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Mental health in low- and middle-income
countries: Needs, gaps, practices, challenges and
recommendations
VVVV
Bhava Nath Poudyal1 and Yubaraj Adhikari2
1Tribhuvan University, Nepal
2University of Nicosia, Cyprus
__________________________________________________________
How to cite this article (APA 7):
Poudyal, B.N., & Adhikari, Y. (2022). Mental health in low- and
middle-income countries: Needs, gaps, practices, challenges and
recommendations. In Adhikari, Y., Shrestha, S., & Sigdel, K.
(2022).
Nepalese Psychology: Volume One
(pp.195-
229)
.
Evincepub. India: Chattisgarh.
Abstract
Task shifting is a process where tasks are delegated and shared among
care professionals through adding skills or qualifications to cover the
treatment gap. Task shifting in the mental health and psychosocial
support (MHPSS) sector in low and middle-income countries (LMICs)
is not a new concept, nevertheless, the approach has notable challenges
for implementation. Inadequate trained human resources, low level of
funding in the mental health sector, supervision, quality assurance, and
enhancement of proximity of mental health services to the people in
need are issues still prevalent. The quality of the contemporary
practices, including training, supervision, and research of
interventions, are often biomedical focused, and contextual practices
such as socio-cultural-anthropological aspects are still not well taken
196
into considerations. This paper reviews the needs, gaps, and practices
in the task-shifting approaches of public mental health practices and
outlines concrete steps to take into consideration in addressing the
identified gaps. Authors’ empirical knowledge and observations during
service delivery in LMICs are also reflected in the paper. The article
concludes by stressing the need in LMICs for considerably more
investment, empowerment, training with sustainable supervision of
paraprofessional service providers, de-stigmatization of mental illnesses
through public awareness, and concerted efforts to enhance the
MHPSS services to fill the treatment gap for those in needs.
Keywords
: LMICs, task shifting, MHPSS, paraprofessionals,
explanatory models
Mental health in low- and middle-income countries: Needs, gaps,
practices, challenges and recommendations
This article is based on observations and reflections of the authors
who have worked in the humanitarian mental health and psychosocial
support (MHPSS) initiatives as well as on available literature on the
subject in low and middle income countries (LMICs). It highlights the
enormous needs in mental health (MH) care in LMICs and treatment
gaps, which has resulted in the practice of “task shifting” where lay
people are trained and mobilized in MH service provision. Taking this
approach is a viable solution for scaling up services, this paper will also
detail the challenges with over emphasis on biomedical model of MH
interventions; insufficient focus on psychological interventions; the
challenges posed by context, culture and language; and the challenges
with the differences in the way people perceive and understand their
suffering versus the classification of disease through psychiatric
nosology and diagnostic tools. Finally, the article provides
recommendations for ways forward to address these challenges.
Mental Health in LMICs: Needs and Gaps
Needs
Globally, over 600 million people are affected by depression and
other common mental health (MH) problems (WHO, 2017). Over
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70% of MH cases reported are from low- and middle-income countries
(LMICs; Alloh et al., 2018). MH is also a leading cause of disability. It
accounts for an average of 32.4% of years of life lived with disability
(YLD; Vigo, Thornicroft, & Atun, 2016). The burden of depression
and substance-use disorders is over 60% on the global YLD: 40%
depression and 20% of substance-use disorder; globally, an estimated
14% of deaths are related to mental illnesses (Lommerse, Stewart &
Rahman, 2020; Kola et al., 2021). 800,000 people commit suicide every
year, out of which 78% are from LMICs. The major differences
between high-income countries (HIC) and LMICs was that young
adults and elderly woman in LMICs have much higher suicide rates
than their counterparts in HIC (WHO 2016). A majority of people in
LMICs are also affected by disasters, violence, and conflict situations
every year, in addition to the existing social inequalities, and poverty
(Lommerse, et al., 2020; Alloh et al., 2018; Patel, 2012).
Gaps
Treatment Gap. The population in LMICs have the highest
treatment gap (Rathod et al., 2017; Uwakwe & Otakpor, 2014) with
low treatment outcomes due to social stigma on MH; high out-of-
pocket expenses to access MH services; higher time investment to
reach care facilities; and lower benefit of treatment due to slow
technological skill transfer (Qin and Hsieh, 2020). The treatment gap
for severe MH disorders is over 70% and even higher for common MH
disorders (WHO, 2013). Resources are limited for developing and
maintaining MH services in LMICs (Iemmi, 2020). The scarcity and
unequal distribution of services imply that 76–85% of people with MH
conditions do not receive the care they need; this treatment gap
exceeds 90% in many LMICs (WHO 2018). In addition, resources,
policy, and legislative issues, administrative barriers, information and
knowledge gaps are other obstacles contributing to treatment gaps
(Sarikhani et al., 2020; Kakuma et al., 2011). In a qualitative study
exploring service issues in primary care setting, socio-cultural-
linguistic issues and concerns related to inadequate knowledge
amongst service providers about the problems of the affected
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populations were key barriers to implement MH services in primary
care settings (Martinez et al., 2017).
Shortage of Mental Health Professionals. The World Health
Organization (WHO) reports a significant shortage of trained human
resources to address the treatment gap for MH disorders in LMICs.
While the median number of trained MH professionals covering a
population of 100,000 was nine, a huge disparity exists between HIC
and LAMICs. While in HIC the number was as high as seventy-two
professionals per 100,000 population, in LMICs it was just one (WHO,
2018). Between the World MH Atlas 2005 and 2011, HIC saw a
median increase in number of psychiatrists of 0·65 per 100,000
population, whereas in LMICs the number fell by 0·01 per 100,000
population (Kakuma et al., 2011). Shortage of MH workers remains a
challenge (Kakuma et al., 2011, Tol et al., 2011; Patel et al., 2018).
Furthermore, in LAMICs psychologists and psychiatrists generally
prefer to work in urban cities leaving a further gap in rural settings.
Scarcity, inequity, inefficiency, and emigration or migration of MH
expertise remains as crucial issues to address the treatment gap.
Practices: Task Shifting
To address the scarcity of trained MH professionals, the concept of
task shifting (or task sharing) has emerged. Task shifting is the name
given to a process where tasks are delegated, where appropriate, to a
less specialized workforce (Patel, 2009). The concept mobilizes non-
specialist nurses, physicians, and community health workers.
Community health workers receive training on screening,
identification, and referral of mental illnesses to health facilities for
necessary diagnosis and treatment. Primary health care practitioners
who are non-specialists on MH issues administer psychiatric treatment
under the training and guidance of psychiatrists, and are expected to
provide social support, psychoeducation and psychological therapies to
patients and caregivers (Mendenhall et al., 2014). LMICs, especially in
post-conflict and post-disaster situations, have adopted task shifting to
address a variety of common MH disorders (Cohen & Yaeger, 2021).
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Apart from shortage of MH professionals in LMICs, a major issue
is also 'how to deliver the services' rather than 'who delivers it' (Peters
et al., 2009), so that available human resources can perform better
(Fulton et al., 2011). Aiming to bridge this gap, the WHO, in 2010,
launched the MHGap Intervention Guide (mhGAP-IG) with a simple
clinical model and algorithms for assessing and treating mental,
neurological, and substance use disorders in LMICs, followed by
another version, with addition sections for grief and PTSD as a
Humanitarian Intervention Guide (mhGAP-HIG;WHO-UNHCR,
2015).
After the WHO’s initiatives on task shifting with additional
material on Psychological First Aid (PFA) and Problem Management
Plus (PM+), an increasing trend in non-specialist facilitated talk
therapies in humanitarian crises is observed. Common Elements
Treatment Approach’s (CETA) trans-diagnostic adaptation of the
CBT technique delivered through trained local non-specialists has
shown some treatment effects in five LMICs (Ryan et al., 2021). In
Pakistan, India and Kenya, CBT-based talk therapy plus problem-
solving approaches delivered through community health workers
demonstrated promising results in reducing symptoms and increasing
functionality (Atif et al., 2016; Atif et al., 2019; Bryant et al., 2017;
Rahman et al., 2016). Group Problem Management Plus (Group PM+)
was found effective in Pakistan with female populations, and is
currently being tested in Nepal (Chiumento et al., 2017). Barnett et al.,
(2018) outlined that two-thirds of interventions done by non-
professionals in addressing clinical disorders including depression,
anxiety, trauma, and disruptive behaviors were found efficacious to
reduce symptoms and improve daily functioning.
Despite progressive trends on the non-specialist delivered brief
therapies in LMICs, the coverage of such interventions is focused on a
small number of countries in Asia and Africa. Except for CETA and
PM+, a prevalent challenge is the narrow focus of interventions using
specific therapies in only one or two common MH disorders (Ryan et
al., 2021).
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Challenges in Task Shifting
Task shifting is a promising approach filling the gaps in lack of MH
professionals in LMICs. However, it comes with its own set of
challenges. Some major challenges to mobilization of non-specialists
for multiple types of treatment are funding, scarcity of skilled
personnel, inadequate cultural consideration, and adaptation process of
treatment protocols. Researchers fail to report detailed processes and
methodology of the intervention, cost-effectiveness, and delivery
process that makes replication a challenge (Singla et al., 2017). Lastly,
discontinuation of funding, lack of regular supervision capacity,
difficulty in retention of staff, and logistical as well as socio-cultural
challenges remain major barriers in sustaining services in the task-
shifting approach (Atif et. al., 2019). The western individualized form
of psychotherapy and group interventions in clinical settings often pose
challenges to replicate easily in LMIC (Stein et al., 2019).
Biomedical Approach without Psychological and Psychosocial
Support. The model of task shifting through public health systems
currently focuses heavily on the biomedical approach of MH. The risks
of promoting a ‘cookbook’ of psychiatry and individualized therapy in
a medical setting without assessing much of the socio-cultural and
spiritual aspects of illness becomes counterproductive due to the risk of
the medicalization of human sufferings (Weinmann & Koesters, 2016;
Petersen et al., 2017; Chase et al.,2018). The reliance on psychotropic
medications for mental illness without proper psychoeducation,
psychological support, community outreach and follow up opens it up
to potential negative outcomes from non-adherence to treatment due
to side effects and increased potential stigma. Additionally, when
patients, families and communities do not understand the treatment
and prognosis, help seeking behavior is also reduced (Gómez-Carrillo
et al., 2020).
Lovell et al., (2019) highlighted the potential risks of expansion
of psycho-pharmaceuticals that medicalizes the political, social, and
economic factors affecting distress in people. They claimed that the
mhGAP has adopted the language of International Classification of
Diseases (ICD) diagnostic classification and promotes disease specific
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medicines, largely undermining the local notions of expression of
distress and traditional practices of healing. Concern is equally related
to the availability of trained professionals, and their allocation of time
to each patient for assessment, treatment plan, education of the patients
and care providers, and follow up. At the field level implementation,
the authors agree with Charlson et al., (2019) that mhGAP trained
doctors can barely spend five to ten minutes with a patient, irrespective
of the patient’s problems, due to the overburden of caseload in addition
to their regular medical services.
Contextual Challenges. The Inter-Agency Standing Committee
(IASC) guideline on Mental Health and Psychosocial Support (IASC,
2007) recommends social considerations with basic services including
safety, strengthening family and community support, and focused
non-specialized support (person-to-person or self-help groups) before
immediately thinking that people require specialized support. The role
of family members, peers, social and religious leaders are underutilized
in practice, while these institutions are the foundations of the recovery
process for people challenged by mental illnesses in LMICs (Kirmayer,
2012). The outcome evaluation of Programme for Improving Mental
health care (PRIME) project in five countries outlined challenges on
lack of data on treatment coverage, absenteeism of trained professionals
on site, shortages of essential drugs, inadequate outreach, lack of
multisectoral collaboration and exclusion of community support
structures including traditional healers (Hanlon et al., 2014). In
collective societies, people try their best to seek help from family,
friends, and traditional healing mechanisms. Abera et al., (2014)
reported that over 90% of primary health workers (PHWs) in Ethiopia
considered supernatural and spiritual factors causing mental illnesses
and highlighted the need for training on therapeutic alliances and
treatment protocols. Uwakwe and Otakpor (2014) emphasize the
inclusion of traditional healing approaches to address the MH gap.
In the humanitarian sector, organizations both local and
international involved in “psychosocial support” focus on normative
and preventive interventions; such as, psychological first aid (PFA),
recreational activities, tips on stress management, education,
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protection, livelihood activities etc. Unfortunately, these normative
interventions are misunderstood as “psychological intervention” for
traumatized populations by local service providers. A five-year
retrospective study of PFA mentions that “PFA has been used as a
panacea where other MHPSS responses don’t exist – many times, long
after the disaster – as a psychological intervention” (Snider (2018).
Similarly, child focused recreational activities were perceived as a
psychological intervention to treat “trauma”. NGO staff believed that
‘the trauma of the children will go away if they play’ with toys under
the tents (Poudyal et al., 2008). Jordans et al., (2020) observed gaps in
terms of relevance, effectiveness, quality, and feasibility of task shifting
interventions in LMICs and proposed a ‘roadmap to impact’ in order
to address cultural and contextual challenges.
Challenges in Problem Formulation and Explanatory Models. In
anthropology, and social and behavioral sciences, emic and etic refer to
two kinds of perspectives (Berry, 1989; Van de Vijver, 2010): emic,
from within the social or cultural group (from the perspective of the
person within a cultural context) and etic, from outside – as a universal,
across-culture phenomenon. In the context of the MHPSS, the service
provider has the option of a) trying to understand the issue from or
within the context of the culture and what it means to the patient/client
(emic), or b) viewing the problem from the perspective of the MH
professional trained in “western” psychiatric nosology
(etic). Understanding narratives from the perspectives of the patient
allows space for a possibility of negotiating for a common
understanding of the nature of the illness experience and hence, an
ability to persuade a healing process where the patient finds meaning
and is willing to adhere to the treatment (Poudyal, 1999).
Anthropological MH experts’ critique of contemporary medical
and MH practice is that it has increasingly become a one-sided
understanding, interventions and expectations. To quote Kleinman,
“Modern physicians diagnose and treat diseases (abnormalities in the
structure and function of body organs and systems), whereas patients
suffer illnesses (experiences of disvalued changes in states of being and
in social function; the human experience of sickness). Illness and
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disease, so defined, do not stand in a one-to-one relation. Similar
degrees of organ pathology may generate quite different reports of pain
and distress. Illness may occur in the absence of disease (50% of visits
to the doctor are for complaints without an ascertainable biologic base);
and the course of a disease is distinct from the trajectory of the
accompanying illness. Moreover, the remedies prescribed by
physicians may fail to cure disease, despite effective pharmacologic
action, when patients fail to follow through on the medical regimen
because they do not understand (or do not agree with) the physicians’
stated rationale for their actions (Kleinman, Eisenberg & Good, 1978
p. 251-252).''
To illustrate this, one can take an example of the Hindu and
Buddhist culture for the expression of distress known as “vairagya
lagyo'' in Nepali. The terminology implies a symptom of quietness,
detachment, sadness, loss of interest in everyday activities, being
dispassionate etc., which would align with the ‘etic’ model of
“depressive symptoms' '. However, in the cultural context, someone
expressing “
vairagya”
does not equate to being depressed and needing
psychiatric care necessarily. On the contrary, Hindus and Buddhists see
“
vairagya”
as the first step towards the necessary spiritual growth. The
term means that all attachment and possessions are transient, and we
have to recognize their transitory nature (Manisha & Ajay, 2019).
Someone with
“vairagya”,
if taken to the health care system would most
likely be diagnosed as suffering from depression and given
psychotropic medications based on the current mhGAP training, while
within the cultures, it is not seen as a MH problem.
Unfortunately, even local MH experts tend to rely too much on
the training they receive from theories and practices based on western
literatures, and, feeling “very knowledgeable”, tend to forget – or
ignore – the local context and meaning-making as “superstition” and
“irrational beliefs'' the communities have. When the first author started
his career in helping survivors of torture in his native country, based
on his training, he approached clients with the Post Traumatic Stress
Disorder (PTSD) model of normalization, stabilization and
psychoeducation of trauma and the offer of trauma re-processing.
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Patients did not want to pursue further because it did not resonate with
their explanatory model, and the therapist was not curious to ask for it,
because he felt he knew both the cause and the solution for it based on
his knowledge of the trauma-treatment model.
Reading Kleinman’s viewpoints (Kleinman, 1978) brought a shift
when explanatory models (emic) of patients’ experience and their
meaning-making was explored. For example, a torture survivor, when
probed, would typically state
Because of last year’s torture my blood vessels are broken,
causing my leg to hurt. I will probably die because of my
broken blood vessels. I am weak, I cannot work, and I am
therefore useless. People in my village look down on me,
because I am weak, and because I do not work. “I traveled here
to get pills for my broken vessels. The pills will heal my vessels,
but I will remain weak (Van Ommeren et al., 2002 p. 271).
On further probing, he could explain that all this calamity
happened to him because of being disrespectful to the gods when he
was younger by urinating near the temple. The treatment included
pain medications, re-attribution and psychoeducation, and finding
solutions to go to the temple ‘Pashupatinath’ in the capital where he
believed he could ask for forgiveness from the gods, and receive
ablution in the holy river of the temple.
Kohrt and Harper (2008) wrote that the Nepali society divides
psychological and MH issues into two parts -
maan
(heart-mind) and
dimaag
(brain-mind).
Dimaag
(brain-mind) is associated with
thoughts and
man
(heart-mind) with emotions. In Nepali society,
people believe that mental illness (brain-mind) is contagious;
communities refrain from renting houses from or marrying someone
with family members suffering from mental illness. Nepali society
stigmatizes a person having MH problems; in contrast, a dysfunctional
person with
maan
(heart-mind) related problems is not.
Studies in Nepal and Sri Lanka on the needs of the families of
missing persons showed that the families interviewed by the
International Committee of the Red Cross (ICRC) were not ready to
205
receive counseling services, as counseling services were understood as
services for people with mental illness (stigmatizing). Families
expressed that they would like to share with others like them, and
participate in group commemorative events in relation to their missing
relatives (ICRC, 2016; Robbins, 2008)
In the study of Beiser et al., (2003) on help-seeking behaviors of
Tamil people affected by war, out of 1110 surveyed in Toronto, 38%
believed that their problem would go away in time; 27.3% were
confident of solving their problem on their own; 22% believed that the
available support does not help them; 17.7% expressed potential
discrimination by others if they went for treatment; and 15.5%
believed that seeking help at this point of time would not help them
based on their consultation with an astrologer. Even after two decades,
the perception of Tamil communities living in Canada with advanced
MH services had not changed. Manifestations of war trauma were
discussed at an interpersonal and collective level and were not
perceived as pathological and needing treatment. Diagnostic
categories, including post-traumatic stress disorder (PTSD), did not
appear to fully capture the breadth of war trauma for Tamils
(Kanagaratnam et al., 2020).
Summerfield (2008) challenged the approach of assessment and
diagnostic process of mental illness, and treatment protocols developed
in the west and their application in LMICs. He argued, the diagnostic
manuals on MH practice brought from the west are ‘descriptive
syndromes not disease’, the presented categories are not globally valid,
and perceived MH problems are merely the reaction to their hardships
and conditions of living rather than any illnesses as categorized in the
west. There is a need to look at the anthropological, social and
linguistic dimensions of mental illness before bringing the treatment
protocols and assessment scales developed in other contexts in LMICs
(Poudyal et al., 2009).
A review of Patel et al., (2018) illustrated that over 80% of people
with mental illnesses in India and China have not sought treatment,
even though both countries have embedded MH services in their
public health system. Marsella and Christopher (2004) have emphasized
206
the relevance of the elements of local culture in the assessment and
treatment process and encouraged the applications of indigenous
services. ‘Virtually all cultures have therapeutic systems that reflect their
particular worldview and values (p. 532).’ The evidence of outcomes
on task shifting interventions are observed. However, such efforts are
on a low scale, limited to a small number of LMICs and have a limited
transformation from program level to systemic approaches (Weinmann
& Koesters, 2016). Socio-cultural nuances remain a fundamental
challenge to address because the concept, understanding, and help-
seeking behaviors of people with MH problems in the LMICs differ
from high income countries (Adhikari, 2019; Petersen et al., 2017).
Challenges in the selection of Paraprofessionals for the role of Task
Shifting. Non-MH personnel selected for task shifting are typically
from: a) health care facilities, and b) community-based service
providers. Below, the authors outline some of the challenges on the
selection and retention of paraprofessionals from these two sectors.
Health Workers.
Both research and aid agencies supporting
MHPSS programming at the health care facilities typically rely on
existing health workers (doctors, nurses) to take on the additional task
of providing MH services. At face value, this approach looks logical. It
poses several problems, however. First, as mentioned earlier, health
workers already have an enormous caseload, and allocate less than ten
minutes per patient. Second, not all the trained health workers are
interested in providing psychological and psychiatric care. The
provision of psychological care requires time, readiness, and
commitment on the part of the service provider. When this is not the
case, the majority will quickly resort to prescribing psychotropic
medications with some advice, resulting in possible misdiagnosis, over
diagnosis, over prescription or under prescription.
Community Level Workers.
In the selection of community level
service providers, institutions have reported selecting lay people with
some basic level of education, good interpersonal skills, attitude and
motivation to help others and who have time to function as counsellors
(Murray et al., 2011; Larson-Stoa et al., 2015; Andersen et al., 2020;
ICRC, 2016). Andersen et al., (2020) provide a successful example of
207
recruiting “peer counsellors” from the victims group themselves. One
common factor in all of these is that these lay counsellors have a defined
and designated role to function as counsellors, and they receive
monetary incentive to sustain them.
Teachers, community and religious leaders, traditional birth
attendants etc., will have pre-existing roles and tasks and will not be
able to allocate the time required to provide psychological services. At
best they can be utilized for community awareness raising activities,
identification and referrals, and to provide basic PFA in their pre-
existing roles. In contexts where the ministry of social services and
welfare is active, the approach of allocating a special role as with the
health care facilities mentioned above can be espoused.
Challenges in Training, Supervision, and Capacity Building. After
a disaster, there is a trend of proliferation of well-intentioned western
psychologists wanting to go to help for the short-term. This does not
help the humanitarian context. Without living in the context, and
understanding the social, cultural, linguistic intricacies that form the
world view and the ‘emic’ of the population, it is not possible to design
a comprehensive psychological intervention in order to fill the most
needed gaps. Brief training programs, without rigorous supervision,
mentoring and monitoring do not bring behavioral change (Beidas &
Kendall, 2010; Murray et al., 2014). Interventions by expatriate
psychologists need to be invested in longer term engagement with
local MH experts to function as supervisors (Murray et al., 2011). Many
organizations have expatriates who are MHPSS experts living on-site
to implement their MHPSS programs. They are retained until the
national staff can confidently implement a quality program on their
own. This practice should be encouraged.
The training and implementation of mhGAP in LMICs has not
addressed the contextual and cultural factors relating to the MH
treatment (Faregh et al., 2019). Faregh et al., (2019) a discussed on the
importance of integrating local cultural knowledge in training, address
biases, stigma, and beliefs related to mental illness, and develop a
framework with a strong cultural and contextual knowledge in
assessment, treatment, and addressing problems related to social-
208
cultural predicaments. Focusing the training solely on the broad
category of symptoms illustrated in the mhGAP handbook, challenges
with misdiagnosis, over-diagnosis and over-prescription will exist,
especially if there is a lack of adequate supervision. Moreover, many
training programs are designed as presentations and didactic lectures.
This limits the opportunity for experiential learning. Contemporary
research have suggested the inclusion of appropriate communication
skills (Egan, 2013; Ivey, Ivey, & Zalaquett, 2013), and understanding
explanatory models (Kleinman 1978), deconstruction of psychological
jargon into simplified local language, and pragmatic and solution-
focused intervention guidelines (Kohrt and Bhardwaj, 2019) in the
training of paraprofessionals. Experiencing the process of therapy itself
allows the learner to understand the logic of the intervention, to have
a mutual and respectful feedback in the learning process, to experience
how the intervention works, and thus to have a greater opportunity to
learn through practice (Andersen et al., 2020; Van Der Veer, 2006).
Van Ommeren et al., (2001), Jordan (2002), Jordans et al., (2003), and
Murray et al., (2011) have also outlined very good examples of such
training and supervision mechanisms.
When implementing MH programs in LMICs with lay counselors,
Murray et al., (2011) stress the pertinence of having a plan for
supervision and mentoring, including support for clinical emergencies.
The lay counsellors will need additional hands-on coaching while they
begin to practice what they have learned in the training. They will not
be able to manage high risk patients such as suicide or homicide and
will need local MH specialist supervisor.
The concept of Training of Trainers (TOT) is also very common
in LMICs. This is perceived as an efficient way to have a cascading
effect. However, when the trained counsellors do not receive proper
initial training with rigorous supervision on case management, and are
expected to train others, there are deep concerns of potential harm.
Baron (2006) illustrates this with the example of what happened when
two-week trained religious leaders were declared “counsellors”: they
forced clients to tell the whole trauma narrative two years later because
they believed it was the process that would help them from “trauma”
209
and prevent PTSD. They closed their sessions with a prayer to make
the person “feel better”.
Guidelines such as ‘PM+’ and ‘Doing What Matters in Times of
Stress’ are good simple manuals, however, these manuals still lack the
basic therapeutic communications skills, and ‘emic’ aspects of
intervention that is required to bridge the gap between “western
psychological concepts” and the local experience and meaning of the
illness and suffering, and may have limitations due to this aspect in
terms of adherence to the protocol (Jordans et al., 2003; Heim & Kohrt,
2019).
Coleman et al., (2021) in their “lessons learned” in adapting the
PM+ mention that training and curriculum materials were
contextualized based on cultural considerations while maintaining
fidelity to core psychological elements of PM+. Their adaptations
predominantly focused on enhancing fit for context within existing
materials as opposed to changing core content. However, they do not
explain how local explanatory models were integrated in their
understanding of the problem and the solution (PM+ treatment). The
authors assert that training on core competencies, and cultural
competencies need to precede any training on standardized protocols
of psychological interventions.
Since many people in the midst of a disaster may be on the “move”
or be overwhelmed by the multitude of their needs, they may be unable
to adhere to multi-session oriented psychological interventions. Paul
and Van Ommeren (2013) presented a primer on SST’s potential
application in humanitarian settings. It is also important for
psychologists to be well versed in the framework of Single Session
Therapy (SST), especially if they are working in health care settings.
Based on his experience in Haiti, Guthrie (2016) has outlined a viable,
post-disaster MH intervention where continuity of access to MH
intervention may not be possible.
The pertinence of self-care, especially when it comes to lay
counsellors, should not be ignored, since it is an integral component in
any MHPSS programming. Paraprofessionals are many times from
communities that are also affected by conflict. They may be primary
210
victims themselves. Even when this is not the case, they will be exposed
to horrendous narratives from their clients. Paraprofessionals providing
counseling support in Nepal faced challenges of burnout and secondary
traumatic stress (Adhikari, 2020). An experiential learning process
during training programs does facilitate acquisition of skills in
managing distress for themselves as well. However, a mechanism needs
to be set in place for lay counsellors to have group and individual
support for the distress they will experience during this kind of work.
Challenges in Cultural Adaptation of Assessment and Screening
Tools.
For assessment of MH and psychosocial problems in non-
Western environments, it is typical for programs and researchers to
translate standard assessment tools developed in western countries and
conduct screening. Field practitioners often express concerns over such
methodology. The first author’s experience includes situations when
survivors of torture answered that they always have recurrent
memories of the traumatic event when screened through a translated
Harvard Trauma Questionnaire, but on further probing, the recurrent
memories were actually of loss of cattle and property, and not the
recurrent memory of the torture (Poudyal et al., 2009). This raises the
challenge of the assessment tool’s validity in the local context.
Chowdhary et al., (2014) highlighted the need for culturally and
linguistically adapted assessment tools and intervention procedures in
LMICs.
Distress detection through a standardized translated scale misses the
components associated with distress that are shared in native languages
during the assessment process in a cross-cultural context. Local
language experts tend to try to get the “correct” linguistic translation
and do not use the colloquial terms that the general population
understands better. Cork, Kaiser, and White (2019), in their systematic
review of local expressions of distress in LMICs, explored that most of
the studies mentioned their importance, however, information on the
process of generations of idioms and anthropological-cultural-
linguistic aspects of the assessment and treatment protocols were often
inadequately reported.
211
The process of translation and cultural adaptation is often
challenging. Baird, LeMaster, Harding (2016), in the process of
translation and adaptation of commonly used HSCL-25 in Nepali were
not able to find an exact meaning and word for ‘Anxiety’. Metaphors
and colloquialisms derived and narrated in English are difficult and
sometimes impossible to interpret and adapt. An item for depression in
HSCL-25, ‘feeling blue’ has no meaning and cultural understanding in
Nepali communities. Issues related to loss of sexual desire and interest
is not easy to ask unmarried people and women and girls due to sex
being a culturally inappropriate topic to talk about. “Feeling
everything is an effort,” has no exact meaning, and participants – men
and women – understood it as ‘laziness’.
Development of localized scales with the participation of the
affected communities has proven useful in LMICs through a free-
listing approach with further consultations with key informants
(Bolton & Tang, 2002; Poudyal et al., 2009). It allows for an
understanding of local idioms of distress to gain a more in-depth
understanding of local MH symptomatology. Poudyal et al., (2009)
identified several expressions of distress in Acehnese: “
Ule Mekerlep
”,
translated as ‘cockroaches running around in your head’ and “
Jantoeng
ie meu en
”, translated as “heart is playing.” The first expression meant
“having too many thoughts”, and the latter, “restlessness, anxiousness”.
Additionally, in many cultures, depression and anxiety are not separate
silo concepts as recommended in the ICD 10 or DSM-5. In LMICs,
there is comorbidity and communities merge the two with overlapping
symptoms (Poudyal et al., 2009).
Medically unexplained illnesses, possession disorders, culture-
bound syndromes are associated with common beliefs, and local
cultures attribute the illness differently from the “disease model”. Fear
of possession and associated fear of dying expressed by the Bhutanese
refugees suffering from a mass psychogenic fainting probably led them
to the state of hyperventilation, fainting, and altered states of
consciousness (Van Ommeren et al., 2001). The current mhGAP
training misses these elements. The authors have witnessed people with
212
this kind of psychogenic fainting being mis-diagnosed as having
epilepsy and receiving prescriptions.
Recommendations
Task shifting and services to people by non-specialists are an
alternative solution due to lack of MH professionals for MH services in
LMICs, thus resources need to be allocated. Community-based
interventions are the foundations to address the demand for care; and
greater coordination is required for a cross-referral system between the
community and MH specialists for a comprehensive scaling up. Based
on the challenges explained earlier, the authors propose
recommendations to be considered when implementing MHPSS
programs through task shifting in LMICs in the following section,
Multi-sectorial Needs
People in humanitarian settings, not only have MH needs. They
have multi-sectoral needs that may include food, shelter, protection,
healthcare, and economic/livelihood support, support for education
etc. These basic supports are generally dealt by the government or
non-governmental organizations. Information on where these services
are, and how to access them are confusing to many people who are
suffering, especially with MH problems.
The authors present an inverted Inter-Agency Standing
Committee (IASC) pyramid for MHPSS support with examples of
different activities/interventions to propose the role of MHPSS
paraprofessionals. The community-based paraprofessionals need to be
trained to map resources so they are able to refer and accompany their
clients as needed to the various services available in the area. In other
words, a paraprofessional (lay counselors) who fills the gap in providing
psychological interventions, will also need to function as a social
worker and have a double role in LMICs.
213
The MH paraprofessionals need to be additionally trained to map
available resources, facilitate referrals, and have advocacy skills. As
“talking cure” is not socialized or understood and accepted; the
counselor is rather seen as a “helpful person” in most LMICs (Poudyal,
1999). This additional support of listening to other needs, and
providing information and referral services to the people in need of
assistance, not only provides a more tangible, necessary, and
understood support (as expected from a helper), it also allows for a
better relationship of trust, and thus a likelihood for adherence to the
MHPSS intervention provided by the “helper” paraprofessional.
Inclusive Focus on Culturally Adapted Psychological Interventions
1) There is a need to consider the importance of anthropological,
social and linguistic dimensions of mental illness before implementing
treatment protocols developed in HICs.
2) Tailored interventions need to report detailed processes and
methodology of the intervention, cost-effectiveness, and delivery
process of the treatment (such as, whom, what, where, how long, by
whom, and how) for further references for replication.
3) Although the biomedical approach is important, it can be
harmful to patients if it is implemented as the sole intervention without
a comprehensive integration of tailored psychological and other
support systems.
214
4) The role of family members, peers, social and religious leaders
in the healing process need to receive further attention and even be
actively mobilized.
Selection of Paraprofessionals for the role of Task Shifting
1) In the health sector, a separate profile with a clear job description
of a MH care provider, including supervision and accountability
mechanisms, need to be established. This will entail discussions and
buy-in from the local administration hierarchy of the health facilities
and might even entail providing an incentive or salary for a certain
period if a new recruitment is required (since they might not have the
budget).
2) Community workers with pre-existing roles cannot have the
time to provide sustainable psychological support. At best, they can be
utilized for PFA, identification and referrals. More investment needs to
be made into getting designated “counsellors” who are interested in
helping people. Cutting corners with financing by taking on people
with pre-existing roles will also result in cutting corners when it comes
to delivery of services.
3) Attitudes and motivation of care providers need to be given due
consideration.
Training, Supervision and Capacity building
1) Brief training by “flying experts” with experience working only
in western contexts, without a comprehensively integrated follow up
coaching and supervision mechanism with full time, trained and
designated local MH experts need to be discouraged. The approach
should be to build the capacity of local MH clinicians.
2) Brief two to three days of training without skills on core
competencies need to be discouraged in order to prevent potential
harm.
3) Training needs to be contextualized, skills-based, and
experiential with practical intervention guidelines for individualized
and group support. The contents should deconstruct psychological
215
jargon into simplified local language; proverbs, metaphors and parables
help.
4) Regular supervision, mentoring, monitoring, and evaluation of
interventions are required to increase the evidence-base of
contextualized culturally blended MHPSS services.
5) Training on mhGAP needs to allocate more time on
communication skills, emic, and include only health workers who are
interested and willing to be the focal MH service providers, with an
integrated follow up, coaching and supervision mechanism.
6). Training should also include the screening tools, monitoring
processes, treatment outcomes measurement mechanisms and follow
up processes of the person receiving support.
7) Training should include the referral process and record keeping
of both vertical (advance mental health care) and horizontal (other
basic, administrative, assistance related or social support needs).
8) Training of Trainers (TOT) should only be pursued when the
initially trained counsellors have completed certain hours of
counselling work under supervision. Continuous
learning/developments to update their knowledge should be the part
of the entire process if any ToT process is followed.
9) Include the framework of Single Session Therapy (SST),
especially if working in health care settings or work during post-
emergencies.
10) Care for care providers and mechanisms for experiential
learning that facilitates acquisition of skills in managing with distress
for themselves needs to be integrated in any MH program, in addition
mechanism needs to be put in place for lay counsellors to have group
and individual support for the distress they experience.
Cultural adaptation, translation and contextualization of tools
1) If any existing tools are to be used in a new context, the process of
translation and cultural adaptation of standardized tools needs to
be guided by local psychologists and focused on content
translation in easily understood local terminology. Translation,
216
back translation, feedback from experts and piloting with the
targeted population is essential before deployment (Heim &
Kohrt, 2019; Baird et al., 2016).
2) The entire process of this adaptation: consultation, discussions,
gaps, challenges, limitations and psychometric properties need to
be well documented and disseminated for future references so that
it can be replicated.
3) The development of localized scales with the participation of the
affected communities needs to be promoted. It not only provides
a locally valid tool, but also informs the intervention choice and
design (Poudyal et.al, 2009).
Conclusion
Over the years in LMICs, the MH Psychosocial Support (MHPSS)
sector has invested to reduce the treatment gap and address MH
problems through community-based and primary health
structures. The extensive work of task shifting requires increasing
numbers of lay and trained MH professionals representing socio-
cultural-linguistic diversity; mandatory supervision at community and
primary care settings; and adequate training with proper compensation
for sustainability (Mendenhall et al., 2014). The non-governmental
MHPSS actors will need to fill the gap for the third tier of the Inter-
Agency Standing Committee (IASC) pyramid (psychological support)
until governments can integrate such services. Training needs to be
contextualized, skills-based, and experiential with practical
intervention guidelines for individualized and group support with
integrated supervision mechanisms. As also stated by (Kohrt &
Bhardwaj, 2019; Patel et al., 2018; Scheffler & WHO, 2011; Singla et
al., 2017), LMICs requires more investment; more training with
sustainable supervision; de-stigmatization of mental illnesses through
public awareness; and concerted efforts to enhance the productivity of
MH workers.
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