Common Elements Treatment Approach (CETA) Thailand
To provide evidence-based treatments for depression, anxiety, substance use, and trauma and stress-related disorders.
Lay workers providing evidence-based treatment to Burmese trauma survivors in Thailand.
Common Elements Treatment Approach (CETA) is a trans-diagnostic mental health intervention developed for delivery by non-professionals in low- and middle-income countries. CETA uses elements that are common to effective treatments for mental health problems (e.g., depression, anxiety, trauma, etc.) and combines them into a single treatment model for all of these problems1. The evidence-based treatments can be used to treat individuals with mental health problems and with any combination of these problems and can be provided to people in their own communities by trained and supervised lay providers2.
The current research project used CETA approach and tested its effectiveness for treatments of varying and co-morbid disorders among Burmese survivors of imprisonment, torture, and related traumas living in Thailand. Participants were randomly assigned to CETA (n = 182) or Waitlist Controls (WLC, n = 165). Outcomes were assessed by interviewers blinded to participant allocation using locally adapted standard measures of depression and posttraumatic symptoms (primary outcomes) and functional impairment, anxiety symptoms, aggression, and alcohol use (secondary outcomes)3.
- Participants were randomly assigned to CETA (n = 182) or wait-list control (WLC) (n = 165).
- Counsellors were 11 females and 9 males with the mean age of 34 y. Some of them had worked previously as teachers (seven) or health workers (four). There were three supervisors, all males, aged 28–57 y: a doctor, a mental health counsellor, and a former political prisoner with no counselling experience or advanced degree.
- CETA participants experienced significantly greater reductions of baseline symptoms across all outcomes with the exception of alcohol use. The difference in mean change from pre-intervention to post-intervention between intervention and control groups was a 77% reduction in mean baseline depression score compared to a 40% reduction among controls, with respective values for the other outcomes of 76% and 41% for anxiety, 75% and 37% for PTS, 67% and 22% for functional impairment, and 71% and 32% for aggression.
The objective of the research project described here was to test CETA, developed for the treatment of co-morbid presentations of depression, anxiety, and trauma symptoms among survivors of imprisonment, torture, and related traumas in Burmese refugees in Thailand. CETA is based on existing trans-diagnostic manuals and is designed specifically for delivery by non-professional providers in low-resource settings4.
CETA is an inexpensive and widely accessible approach that can reduce the burden of disability due to common mental health problems. In Thailand, CETA was delivered by lay workers to Burmese refugees. Eligible participants reported trauma exposure and met severity criteria for depression and/or posttraumatic stress symptoms (PTSS).
- Psychoeducation (introduction)
- Anxiety management (relaxation)
- Behavioral activation (getting active)
- Cognitive coping/restructuring (thinking in a different way)
- Imaginal gradual exposure (talking about difficult memories)
- In vivo exposure (live exposure)
- Safety (suicide/homicide/danger assessment and planning)
- Other elements (Skills building, talking about difficult memories, problem-solving)
This was a single-site, two-arm (1:1 allocation), single-blinded, wait-list RCT. Outcomes were assessed by interview using locally adapted and validated instruments. Interviews were conducted at recruitment (baseline) and approximately 4 months later (the maximum duration of treatment plus 1 mo to allow for delays) for both intervention and control groups.
The results showed that CETA provided by lay counsellors was highly effective across disorders among trauma survivors when compared to waitlist controls. These results support the further development and testing of this and similar trans-diagnostic approaches as possible treatment options alongside existing EBTs.
Culturally-competent and local staff:
- Counsellors and supervisors were staff at one of three local service organizations; qualifications were literacy in Burmese and demonstrated an interest in mental health and counselling. All counsellors and supervisors were Burmese refugees, members of the Burmese community, and shared many cultural, religious, and political experiences with their clients (e.g., imprisonment, forced labour, loss of property).
- Clinical supervisors had at least a high school education, were bilingual in English and Burmese, and preferably had counselling experience.
- These findings may not be generalizable to other low-resource settings.
- They provide no information about long-term outcomes.
- The study cannot identify which aspects of CETA were responsible for symptom improvement or explain the improvements seen among the control participants.
- Given that the study compared CETA to no treatment rather than a placebo (dummy) or active comparison intervention, it is not possible to conclude that CETA works better than or equal to existing treatments.
CETA has been implemented and evaluated in multiple settings within Africa (Ethiopia, Somalia, Zambia), Europe (Ukraine) and Asia (Thailand, Myanmar).
- This was a single-site, two-arm (1:1 allocation), single-blinded, wait-list RCT. It was single-blinded in that interviewers at baseline and follow-up did not know to which study arm the interviewees belonged.
- Outcomes were assessed by interview using locally adapted and validated instruments. Interviews were conducted at recruitment (baseline) and approximately 4 months later for both intervention and control groups.
- Participants were Burmese adult individuals. Eligibility criteria were a) witnessed or experienced a traumatic event and b) moderate to severe depression and/or post-traumatic symptoms.
- The presence of moderate to severe depression was determined by applying modified versions of previously developed DSM IV–based algorithms
Randomized controlled trial:
- Participants were randomly assigned to CETA (n = 182) or WLC (n = 165).
- Lay counsellors treated the participants in the CETA arm by delivering CETA components chosen to reflect the client's priority problems at the point of initial presentation.
The sample included 347 participants with baseline assessments and 274 (79%) with follow-up assessment. Patients were randomly allocated to CETA (n=182) and WLC (n=165). In CETA group 148 people completed the program up to the follow-up assessment and in control group 126 subjects did the follow-up assessment.
- The researchers assigned Burmese survivors or witnesses of imprisonment, torture, and related traumas who met symptom criteria for significant depression and/or posttraumatic stress to either the CETA or wait-list control arm of their trial. Participants in the control arm received regular calls from the trial coordinator to check on their safety but no other intervention.
- Primary Outcomes: Both study arms experienced significant improvements in both primary outcomes (depression and post-traumatic symptoms). Results indicated that the mean difference in improvement from pre- to post-intervention for depression symptoms between treatment and control groups was 20.49 (95% CI: 20.59, 20.40), with a corresponding effect size of d=1.16. The mean difference in improvement from pre- to post-intervention for PTSS scores was 20.43 (95% CI: 20.51, 20.35), with d=1.19.
- Secondary Outcomes: Both study arms showed significant improvement in secondary outcome measures. The mean difference in improvement from pre- to post-intervention scores between intervention and control groups was 20.42 (95% CI: 20.58, 20.27) for impaired function, 20.48 (CI: 20.61, 20.34) for anxiety symptoms, and 20.24 (CI: 20.34, 20.15) for aggression behaviors, with corresponding effect sizes of d=0.60, d = 0.79, and d = 0.58, respectively.
- These findings suggest that, among Burmese survivors and witnesses of torture and other trauma living in Thailand, CETA delivered by lay counselors was a highly effective treatment for co-morbid mental disorders compared to no treatment (the wait-list control).
- Murray, LK, Dorsey, S, Haroz, E, Lee, C, Alsiary, MM, Haydary, A, Weiss, WM, Bolton, P (2014). A common elements treatment approach for adult mental health problems in low- and middle-income countries. Cognitive and Behavioral Practice 21, 111–123 (Link)
- Murray LK, Skavenski S, Kane JC, Mayeya J, Dorsey S, Cohen JA, Michalopoulos LT, Imasiku M, Bolton PA (2015). Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia: a randomized clinical trial. JAMA Pediatrics 169, 761–769.
- Bolton P, Lee C, Haroz EE, Murray L, Dorsey S, Robinson C, Ugueto AM, Bass J. A trans-diagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand. PLoS Med. 2014 Nov;11(11):e1001757. doi: 10.1371/journal.pmed.1001757.
- Barlow DH, Farchione TJ, Fairholme CP, Ellard KK, Boisseau CL, et al. (2011) Uniform protocol for transdiagnostic treatment of emotional disorders: therapist guide. New York: Oxford University Press.