When it comes to mental health, the past two decades have resulted in multiple positive advances. Ethnographic studies have taught us about cross-cultural presentations of mental health conditions, assessments have been validated, increased awareness has begun to reduce stigma, and trials have shown the effectiveness of treatments and an ability to train lay providers.
As a result, global mental health efforts in low- and middle-income countries are growing in interest, funding, and awareness.
Thus far, most efforts have followed the mental health care systems of high-income countries that include assessing and treating based on categories. For common mental health disorders — for example, depression, post-traumatic stress disorder, or substance misuse — studied treatments have primarily focused on one problem, one level of severity, and usually one age bracket.
The silo effect
In her book “The Silo Effect,” Gillian Tett makes the case that silos have been around since the dawn of industrialization. Specialization has been a key concept in, arguably, making companies more effective and profitable by breaking down processes into smaller units, and training workers to perform highly skilled, specific tasks.
Mental health in most high-income countries follows the silo trend: Providers specialize in treating adults or children, and usually within a problem area or two. Programs are studied in trials where measured outcomes usually represent the one problem area the program was designed to address.
Globally, funders and implementers also silo off programming, for example, by testing models designed for single foci such as PTSD in adults, maternal depression, gender-based violence, or parenting skills.
While silos can have their advantages, they hinder communication, limit progress, and squash creativity. For example, an adolescent might visit a clinic for HIV care and disclose that they are depressed, that there is violence in the home, and that they have been raped. There are no scientific-based services for trauma and depression in her region, just nonspecific counseling consisting of active listening and advice giving.
Or a veteran in Iraq who watched family and friends gassed to death, and is struggling with nightmares and anger, may only be able to find evidence-based treatment for depression. Or a woman being abused at home may tell a friend she wants to kill herself. A primary contributor to the violence is substance misuse by the male and while there might be services to support the woman, there are none for substance misuse as this problem area is often segregated from other mental health care.
How to take an integrated approach to mental health care
Our team, with the support of USAID Victims of Torture Fund, developed a new approach in 2010. Our goals include: 1) lay providers could learn a single approach to treating a wide range of symptoms and problems; 2) different severities of need from mild to moderate to severe could be addressed; 3) a method of training and supervision that assures quality care to recipients with adherence over time and; 4) a measurement-based system that triages and tracks outcomes.
This resulted in the Common Elements Treatment Approach, which is conceptually different as it’s an all-encompassing system of care that eliminates many of the silos. This begins with a practical, multi-problem assessment for triage. CETA combines the most effective, well-studied elements of mental health care in a myriad ways to address a wide range of problems at low, moderate, and high severity. CETA teaches decision making so providers can assess and address mental health comorbidities and differences in severity. The system incorporates science-based processes of monitoring, evaluation, and implementation.
Our team, funders — including U.S. Agency of International Development, National Institutes of Health, U.S. Centers for Disease Control and Prevention, United Nations Development Programme, International Rescue Committee, and World Vision — and numerous implementing partners continue to be on a learning journey, striving to be open to changes in the system as challenges and successes are evaluated. Given our success across numerous health sectors, populations, and settings, we believe mental and behavioral health programs should be a part of all programming.
Some lessons we have learned include:
1. The critical need to strategically plan how the system will best work in unique contexts and settings. The idea that mental health is a quick add-on does not lead to success.
2. A choice of providers is more economical the more time they have to spend on mental/behavioral health skills.
3. Technology is able to help deliver soft-skill training, and future success in this area is important.
To date, CETA is the only model that addresses — and shows effectiveness for — such a wide number of mental and behavioral health issues including depression, trauma, interpersonal violence, substance misuse, anxiety, child problems, parenting, anger, and functioning. It also allows for a lay provider to be trained in how to work with people of all ages, simplifying the referral systems and decreasing the numbers of providers needed.
Economically, this innovation highlights the cost difference of scaling up multiple programs versus just one approach.
Are we ready to embrace change?
The ongoing COVID-19 pandemic has catapulted the entire world into ongoing change whether it be the way we work, live, or travel. Change is hard at any time, but perhaps especially now when so many other things are in flux. Or perhaps we are improving at the art of change.
The CETA system of care challenges existing ideas and processes that exist in mental health, such as diagnosing and treating one problem at a time, divided by population, and/or age group. While silos are often discussed in the context of institutions, they also exist in our own minds. One hurdle is funding silos, but powerful institutions are led by individuals who think this is the only way and continue to endorse it — or not really understand the ability of a truly multi-problem approach.
Are we ready to positively disrupt the global mental health system? We posit that reimagining and de-siloing could better help people and organizations become more innovative and solve additional barriers to effective, efficient mental and behavioral health care.
To find out more about the CETA approach, visit www.cetaglobal.org.
About the author
Dr. Laura Murray@LauraMurray_phd
Dr. Laura Murray, a clinical psychologist, is a senior scientist at Johns Hopkins Bloomberg School of Public Health. Murray has extensive expertise in a wide range of evidence-based treatments, including training, implementation, and evaluation. She has conducted evaluations ranging from qualitative understanding of mental/behavioral health, to full randomized trials of treatments all over the world, working with numerous health sectors. She has a passion for innovating new solutions to improve service quality and delivery with a systems approach. Murray publishes extensively in top journals, trains globally, regularly speaks at conferences and organizations, and consults with organizations on skills-training for stress, resilience, and leadership.
