Chapter 2. Review of literature
2.4 Mechanisms of change in task-shared interventions
30 In recognition of the need for localised adaptation of interventions, Bolton (2019) recommended following seven steps for adaptation:
1) Preliminary understanding of local priority mental problems 2) Selection of treatment approach
3) Conversion of manual and training materials into simple language 4) Translation of the manual and training materials into local language 5) On-site provider training
6) Piloting
7) On-going adaptation
Following these steps may be extremely helpful for interventions to be more responsive to need, address the need correctly, experience less attrition, attain better outcomes, and be more sustainable for scale up into the greater community.
In conclusion, there are many elements that need to be considered for task sharing to be appropriate and acceptable to local populations, as well as feasible for scale-up and long-term sustainability. It is increasingly acknowledged that in-depth consultation and co-development of interventions with CHWs and service users is essential. This would consider the socio-political context in which the population is situated and assist in responding to identified needs, ultimately leading to improved treatment outcomes.
31 strongest associations with treatment outcome. This analysis heads in the valuable direction of identifying the actual elements or mechanisms of effective treatment. The review included 27 task-shared interventions in LMICs. They found that the strongest associations were with the following therapeutic elements:
1) interpersonal elements (β = 0.442, p = 0.029). These were: identifying or eliciting social support, communication skills, assessing relationships
2) emotional elements (β = 0.415, p = 0.046): identifying/eliciting affect, linking affect to events, emotional regulation, emotional processing, and
3) nonspecific (engagement) elements (β = 0.409, p = 0.052): collaboration, empathy, active listening, normalisation, involvement of significant other.
Research conducted by Jordans et al. (2012) with children in Burundi found that it was the use of particular treatment mechanisms by the counsellors that predicted positive changes in depression and anxiety, rather than through a specific treatment modality. The authors identified five treatment mechanisms associated with outcome trajectories, being client centeredness, therapeutic alliance, active problem solving, trauma focused exposure, and family involvement. Interestingly, although there were issues with translating Western-oriented psychotherapeutic concepts into a culturally different context, there were still therapeutic elements or
‘working mechanisms’ that lead to the reported therapeutic effects.
Although North America-based, Norcross and Lambert (2018) identified the most ‘demonstrably effective’
elements in therapy through their ‘Task Force on Evidence-Based Relationships and Responsiveness’. These elements were collaboration, goal consensus, cohesion in group therapy, empathy, therapeutic alliance, positive regard and affirmation, and collecting and delivering client feedback. These endorse those found by Singla et al. (2017), even though they were not from task-shared situations.
2.4.2 Therapeutic alliance
As a therapeutic element, the therapeutic alliance may be the most important factor for treatment effectiveness, and is a necessary target of therapy (Cuijpers, 2019, p. 281). This alliance involves the bond between the therapist and client, agreement about the goals of therapy, and agreement about the tasks of therapy (Wampold, 2015), or the “collaborative nature of the patient-therapist interaction, their agreement on goals, and the personal bond that emerges in treatment” (Kazdin, 2009, p. 420).
Many authors further confirm that the therapeutic alliance contributes to treatment outcome independent of the type or modality of therapy (Barth, Lee et al., 2012; Norcross and Lambert, 2018; Timulak and Keogh, 2017).
32 Indeed, two of the three key effective elements identified by Singla et al. (2017) were interpersonal elements and engagement elements, both of which are core to the therapeutic relationship.
Wampold and Budge (2012) wrote that the alliance with a therapist is therapeutic because it involves a significant other who is genuinely invested in the clients’ wellbeing. Wampold later wrote that psychotherapy should provide a client with a human connection, which, if appropriate, will be health promoting and healing in itself, particularly in contexts of social isolation and insecurity. This connection could be described as attachment, belongingness, social support, or the lack of loneliness (Wampold, 2015). Within task-shared interventions in LMICs, Mayston et al. (2020) reported that many studies emphasised the therapeutic effects of connection with others, and that through being able to share problems, participants were able to heal and experience the preventative effects of social interaction.
2.4.3 Common elements
Researchers are now acknowledging that many of these therapeutic elements span across most forms of treatment or therapeutic modality and refer to them as common elements or common factors. These are described differently by different scholars, but in the main, relate to the therapeutic relationship established between client and counsellor. Warmth, empathy, genuineness, trust and rapport-building are common threads, along with other skills such as incorporating client’s expectations, using culturally appropriate concepts for distress, and promoting hope and expectations for recovery through procedures or rituals acceptable to the client (Barth et al., 2012; Cuijpers, Reijnders et al., 2019; Laska, Gurman et al., 2014; Pedersen et al., 2020).
Wampold (2015) developed the ‘Contextual Model’ of common factors, based on a large body of previous research. In this model, therapy is hypothesized to work through three pathways, following the initial establishment of a therapeutic relationship. The first pathway is the creation of the ‘real’ and personal relationship between client and therapist through connection to a caring and empathic person. This is marked by genuineness in interactions with each other. The second pathway is the creation of expectations and hope, through explanation of the disorder and its causes, what the treatment will involve, and a means to cope with problems. Wampold writes that the therapy should give clients hope that they are capable of completing the therapeutic tasks, and that when the tasks are completed, they will be able to cope with their problems. The third pathway involves the ingredients of specific therapies or health promoting actions, which would differ depending on the type of therapeutic modality. An explanation of the particular therapeutic ingredients that the client finds acceptable, should again create expectations from the client that the therapy will be helpful,
33 leading to subsequent actions toward greater mental health. In sum, Wampold argued that if the treatment elicits healthy client actions, it will be effective, no matter the treatment type.
2.4.4 Acknowledgement of clients’ background
There is also evidence of the value of acknowledging clients’ backgrounds and economic situation in low income settings, and the subsequent incorporation of practical methods to deal with problems related to this, in therapy. Two studies conducted with low-income women in the USA suggest that participants found therapy to be effective when their therapists were aware of the nature of poverty and poverty-related stressors, and had some direct exposure to poverty themselves (Pugach and Goodman, 2015; Thompson et al., 2012). In addition, both studies identified instrumental support as a key factor that participants found meaningful and which was in fact identified as an essential element of therapy. This included instances of identifying resources for food or financial support, acts of advocacy or alliance with the participant, practical support (such as searching for housing resources, provision of material items, assistance with paperwork) or referrals.
Interestingly, when therapists did not offer this kind of support, “some participants felt that the therapy seemed irrelevant to their real lives” (Pugach and Goodman, 2015, p. 413).
An example of the above was demonstrated through the process evaluation conducted by Rahman (2007), that unpacked the implementation of the THP trial in Pakistan. The study reported that because the CHWs were from the same communities as the participants and were aware of community resources, the CHWs were able to help participants in valuable practical ways. For example, one CHW motivated a participant to take out a small loan to buy a buffalo to produce milk to sell, which ultimately led to a marked improvement in self- worth, confidence, finances, and in depressive symptoms. Another CHWs set up a neighbour support group which significantly helped a socially withdrawn mother. A third CHW intervened in a participant’s experiences of IPV by speaking to the participant’s husband’s spiritual mentor who then counselled the husband, leading to a marked improvement in his behaviour (Rahman, 2007).
This example is included in full to demonstrate the relevance and value of CHWs coming from the same community as the participants. Because of their understanding of the context and insight into the available resources and support within communities, they were able to help participants practically, going beyond basic psychosocial counselling. This is a strength for task-shared interventions, and highlights that in low-income situations particularly, therapists need to treat the ‘whole person’ in their contextual system, rather than focusing exclusively on symptoms of mental illness (Thompson et al., 2012).
34 There are thus a variety of therapeutic mechanisms that can be used in task-shared interventions for perinatal and general CMDs that span across different treatment modalities. In combination with responding to contextual need and the other requirements for task sharing discussed above, these mechanisms need to be incorporated into future treatment programmes, with a prioritisation of training and competency in these elements (Jordans et al., 2012; Singla et al., 2017).