Every year, the US spends twice as much money on Halloween costumes for its pets than developing countries receive in aid for mental health care.
Demand for mental health services outstrips supply in almost every country across the world, but in developing countries — particularly those wracked by conflict — the service gap looks more like a chasm.
But amid the most challenging of financial constraints, researchers and practitioners in the global south have developed community-based ways of providing therapeutic support that could overturn clinical orthodoxies in the global north.
Repeated clinical trials have proven lay people to be as effective as trained psychotherapists in providing care for a range of mental health conditions, and at a fraction of the cost. Could ordinary people lead the mental health revolution?
Building a base
Every year, depression and anxiety disorders cost the global economy over $1 trillion in lost productivity. But according to the WHO, almost half the world’s population lives in a setting where, on average, only one psychotherapist serves 200,000 people.
Perhaps it’s no surprise that only one in five people get the help they need when even rudimentary services are lacking.
In the global north, training for psychotherapists can stretch into the hundreds of thousands of dollars. Needing to take an undergraduate degree, postgraduate study, and extensive professional training just to be allowed to practice is not unusual.
In the global south, scarce resources and limited technical capacity meant that approach was never on the agenda. For over a decade, WHO guidelines have instead recommended “task shifting” — training non-medical professionals to deliver evidence-based therapies, reserving only the most complex cases for specialist psychotherapists.
Advanced qualifications come second to the motivation to make a difference. “Lay providers are folks with no formal mental health training and often limited education,” said Laura Murray, associate scientist at Johns Hopkins and a trained clinical psychologist. “Perhaps the most important qualification you need in individuals is an interest in doing this work and the time to do it.”
One of the most robust trials of task sharing took place in Lusaka, the capital of Zambia. Local people without prior training were provided with 10 days of intensive training in trauma-focused cognitive behavioural therapy (TFCBT), with weekly supervision from psychotherapists thereafter.
These “lay counsellors” then provided between 10 and 16 therapy sessions to 131 traumatised children aged between 5 and 18 years old. The results were dramatic.
Children receiving TFCBT saw their trauma symptom scores reduced by just under 82% — an almost fourfold improvement on treatment as normal.
Those remarkable results were not entirely exceptional, either.
In Uganda, former child soldiers experienced a clinically significant reduction in PTSD symptoms when provided with narrative exposure therapy by lay counsellors.
And in Sierra Leone, war-affected youth experienced improved emotional regulation and were six times more likely to persevere with school when they received 10 sessions of therapy drawing from CBT and interpersonal therapy.
The evidence that lay counsellors could provide specific forms of care effectively was “conclusive”, according to Murray, but no single therapeutic approach is likely to fit an entire population.
Researchers still didn’t know whether lay counsellors could provide care to more complex forms of trauma.
Upping the stakes
Much of the work of trained psychotherapists consists of diagnosing patients’ different needs, and handling multiple forms of trauma simultaneously by combining different therapeutic approaches.
Training people in only one therapeutic approach may help one segment of a traumatised population but not others. But training lay counsellors in multiple therapy styles drastically increases both the cost and time required to get them ready to practice.
“The way that trauma manifests can cut across disorder categories,” said Theresa Betancourt, Salem Professor in Global Practice at the Boston College School of Social Work: singular approaches don’t always work.
“But PTSD, conduct problems and depression can all have a common mechanism of emotion regulation — traumatised people can’t modulate their reaction to stressors very well.” Finding commonalities across different forms of trauma laid the ground for a more universally effective form of care.
In the global north, a “transdiagnostic” approach, which treats multiple traumas at the same time by combining common elements across evidence-based therapies, has been standard practice for around a decade. “Instead of taking a model that only addresses trauma or depression, transdiagnostic just means that you create a model that addresses multiple problems at the same time. It has huge implications for scale up and cost,” said Laura Murray.
Common Elements Transdiagnostic Approaches (CETA) has been proven effective across the global north, but it requires practitioners to apply complex decision-making skills, and to show flexibility in adopting different therapeutic approaches. As such, it once seemed beyond the capacities of lay counsellors.
“The question was: can we teach this to lay providers?” said Laura Murray. “Well, after four trials, we’ve pretty definitively proven that you can.”
In the last five years, repeated trials have proven that lay counsellors are capable of providing CETA — and with remarkable successes for traumatised communities.
One evaluation in a Somali refugee camp showed significant decreases in post-traumatic stress and improvements in wellbeing.
A randomised controlled trial for refugees in Thailand showed dramatic decreases in depression, anxiety, post-traumatic stress and improvements in functioning.
And in Iraq, not only did CETA provide large effect size changes across a range of trauma symptoms, it outperformed specialised, single-approach cognitive processing therapy.
Precisely because CETA works across different traumas and is effective even when delivered by lay providers, it could affordably and dramatically improve the mental health of millions in low-and-middle income countries.
CETA is now standard practice across mental health centres in Zambia, and is currently expanding along the Thailand-Myanmar border.
According to both Betancourt and Murray, effectively scaling mental health services like CETA could not only alleviate the immense human burden of psychological suffering, it could — if adequately funded — kickstart much broader development goals.
“This slow realisation is coming that with highly traumatised populations we have not had the impact we hoped to have because we have left out trauma,” said Theresa Betancourt. The billions of dollars invested in employment training or skills programs have ignored the mental health challenges rife across the developing world, particularly in post-conflict or war-affected settings. Consequently, that’s money that hasn’t always been well spent.
But the findings also suggest the potential for radical changes to mental health coverage in the global north. Confining care to specialists in overburdened health services has left immense coverage gaps even in some of the world’s leading healthcare systems. The solution might not be simply more investment in centralised, but comprehensive training for communities to build an informed and competent population capable of caring for itself and its neighbours. — Edward Siddons
(Picture credit: Flickr/DFID/Jessica Lea)