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70 ReferencesContextual Behavioral Science and Global Mental Health: Synergies and Opportunities
Abstract
Global Mental Health (GMH) initiatives aim to address inequities in mental health care across the world. Particular emphasis is placed on building mental health service capacity in low- and middle-income countries (LMIC) where over 80% of the global population lives. Consistent with this approach, concerted efforts are being made to globally disseminate psychological interventions. These initiatives must negotiate tensions that exist between making interventions sufficiently scalable, whilst retaining aspects of the psychotherapy process that maximize both the acceptability and efficacy of psychological interventions. This paper reflects on the important contribution that Contextual Behavioral Science (CBS) can make to GMH. CBS draws on behavioral and environmental principles that translate into various therapeutic applications [including Acceptance and Commitment Therapy (ACT) and Functional Analytic Psychotherapy (FAP)] and social change initiatives (such as the PROSOCIAL approach). Consideration will be given to the cross-cultural utility and validity of CBS approaches, and the way in which these can help ensure that GMH initiatives extend beyond narrow efforts to address symptoms of mental disorders to include a focus on enhancing wellbeing. It is proposed that knowledge from ACT and FAP can help build sophistication in efforts to develop and deliver ‘therapist-free’ psychological interventions that will need to retain sensitivity to clients’ emotional expressions. In addition, the PROSOCIAL approach provides opportunities for groups of people to cooperate effectively to achieve shared aspirations and build ‘communities of support’ that can serve to optimize peoples’ mental health and wellbeing.
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Abbreviations: ACT: Acceptance and Commitment Therapy; CBS: Contextual Behavioral
Science; FAP functional Analytic Psychotherapy; GMH: Global Mental Health; HIC: High-
income Countries; LMIC: Low- and Middle-income Countries; WHO: World Health
Organization
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Contextual Behavioral Science and Global Mental
Health: Synergies and Opportunities
Citation: White, R.G., Gregg, J. Batten, S., Hayes, L.L. & Kasujja, R. (2017).
Contextual Behavioral Science and Global Mental Health: Synergies and
Opportunities. Journal of Contextual Behavioral Science. In press
http://www.sciencedirect.com/science/article/pii/S2212144717300583
Ross G. White1*, Jennifer Gregg2, Sonja Batten3, Louise L. Hayes4 & Rosco Kasujja5
1Institute of Psychology, Health and Society
University of Liverpool,
G.10, Ground floor, Whelan Building
Quadrangle
Brownlow Hill
Liverpool
L69 3GB
U.K.
*Corresponding author
Email: ross.white@liverpool.ac.uk
2San José State University
One Washington Square
San José,
CA
95192-0120
U.S.
Email: jennifer.gregg@sjsu.edu
3Booz Allen Hamilton
Washington D.C.
U.S.
Email: sonjavbatten@gmail.com
4!Centre for Youth Mental Health, The University of Melbourne, & Orygen The
National Centre of Excellence in Youth Mental Health
Melbourne
Australia
Email: louisehayes@me.com
5Makerere University
College of Humanities & Social Sciences
School of Psychology
Department of Mental Health
Kampala
Uganda
Email: rosokasug@gmail.com!
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Abbreviations: ACT: Acceptance and Commitment Therapy; CBS: Contextual Behavioral
Science; FAP functional Analytic Psychotherapy; GMH: Global Mental Health; HIC: High-
income Countries; LMIC: Low- and Middle-income Countries; WHO: World Health
Organization
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Abstract: Global Mental Health (GMH) initiatives aim to address inequities in mental
health care across the world. Particular emphasis is placed on building mental health
service capacity in low- and middle-income countries (LMIC) where over 80% of the
global population lives. Consistent with this approach, concerted efforts are being
made to globally disseminate psychological interventions. These initiatives must
negotiate tensions that exist between making interventions sufficiently scalable,
whilst retaining aspects of the psychotherapy process that maximize both the
acceptability and efficacy of psychological interventions. This paper reflects on the
important contribution that Contextual Behavioral Science (CBS) can make to GMH.
CBS draws on behavioral and environmental principles that translate into various
therapeutic applications [including Acceptance and Commitment Therapy (ACT) and
Functional Analytic Psychotherapy (FAP)] and social change initiatives (such as the
PROSOCIAL approach). Consideration will be given to the cross-cultural utility and
validity of CBS approaches, and the way in which these can help ensure that GMH
initiatives extend beyond narrow efforts to address symptoms of mental disorders to
include a focus on enhancing wellbeing. It is proposed that knowledge from ACT and
FAP can help build sophistication in efforts to develop and deliver ‘therapist-free’
psychological interventions that will need to retain sensitivity to clients’ emotional
expressions. In addition, the PROSOCIAL approach provides opportunities for groups
of people to cooperate effectively to achieve shared aspirations and build
‘communities of support’ that can serve to optimize peoples’ mental health and
wellbeing.
Key words: Global Mental Health, Contextual Behavioral Science, Acceptance and
Commitment Therapy, Functional Analytic Psychotherapy
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1. Introduction
Global Mental Health (GMH) has been defined as a field of study, research and
practice concerned with addressing inequities in mental health provision across the
globe (Patel & Prince, 2010). GMH has been influenced by a variety of factors,
including the emergence of the field of Global Health and the development of metrics
such as the Disability Adjusted Life Year (DALY), which have helped to facilitate
comparison of the impact of various health conditions across the globe. A key focus
of GMH has been to address the apparent lack of infrastructure for supporting the
mental health and wellbeing of people living in low- and middle-income countries
(LMIC). A total of 6.16 billion people live in LMIC, which equates to 84% of the
global population (World Bank, 2015). Inadequacies have been highlighted in the
availability of policies, legislation and workforce for mental health care in LMIC (The
Lancet Series on Global Mental Health, 2007, 2011). However, concerns have been
expressed that GMH activity may risk perpetrating forms of ‘epistemic injustice’ by
prioritizing Western models of mental disorders over local ways of understanding
distress (Watters, 2017). There is widespread recognition that researchers and
clinicians interested in GMH need to work closely with local stakeholders to tailor
interventions to the local context, and to address social determinants of distress (Patel,
2014; White, Jain, Orr, & Read, 2017).
2. Human Resources
Traditional models of mental health service delivery have relied on the availability of
a large number of professional and human resources. Unfortunately, this level of
human resource is not available in LMIC (Kakuma, Minas, van Ginneken, Dal Poz,
Desiraju,...Scheffler, 2011; Saxena, Thornicroft, Knapp & Whiteford, 2007).
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Drawing on innovative and pragmatic strategies from Global Health, the Movement
for Global Mental Health (http://www.globalmentalhealth.org) and international
agencies [such as the World Health Organization (WHO) through its mhGAP
programme: http://www.who.int/mental_health/mhgap/en/)] have advocated for the
use of ‘task-sharing’ initiatives where health related activities are delegated to non-
specialist workers. The ‘global dissemination’ of psychological interventions has been
recognized as an important priority for GMH (Fairburn & Patel, 2014). Three
particular strategies have been proposed to meet the considerable shortfall of available
psychotherapists, and to provide increased training opportunities for delivering
psychological therapies: 1) ‘Task-sharing’ psychotherapist roles with non-specialist
workers, 2) Employing computer programs/online systems to train psychotherapists,
and/or 3) Utilizing ‘therapist-free forms of treatment delivery’ (i.e. ‘program-led’
interventions in which the intervention is delivered by the program/online system)
(Fairburn & Patel, 2014, P.495). Fairburn and Patel (2014, 2017) indicated that
‘training for trainer’ approaches, which focus on training a smaller number of people
in particular contexts and cascading this knowledge down to others, are not scalable
and that emphasis should instead be placed on program/online delivery. More
recently, Bockting, Williams, Carswell and Grech (2016) proposed that capacity for
addressing mental health difficulties can be boosted by: 1) The delivery of evidence-
based, low-intensity interventions by non-specialists; 2) Utilizing intervention
protocols that are trans-diagnostic; and 3) Harnessing technology to support people to
access interventions. Below we will describe how Contextual Behavioral Science
(CBS) can speak to these issues and serve as a framework for advancing GMH
research and practice.
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3. Contextual Behavioral Science
CBS is defined as an empirical approach that aims to promote intentional, positive
change in the world (Hayes, Barnes-Holmes & Wilson, 2012). It utilizes a functional
contextual approach, which firmly situates behaviors (including thoughts, feelings,
and other private events) in the context (and related contingencies) in which they
occur. Functional contextualism places particular emphasis on the prediction of
behavior with precision, scope, and depth. A lack of adequate consideration of
contextual factors may increase the risk of biases occurring in the interpretation of
individuals’ behavior. As White and Jha (2014) stated: 'If all context, all trace of
interaction, all of the essentially qualitative particularities that make up subjectivity
are removed to produce ‘pure’ numerical data, the only subjects who remain are the
analysts themselves. It is they who will re-invent the context required to make sense
of the data, re-crafting the life-worlds of those researched to fit their own image'
(P.273)
The CBS principles are highly relevant to the vision and objectives of GMH because
of the specific emphasis that is placed on developing the: 1) Precision to reliably and
unambiguously predict that distress will arise in particular contexts across the world;
2) Scope to account for the broad range of behaviors that are linked to the experience
of distress in the diverse contexts; 3) Depth to be consistent with other theoretical
frameworks that are relevant to GMH e.g. theories of human and economic
development. Interventions based on CBS principles [such as Acceptance and
Commitment Therapy (ACT: Hayes, Strosahl & Wilson, 1999, Hayes, Strosahl &
Wilson, 2012) and Functional Analytic Psychotherapy (FAP: Kohlenberg & Tsai,
1994, Kohlenberg & Tsai, 2012)] do this by exploring the function of problematic
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behavior and elucidating long-term positive reinforcers (personally-defined values)
that can serve to enhance well-being, as well as reducing levels of distress. This
article will reflect on the important synergies and opportunities that exist for
integrating CBS with GMH.
4. The Application of Contextual Behavioral Science to Global Mental Health
4.1. The delivery of evidence-based, low-intensity interventions by non-specialists
The WHO has launched an initiative aimed at developing ‘low-intensity
psychological interventions for people in communities affected by adversity’
(http://www.rcpsych.ac.uk/pdf/WHO-%20Volunteering%20and%20Internships-
%20Brochure.pdf). ‘Low intensity’, in this instance, is defined as any evidence-based
brief professionally-delivered interventions, guided self-help interventions, or entirely
self-help interventions. There is growing evidence for these types of ‘low intensity’
interventions for common mental disorders (including anxiety disorders and major
depressive disorder) owing to that fact that they can be disseminated to the large
numbers of people affected by these difficulties. These therapist-free forms of
intervention may have the added benefit of reducing the risk of stigma and feelings of
disempowerment that some clients might experience when faced with meeting with a
therapist in person (Owen, 1995; Joinson, 1998; Fink, 1999). Cavanagh, Strauss,
Forder and Jones (2014) conducted a meta-analysis of 15 randomized controlled trials
evaluating low-intensity self-help mindfulness/acceptance-based interventions
(including seven RCTs evaluating ACT-based interventions. Six studies reported on
self-administered psychological interventions (i.e. with no therapist support); four
studies reported on predominantly self-help based interventions (< 90 min of therapist
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support) and five studies reported on minimal contact therapies. The meta-analysis
noted significant benefits of low-intensity mindfulness/acceptance-based
interventions relative to control participants for depression and anxiety with small to
medium effect sizes (Cavanagh et al., 2014). Building on the promise that these
interventions offer, the WHO has developed an ACT-based self-help intervention
called ‘Self-help Plus’ (SH+). This intervention has been piloted amongst Sudanese
Refugees living in Northern Uganda, with the intention of adapting it for use amongst
Syrian Refugees in the Middle-East (Epping-Jordan et al., 2016).
The fact that low-intensity/self-help interventions do not rely on the presence of a
skilled psychotherapist creates opportunities for flexibility in how these interventions
are delivered. The internet is one mode of delivery that may be particularly important
for these forms of intervention. Access to the internet in LMIC is growing rapidly and
can reach beyond the limited capacity of the comparatively small number of available
trained psychotherapists. However, efforts aimed at harnessing technology to make
psychological interventions more widely available should be balanced with a need to
retain, where possible, the key aspects of the one-to-one psychotherapeutic experience
that contribute to both the efficacy and acceptability of the psychotherapies on which
the low-intensity interventions are often based. Research has highlighted that so-
called ‘non-specific’ aspects of psychotherapy (e.g., alliance, empathy, expectations)
are important for influencing outcome (Kazdin, 1979; Wampold, 2015). Indeed,
Wampold (2015) suggested that ‘psychotherapy is a special case of a social healing
practice’ (p. 270, emphasis added). As such, efforts aimed at globally disseminating
psychological interventions need to be balanced against an appreciation that the
psychotherapeutic relationship can serve as an important vehicle for change. Rather
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than a standardized platform that offers a ‘recipe-book’ approach to working with
distress, online and program-delivered interventions will benefit from having the
necessary sophistication to respond to the wealth of verbal and non-verbal cues that
clients are providing about the nature of their distress and how it is impacting on
him/her.
Contextual Behavioral Science rests on a solid theoretical base of evolutionary and
behavioral principles, and has a broad range of therapeutic applications. CBS
interventions (such as ACT and FAP) place specific emphasis on attending to clients’
in-session affective responses and using the therapeutic relationship as a context for
identifying patterns of experiential avoidance; exploring the inextricable link between
distress and values, and building a courageous willingness in clients to live a life that
is consistent with their values and the sense of meaning that these values bring. CBS
therapists appreciate how crucial the interactions with clients can be for facilitating
the spontaneous, synchronous deriving of new relations, and reinforcing efforts to
move towards values. For example, FAP is built on a framework in which the
moment-to-moment therapeutic relationship is used to directly shape more effective
behavior over time. Consideration needs to be given to how the sensitivity and
responsiveness of online interventions can be tailored to individual users. CBS
therapists are well placed to make an important contribution to debates about the
merits/demerits of program-led interventions, and to inform the design and
development of these interventions.
There is growing recognition of the important role that implementation science
research has for understanding what factors related to interventions, individuals and
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systems may influence the process of transitioning efficacious interventions to
scalable dissemination of those therapies (Murray, Dorsey, Bolton, Jordans, Rahman,
Bass & Verdeli, 2011, Betancourt & Chambers, 2016, De Silva & Ryan, 2016). By
definition, CBS is well placed to inform efforts associated with the uptake, adaptation,
and sustainable use of psychological interventions in LMIC. CBS begins with the
assumption that efforts to understand behavior must take the context into account. As
such, CBS can make an important contribution to the need to ‘shine a lens on the
important context-determined use of effective interventions, the ongoing study of
local adaptation, and the collection of shared lessons from which global mental health
can benefit’ (Betancourt & Chambers, 2016; P.100). By drawing on frameworks such
as Normalization Process Theory (http://www.normalizationprocess.org) [and the
emphasis that this places on the need for: 1) coherence 2) cognitive participation 3)
collective action and 4) reflexive monitoring] CBS practitioners and researchers can
play an important role in efforts to implement efficacious interventions in low
resource settings.
4.2. The Cross-cultural Applicability of CBS
As highlighted earlier, there is a need for GMH initiatives to be sensitive to local
needs and developed or adapted to reflect the local cultural context (White &
Sashidharan, 2014; Ventevogel, 2014). It has been suggested that CBS approaches
can be applied across different cultural contexts because they rest on broad principles
of how people behave and adapt to various contexts (Hayes, Muto, & Masuda, 2011;
Hayes, Pistorello, & Levin, 2012; Hayes & Toarmino, 1995; Stewart et al., 2016).
The cross-cultural credentials of CBS interventions (such as ACT) rest on the idea
that the process of conducting ‘functional analyses’ of behaviors, promotes sensitivity
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to cultural knowledge and local context, rather than being based solely on the
topographical features of these behaviors (Hayes & Toarmino, 1995). ACT draws on
understanding from Relational Frame Theory (RFT; Hayes, Barnes-Holmes, Roche,
2001), which proposes that humans learn through observation to verbally relate
stimuli from particular perspectives. Research has show that deictic relations (i.e. the
distinctions between here/there, now/then and I/you) are central to situating people in
the contexts in which behaviors occur (McHugh, Barnes-Holmes, Barnes-Holmes,
Whelan & Stewart, 2007). It is suggested that the ‘I/you’ distinction facilitates a sense
of self that ‘is inherently social, expansive, and interconnected’ (Hayes et al., 2012).
This is a perspective not unlike the indigenous Southern African concept of
personhood captured in the concept of unbuntu (a Ngani Bantu language term), which
can be translated as ‘humanity towards others’, but is regarded as a philosophical
perspective that states that: ‘A person is a person through other people' (Eze, 2016).
The emphasis that ACT places on exploring individual’s ‘values’ has also been
highlighted as an aspect of the approach that boosts its cross-cultural credentials
(White & Ebert, 2014). Values have been defined as: ‘learned, relatively enduring,
emotionally charged, epistemologically grounded and represented moral
conceptualizations that assist us in making judgments and in preparing us to
act...Values can be grounded in the cultural heritage of a society and pervasively
housed within the institutions of the society.’ (Frey, 1994, P.19). From the perspective
of ACT, values ‘are freely chosen, verbally constructed consequences of patterns of
action that establish intrinsic qualities of action as reinforcers in the present’ (Hayes et
al., 2011a; P236). ACT purports to empower individuals to commit to value-
consistent behaviors (which can be shaped by the cultural context) whilst
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demonstrating a courageous willingness to experience challenging thoughts and
emotions. So, although values may vary from culture to culture and from individual to
individual, the functional contextual principles and processes that ACT espouses in
relation to an individual’s values ‘allows a natural cultural adaptation that is sensitive
to the individual and yet maintains contact with underlying behavioral processes’
(Hayes, Muto, & Masuda, 2011; P236). Pasillas and Masuda (2014) suggested that
the way in which ACT focuses on the ‘idiographic, functional, and contextual nature
of therapeutic work’ has the potential to minimize the negative impact of cultural
biases (P.110).
A number of research trials have evaluated the feasibility and efficacy of ACT in
LMIC for a variety of physical and mental health related issues. These include studies
undertaken in Iran (Mo'tamedi, Rezaiemaram & Tavallaie, 2012, Hosseinaei, Ahadi,
Fata, Heidarei & Mazaheri, 2013, Hoseini, Rezaei & Azadi, 2014, Mohabbat-Bahar
Maleki-Rizi, Akbari & Moradi-Joo, 2015), South Africa (Lundgren, Dahl, Melin &
Kies, 2006), and India (Lundgren, Dahl, Yardi & Melin, 2008). Consistent with the
task-shifting initiatives advocated by proponents of GMH, Stewart, White, Ebert,
Mays, Nardozzi and Bockarie (2016) reported on the feasibility of training health
workers and teachers to deliver ACT interventions in Sierra Leone. Recipients of the
training demonstrated significant increases in psychological flexibility and
satisfaction with life between pre-workshop and 3-month post-workshop assessments
(Stewart et al., 2016). Liu et al. (2016) conducted a systematic review of research
investigating mental health training for health workers in Africa. The review found
that although changes in participants’ knowledge and attitudes about mental illness
were routinely measured, skills and practice were less frequently evaluated. The
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authors of the reviews noted that the methodological rigor of the 37 studies that met
the inclusion criteria was generally poor. Importantly, the review emphasized the need
to build capacity and competencies in Africa to conduct rigorous research into the
effects of mental health training, and for specific learning objectives to be identified
that reflect the key competencies that the training should address (e.g., clinical skills,
advocacy, scholarship and communication) (Liu et al., 2016). Only two studies
(Chibanda, Mesu, Kajawu, Cowan, Araya, & Abas, 2011, Jenkins, Othieno, Okeyo,
Kaseje, Aruwa, Oyugi, Bassett & Kauye, 2013) assessed how mental health training
impacted the clinical outcomes of people that the trained individuals had worked with.
Both studies revealed significant improvements in the people receiving the
intervention that the workers were trained in. All of the studies reviewed by Liu et al.
(2016) were published in English – studies were completed in a total of 11 African
countries, 10 of which were Anglophone. Moving forward, there is a need for further
research in this area, particularly in linguistically diverse settings, to assess the
generalizability of such interventions across language differences.
4.3. Trans-diagnostic Potential of CBS
Bockting et al.’s (2016) recognition that ‘trans-diagnostic interventions’ may have
wider applicability and greater feasibility for use in LMIC. Similarly, Murray et al.
(2014) noted that trans-diagnostic approaches have greater ecological validity because
they provide scope for addressing high levels of comorbidity evident in people
experiencing mental health difficulties. Rather than being a symptom-based approach,
CBS (such as ACT) interventions instead target psychological inflexibility which
develops when efforts to avoid threat serve to prevent people engaging in behaviors
that are consistent with their values. As such, CBS interventions have been applied to
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a broad range of different presenting problems including chronic pain, anxiety
disorders, psychosis, addictions, depression, and eating disorders (A-Tjak et al.,
2015). The trans-diagnostic potentiality of CBS interventions, and the focus they
allocate to distress rather than ‘symptoms’ and ‘syndromes’, may offer promise for
addressing the ethical ‘elephant in the room’ relating to the seemingly ad infinitum
preoccupation with conducting and publishing mental health-related research that
employs diagnostic categories that lack sufficient validity and reliability in high-
income countries, never mind in culturally diverse low- and middle-income countries.
4.4. A Focus on Mental Health and Wellbeing
The WHO (1946) constitution states that ‘Health is a state of complete physical,
mental and social wellbeing and not merely the absence of disease or infirmity’.
White, Imperiale and Perera (2016) highlighted that, to date, GMH initiatives have
tended to focus predominantly on indicators of mental disorders and disability, and
have been characterized by a lack of sophistication in determining what constitutes a
‘good outcome’ for people experiencing mental health difficulties. In the absence of
greater clarity on this issue, White (2017) suggested that GMH initiatives risk falling
foul of what George Santayana (1905) referred to as ‘redoubling your efforts when
you have forgotten your aim’. White et al., (2016) highlighted that there is a need for
GMH initiatives to address the ‘recovery gap’ i.e. the difference between the types of
outcomes that professionals and services might prioritize and the outcomes that
individuals with a lived experience of mental health difficulties might prioritize.
To address this issue, White et al. (2016) proposed that the Capabilities Approach
(CA), a human development approach, could be used to guide GMH initiatives. The
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CA has the advantage of emphasizing the importance of interventions being shaped
by understanding: 1) What individuals in particular settings value as being important
to how they want to live their lives, and 2) The personal and structural factors that can
promote, or hinder, individuals’ freedom to realize their capabilities and engage in
valued forms of being and doing (White et al., 2016; P8). Clear synergies exist
between ACT and CA (White et al., 2016). ACT interventions [including self-help
ACT interventions (Fledderus, Bohlmeijer, Pieterse & Schreurs, 2012)] have been
shown to reduce distress whilst also boosting subjective wellbeing. Most recently,
Trompetter, Lamers, Westerhof, Fledderus and Bohlmeijer (2017) (in post hoc
analyses of data that were gathered during a randomized controlled trial) reported that
a ACT-based self-help intervention produced changes in both psychopathology (i.e.
depression and anxiety) and mental wellbeing (as assessed by the Mental Health
Continuum-Short Form). Further research investigating the impact that CBS
interventions have for enhancing capabilities and promoting mental wellbeing is
merited.
4.5. Building ‘Communities of Support’ – PROSOCIAL and Beyond
It has been suggested that GMH initiatives need to move beyond a focus on the
individual and instead harness the collective strengths that group collaboration can
bring. For example, Jansen, White, Hogwood, Jansen, Gishoma, Mukamana and
Richters (2015) highlighted a need to harness the concept of ‘community’ as a
therapeutic vehicle for supporting healing, as opposed to more narrowly considering
community-based approaches as a way of accessing greater numbers of individuals.
Consistent with these insights, prominent CBS researchers have been involved in
developing the PROSOCIAL approach (https://www.prosocial.world) which utilizes
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Nobel Laureate Elinor Ostrom’s, ‘design principles’ to help groups address social
dilemma [i.e. ‘settings where uncoordinated decisions motivated by the pursuit of
individual benefits generate suboptimal payoffs for others and for self in the long run’
(Ostrom, 2014, P.101-102)]. One example of the PROSOCIAL approach is provided
by the work of commit and act, a not-for-profit organization in Sierra Leone, who
used it to support local communities to limit the transmission of Ebola Virus Disease
during the outbreak in in Sierra Leone (Stewart, Ebert & Bockarie, 2017). Reflecting
the growing interest in how ecological factors such as climate change impact on
mental health, White (2017) highlighted that the PROSOCIAL approach can be used
to support people in different parts of the world to engage in valued forms of being
and doing whilst simultaneously promoting environmental justice.
Whilst the formation of ‘communities of support’ that adhere to PROSOCIAL
principles may be advantageous for responding to acute episodes of distress that
people may experience, they may equally provide important opportunities for
promoting wellbeing and preventing mental health difficulties emerging. There is
growing evidence of the toxic effect that fragmented or deprived community life can
have on people’s mental health. For example, McManus, Meltzer, Brugha and
Bebbington (2009) indicated that living in neighborhoods that are deprived, having
very low income, being subjected to poverty, racism and/or childhood abuse are all
associated with an increased risk of depression and schizophrenia. In recognition of
the important role that social factors can play in mental health, the WHO (2014)
published a report entitled The Social Determinants of Mental Health. Based on a
systematic review, Leamy, Bird, Le Boutillier, Williams and Slade (2012) proposed a
theoretical framework that highlighted key themes for facilitating recovery from
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mental health difficulties, which included: Connectedness, Hope, Identity, Meaning
and Empowerment (CHIME). Equally, it could be argued that making these factors
central to individuals’ community life may prevent mental health difficulties
emerging in the first place.
Sir Michael Marmot, Professor of Epidemiology at University College London, stated
that ‘…the health and wellbeing of people is heavily influenced by their local
community and social networks. Those networks and greater social capital provide a
source of resilience’ (Foot, 2012 P3). Indeed, joining local groups (especially sports
and religious groups), and having social contact and trust with neighbors, have been
highlighted are as important assets for both physical and mental wellbeing (Foot,
2012). So interactions that people have in the spaces and places were they lives their
lives can serve to prevent mental health difficulties emerging. This can include
school-based activities such as the Dream a World Therapy Program in Jamaica
(Hickling, 2017), which aims to support the wellbeing of high-risk primary school
children in impoverished, disadvantaged, inner-city communities. There is growing
evidence that CBS-informed community programs and policy initiatives can
contribute to the amelioration of social problems and the prevention of mental health
difficulties (for examples see: Biglan, 2015). It will be important to explore the
potential that these kinds of initiatives can have for providing cost-effective ways of
preventing mental health difficulties emerging in LMIC.
4.6. Scalability Through Technology
It is increasingly clear that technology will be an important factor in determining how
mental health interventions are delivered in the future (Fairburn & Patel, 2017). To
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date the majority of ‘digital’ interventions have been based on Cognitive Behavioral
Therapy (Andersson, 2014). There is marked variation in the format, functionality and
mode of delivery that digital interventions use (Fairburn & Patel, 2017). It has been
shown that digital interventions work best if accompanied by follow-up support from
a trained person, and that these could be as effective as face-to-face psychotherapy
(although there are some methodological issues with the research that has been
conducted to date) (Fairburn & Patel, 2017). Naslund, Aschbrenner, Araya, Marsch,
Unützer, Patel and Bartels (2017) conducted a systematic review of 49 studies that
used digital technology for either directly addressing mental disorders, or for
supporting the training of health workers to address mental disorders. Whilst
acknowledging that these digital forms of disseminating psychological interventions
have great potential for addressing workforce capacity issues and empowering
individuals and communities to access support they require, it was highlighted that
there has been comparatively little formal evaluation of the effectiveness of these
approaches in low resource settings.
There is a growing body of research suggesting that web-based ACT interventions
appear to be acceptable and feasible for a range of presenting problems (Bricker,
Wyszynski, Comstock, & Heffner, 2013, Levin, Pistorello, Seeley & Hayes, 2014,
Trompetter, Bohlmeijer, Veehof & Schreurs, 2015; Fiorillo, McLean, Pistorello,
Hayes & Follette, 2016; Levin, Haeger, Pierce & Twohig, 2017). The strongest
evidence for the efficacy of web-based ACT interventions to date appears to be in the
treatment of depression (Brown, Glendenning, Hoon, & John, 2016; Pots, Fledderus,
Meulenbreek, ten Klooster, Schreurs & Bohlmeijer, 2016). Vilardaga, Bricker and
McDonell (2014) highlighted important opportunities that exist for utilizing mobile
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technologies, such as how smart phones have been used in ACT and how this can
help supplement one-to-one therapy. There has also been growing interest in the
development of ACT-based apps for mobile technology. Pierce, Twohig and Levin
(2016) conducted a survey of members of the professional association for ACT
professionals, the Association for Contextual Behavioral Science (ACBS), to elicit
views about the potential costs and benefits of using ACT-based apps. Results
indicated that respondents felt that apps can be helpful for supporting between-session
practice of ACT-related processes. However, a lack of clear consensus on which apps
to choose, potential ethical issues relating to data storage, and concerns about the
effectiveness of the content provided were highlighted as important issues by
respondents (Pierce et al., 2016). These concerns, and the aforementioned need to
enhance the sensitivity and empathic responsiveness of online/web-based
interventions to the idiosyncrasies of individual’s presentations of distress, will
require careful consideration.
5. Moving Forward
In terms of specific next steps, the following six recommendations are proposed for
advancing the role that CBS can contribute to GMH. CBS practitioners and
researchers should:
1. Support the development of researchers in LMIC (through on-line resources and
in-country training workshops) to build capacity for conducting CBS research in
these settings.
2. Conduct further research to investigate the adaptation, acceptability and efficacy
of CBS interventions for improving the mental health and wellbeing of people
living in LMIC. This should include a focus on how the PROSOCIAL
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Development Team (https://www.prosocial.world) can assist with building
communities of support in LMIC that are committed to working collaboratively to
enhance wellbeing.
3. Engage in interdisciplinary collaboration with social scientists and anthropologists
to explore the way in which notions of ‘mental health’ and ‘illness’ are culturally
situated, and how local beliefs and practices can be integrated into protocols and
assessment measures aimed at supporting individuals’ to engage in valued forms
of being and doing. This should include the completion of qualitative and
ethnographic research aimed at eliciting information about what people living in
particular contexts regard as being of value to them, and how efforts to engage in
behaviors consistent with these values may be supported and/or thwarted.
4. Facilitate the equitable exchange of knowledge between the Global North and the
Global South about issues relevant for mental health and wellbeing. The ACBS
has a Developing Nations Committee that provides a good platform for knowledge
exchange between various practitioners conducting this work. Regular webinars
could be organized by the committee to facilitate knowledge exchange activity. It
will be important to ensure that these events have good representation from both
the Global South and the Global North.
5. Build training capacity for empirically supported CBS approaches in LMIC – this
might involve exploring ways of increasing the dissemination of online training
resources, but will also require the establishment of supervision networks. The
ACBS (https://contextualscience.org) currently offers scholarship opportunities to
facilitate people from LMIC to attend the annual ACBS World Conferences. In
addition, ‘ACBS peer-reviewed trainers’ have travelled to LMIC to deliver in-
country training courses. These targeted trainings can reach larger numbers of
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people, but requires close collaboration and consultation with local stakeholders to
ensure that the training is tailored to local needs.
6. Play an active role in contributing to the development and evaluation of
sophisticated program-led interventions that are sensitive to the nuances of
emotional expression in different cultural contexts, and capable of responding
appropriately to these at an individual level.
Clearly CBS is not a panacea that will cure all ‘Global Mental Health’ ills. Important
questions remain about the extent to which CBS interventions are valid across
different cultural contexts, and whether CBS can help inform efforts to improve
access to mental health interventions. Although the initial indications are promising,
further research activity is required to address these important empirical issues. What
we are calling for is time, effort, and resource to be invested in exploring the
opportunities that exist for CBS to make a contribution to GMH, and to ultimately
make a difference for people living in LMIC who are experiencing distress.
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Declarations of Interest
Ross G. White is a co-investigator on a clinical trial evaluating the efficacy and cost-
effectiveness of using an ACT-based self-help intervention to support Sudanese
refugees in Uganda (Self Help +): http://www.elrha.org/map-location/who-
psychosocial-selfhelp-call2/
Acknowledgments
None
Funding
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
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- [Show abstract] [Hide abstract] ABSTRACT: Few individuals living with mental disorders around the globe have access to mental health care, yet most have access to a mobile phone. Digital technology holds promise for improving access to, and quality of, mental health care. We reviewed evidence on the use of mobile, online, and other remote technologies for treatment and prevention of mental disorders in low-income and middle-income countries. Of the 49 studies identified, most were preliminary evaluations of feasibility and acceptability. The findings were promising, showing the potential effectiveness of online, text-messaging, and telephone support interventions. We summarised the evaluations as: technology for supporting clinical care and educating health workers, mobile tools for facilitating diagnosis and detection of mental disorders, technologies for promoting treatment adherence and supporting recovery, online self-help programmes for individuals with mental disorders, and programmes for substance misuse prevention and treatment. Continued research is needed to rigorously evaluate effectiveness, assess costs, and carefully consider potential risks of digital technology interventions for mental disorders, while determining how emerging technologies might support the scale-up of mental health treatment and prevention efforts across low-resource settings.
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