A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries,☆☆

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Highlights

  • We describe a transdiagnostic approach for low/middle income countries (LMIC).

  • Preliminary data on pilot cases shows decrease in clinical symptoms.

  • Pilot clients were retained in treatment, suggesting acceptability.

  • Local lay workers can learn the components and the decision-making with supervision.

  • A common elements approach may be a feasible and effective alternative in LMIC.

Abstract

This paper describes the Common Elements Treatment Approach (CETA) for adults presenting with mood or anxiety problems developed specifically for use with lay counselors in low- and middle-income countries (LMIC). Details of the intervention development, training, supervision, and decision-making process are presented. Case vignettes are used as examples throughout. Preliminary findings are presented on counselor/supervisor performance and client outcomes from practice cases completed prior to randomized controlled trials (RCT) conducted at two sites for adult survivors of torture and/or systematic violence in (a) southern Iraq and (b) Thailand-Burma border.

Data suggest that local supervisors and lay counselors with little prior mental health training or experience maintained fidelity to the model. The majority of pilot clients were retained in treatment, suggesting acceptability. Using the Reliable Change Index (RCI) for each individual we examined the number of clients above a minimal threshold (z > 1.96) for each outcome. In Iraq 100% of clients had RCIs above the threshold for depression and posttraumatic stress, and 81.8% for impaired function. In Thailand, 81.3% of clients had RCIs above minimum threshold for depression, 68.8% for posttraumatic stress, and 37.5% for impaired function.

Implementation of CETA is discussed in relation to cultural issues within LMIC. These findings, combined with US-based evidence, suggest that a common elements approach warrants further development and testing as a means for addressing the treatment gap for mental health problems in LMIC.

Section snippets

Intervention Development

Development of CETA was based on a literature review of EBT and other common elements approaches. For LMIC, development required consideration of two main challenges. First, given the unavailability of a skilled mental health workforce in LMIC, developing CETA materials and the training involved using a simple, concrete format to ensure that local lay counselors with little or no previous mental health training could learn and implement the components. Second, as reliance on higher-level mental

Performance of Supervisors and Counselors

The five supervisors (Iraq = 2; Thailand = 3) all showed adequate uptake of the model in the training evidenced by skills demonstrated in role-plays, “catching” errors of counselors, and being able to explain how to do a component or redirect a counselor in a role-play. Supervision calls were done via Skype (no video) when possible, or mobile phones, when Internet was weak. One supervisor in Iraq attended all scheduled supervision calls with the U.S.-based trainers; a second supervisor missed two

Discussion

A growing research base demonstrates that EBTs are transportable, adaptable, acceptable, and effective in LMICs (e.g., Bolton et al., 2007, Patel et al., 2011, Rahman et al., 2008, Verdeli et al., 2008). This paper describes a common elements approach, CETA developed specifically for use with lay counselors in LMIC. We chose this approach for LMIC for three reasons. First, CETA is flexible and developed to guide the management of comorbidity within a single treatment approach (e.g., Mansell et

Conclusion

A common elements approach, CETA, offers promise for scaling up delivery of mental health services for individuals with need in LMIC. We hope that this paper adds to the limited literature describing treatment development, training, and supervision processes implementing EBT in LMIC. The pilot of CETA in two sites suggests that local supervisors and counselors can learn the elements and decision-making rules with ongoing supervision, further supporting the idea of task shifting. The preliminary

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    The authors wish to thank our local partners: Heartland Alliance in Iraq and in Thailand Social Action for Women, Assistance Association for Political Prisoners–Burma, Mae Tao Clinic, and Burma Border Projects. We also extend gratitude to the local counselors and clients for their participation and for allowing us to learn from and with them. We extend special thanks to our supervisors with whom we have developed both collegial relationships as well as friendships. Our warm appreciation to Dr. Maythem Alyasiry, Dr. Amir Haydary, Dr. Htin Zaw, Ko Kyaw Soe Win, and Ko Myo. We also thank Dr. Mark van Ommeren for his thoughtful comments on the manuscript.

    ☆☆

    This work was supported by the USAID Victims of Torture Program Associate Cooperative Agreement No.DFD-A-00-08-00308-00. Additional support for the preparation of this article was provided by: NIMH K23 Grant (MH077532; LM), NIMH R34 MH081764 (SD), Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative (QUERI) (LM & SD).

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