"Where there is no psychologist”: implementing low intensity psychological interventions for people in communities affected by adversity

What do we mean by communities affected by adversity?

 “Communities affected by adversity” refers to communities affected by incidents, such as a natural disaster, industrial accident, or an act of terrorism, through to more sustained problems, such as chronic poverty, long term conflict, displacement, gender based or community violence. One frequent similarity between communities affected by such problems is the limited access to effective mental health  and psychosocial support.

What is the impact of adversity?

We know from decades of psychological studies, that adversity can affect people’s quality of life, their functioning and increase the chance of them developing a mental health or substance use problem. WHO estimates that on average, in a humanitarian emergency, rates of severe mental disorders increase from 2-3% to 3-4%., Mild to moderate disorders may increase from 10% to as much as 15-20%. These statistics convert to substantial numbers of people when considered at a population level..

What are low intensity interventions

Low intensity psychological interventions refer to interventions that do not rely on specialists and are modified, brief evidence-based therapies including guided self-help or e-mental health. They tend to be transdiagnostic, delivered by para-professionals and have a primary focus on teaching self-management skills to clients.

In recent years there has been a lot of interest in low intensity interventions in a few high-income countries as part of a stepped care model. There is growing evidence for the effectiveness of these approaches and models for treating people suffering high levels of stress, depression and anxiety. The current data suggest that they may be equally effective as care by professionals.

Low intensity interventions are particularly well suited to communities affected by adversity, as they use fewer resources which makes them much more scalable. There is a growing body of literature showing that adapted forms of therapy such as CBT, Interpersonal Therapy (IPT) and other approaches can be effective in different cultures around the globe, when they are adapted for the country or local cultural context.

WHO development of low intensity interventions

As highlighted by WHOs Mental health Global Action Program (mhGAP), there is a large gap between the prevalence of mental health problems and the evidence based services available to those in need. We know that psychological problems affect a range of communities, but access to interventions is rare. As part of extensive reviews by WHO “guideline development groups” – which comprise of global mental health experts - psychological interventions have been recommended for addressing the mental health treatment gap.

When developing and testing these interventions, the WHO Department of Mental Health and Substance Abuse (MSD) firstly works with experts in the field to develop a suitable manual or obtains a suitable manual from partner global mental health experts., It then follows a comprehensive five phase model for developing and testing the intervention.

The first step is to adapt the psychological intervention to the country context using a highly sensitive cultural adaptation protocol developed by the WHO MSD. The adaptation process involves several steps including literal translation, focus groups and key informant interviews to ensure the accuracy of the translation, that the intervention is appropriate for the culture, and that is not offensive or harmful in any way. The second step is a small pilot randomised controlled trial (RCT) with step three being an in-depth process evaluation of the intervention and pilot trial. Step four is a large, definitive RCT, with a further process evaluation comprising step five.  

WHO is aiming to conduct 2 definitive RCTs per low intensity intervention in order to build an evidence base for their use. Following development, WHO will publish the interventions through WHO Press where they will be freely available for use as a public good. WHO will also work with national governments to assist scale up of the interventions.

Examples of current developments

The first low intensity intervention released is called “Thinking Healthy” and is a manual for the psychological management of perinatal depression. This was developed by Professor Atif Rahman of Liverpool University and was tested in Pakistan. The manual was kindly provided by Professor Rahman to WHO for global publication and use.

In addition to this, WHO are currently developing and testing two other interventions. The first is called Problem Management Plus (PM+) and is a group or individual Cognitive Behavioural Therapy-based intervention which develops client problem solving and stress management skills. PM+ is designed to be delivered by para-professionals. The second is Self Help Plus (SH+) which is a brief, facilitated, audio self-help course, with accompanying illustrated self-help book based on Acceptance and Commitment Therapy (ACT). It was developed to address the problem of delivering psychological interventions in areas where it may not be possible to train and supervise staff in conventional face-to-face psychological interventions, for example in current conflict areas.

Trials are underway in Pakistan, Kenya and Uganda. WHO is currently working on  further low intensity interventions, including  e-mental health and an intervention for children and adolescents.

For further information contact: Dr Mark Van Ommeren (vanommerenm@who.int)

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