Cognitive Behavior Therapy is the most widely practiced (Knapp, et al., 2015) and heavily researched form of psychotherapy (David, et al., 2018) throughout the world. It has been shown to be effective in over 2,000 studies for the treatment of a wide range of health and mental health conditions and quality of life concerns. But developing effective treatments for mental health disorders is only the beginning. To help more people around the world, researchers, clinicians, and advocates must consider barriers to access, and develop treatment delivery systems to get evidence-based CBT to those who need it the most.
Appreciating the barriers to care is critical in bringing the benefits of evidence-based treatment to all individuals. Barriers can include cost, transportation, lack of childcare or eldercare, violence in the home or community, stigma around seeking services, lack of trained clinicians, and distrust or scarcity of medical professionals. Services must be made available using methods that meet people where they are. This includes providing services through community-based settings, including community health centers, primary care settings, religious settings, and within the public school system. This can also include home visits by social workers, outreach teams, nurses, and other care providers.
Much work is being done to make CBT more widely available in low-resourced areas using novel delivery systems. These include task-sharing, where care responsibilities are shared with peers and lay counselors. This is particularly important in areas where there are not enough mental health practitioners to meet the needs of the community. This blog will highlight some of the creative ways researchers have been successful in overcoming barriers to care to reach vulnerable individuals around the world.
Example One: The Friendship Bench in Zimbabwe
Through The Friendship Bench program, lay health workers are trained in basic CBT skills with an emphasis on problem-solving (Chibanda, et al., 2015; Chibanda, et al., 2016). People suffering from depression and anxiety receive referrals to meet with these specially trained workers on benches outside. The welcoming setting, away from a conventional behavioral health office or hospital, helps individuals feel safe, and less stigmatized for seeking care. Individuals suffering from mild to moderate depression or anxiety receive brief evidence-based interventions that help them solve current problems, identify future problems, and find solutions. They are also invited to join special peer-led group support sessions, so that they can connect with other people. Sometimes the groups complete projects, like making bags or mats out of recycled materials. This serves as behavioral activation, an important component of CBT for depression. As an added benefit, the completed projects are sold in the community, providing much-needed opportunities for generating income.
Example Two: The Healthy Activity Programme in India
This program was developed to provide lay counsellor delivered psychological interventions within primary care settings. Patients with moderately severe to severe depression are taught evidence-based strategies to address tobacco use, sleep problems, and rumination. Counselors also address skills deficits in communication and problem-solving, and teach relaxation methods. Great care is taken to adapt treatment to the individual, such as meeting with individuals in their homes, including family members in treatment as appropriate, and providing image-based resources instead of text, when necessary. A randomized controlled trial showed the approach to be sustainable, effective, and cost-effective (Weobong, et al., 2017).
Other Notable Programs Around the World
Another interesting program is the Thinking Healthy Programme, a mother-to-mother intervention for perinatal depression in India and Pakistan (Atif, et al., 2017). This program was developed to address the lack of adequately trained clinicians in these areas. A stepped-care program for depressed women in Santiago, Chile, includes interventions in a primary care setting by non-medical health workers, and group interventions with scheduled follow ups (Araya, et al., 2003). Finally, trauma-focused CBT and problem-solving therapy is being delivered by lay counselors to children affected by community violence in Indonesia (Dawson, et al., 2018).
Initiatives like these offer creative solutions to reaching individuals from different cultures and backgrounds and overcoming barriers to treatment.
References:
Knapp, P., Kieling, C., & Beck, A. T. (2015). What do psychotherapists do? A systematic review and meta-regression of surveys. Psychotherapy and Psychosomatics, 84(6), 377-378.
David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in psychiatry, 9, 4.
Chibanda, D., Bowers, T., Verhey, R., Rusakaniko, S., Abas, M., Weiss, H. A., & Araya, R. (2015). The Friendship Bench programme: a cluster randomised controlled trial of a brief psychological intervention for common mental disorders delivered by lay health workers in Zimbabwe. International journal of mental health systems, 9(1), 1-7.
Chibanda, D., Weiss, H. A., Verhey, R., Simms, V., Munjoma, R., Rusakaniko, S., … & Araya, R. (2016). Effect of a primary care–based psychological intervention on symptoms of common mental disorders in Zimbabwe: a randomized clinical trial. Jama, 316(24), 2618-2626.
Weobong, B., Weiss, H. A., McDaid, D., Singla, D. R., Hollon, S. D., Nadkarni, A., … & Patel, V. (2017). Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial. PLoS medicine, 14(9), e1002385.
Atif, N., Krishna, R. N., Sikander, S., Lazarus, A., Nisar, A., Ahmad, I., … & Rahman, A. (2017). Mother-to-mother therapy in India and Pakistan: adaptation and feasibility evaluation of the peer-delivered Thinking Healthy Programme. BMC psychiatry, 17(1), 1-14.
Araya, R., Rojas, G., Fritsch, R., Gaete, J., Rojas, M., Simon, G., & Peters, T. J. (2003). Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial. The Lancet, 361(9362), 995-1000.
Dawson, K., Joscelyne, A., Meijer, C., Steel, Z., Silove, D., & Bryant, R. A. (2018). A controlled trial of trauma-focused therapy versus problem-solving in Islamic children affected by civil conflict and disaster in Aceh, Indonesia. Australian & New Zealand Journal of Psychiatry, 52(3), 253-261.