“I see all these new developments in psychological treatments — digital tools, chatbots, single-session interventions, brief treatments. As a clinician I see every day how important human contact is to help patients get better. I am afraid that these developments towards digital, shorter, more efficient treatments are only useful for health insurance companies, and that patients do not get the right help anymore.”
Why we cannot give everyone full individual therapy
It would indeed be wonderful if it were possible to give full individual therapy to everyone with a serious mental health problem. Unfortunately, that is not possible. There are simply too many people with mental health problems.
Currently, fewer than 40% of individuals with depression, anxiety, or substance use disorders receive any form of treatment in high-income countries, and among those who do, less than half receive care that meets minimal quality standards. Furthermore, more than 80% of the almost one billion people with mental health conditions live in low- and middle-income countries, where evidence-based treatments are only sporadically available.
It would be impossible to provide individual treatments by highly trained clinicians to all these people who currently do not get treatment. The costs would be enormous. But it would also require enormous numbers of trained clinicians, which are currently clearly not available. That is certainly the case in low-resourced settings, where often only a handful of clinicians are available for populations of hundreds of thousands or even millions.
More tools mean more people helped
Digital tools, chatbots, single-session interventions, treatments by lay health counselors, brief and ultra-brief treatments — they are all needed to help more people than are currently treated. They will not replace individual therapies delivered by highly trained clinicians. Because they are more easily available and the threshold to use them is often lower, they will only make it possible that more people will be treated and that more people can benefit from evidence-based interventions.
The ethical question
There is also an ethical element in this issue. Suppose you give every patient with a mental health problem, such as depression or anxiety, a full course of therapy, consisting of 25 or 30 sessions (which is the case in some countries). These patients get the best treatment available, and they have an optimal chance of getting better.
However, there is no evidence that a therapy of 25 sessions is more effective than a brief treatment of 6 or 8 sessions. And digital tools with human support are also as effective as longer therapies. But if we give every patient a full 25-session therapy, that means that we can treat far fewer patients with the same amount of money and resources.
One could argue that this is unethical, especially when there are waiting lists for other patients to get treatment. But even when there are no waiting lists, shorter and simpler treatments would make resources available to treat other patient groups, in different settings, in other communities.
Therapy is effective, but not that effective
It is important to remember that psychotherapies are effective, but not that effective. More than half of the people who get treatment don’t respond — and that is true for longer therapies, but also for brief, digital, guided self-help or other treatments. And there is no evidence that the response rates differ across these treatments.
That means that a lot of patients have not recovered after treatment, and that they need another treatment, an extension, or additional medication. Individual therapy, with intensive human contact, will at some point be necessary for many patients who do not get better after one or two standardized treatments that do not involve human contact. So, therapies with human contact will remain necessary to get most people better.
Some patients actually prefer digital tools
One final comment on the issue of human contact in therapy: there is also a group of patients who prefer not to have personal contact with a therapist. As one of the pioneers of digital therapies, Professor Isaac Marks, said:
“A computer has no eyebrows.”
It is not clear how large this group is, but there is certainly a substantial group of patients who prefer digital tools over individual therapy.
In summary
There are so many people with mental health problems that it is impossible to treat them all with individual, extensive psychotherapies. Many people can be helped with brief, digital, single-session or other therapies with less human contact. But because many patients will not recover from their first treatment, the need for intensive individual therapies will not decrease.
- For whether human contact is really the active ingredient, see Is human contact the most important part of therapy?
- For the evidence on one-session help, see Are single-session interventions effective?
- For whether AI and chatbots can help, see Can I use AI as therapy for mental health problems?
Pim Cuijpers is professor emeritus of clinical psychology and scientific director of Metapsy. He has been involved in more than 1,100 scientific studies, mostly on psychological treatments of mental health problems. This is one of a series of evidence summaries in which Prof. Cuijpers tries to answer questions from patients and clinicians, based on what is known in science about treatments. The knowledge is mostly drawn from collective work of the Metapsy collaboration of at least 15 years. Do you have other questions you would like Prof. Cuijpers to discuss? Feel free to contact us.
Literature
- Evans-Lacko S, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Benjet C, Bruffaerts R, et al. (2018). Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys. Psychological Medicine, 48, 1560–1571.
- Thornicroft G, Chatterji S, Evans-Lacko S, et al. (2017). Undertreatment of people with major depressive disorder in 21 countries. British Journal of Psychiatry, 210, 119–124.
