How to provide therapy to the world?

In short: Mental health problems are very frequent and most people do not get access to therapy. Even if we were able to train many more therapists than we train now, we still could not train enough to manage the demand. We discuss an article on the American Journal of Psychiatry looking at what can be done.

This month the good people from the American Journal of Psychiatry published an article reflecting on the huge need that exists to provide psychological therapy at scale in both richer and poorer countries. Mental disorders are very common yet even in places like the US or the UK most people who suffer from them are not receiving treatment. Before we started this project Russ and I have many times used medication to help with some of the symptoms, but we know that very often psychotherapy alone would be sufficient. In some more serious cases we know that medication can be necessary, but we also know that the best approach would be to combine it with therapy. However many times we are told it will be months before anyone can see the person we want to help.

The article mirrors what we know from clinical practice and reflects on the fact that we need to figure out a way to provide psychological treatments at scale to the world. While we are all clear that there is a need for this, these treatments are really hard to scale up.

The authors propose a few strategies to solve the problem like increasing the number of therapists by delegating to lower and lower qualified staff to provide these treatments. The idea is to provide people with very basic training and set them to work. Other proposals to increase the number of therapists include providing training via the Internet, and using train-the-trainer models. The trouble with all of these proposals is that the quality of care may suffer. You still have to screen (as they will be interacting with vulnerable people), supervise and pay all this lower skilled therapists. This approach does not get around the problem of the 1/3 of people with mental health problems that never seek formal help.

The article also explores book-based and computerised forms of self-help. They mention the common problems with these, which come mainly from lack of engagement. Only around 10% of people who start on them finish them. However the advantages are clear: this method is the most scalable and cost-effective way of providing therapy to the millions of people around the world who need it. The software can be used as it is are and be completely therapist-free or it can be provided with support from a remote therapist that would invest her or his time ensuring that people stay with the treatment and to helping people when they are stuck.

The authors conclude that we will never be able to train and supervise enough therapists to provide help to all those that need it and that easy-to-use software-based tools that people can use themselves or use to help one another are the only real way to scale up therapy.

We were very pleased to read the article and to have the problem that we are trying to solve so clearly acknowledged by such a prestigious peer-reviewed publication. We believe our approach to use games to make it easier for people to engage with the treatments is the missing piece to make this type of treatment truly accessible. This article gives us new resolve to create solutions that work and that people like to use.