Psychiatric Annals

CME Article 

Using Layperson-Delivered Cognitive-Behavioral Therapy to Address Mental Health Disparities

Dominika A. Winiarski, PhD; Anne K. Rufa, PhD; Niranjan S. Karnik, MD, PhD

Abstract

As mental health needs continue to grow globally, it is critical to address these concerns in a timely and efficient manner. Creative approaches should be developed to reduce disparities in access to mental health care in underserved and under-resourced communities. Exclusively focusing efforts on increasing the number of licensed mental health providers is not likely to yield significant improvements in mental health access as the demands generally greatly outweigh the availability of licensed providers. One alternative solution draws on experience and studies from less-resourced settings that have promoted the use of laypeople in community settings to provide evidence-based interventions. This article reviews the evidence on layperson-delivered cognitive-behavioral interventions, discusses important logistical and ethical issues, and makes suggestions for how to disseminate this model in the United States. [Psychiatr Ann. 2019;49(8):353–357.]

Abstract

As mental health needs continue to grow globally, it is critical to address these concerns in a timely and efficient manner. Creative approaches should be developed to reduce disparities in access to mental health care in underserved and under-resourced communities. Exclusively focusing efforts on increasing the number of licensed mental health providers is not likely to yield significant improvements in mental health access as the demands generally greatly outweigh the availability of licensed providers. One alternative solution draws on experience and studies from less-resourced settings that have promoted the use of laypeople in community settings to provide evidence-based interventions. This article reviews the evidence on layperson-delivered cognitive-behavioral interventions, discusses important logistical and ethical issues, and makes suggestions for how to disseminate this model in the United States. [Psychiatr Ann. 2019;49(8):353–357.]

Rates of mental illness have been steadily increasing over the last decade, making mental health problems a global crisis.1 This is apparent not just in rates of diagnosis of depression and anxiety, but also in closely related outcomes such as increasing rates of suicide, violent crime, and poverty. For example, the World Health Organization identified suicide as the second-leading cause of death among people age 15 to 29 years in 2016.2 Similarly, research over the past several decades has illustrated that the relationship between mental health and poverty is bidirectional, such that poverty leads to increases in mental health problems, which then further perpetuate the cycle of poverty (eg, inability to work, increased medical expenses).3

At the same time, researchers have been highlighting the shortage of mental health workers (ie, psychologists, psychiatrists, counselors) in both urban and rural areas,4–6 with both rural residence and per capita income emerging as two stable predictors of unmet psychological and psychiatric need. Not surprisingly, certain mental health problems occur at higher rates in rural and low-income urban areas, with suicide rates of rural youth being nearly double that of urban youth. Further complicating this issue is the discrepant access to mental health care in these underserved communities.7 These differences are also pronounced in developing countries, where access to mental health care is similarly restricted.8,9

Years of promotion of expanded training programs have produced little impact on the overall workforce numbers of mental health providers, but global mental health needs have continued to rise. Any approach to treating this systemic failure must instead harness resources that are already available, such as training community members to deliver empirically supported mental health interventions. This article presents data from communities where layperson-delivered cognitive-behavioral therapy (CBT)-based treatments have been implemented, proposes a basic model of layperson-delivered mental health care, and offers suggestions for future research and dissemination.

Important Considerations

Several important points should be considered before implementing a layperson-delivered model. The general purpose of training laypersons to implement cognitive-behavioral interventions is not to make licensed providers obsolete, but rather to alleviate provider burden and increase access to care in high-need, low-resource communities. Training a layperson to deliver cognitive-behavioral interventions to individuals experiencing mild depression and/or anxiety, adjustment concerns, grief, or to those in need of day-to-day stress management tools could dramatically increase the number of patients receiving care. This approach is not appropriate in cases of severe mental illness, suicidal/homicidal ideation, and/or cases in which medication management is clearly the most appropriate follow-up.

Before this model is deployed, there should be a clear training plan and evaluation process in place. Ideally, laypersons should be integrated within existing mental health care systems so their work could be overseen by licensed providers who could in turn provide training, direction, and evaluation. Furthermore, a tiered supervision approach, as well as a clear case triage plan for more extreme cases involving mandated reporting and responsiveness to suicidal and homicidal ideation, should be developed. Additionally, although beyond the scope of this discussion, it is worth noting that technology can be used to facilitate layperson-delivered models of care. For example, layperson providers could be given cell phones or tablets with preprogrammed numbers to crisis lines and on-call supervisors, as well as resources to use during meetings with patients (eg, treatment manuals, handouts, CBT worksheets, and additional resources such as support groups and wellness apps). This system could also help to facilitate supervision of laypersons by licensed staff. Technology could also be harnessed to train and certify layperson providers. Before implementing these tools in the community, it would be critical to evaluate the existing infrastructure for supporting clinicians through supervision as well as effectively managing legal considerations and the possible liabilities of providing layperson-based care.

Existing Evidence

Much of the existing literature on layperson-delivered therapy comes from data collected internationally in low- and middle-income countries (LMICs) where access to evidence-based treatments for common mental health problems (eg, depression, anxiety) is scarce. However, elements of the models summarized below could translate into underserved communities in the United States. Each of the following approaches adhere to core CBT principles and are theoretically driven and empirically supported, but their general frameworks are transdiagnostic in that they are broad enough to be applied to a range of mental health disorders.

The Friendship Bench

One successful implementation of cognitive-behavioral principles by laypersons is the “Friendship Bench” project in Zimbabwe.10–12 This program was developed from a problem-solving treatment approach originally implemented to combat depression and anxiety in poorly resourced communities in Zimbabwe.8 In the pilot study of the Friendship Bench, 20 lay health workers were taught to administer a modified version of a problem-solving intervention, which included basic CBT-based skills (eg, behavior activation). Sessions took place on a bench in a private area outside the village clinic. General symptom outcomes for patients were favorable with both statistically and clinically significant reductions on a culturally sensitive measure of common mental health problems. Equally important were the favorable self-perceptions of the lay health workers' abilities to deliver the treatment efficaciously and reliably. Overall, outcomes from the pilot study suggested that the program was well received by patients, lay health workers, and the community at large. Although not assessed in early efficacy studies, lay health workers' adherence to the treatment model should be evaluated in future research. Chibanda et al.11 are presently developing an RCT to further assess the clinical utility of training lay health workers to address the treatment gap for common mental health disorders. The authors propose to train 24 lay health workers to provide services at 24 randomly selected clinics. Participants in the intervention arm will receive 4 to 6 weeks of a problem-solving intervention delivered by the lay health workers.

A review of the available literature on the Friendship Bench suggests that there are commonalities among the lay health workers: they are predominantly female, middle-aged, and all were appointed to their positions by key stakeholders within their communities (eg, clergy and other respected community leaders). Community stakeholders can also help shed light on the specific needs of the groups you are trying to reach with your intervention and can provide focus group data in trying to scale up pilot interventions.12

Layperson Treatment Embedded within a Medical Model

Similar to the Friendship Bench model summarized above, Patel et al.9,13 describe a lay health worker-run program for treating depression and anxiety in rural India. Unlike the Friendship Bench, which was developed to function within the community, this program was directly embedded into the health care system. The layperson providers delivered a minimum of six sessions of interpersonal therapy and psychoeducation to people identified as having a common mental health disorder and also helped to facilitate plans of care and future discharge from treatment. Patients who did not respond to the layperson-delivered treatment, such as those who were at high risk for suicide and/or had comorbid substance use problems or significant medical conditions, could be referred to a visiting psychiatrist who rotated in the clinics. Similar to the Friendship Bench model, the lay health workers in this study did not have a formal education in mental health and instead were enrolled in a 2-month training program and then closely supervised by patients' primary care physicians and clinical specialists. The results of a stratified cluster randomized design study showed symptom reduction, reduced risk of suicidal behaviors, and reductions in the number of work days missed over the course of 1 year.9 Although outside the scope of the present review, it is important to consider the various legal and ethical implications involved with delegating provision of mental health services to nontraditional clinicians. Before models like the Friendship Bench can be fully integrated into the US health care system, pilot programs would need to be evaluated, and it would be advisable to not only test implementation and feasibility of these approaches into target communities, but to also involve legal and ethics consultants who can help to address additional logistical barriers that may arise.

Trauma-Focused Work

The minimal access to mental health resources in LMICs creates particular challenges as many people may not only struggle with common mental health concerns but may also have experiences of trauma resulting in the development of posttraumatic stress symptoms. Fortunately, there is evidence to suggest that trained lay people can become well equipped to provide interventions targeting these specific concerns. One intervention that has been examined is the Common Elements Treatment Approach (CETA), a transdiagnostic model using common CBT skills and psychoeducation.14 Training in this model provides lay people with the skills to address a number of concerns without needing to learn multiple interventions, and with an ability to target symptoms without needing more sophisticated knowledge of diagnoses and co-occurring conditions. This flexibility is important due to the myriad clinical presentations known to arise following traumatic experiences. Randomized controlled trials that have examined the outcomes for those treated with CETA provided by laypeople compared to waitlist controls have shown significant improvements in depression, posttraumatic stress, and anxiety for Burmese refugees in Thailand (n = 20 lay providers)15 and trauma survivors in central Iraq (n = 12 lay providers).16

Similar positive results have been found in studies where lay people have been trained in specific trauma-focused therapies. Lay people with the equivalent of a high school education in the Democratic Republic of Congo were trained in Cognitive Processing Therapy (CPT), which is a trauma-focused cognitive behavioral intervention and a first-line treatment for posttraumatic stress disorder (PTSD). Layperson providers administered group treatment to survivors of sexual assault in their village. Although both those who received standard individual support and those who engaged in the CPT group exhibited improvements after the intervention and 6 months later, the participants in the CPT group showed significantly greater reductions in symptoms of PTSD, anxiety, and depression compared to their control group counterparts.17 Findings from another study in which 17 laypeople provided CPT to trauma survivors in Southern Iraq similarly indicated significant improvements in posttraumatic stress symptoms and depression.16

These effects have been found for lay people trained in other trauma treatments as well, such as group-based and culturally modified trauma-focused CBT for adolescent girls exposed to rape and sexual assault in war zones18 and narrative exposure therapy (a CBT-based treatment) provided to Rwandan and Somali refugees in Uganda who were diagnosed with PTSD.19 Although research to-date has primarily focused on training lay people in LMICs, such models could be effective in low-income US communities where trauma exposure is prevalent and significant disparities in access to mental health care exist.

Future Directions

Successfully leveraging community partnerships to integrate lay health workers into high-need, low-resource areas has the potential to help alleviate the growing mental health crisis across the country. However, as this novel strategy continues to gain traction and various approaches to dissemination are developed, there are several important points that should be carefully considered.

One of the benefits of working with a team of lay providers is that these individuals can be integrated within the communities that clinicians are often trying to reach. For example, the lay health workers in the Friendship Bench studies had “status and possess[ed] an intimate knowledge of the local language, norms and context, and a unique social and cultural understanding of the issues facing their patients.”10 The “community clout” that lay providers bring to the table is an essential and unique part of the patient-provider relationship that licensed professionals may not always have. Each community has its own sense of mores and norms, and previous research has established that an emic approach (ie, one that considers an individual's culture as the starting frame of reference, including when making therapeutic recommendations20) is the most effective. This is another reason why clinicians should find ways to integrate people who are already embedded within the culture, respected by their communities, and who personally understand the daily struggles for which their community members may be seeking help.

Lay providers may also be the best bridge to formal treatment for individuals who are fearful or mistrustful of the mental health profession due to personal experiences or historical factors. As the first point of contact with the mental health system, layperson providers can also function as advocates for mental health treatment. Also, although stakeholders should help to identify members of the community who are most likely to be successful in this role, diversity of race, religion, sexual orientation, and other important socio-demographic characteristics that may play a role in service utilization ought to be considered.

As discussed above, lay health workers must practice under the supervision of a licensed mental health professional who can provide them with access to peer supervision and support. Just like licensed providers, lay mental health workers may suffer from burnout or, in cases of exposure to repeated traumatic narratives, vicarious trauma.21 Thus, in developing protocols for lay health worker-delivered interventions, researchers should be mindful of this fact and should clearly integrate some kind of provider support into their intervention framework.

The authors are presently working on integrating the models summarized above to help target underserved communities within the city of Chicago. One program that holds promise for successful integration into these layperson-delivered formats is Families OverComing Under Stress (FOCUS), which was specifically developed and adapted for families dealing with complex challenges, such as serious medical illness or parental deployment to war zones.22 FOCUS can be effectively deployed by a wide variety of providers once they are taught the core CBT-based elements of the model: emotion regulation, communication, problem-solving, goal setting, and managing trauma and stress reminders. The FOCUS manual illustrates and addresses each of the five core elements, and the skills outlined in the manual can generally be taught in six to eight modules, which is roughly the same time frame used in the models described above. The adaptability, ease of implementation, overall emphasis on building resilience in individuals and families, and the applicability to a range of commonly experienced mental health challenges (eg, trauma exposure, depression, anxiety) makes FOCUS a promising tool. Additional research, including randomized control trials, is needed before the impacts of this approach are known. As mentioned above, FOCUS utilizes CBT strategies to teach resilience skills in the face of adversity, and future applications of a layperson treatment delivery model should be broad enough to treat a variety of mental health concerns.

Lastly, there are many important ethical issues that arise when a patient-provider relationship is initiated (eg, issues of breaching confidentiality, establishing boundaries), and these issues may be even more salient for lay providers. Trusted lay providers, particularly those in small, tight-knit communities, are more likely to have daily interactions with their patients (shopping, worship, bringing children to school), thus increasing the likelihood of breached confidentiality or blurred boundaries. Thus, it is especially important for supervisors to communicate strategies for anticipating and navigating these interactions, and for lay providers to understand and be comfortable with the dual role they will be playing in their communities. In models akin to the Friendship Bench, it is also important to recognize that patients lose a certain degree of anonymity that often comes with traditional mental health treatment. Despite this concern, the risks associated with maintaining the status quo with regard to mental health care in underserved and hard-to-reach communities are much higher than those associated with the ethical concerns raised here. Providers have a moral, professional, and human obligation to maximize the opportunities people have to receive much-needed mental health care. Leveraging community networks to train lay mental health workers to disseminate empirically supported care is one avenue by which this can be achieved.

References

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Authors

Dominika A. Winiarski, PhD, is an Assistant Professor. Anne K. Rufa, PhD, is an Assistant Professor. Niranjan S. Karnik, MD, PhD, is the Associate Dean for Community Behavioral Health. All authors are affiliated with Rush University Medical Center, Department of Psychiatry and Behavioral Sciences, Section of Population Behavioral Health.

Address correspondence to Dominika A. Winiarski, PhD, Rush University Medical Center, Department of Psychiatry and Behavioral Sciences, 1645 West Jackson Boulevard, Suite 600, Chicago, IL 60612; email: Dominika_A_Winiarski@rush.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20190711-02

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