Scalable Psychological Programmes (Stepped care)
Given the predicted increase in mental health problems due to the pandemic, any response needs to be highly scalable and able to address the needs of many people in a way that maximises the use of resources. The World Health Organization (WHO) has developed a number of scalable psychological interventions for populations affected by adversity.
A core feature is that all WHO scalable interventions are based on task-shifting, which means that they can be taught to and delivered by non-professional helpers, such as a trained peer, or helper at the workplace, or a psychosocial worker. They have also been designed to be widely applicable to a variety of mental health problems (depression, anxiety and PTSD) and easily adaptable to different populations, cultures and languages. Finally, the interventions and their implementation materials are open access.
Two evidence-based psychological interventions are to be employed in RESPOND:
Doing What Matters in Times of Stress (DWM)
DWM is an illustrated self-help stress management guide that is one part of Self-Help Plus (SH+), a WHO group stress management course. The DWM book can be delivered as a guided self-help intervention with support from a briefly trained non-specialised helper. It is based on acceptance and commitment therapy (ACT), a modern form of cognitive-behavioural therapy with a strong focus on mindfulness practices and includes exercises which aim to enhance stress reduction and build social support, adaptive coping and resilience. It has been implemented with different populations of refugees in Europe, Turkey and Northern Uganda.
Problem Management Plus (PM+)
PM+ is a 5-session programme suitable for various disorders that reduces symptoms of depression, anxiety, PTSD, and related conditions, is delivered by trained non-specialized workers or lay people, and is available in individual and group delivery formats for face-to-face delivery. It comprises evidence-based techniques: of (a) problem solving, (b) stress management, (c) behavioural activation, and (d) accessing social support. PM+ has been successfully implemented in Kenya and Pakistan.
Do the programmes work?
The programmes draw upon well-known and evidence-based strategies: problem solving counselling combined with selected cognitive-behavioural (PM+) and mindfulness (DWM) techniques. In combining these strategies, the programmes address both psychological problems (for example, stress, fear, feelings of helplessness) and, where possible, underlying practical problems (for example, livelihood problems, conflict in the family and so on).
All modules have undergone rigorous testing under real conditions by academic researchers to make sure that they work and are safe.
The RESPOND project goes a step further by combining DWM and PM+ into a stepped-care program, and looking at the effectiveness when implemented to high-risk groups affected by the COVID-19 pandemic.
DWM and PM+ are “scalable” interventions. What does that mean and why use scalable interventions?
Interventions can be described as being scalable when they are able to reach more people at lower cost. Globally, the majority of people who experience a mental disorder at some point in their lives do not have access to evidence-based treatment. Scalable psychological interventions are aimed at reducing this treatment gap. Scalable psychological interventions share a number of core features: they are evidence-based, relatively brief, deliverable by a non-specialist workforce, culturally and contextually adaptable, affordable, feasible in a range of contexts, potentially incorporate technology (e.g. online or pre-recorded self-help), and cost-effective.
Why use a stepped care program?
Stepped care is a staged approach to the delivery of mental health services. The most effective but least resource intensive approach is first offered before ‘stepping up’ to more intensive forms of care only if clinically required. Stepped-care models are evidence-based and have been shown to be cost-effective alternatives to conventional care for common mental health symptoms.
In the RESPONSE project scalable psychological interventions are combined in a stepped care approach. Individuals are first provided with DWM consisting of guided self-help in the form of the stress management guide, with brief motivational support from a trained helper. People requiring further help at the end of this are then offered the second step (PM+), providing in-depth engagement from a trained helper, to strengthen coping strategies which are specifically targeted to the individual problems of the person, including behavioural activation, problem-solving and social support, as well as strengthening relaxation techniques learned during the DWM intervention.