expanding access and raising equity questions
• Large language models entering the space, with unresolved questions about safety, therapeutic relationship and accountability
• Continued erosion of the diagnostic system’s authority, and the rise of dimensional alternatives
• Task-shifting to lay and non-specialist providers, driven by global mental health evidence
• The reckoning with psychotherapy’s WEIRD evidence base

Your own model

The final task of a survey course is not to adopt a school but to state a position: what do you think makes people change, what evidence would count against it, and what will you do when a patient does not improve? A therapist who cannot answer those three questions is being carried by their training rather than practising.