1. Practical and evidence-based
interventions for NGOs/PVOs to
address mental health issues in
children
Judith Bass, PhD, MPH
Department of Mental Health
Bill Weiss, DrPH MA
Department of International Health
Johns Hopkins University School of Public Health
Applied Mental Health Research Group (AMHR)

2. GLOBAL MENTAL HEALTH
Low and Middle Income Countries

3. Risks for Mental Health Problems in LMIC
• Armed conflict and past trauma can result in serious
mental health problems
• Poverty, HIV and other chronic conditions increase risk
for mental health problems
• There are 14.8 million youth orphaned by AIDS in sub-
Saharan Africa, with numbers predicted to increase.
– HIV-related stressors, abuse, lack of social
support, neglect leads to mental health problems
and risky sexual behavior.

4. Global mental health
treatment GAP
• MH disorders
account for
approximately
1/3 of years
lived with
disability
(WHO, 2008).
• Depression
3rd on global
burden of
disease
• Despite
this – 90%
of those in
need do
not receive
treatment.

5. Treatment Gap: Children
For each child with need…
.16% receive treatment
Saraceno et al., 2007

6. Global Mental Health and Psychosocial
Support (MHPSS)
 Most commonly reported activities are:
• Provision of child-friendly spaces
• Support of community-initiated social
supports
• Non-specific counseling for
individuals and family
• Lack of empirically supported
activities
 Rarely are MHPSS programs
comprehensively evaluated
Specialized
services
Focused non-
specialized
supports
Strengthening community
and family supports
Social considerations in basic
services and security

7. WHAT DO WE KNOW
ABOUT WHAT WORKS

8. Evidence-Based Treatments
• Conditions set by APA, 1996
–Manual-based
–Sample characteristics detailed
–Tested in a randomized clinical trial
–At least two different investigatory teams
must demonstrate intervention effects

9. Current Research in Evidence-Based
Treatments for Adults in LMIC
RCTs demonstrate that EBTs can be implemented in
LMIC with positive clinical outcomes
• (e.g. Bolton et al., 2007; Patel et al., 2010, Rahmen et al., 2008)
WHO mhGAP recommended EBTs
**But does not address HOW to do this!

10. Evidence-Based Treatments for
Children/Adolescents based on
Research from the West
• Anxiety (GAD, OCD, SAD)
– Cognitive-Behavioral Therapy
– Psychodynamic – may be effective after 2+ years
• Depression (MDD)
– Cognitive-Behavioral Therapy
– Medication
– Interpersonal Therapy For Depression (IPT-A)
• Conduct Problems (ODD, CD)
– Parent Training
– Behavioral Programs
– Multi-level, intensive (primarily for adolescents)

11. Evidence-Based Treatment Research
for Child-Adolescents in LMIC
• Trauma-Focused Cognitive Behavioral therapy
(TF-CBT)
– Completed Feasibility studies:
• Cambodia
• Zambia
– Completed RCT in Congo
– Ongoing RCTs (2) in Zambia
– Ongoing RCT in Tanzania (for traumatic grief)

12. Our DIME Approach
DIME:
– Design
– Implementation
– Monitoring
– Evaluation
– **Uses empirically
Based assessments
And treatment
To provide a single logical approach to the measurement and evaluation
needs of programs, to result in effective and accessible services

13. Comparison with “Typical” CS Project
• More emphasis on qualitative research at the start
– Learn local mental health concepts and local priority issues
– Use this information to develop the quantitative tools
– Use this information to identify appropriate interventions
• More emphasis of development/validation of instruments
– Often have to design new sections/items
– Adapt/validate concepts from Western instruments
• More emphasis on randomized trials
– Many interventions without an evidence base
– Few proven interventions with „local‟ evidence base
• More emphasis on learning about unintended results
– Positive and negative results
– Qualitative followed by quantitative methods

14. IMPLEMENTATION
STRATEGIES IN GLOBAL
MENTAL HEALTH
1. Apprenticeship Model of Training and Supervision
2. Common Elements Treatment Approach (CETA)
3. Implementation with safety for suicide

15. APPRENTICESHIP MODEL
OF TRAINING AND
SUPERVISION

16. Implementation Barrier to
Addressing Treatment Gap
in LMIC
Mental
health
professionals
“Task Sharing
Approach”
Lay Counselors—
Little or No
Mental Health
Training with Supervisors
And more HighlyTrained
Personnel Overseeing
Patel, 2009

17. Apprenticeship Model
Based on Research in US
 One-off trainings ineffective for behavior change.
 “Train and hope” approach does not work (e.g., Kelly et
al., 2000)
 Ongoing supervision with on-the-job coaching critical (Beidas &
Kendall, 2010)
Thanks to Mary McKay for the cartoon

18. Apprenticeship Model of
Training and Supervision
A detailed
implementation
process that can be
used for task-sharing
MURRAY et al., 2011

19. Apprenticeship Model
Smallest Part

20. Apprenticeship Model
• Continuous feedback cycles
• Regular cross-cultural adaptations (by LOCAL counselors)
– Balancing Fidelity (expert) and Flexibility (counselors)

21. COMMON ELEMENTS
TREATMENT APPROACH
(CETA)

22. • Most target specific syndrome (i.e.
depression, anxiety, PTSD)
• Training in multiple EBTs is unfeasible given
resources (financial, personnel.. etc.)
• Requires larger referral system
• Comborbidity is common
Evidence-Based Practices – Single Disorder
focus

23. Common Elements Treatment Approach
(CETA)
• A manual-based treatment built from common
elements of EBTs
• Includes components for multiple common mental
disorders (anxiety, depression, PTSD + behavior
problems in children)
• Selection of components to add specific to client‟s
needs based on symptom presentation at intake

24. CETA Common Components in our current
trials
• Engagement
– Encourages participation, works with client to identify and manage
barriers to participation, brings in family as appropriate
• Psychoeducation
– Provides information about the program (# sessions, expectations)
– Normalizes and validates current symptoms and problems
• Cognitive coping/restructuring
– Helps client understand associations between thoughts, feelings and
behavior
– Teaches client to evaluate and restructure thinking to be more accurate
and/or helpful
• Imaginal gradual exposure
– Helps client to face memories that evoke fear and avoidance through
talking about details of the memories and the associated thoughts and
feelings
– Going through this process results in gradual desensitization to the
memories

25. CETA Selective Components
• Behavioral activation (for depressive symptoms)
– Helps client identify and engage in pleasurable, mood-boosting, or
functionality-increasing activities
• Relaxation (for anxiety symptoms)
– Teaches strategies to reduce tension, uses local practices as well as
suggesting new options when appropriate.
• In Vivo exposure (for trauma symptoms when safety ok)
– Works with client to directly face innocuous triggers/reminders in the
clients environment
– Going through this process results in gradual desensitization to the
triggers/reminders

26. CETA assessments and planning/services
• Suicide/homicide/danger assessment and planning
– Assessing client risk for danger to self/others
– Developing a focused plan with the client and client‟s family (when
appropriate) to keep client safe
– Additional referral when needed
• Alcohol misuse assessment and brief intervention
– Assessing client misuse of alcohol
– Utilizes concepts of motivational interviewing to get client buy-in to
change substance misuse behavior

27. SAFETY: SUICIDE
IDEATION MANAGEMENT

28. – Qualitative research shows critical reason for
NOT implementing Mental Health programs in
LMIC….
identification of a serious problem
(e.g., suicidal thoughts/behaviors)
with no where to refer and no training
in how to manage.
Implementation Barrier

29. Safety
A detailed
process of how
to develop
safety plans in
LMIC
No MH
SYSTEMS
 Individualized
for setting
 Appropriate for
lay counselors
Safety protocol
Initial responses by the counselor
· The counselor finishes the checklist of symptoms form, and the follow-up form. Asks
questions directly to the client with suicidal or homicidal ideation, who is victim of
domestic violence or with psychosis or is abusing substances.
· If the client indicates suicidal ideas….
Further evaluate:
a. “Have you ever tried to end your life?”
b. “Are you thinking about ending your life?”
c. “Do you have a plan to end your life?”
d. “Do you have access to that plan, in other words, do you have the means to execute your
plan?”
If the client answers YES to any of these questions, please move on to the following steps:-
· Say to the client: "Can we agree together that if you have thoughts of killing yourself,
you will speak to me personally before carrying out a plan to harm yourself?" “How can
we be sure that you be able to speak with me?”
· If the person says "yes" or "I don't know," to the questions c and d, Say: "What I am
hearing is that you are in a lot of pain right now and thinking of ending your life, so I
want you to come with me to SHARPZ offices right now and get some help to feel better
right away. I will make sure you get there safely. Is there a family member or someone I
can call to go with you?" Or tell the person you will go with them yourself.
· Arrange for the person to be accompanied to SHARPZ, and call ahead to tell Sr Roda
that you are coming.
· If the person refuses, then ask the person to wait there with someone while you call Sr.
Roda in another room to report that the person has threatened suicide. Ask Sr Roda to
come and accompany the person to the SHARPZ offices.
Talk to your supervisor while the client is still working with you. Decide, or agree on a plan
BEFORE the client leaves.

30. RESULTS FROM SELECT
AMHR TRIALS

31. 2 AMHR Trials:
1. Apprenticeship Model
2. Safety
Karbala
Mae Sot

32. Southern Iraq CETA Counselors
• N=12 counselors
• Medics or nurses
• No formal mental
health training
• In MoH clinics
• Task sharing
– Supervisors
were
psychiatrists at
torture
treatment
centers

33. Training involved
active
participation
Use of Apprenticeship Model

34. S. Iraq CETA Study Results

35. Implementation Challenges
During RCT
• Cultural
–Females not allowed to travel or meet with
male clients alone
–Female clients not allowed to meet
alone, and needed “permission” to
participate
• Client mobility and security
–Consistent bombings throughout trial
–Inability to travel, or increased time at
checkpoints

36. CETA Trial: Mae Sot Thailand
Mae Sot
PRIOR RESEARCH
Elevated symptoms of
depression, anxiety and
PTSD among Karenni
refugees (Cardoza et al.,
2004)
High rates of reported
traumatic events and
related symptoms
among Burmese
dissidents in Thailand
(Allden et al., 1996)

37. Mae Sot, Thailand CETA counselors
(Burmese refugees)
N=20 counselors
Identified by one of
three local partner
organizations
4 had past
counseling
experience
Req to be able to
work part-time.
• Task sharing
– Supervisors were
staff from NGOs: 1
medical doctor and
2 with supervisory
experience – none
had MH experience

38. 0
0.2
0.4
0.6
0.8
1
1.2
1.4
baseline follow-up
AverageDepressionSymptoms Depression Symptoms
CETA
Control
0
0.2
0.4
0.6
0.8
1
1.2
baseline follow-up
Averagetrauma-relatedsymptoms
Trauma-related symptoms
CETA
Control
0
0.2
0.4
0.6
0.8
1
1.2
baseline follow-up
Averageimpairedfunction
Female Function
CETA
Control
0
0.2
0.4
0.6
0.8
1
1.2
baseline follow-up
AverageImpairedFunction
Male Function
CETA
Control

40. Thailand Implementation Outcomes
• Feasibility
– Training:
• All but 1 counselor was able to learn CETA
• 3 (out of 4) local supervisors able to teach, coach
• 2 counselors needed to take additional practice case
– Study:
• All counselors continued onto study
• Fidelity
– Local supervisors‟ and trainers‟ notes suggest good fidelity to
the model, as evidenced by moving from one component to the
next and completing most of each component‟s steps.
• Acceptability
– Counselors and supervisors liked the model, found it helpful
and effective
– Clients referred others in community

41. Implementation Challenges
During RCT
• Community understanding of mental health and
research
– “I‟m not crazy”
– Randomization
• Client mobility and security
– Scheduling counseling sessions
– Drop out
– Inability to travel
• Organizational
– “Turf issues”
– Lack of support/leadership from organizations

42. Acknowledgements
JHU team:
• Laura Murray, PhD (developed from her slides!)
• Paul Bolton, Bill Weiss, Courtland Robinson, Cate Lee, Emily
Haroz, Zayan Mahmooth
• Applied Mental Health Research Group:
• http://www.jhsph.edu/refugee/response_service/AMHR/
Iraq/Thailand-Burma project:
• Heartland Alliance,
Funder:
• USAID Victims of Torture Fund

43. Thank you!