Ten years is long enough to tell the difference between a fashion and a structural change. Storm’s Edge Therapy opened in October 2016, and a good deal of what has changed has seemed to be merely disruptions to be weathered. Some of it was. The rest has settled into the ordinary conditions of the work.
I came to clinical psychology from an earlier career in technology and media. During the first internet boom I was developing and teaching online technology at postgraduate level, chairing a new media laboratory that led online journalism across a continent, and running an annual conference on what the internet was about to do to everything. That period taught me how confidently wrong both the enthusiasts and the sceptics were, and I try to hold it in mind when assessing the decade just gone.
The Screen Became Ordinary
The profession as a whole has moved onto video, and that took adjustment. We began delivering sessions by video in 2017, three years before the pandemic forced the question, because our client group was never geographically contained. Even so, the shift that mattered was not technical.
When we first started working this way, we felt the difference strongly. There are elements of working with somebody in the room where a client’s emotional state can be tracked far more easily, and I still hold that video is not as effective in that respect. What has changed is not the medium. Video has become so normalised and everyday that psychologically and biologically we have adapted to making an emotional interpersonal connection over a screen. When we began, that embodied adaptation had not happened, in us or in our clients, and the gap was obvious. It is now much less so. In some ways video therapy is not quite as effective as therapy in person, but it is now close enough, and the cost-benefit has been managed well.
The transition in our own practice was not a decision so much as a tide. During the breaks in the lockdowns, I kept returning to our Clerkenwell premises and found myself almost alone. A building that frequently held a dozen or more therapists was down to one or two, and it lost the energy that had been a real professional support. Clients, meanwhile, would message a few minutes before a session to ask whether we could switch to video, so I was often sitting in physical premises conducting a video meeting. The threshold for shifting had collapsed. Eventually the numbers preferring the room over the screen fell far enough that meeting in person made no sense at all.
Four years into working exclusively online, I no longer feel that loss as sharply as I did when I was used to the room.
Clients Arrive Already Informed
Clients now come with a great deal more knowledge and understanding of mental health, drawn from social media, AI chats and search engines. The impact is mixed. Some of that knowledge is helpful and reasonably accurate. Much of it, particularly from social media, is thin or overhyped, with certain elements overemphasised out of all proportion. What it never arrives with is context or framework.
Unless somebody is well informed about their symptoms and has lived with them for a long time, the opening phase of therapy now involves a re-education and a recontextualising. This is not usually a matter of counteracting what a client believes. It is a matter of setting that understanding inside a broader framework, so that it can be seen in relation to their mental health as a whole and to the life they are living. That work needs careful management, and it is considerably harder when a client arrives with confidence in what they have read, or has already rebuilt their identity around it, and holds some defensiveness as a result.
The Language Escaped the Clinic
Alongside this, the profession’s vocabulary has entered everyday speech. Boundaries, gaslighting, trauma, attachment style, dysregulation and projection are now common currency, used fluently by people who have never been in a consulting room.
This has done real good. It has given people language for experiences that previously had none, and it has made some conversations possible that were not possible before. It has also flattened the terms it borrowed. Words that named specific clinical phenomena now serve as descriptions of ordinary interpersonal friction, and a client who says they were gaslit may mean anything from sustained psychological manipulation to a disagreement about what was said last Tuesday. Part of the assessment now involves finding out what a person means by the words they are using.
Disorders in Fashion
Diagnoses have always moved in phases. What has changed is the intensity. Particular disorders now dominate to the point of putting pressure on the therapeutic process itself.
Over this last decade narcissistic personality disorder went through an extraordinarily intense phase, with people using the concept to diagnose and attack those around them. At the other end of the spectrum, neurodiversity and neurodivergence went through a phase of people using the concept to diagnose and identify themselves. The two waves look opposite and are not. Both take a clinical construct and put it to work as a way of settling a question about a relationship or a self.
Social media and online resources give a skewed picture and set artificial priorities. They also give exposure that these conditions have never had before, reaching people who would otherwise have had no language at all for their experience.
What the Manuals Did
The most consequential change of the decade in my own area received almost no public attention. ICD-11 abandoned the categorical personality disorder diagnoses and replaced them with a dimensional model: severity graded mild, moderate or severe, five trait domains, and a borderline pattern qualifier retained largely because too much treatment evidence was attached to it to discard.
Conceptually this is the right direction. Personality difficulty has never divided cleanly into ten types. In practice, the change lands awkwardly on exactly the group this practice was founded to serve. A system organised around severity makes the severity threshold the operative question, and the people we opened for are the people whose difficulties are serious, persistent and not severe enough to qualify. A dimensional model could have made that group visible. Used as a gatekeeping instrument, it makes them easier to score below a line.
Alongside this, complex PTSD has absorbed a great deal of what was previously called borderline personality disorder, in public discourse and increasingly in clinical language. Something real is being recognised. But a reframing that succeeds partly because it carries less stigma should be examined rather than simply welcomed, and the question of whether the underlying formulation has actually changed is one the field has not properly answered.
The Assessment Decade
Adult assessment for ADHD and autism went from a specialist referral to a mass phenomenon. Waiting lists became unmanageable, a substantial private assessment market emerged, and routes intended to relieve pressure produced their own distortions, with assessment provision expanding faster than the post-diagnostic support that would make a diagnosis useful.
The clinical consequence I see most often is diagnostic overshadowing. Once a neurodevelopmental explanation is in place, it tends to absorb everything: personality difficulty, developmental trauma, attachment disruption and mood disorder all get read as features of the diagnosis. The reverse also happens, with a lifelong differently organised cognitive profile written off as a personality problem. My own work sits at that intersection, and the honest position is that we are still poor at telling these apart, largely because the research has not been done.
Therapy at Scale
The past decade also saw psychological therapy delivered at a scale the profession had never attempted. That made treatment available to enormous numbers of people who would previously have received nothing, which is a genuine achievement and should be said plainly.
What it also did was standardise. Manualised, time-limited protocols became the default unit of therapy, and routine outcome measurement became the mechanism of accountability. Measurement is not the problem. What gets optimised when sessions are counted is the problem. A model built to deliver a defined intervention in a defined number of sessions handles the presentations it was designed for well and handles complexity by excluding it. The people at the edges, the ones whose difficulties are relational, longstanding and not reducible to a symptom score, get referred on, discharged as unsuitable, or cycled through the same short intervention repeatedly.
Body and Mind Stopped Being Separate
Quietly, the split between physical and psychological presentation has become untenable. Long Covid, chronic pain, functional neurological presentations and the psychological dimensions of chronic illness have pushed into services designed on the assumption that a difficulty is one or the other. Practitioners who work across that boundary are still scarce, and the clients who need them are still being passed between services that each consider the problem to belong to the other.
The Threshold Fell
The large online therapy platforms have driven the profession toward its lowest common denominator. The threshold for becoming a therapist is far lower than it was. This has made therapy more accessible and more democratic, and both of those are real gains. It has also created a problem where specialist skill and deeper experience are needed and neither the client nor the therapist can see where that threshold sits.
The structural conditions were already there. Counsellor and psychotherapist remain unprotected titles in the UK, ten years and several attempts at reform later, while practitioner psychologist is protected. The attempt to map competence across the talking therapies has consumed a great deal of professional energy and produced a great deal of professional conflict without settling the question. A field that cannot say what its practitioners are qualified to do is not well placed to tell a client when they need someone else.
I have spent most of my career repairing clients’ relationship to therapy. People arrive having seen several therapists who were not equipped for the intensity of the psychological struggle that clinical psychologists are trained to work with. The damage is rarely confined to the presenting difficulty. It extends to what the person now expects of therapy and whether they believe it can help them at all.
What Happened to the Evidence
Two things happened to the evidence base this decade and they pull in opposite directions.
The replication crisis arrived in clinical psychology, and confidence in the manualised protocols is lower than it was. Effect sizes shrank on re-examination, publication bias turned out to be substantial, and the gap between what a protocol achieves in a trial and what it achieves in a clinic became harder to talk around.
Meanwhile the psychedelic and ketamine research generated the most enthusiastic coverage psychiatry has had in a generation. A decade on, the position is more sober than the reporting suggested. Ketamine is in clinical use with a real evidence base and real questions about durability. MDMA-assisted therapy hit regulatory difficulty over trial design that the field had been warned about. Psilocybin is closer to approval than it has ever been, and still not approved. What the episode demonstrated most clearly is how much of the reported effect depends on the therapy wrapped around the compound, which is the part of the model receiving the least funding and the least attention.
Who Stopped Coming
The decade ended with therapy becoming a discretionary spend for a great many households. That is not a clinical observation, but its clinical consequences are visible: people presenting later and in worse condition, work ending on affordability rather than completion, and the gap widening between those who can hold a long piece of therapy and those who cannot. A profession that has spent ten years discussing access has spent rather less time on the fact that the specialist end of it has been quietly pricing itself out of reach.
What It Adds Up To
Set out together, the decade looks less like a story about technology than the coverage suggests. Delivery moved onto a screen and the profession adapted. What changed more substantially is who therapy is organised around: a system increasingly built for defined problems, defined durations and measurable outcomes, staffed at its accessible end by practitioners with less training than the work in front of them requires. That is a reasonable system for many people and an actively poor one for the people this practice exists to serve. Ten years on, those people are more visible than they were, better informed about themselves than they were, and no better provided for.d in 2016 for the people at the edge of the storm. Whatever the next ten years bring, that edge will still be there, and so will they.
Storms Edge Therapy is a private psychological practice working with adults across the UK and internationally. Our team of clinical and counselling psychologists offers support for a wide range of individual and relational challenges. To find out more or to book an initial consultation, get in touch.
Frequently Asked Questions
Is therapy over video actually less effective than seeing someone in person?
There is a real difference, and it is narrower now than it was ten years ago, because both therapists and clients have adapted to reading each other over a screen in a way we had not in 2016. What matters more than the medium is whether the practitioner has been working this way long enough to have developed the specific skills it requires, rather than having transferred a room-based practice onto a screen and left it there.
I have already read a great deal about my own difficulties. Will that get in the way?
Not usually, and it often speeds things up. The point worth watching is whether the understanding you have arrived at has room to be revised, or whether it has already hardened into an identity that a therapist will have to work around rather than with.
I was told I do not meet the threshold for specialist support. What does that actually mean?
It means a service applied a severity cut-off, and it says nothing about whether your difficulties are serious or whether specialist work would help you. A large group of people sit above the point where general provision is adequate and below the point where specialist services accept referrals, and that gap is an artefact of how services are rationed rather than a description of what you need.
