Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: Therapy without a therapist: Why unguided self-help might be a better intervention than guided, published by huw on April 9, 2024 on The Effective Altruism Forum.

Summary

Guided self-help involves self-learning psychotherapy, and regular, short contact with an advisor (ex. Kaya Guides, AbleTo). Unguided self-help removes the advisor (ex. Headspace, Waking Up, stress relief apps).

It's probably 7 (2.5-12) more cost-effective

It's about 70% as effective against depression

Beneficiaries use it no less than half as much

It's at least 10-20 cheaper, and might scale sub-linearly

Behavioural activation is a great fit for it (That's where you think about things that make you happy and make structured plans to do them)

It's as effective as CBT and other evidence-based therapies

It's the strongest significant component of internet-based CBT

It might be easier to self-learn since it's simpler

It might be less stigmatising since it's less medicalised

It's less risky, mostly because it scales better

There's less evidence overall, but not much

It scales superbly, so it's highly funding-absorbent

It can fail faster and cheaper

Externalities are small, but displacement is concerning

How much worse is therapy without a therapist?

A lot of work has already been done in EA to emphasise mental health as a cause area. It seems important, tractable, neglected relative to other interventions, and is at least in the conversation for cost-effectiveness[1]. And unlike many other health issues, we can only expect it to get worse over time[2].

Guided self-help is an intervention which incorporates self-directed learning of a psychotherapy, and brief, regular contact with a lightly-trained healthcare worker. It can be deployed in highly cost-sensitive environments, and flagship programmes have been developed with the WHO and deployed across Europe, Asia, and Africa[3][4][5][6].

Off the back of their own research (easily the most comprehensive cost-effectiveness analysis)[7], Charity Entrepreneurship recently incubated Kaya Guides, who are cost-effectively scaling the same programme in India[8].

But the same report also notes that removing the guided component might be even more cost-effective. This is called unguided (a.k.a. pure) self-help, and it's usually defined as any self-learned psychotherapy (regardless of whether that psychotherapy is evidence-based).

The early examples involved reading books, such as the Overcoming series, but modern interventions are usually apps, such as Headspace, Waking Up, Clarity CBT Journal, Thought Saver, UpLift or just versions of Step-By-Step and Kaya Guides without the guides. This report's definition is deliberately broad to keep in line with the cited literature, but when talking about potential interventions I'm generally thinking about apps based on evidence-based techniques.

This report is purely comparative; it's only valuable if you already believe that guided self-help might be a promising, cost-effective intervention. I'll discuss dollar-for-dollar cost-effectiveness, make some arguments for behavioural activation as a uniquely well-suited psychotherapy to apply, and finish up by arguing that since it scales so much better, it's much less risky to try. (Note: That last bit is a bit self-serving since I'm applying to AIM with this idea).

Finally, I'll limit the analysis to depression since it's the most burdensome mental health problem, but many of the included studies also find similar results for anxiety.

Unguided self-help is probably 7 (2.5-12) more cost-effective than guided

Let's start with cost-effectiveness. Here's my chain of reasoning:

It's about 70% as effective against depression

We should compare against waitlist controls, despite possible bias

We should compare against studies which recruited depressed people

The best meta-analyses show...