How Psychotherapy Actually Gets Better with Dr. Pim Cuijpers

[Music] Psychotherapy has no shortage of new ideas, but it may be short on, is actual progress. In this episode, my guest makes the case that if we want better outcomes, we need to stop chasing silver bullets and start thinking more carefully about how treatments actually delivered. We talk about psychotherapy from a public health perspective. Why so many people who could benefit from care still never receive it? And why the most meaningful gains may come from small practical changes, like better therapist patient matching and adjusting session frequency. But first, if you're new here, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia, and welcome to psychotherapy and applied psychology. Rise it down with leading researchers to pull out practical insights peek behind the curtain and hopefully have a little bit of fun along the way. And make sure you head over to our new website, psychotherapy and applied psychology.com, where you can watch or listen to episodes, sign up for email reminders when new ones come out, contact the show, or share the podcast with others, the links in the show notes. This episode begins with my guest responding to my question about how he got interested in psychotherapy research. So without further ado, it is my pleasure to welcome my very special guest, Dr. Pym Kipers. Well, I started studying psychology because I was fascinated by the idea to understand more about human beings. I could have done a lot of other things in high school. I also was good at math and at languages. But I thought psychology is the right thing. And then when I studied psychology, I was, everybody was going to become a therapist. But in Holland at that time, there was this movement of looking also at more, at psychology mental health problems, more as a public health problem. And so we had these community mental health centers and they all were developing prevention departments. And that was part of the funding we have, universal health care. And these institutes are part of that. So they treated a lot of people. But they also had all kinds of prevention projects. And I was fascinated about that. And that's what I liked. And that's what I actually, what I specialized in. I worked in mental health care for a long time. But then as a prevention specialist. We did all kinds of prevention projects. Like I got my PhD on support groups for caregivers of dementia patients. And we had groups for people who had lost somebody through suicide. And we had all kinds of problems, projects for children of parents with mental health problems. And that kind of stuff. And I liked that. And at some point I discovered the coping with depression course from which was developed by Pete Lewinson from Oregon in the late 1970s. And that was a perfect prevention project. And so I translated that into Dutch. And that was taken over by all these prevention departments in the whole country. So everybody was doing these prevention courses, the coping with depression courses. And that's how I got into depression and treatments. Yeah, that's how it all started. But it feels like a long time ago. That's interesting too that your country did like there was that focus on prevention. It feels something that feels unique relative to like the North American context. Yeah, I think it was unique in the whole world at that time. But about 10 years ago there were all kinds of budget cuts. And this and all these prevention departments, most of them just disappeared. So it's becoming more like coming back to us, more like us. Exactly. Were the prevention programs effective? I mean, in general? Well, the coping with depression courses is indeed effective. And well, how do you measure support groups for dementia patients? They were effective, but not in the sense that you could reduce the incidence. And afterwards, I did a lot of research on that as well. But if you look at the, I think it is possible to reduce the incidence of major depression, for example, but that will cost a lot of money. And that we will have to do more research before we can show that that can actually be done on a population level. So what was it that was it just that once you sort of were exposed to psychotherapy and you thought you sort of just sort of love it for a site and you just went down that road. How did that transition into really very much focusing on psychotherapy come about? Well, in the beginning, I wasn't focusing on psychotherapy that came later. So I worked in mental health care as a prevention specialist. And then I went to the national, the Dutch national Institute of Mental Health in the addiction. And there I started actually doing research before that I didn't do much research. And so when I went to the National Institute of Mental Health, that was not only research, but that was also in implementation and policy work to get mental health better on the national agenda. And but that's where I started with research. And there I got, I got a lot of grants and I got, I became department at. So I had a lot of management experience. And then at the UN, at some point in 2004, the free university of Amsterdam needed a new department at. Because the department was not functioning very well. And I had a lot of experience with management. So they asked me to become a full professor. And that's actually where my research on psychotherapy started. That was only in 2004. I was 48 at that time. And then I, because I, as a professor of clinical psychology, I thought, okay, I have to, I was, I had done a lot of work on mad analysis and looking at mental health problems from a public health perspective. And I thought, okay, that's, that's where now I have to focus on psychotherapy and the contribution that psychotherapies can make. To reducing the disease burden of mental health problems at the population level. But actually I was, I was, as I said, 48 before I started my career in psychotherapy research. Wow. And that is so interesting to you listening to your backstory because your work does have that sort of a global mental health disease burden. Like this sort of a, a bit more of that epidemiological kind of, yeah, aspects to it that never disappeared. So that's what I started my career with that you, that you look at the population instead of only looking at what happens between a clinician and a patient. But that you try to look at it at things broader. What can you do at a population level and how can we change psychotherapy so that it can serve more people so that we can rejuice the disease burden. That perspective never changed. I still have that. And I, of course, I do a lot of research with, with that clinical perspective. But that's always with that more public health perspective in mind in a way. Yeah, no, I mean, it really comes across and in your work, you know, you talk about that much of the sort of mental health disease burden is suffered in undeveloped countries. Yeah. And that it's not something, you know, in my world, it's not something I read about very often, right? It doesn't show up and that, you know, that that really shows up, you know, it's one of those, you know, it's one of the problems that your work is looking to address. Yes, exactly. Yeah, I mean, 80% of people with mental health problems live in low and middle income countries. And they hardly hardly, only a few of them have access to evidence based treatments. And even in high income countries, like in Europe or in North America, most people with mental health problems do not get psychotherapy. And I think for depression, it's now 50% in Holland. People with a diagnosis of major depression, about 50% get treatment, which in Holland often includes psychological treatment. And in many other countries, that's much lower. And then there's there's a lot there are many groups with even lower levels of access, like adolescents, adolescents. Don't go to therapists unless they're forced by their parents, so to say. And all the people also don't go to psychotherapists and people ethnic minorities go much less to therapists. People with lower socioeconomic class from so lower socioeconomic classes. So from that perspective, psychotherapy is a very rich, white elite thing. And most people who could benefit from it don't get it. And that's one of the challenges. That's one of the challenges. If you look from a public health perspective, how can you change psychotherapies in such a way that more people benefit from it? So I'm going to ask you about some of those psychotherapy or mental health innovations in a moment. Before I did, I just want to ask you because you've written about this how psychotherapy really hasn't gotten better in the last little while and sort of isn't the person that we're not getting more effective. What's yours? Do you have any thoughts about how come that, why that is? Yeah, that's I think the innovation cycle is wrong. So we have an innovation cycle in psychotherapy, which just doesn't work. And so every couple of years there are people famous professors coming up with a new psychotherapy. And they say, okay, my psychotherapy is much better than the psychotherapies that have been existing until now. It's based on a lot of clinical experience. We've done a lot of research and we're much better than the previous therapies. And then they show that their therapy works and they often work and they do randomized trials. They try to get into the guidelines. But if you look at the comparative outcomes, then these therapies are not better than the existing therapies at all. And so we have this whole innovation cycle of new therapies coming up. People in in in in in clinical practice, they like that because they see that therapies work but not that well. And they they always try to do it better because they want to help their patients. And when they hear that there is a new therapy that is much better than the ones we had. And it makes clinical sense because you understand you you you hear that that new therapy gives a new idea of where mental health problems come from. They take it over and they get training and they get. They get courses and certification for these new therapies. But in the end, no patient gets better because of it. And so I think it's in most parts because of this innovation cycle. And the only solution you you read this paper on innovations in world psychiatry. The the only real solution is not to seek for silver bullets. And we we get all these promises of silver bullets from science, but also in mental health. That this new discovery will change everything and this new therapy will be the thing that will make a huge difference. But it never does. And if we want to change mental health care and improve therapies, we will have to do that step by step with small incremental steps to improve it. Not promising too much, not expecting too much, but with brief small improvements of what we have. That's the only way forward. That's the only way and that's not how do you call it. That's not sexy or attractive or whatever. And it's not you don't get headlines in newspapers or in journals. But if you if you care about improving things, that's the only way. So before we get into some of those innovations, I wanted to read in a 2024 paper in the American psychologist, which is a different one than the one that we were just talking about. This is what this is something you wrote and I just thought it was worth reading. Another important finding is that none of the new therapies that have been introduced over the past 50 years are more effective than previous treatments. It is important, therefore, not to embrace new therapies too easily. But to folks, I love that phrasing that too easily. There's just something about that phrasing that really stood out to me. But to focus on other innovations that will result in better outcomes. And then you go on to list some of them, which we're going to get into here. But I just I think that was in the abstract because I read that and I was just sort of like that. Like what a what a strong you know, that was just written so you know, there the new therapies aren't more effective. And you know, it's not just then the one that last and the last half a half a century, you know. So to not embrace new therapies too easily, because of that, right? And I think I love how you framed it, which is very generous, which I think is right, which is clinicians or like, you know, I'm working with a patient. I'm really struggling. I'm trying to figure out grab one to anything to help make me help this person better. So it's let's let's go grab the new tool, because maybe that one will work better. But you're arguing that no, that's not the data don't support that as often the way that you're going to help patients the most. Exactly. Yeah. Thanks. I mean, this is exactly what I think. And it's it's yeah, not desperation is too strong, but it's the struggle of clinicians to help patients in the best way they can. And they often see that it doesn't work. And what do you do? What do you do? There are no tools anymore for this patient. And then when somebody comes and say, okay, I have this fantastic new tool, evidence-based and a lot of research, famous professor or books, lectures at conferences where everybody goes because it's so exciting. And that's very tempting to do that. But it's yeah, that it's it's important to realize that we've tried that for 50 years, and it hasn't resulted in better therapies. So I have a few that I wanted to ask specifically about, but before I got into some of the specific innovations, I wanted to sort of let you sort of, and I don't want you to go through all of them because there's so much, but are there a couple that either you're most excited about or that you think are most promising, you know, the ones that you're saying, oh, we need to be doing this now or ones where maybe we need to be doing this. We need more data. But what are some of the ones that come, you know, that you're that you think are most promising or most excited about? Well, I'm not excited about anyone, because we've seen it before, and we've seen the excitement before. So I'll try to stay away from excitement. When I see, for example, now all the hype around psychedelics, psychedelics, I've read papers in which they say that's a silver bullet. That's called a revolutionized everything. And I first have to see it. That doesn't mean that I don't believe that there are possible improvements. I do believe there are improvements possible. Maybe psychedelics is one of them, but I haven't seen the research yet, showing it. But it's possible. I mean, psychedelics are pretty pretty. I used them myself when I was a teenager. I used LSD, and it's a pretty heavy experience. And it's something that changes how you look at life. And it was a really very impressive experience. And so I, but what it's not so much the question, does it change you at a shorter? Yes, of course it does. Because it's a drug. It's intended to make you feel good. And so, yeah, of course it works at a shorter. But the question is, does it open a window of opportunity for real change at a longer term? And that's, I haven't seen that. And it's all it has all these complicated research issues like you, it's almost impossible to have good control condition. And how do you examine these therapies? You cannot blind people. And how can you follow people over a long time and compare that with a control group who does not use them? I mean, people can get these drugs also from the black market when they want. So how do you examine that at a longer term? And so that's, that's, it has this field has really very, very important methodological problems. But I do think it has the reason there is a possibility that it helps some people more at a longer term because of the unique characteristics of psychedelics. That's one. But I don't believe it's, I mean, all therapies work. And they work at a longer term. There is a new paper coming out in world psychiatry in which we show that psychotherapy for depression has is effective up to eight years after the start of treatment when you compare it to control groups. So the main effects in the main analysis we found that it has an effect up to eight years after starting therapy, which is, which is, well, it's not one thing, it's not one time thing. It helps you over the long term. And but maybe psychedelics do better. That's possible. And I really hope so. But do they really improve what psychotherapy can already do? I haven't seen it. So yeah, and I mean, there are more promising avenues. I mean, the research from my constantino on which was published in JAMA Psychiatry a couple of years ago, where they assigned patients to therapists, which had been shown to be very good at certain problem areas instead of assigning them to a random therapist. So you you adapt the therapist to the problem area of the patient. And they found much better results than what you find on average for psychotherapy. I mean, that's really very promising. It hasn't been repeated, but it makes complete sense that that works better than giving a therapy to a random therapy to a random patient. Another thing that I think could make a difference in depression, we've done a few studies on that, is that you increase the frequency. So you don't give one session per week, but you give two sessions per week. And I don't know if you know that that backs manual and the manual from IPT, when they were designed, they said that in the beginning you had you have to have two sessions per week and afterwards you can go to one session per week. But we yeah, we do and we've also found in a new trial that two sessions per week are more effective than one session per week. So these are a few, you know, I also think for example that machine learning where you look at large databases of patients when they when they get therapy and you try to predict that who benefits from which treatment that you can better that some people benefit more from one treatment than from another. And by personalization you can find out how that works for specific patients. That hasn't yet worked out very well. There is the personalized advantage index which is promising and that could work, but that could that also has all kinds of methodological problems. So we're not there yet, but all these different innovations that are currently being investigated. Many of them have the potential to improve the outcomes of therapies. And you have to you have to see that in perspective. For example, we've looked in a paper a couple of years ago in world psychiatry at the absolute outcomes. One problem of psychotherapy research is that outcomes are always measured in terms of standardized mean differences. We call them go and see or HsG which indicates the difference between the treatment and the control group after treatments in terms of standard deviations. So if you if the treatment group is more effective than the control group with 0.5 standardized mean difference that means they differ 0.5 standard deviation from each other after the treatment. But nobody understands what that means. Try to explain this to a patient who asks, do I will this treatment work for me? And you're going to have to explain that it makes a difference of 0.5 standard deviation compared to people who don't get it. That's important. Nobody gets it. So what we did is we looked at the absolute outcomes. How many people respond? And we define to response as a 50% symptom reduction from baseline to post-test. That also has all kinds of methodological problems. That's why people don't do it because of these methodological problems. But it's clinically so important to know how many people get better. And so what we found is for depression the response rate, so the 50% symptom reduction, that's only 42% of people who respond to therapy. And for anxiety disorders and PTSD and OCD, that was between 30 and 40%. So most people don't respond to therapy. And so for if you say okay we have a 42% response rate if you've had psychotherapy for depression. Then I think innovations, what we should try to do with innovations is that we improve that 42% with one innovation to 47%. And the other innovation can improve it from 47 to 51%. And another to a big one from 51 to 58%. That's how we have to do it. And each of these innovations, they have maybe they can improve these response rates a little. And yeah, but until now none of them has shown that. And you need to be, I mean that's not a very, as I said, it's not very sexy to say okay we're gonna we're gonna improve treatments from 42 to 47%. That's not not an attractive perspective. It's not something you can go to funders to do research and say okay we're gonna do this crazy new thing and we're gonna improve our 40 to 47%. That's not that's not, but it is the only way forward. So I had Mike Constantino on the podcast a while ago talking about his work in that area and it really, I mean, so great the stuff that they're doing. So the way that they're doing it is they're able to say retrospectively which therapists are better for dealing with which types of problems or patients with which types of problems than they assigned, you know, the treatment group was those those folks with those problems got matched to those therapists and they found these they're really just tremendous effect sizes. I mean, how do you think about you know there've been lots of analyses some after the fact some's you know not experimental, but you're looking at this matching patient to therapist thing. Like what do you think is the most promising or you know way forward in terms of if we were to do this matching or sort of take it a step further and bring it into real life like how we would do that. I don't have specific ideas about that. I do want to say that these these effects were not spectacular. I mean, I think they had an effect size of 0.5 or 0.45 or something something like that which is big but it will not I mean it will it will it will not make a huge difference when you when you when you would do it. It would improve outcomes but it is one of these things going from 42 to 48% so it's another huge effect what I find. But what you well I think what might that it's amazing work. It's really very innovative and I cannot remember exactly how we define the different problem areas but you can you can do that of course in many different ways. You can you can look at the you can make you I mean that's an empirical question. How do you define all this question? Do you ask the patient to do that? Do you do you ask therapists to do that? I think it's very important to explore that better with good empirical research. Okay. Yeah, I think yeah, I was sort of trying to look it up to see if I could find the effect size but I'll see if I can work on this. So one of the things and I because I wanted to hit on this the number of sessions per week thing because this is such a really small change you know in the real world right. If you're a practitioner to have somebody come in once versus twice a week you don't have to go to any training for that you know like that this is easy. So could you talk a little bit more about what you learned maybe where you think where you feel confident making suggestions where maybe you don't feel confident making suggestions in terms of what that could look like for practitioners. Well you say it's easy but it requires from clinicians that they reorganize their whole practice and that's that's not easy because that's how they organize their work and I wouldn't underestimate how complicated it is to change it. But I agree it's a small change and it can have a big effect for some problems. I think it has a big problem, big impacts for in depression that's where most of the evidence is. I'm not sure if this also works and all of this. I could imagine it works also at PTSD and anxiety disorder and OCD but for yeah these are all empirical questions and there's very there's too little research on this. Yeah but I think if there is a chance that it improves outcomes we should do it because it's the it's the as I said we're not looking for huge innovations. We're looking at small incremental steps. Another one which I think is very important is for example the automated feedback so that you that you that every couple of sessions you ask patients to fill in a form about how things are going not during therapy but at home and then the patient can say okay I'm happy I feel I'm I'm changing or she or he can say I I don't feel like I go ahead and they they don't dare to say that during the session to the therapist but then you have something to talk about and maybe you should change type of therapy maybe you should change the therapist or maybe you should add drugs to what is going on and are in the in the research in the meta analysis on this it shows a small but significant improvement of outcomes and I think this this is even easier to do than going from one session to week to two sessions for week. One of the things you've also written about a lot is looking at internet-based therapy versus in-person therapy. That's a wrap on the first part of our conversation as noted at the top of the show be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time