Psychologists are rebranding the field, expanding the one-to-one therapy approach

[This article is part of the 2023 Trends Report]

Psychology is thinking bigger, as a growing number of psychological scientists and clinicians seek to “rebrand” the field. Experts are finding innovative new ways to reach more people and take a more preventive approach by shifting away from the perception of psychology as the practice of diagnosing and treating mental health disorders and broadening the lens of behavioral health.

In February 2022, APA’s governing Council of Representatives adopted a policy calling on psychologists to take a population health approach, working across and within systems to improve the health of entire communities, taking into account such factors as income, education, culture, and environment (Psychology’s Role in Advancing Population Health, 2022 [PDF, 149KB]).

“We’ve been stuck for too long in this narrow idea that the only way we can have a positive impact on people is through one-on-one psychological interventions,” said Kenneth Dodge, PhD, a professor of psychology and public policy at Duke University. The field is positioned to make a bigger impact on policy, on education, and on so many areas of population health, he added. “It’s not that the days of psychotherapy are over. That’s still there. But there is a broader contribution that we as psychologists—both researchers and practitioners—can make.”

It’s a mental leap for a field built on the shoulders of face-to-face psychotherapy. But it’s a necessary one, added Jessica Schleider, PhD, a clinical psychologist and assistant professor at Stony Brook University. “We’ve hit the ceiling in terms of what high-intensity, individual-level interventions can accomplish,” Schleider said. “If we want to reduce the burden of mental illness for individuals and for society, the status quo is not going to cut it.”

Only a fraction of the people who need mental health support receive evidence-based treatments—and the need is only increasing. “To make a difference at the population level, we need to create a more agile mental health system that includes multiple levels of care and multiple contact points at moments of need,” Schleider said. To help solve that problem, her Lab for Scalable Mental Health is developing what she calls “light-touch, single-session interventions” that are either delivered digitally or by lay providers.

In one example, she and her colleagues tested single-session, online interventions in adolescents with elevated depression symptoms who accessed the self-guided 30-minute sessions through social media. They found that both a behavioral activation intervention and an intervention based on teaching that traits are malleable improved 3-month depressive symptoms compared with a supportive control session, even during the high-stress Covid-19 pandemic (Nature Human Behaviour, Vol. 6, No. 2, 2022).

“Most clinical psychologists think of psychology first, and many assume that we can build adaptations around that one-to-one therapy model to enhance scalability or accessibility,” she said. “That default has to change. We have to start without those assumptions regarding what treatments or supportive programs can look like, where they can be, and how people can access them.”

In the effort to expand the reach of behavioral health, increasing the scale of impact is critical—but it’s just one side of the coin, Dodge said. “The second prominent feature of this goal is a trend toward prevention,” he added. To make an impact in preventing mental health problems, he’s proposed a simple yet radical idea: mental health primary care. “In physical health, we take our babies to the pediatrician for well-baby visits; we don’t wait for them to get sick,” he said. “If we begin to think about a primary-care model for mental health, it leads to all kinds of different interventions—it broadens the contribution that psychological science could make to society.”

In his own research, he developed the Family Connects program, which works with families beginning at birth to reduce early child abuse and promote infant health and healthy psychological development. In the community of Durham, North Carolina, the program reaches out to all families having new babies, regardless of their income, education level, or background. Nurses visit participating families up to three times to screen parents for mental illness, substance use, and domestic violence, in addition to asking about their parenting skills, access to social support, and material goods such as cribs and formula. From there, participants are connected to whatever resources and support they might need.

Randomized trials showed Family Connects resulted in fewer cases of maternal depression or anxiety, more community connections, and fewer child abuse investigations (JAMA Network Open, Vol. 2, No. 11, 2019). It has been adopted by several cities and is being rolled out across the entire state of Oregon. “I didn’t think of this as primary care when we started, but it really functions like primary care for parenting,” Dodge said.

A similar mental health primary-care model could be used across the lifespan, Dodge said. It’s easy to imagine the benefit for couples who receive relationship counseling before getting married, or older adults having someone who can support their emotional and cognitive health as they prepare for retirement. “Life transitions, like the birth of a child, school entry, marriage, retirement, can all bring challenges like anxiety but can also afford opportunities,” he said.

Of course, the idea that psychological science can inform prevention efforts isn’t new. One of the field’s most visible success stories may be the widespread adoption of social-emotional learning (SEL) curricula in schools. According to a national report by Tyton Partners, 95% of K–12 districts have adopted SEL in some way. Some 73% of those districts have adopted SEL curricula, while 70% incorporate SEL into professional development (Finding Your Place: The Current State of K–12 Social Emotional Learning, 2020).

Yet with rates of mental health disorders rising among the nation’s youth, researchers continue to study how best to intervene to promote well-being on a larger scale. In one encouraging development, the U.S. Preventive Services Task Force recommended in October that primary-care physicians should screen all children older than 8 for anxiety, in an attempt to improve diagnosis and treatment of a disorder that’s already been diagnosed in some 5.8 million American children. It’s a promising start—yet there is much more that the field can do.

“We can’t wait until people are suffering to apply what we know,” said Alexis Harris, PhD, a research assistant professor of education at Youth-Nex, the University of Virginia Center to Promote Effective Youth Development, and the project director for the Compassionate Schools Project.

With Compassionate Schools, Harris and her colleagues are studying a curriculum that builds on SEL by integrating concepts of mindfulness, compassion, body awareness, healthy eating, and exercise. The study is taking place in 45 schools with some 20,000 children and provides strategies to support educator well-being as well. This kind of holistic, mind-body approach is a trend in prevention science, she added. “After decades of research, it’s evident that there are common root causes and common protective factors that underlie a variety of mental, emotional, and behavioral problems,” she said. “Starting there, we can have a broader impact.”

As the field sets its sights on broadening and strengthening its prevention efforts, there’s also a call to move away from a predominant focus on individual choices and behaviors.

“In many approaches that are focused on promoting adaptive skills and positive behavioral trajectories, a lot of responsibility is placed on the individual. We see that so much with the attention placed on self-care, for example,” Harris said. “That obscures the fact that we need to pay more attention to the conditions in the systems that individuals are functioning within.”

Increasingly, psychologists are taking aim at those larger systems, said Isha Metzger, PhD, a clinical psychologist and assistant professor at Georgia State University. “The things we experience in our environments, our communities, our day-to-day lives impact our mental health and ability to function in society as a whole,” she said. “People can’t focus on their mental health when they have larger social and structural issues to contend with.”

To start addressing those issues, Metzger’s research applies racial socialization (the conversations and practices caregivers use to build youth’s identity, esteem, and coping) to reduce the impact of racial stress and trauma. Daily exposure to racism and discrimination are associated with worse physical, emotional, and behavioral outcomes among Black youth. Other racial traumas, such as the experience of witnessing police brutality, compound those negative outcomes. In a current project, Metzger is integrating practices from racial socialization with trauma-focused cognitive behavioral therapy. Then, she’s using social media and podcasts to provide psychoeducation to Black youth and connect them with evidence-based resources for trauma and stress. Some of those efforts include using social justice activities such as peaceful protests as a means of behavioral activation.

“Black families are already utilizing cultural and family strengths to overcome experiences with discrimination,” she said. “Using social justice work as behavioral activation has mental health outcomes such as reducing hopelessness, helplessness, anxiety, and depression and has a positive impact on society as well.”

Such efforts to address racism and discrimination are important ways for the field of psychology to improve mental, behavioral, and physical health on a broader scale, added Schleider, who is beginning work to address the experience of discrimination in teens who identify as LGBTQ+. “Scholars are increasingly focused on structural influences on mental health and illness, including the laws and policies that impact the stress people are experiencing and the ways they are coping,” she said. “Targeting these social determinants of health is one way we can affect change.”

In some ways, the public is driving these efforts. Following widespread protests after George Floyd’s murder in 2020, large funders began investing more in research on racial socialization and racial trauma, Metzger said. And a growing public conversation around burnout, stress, and self-care postpandemic is also influencing the field. “Social media, mass media, pop culture—these trends are pushing the research, funding, and policy and influencing the way we think about the science,” she said.

Even with buy-in from funders and the public, creating a broader definition of behavioral health won’t be easy. With a health care reimbursement model built on one-to-one therapy, there’s the question of who will pay to establish mental health primary-care providers or disseminate digital interventions to the public. And few clinical psychology programs are designed to train providers to think in these broader ways.

Yet there are vast opportunities for psychologists to grow into this new mindset, Metzger said. “Whatever your focus is, how can you utilize that to think about the underserved—to benefit those most at risk, to have a greater impact on society?” she asked.

Some clinical psychologists might feel threatened by a trend away from traditional psychotherapy. They shouldn’t, Schleider added. “We have a clear evidence base for individual psychotherapy, one very particular level of mental health support. But that’s not going to reduce the burden of mental illness on a broad scale beyond what we’re already achieving,” she added. “It’s time for us to focus our talents and energies and expertise on building additional systems of support. It’s a both/and, not an either/or.”