Taking evidence-based assessments and treatments to LAMIC Laura K. Murray, Ph.D.

1. Do not replicate without permission Taking evidence-based assessments and treatments to LAMIC Laura K. Murray, Ph.D. Asst. Prof.; Clinical Psychologist Applied Mental Health Research Group Johns Hopkins Bloomberg School of Public Health

2. Do not replicate without permission APPLIED MENTAL HEALTH RESEARCH GROUP Johns Hopkins University Depts. International Health and Mental Health

3. Do not replicate without permission Challenges around... How to build up knowledge about needs and effective interventions across cultures and populations?

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5. Design, Implementation, Monitoring, and Evaluation Approach (DIME) • Overcome these challenges through a single integrated process of DIME • Have service organizations conduct applied evaluations as part of programming. • Services agencies will generate the evidence base for both needs and effective interventions. • Aid service agency reporting. • Produce more meaningful outcome indicators for funders/stakeholders. Do not replicate without permission

6. 1. Qualitative Study 5. Validate Instrument 2. Nature of priority problems 6. Study Baseline 3. Draft Instrument 7. Program Intervention 4. Translate Instrument 8. Post Assessment Do not replicate without permission

7. Qualitative Methods • Information from the local perspective • Learn local mental health concepts and local priority issues • Use this information to develop the quantitative tools • Use this information to identify appropriate interventions Do not replicate without permission

8. Qualitative Results…how they guide • Local populations clearly indicate presence of traumatic experiences. • Child sexual abuse (defilement) was one of the most frequently mentioned traumas and closely linked to HIV/AIDS • Discussions with Zambians indicated that: • No evidence-based mental health assessment tools existed • Basic counseling was highly varied • Lack of services for more symptomatic youth • Programs existed for adults, but not for youth. Do not replicate without permission

9. 1. Qualitative Study 5. Validate Instrument 2. Nature of priority problems 6. Study Baseline 3. Draft Instrument 7. Program Intervention 4. Translate Instrument 8. Post Assessment Do not replicate without permission

10. Process of selection, adaptation, translation and testing of instruments/tools • Necessary step because: • How mental health problems are expressed is likely to vary across cultures • Accuracy likely to vary across cultures • Prevalence estimates and statistics • Understanding of burden of disease • Measuring outcome indicators • Relates to amount of funding set aside • Based on ‘Diagnosis’ by local people using locally-defined syndromes • Currently no validated mental health assessment tools in most LMIC Do not replicate without permission

11. Examples: piloting and validity testing • Validation of 4 measures in Zambia • Trauma, Shame and SDQ for youth • CBCL for caregivers • Showed strong validity, including the local items • Validation of the Harvard Trauma Questionnaire and Hopkins Depression Scale in Northern Iraq with Victims of Torture Acknowledgements: NIMH, USAID VTF Fund Do not replicate without permission

12. Pilot project: Integration of MH into HIV Hospices in Zambia Sample of information the tools yielded for NGO Project Participants: • Total sample 335 * Average age: 11.9 years • Females: 53.1% * Males: 46.8% • Currently in school :75.4% • 99.7% of the entire sample reported experiencing at least 1 trauma • 58.9% of those assessed met “criteria” for TF-CBT • Those that reported sexual abuse had higher PTSD and Shame scores Do not replicate without permission

13. 1. Qualitative Study 5. Validate Instrument 2. Nature of priority problems 6. Study Baseline 3. Draft Instrument 7. Program Intervention 4. Translate Instrument 8. Post Assessment Do not replicate without permission

14. Assessment/Triage Phase: Use of evidence-based locally validated assessment tools Referral to HIV Treatment, Medical Services, Drug/Alcohol Services and/or Psychosocial Services Limited Needs: Support Groups Counseling No Immediate Psychosocial Needs: No services Significant Needs: Therapy Do not replicate without permission

15. Current state of service provision • Based on knowledge and experience of service providers, little local input. • Psychosocial programming almost exclusively social. • ‘Counseling’ – generally not well-defined, manualized, or monitored • Some organizations are providing more specific services (i.e. COOPI, World Vision, IRC) but not being evaluated Do not replicate without permission

16. There are promising interventions… • Evidence-based treatment research from the West • A variety of psychotherapeutic models (CBT, IPT, BA) and pharmaceuticals • Many are highly adaptable to low resource contexts. • Psychosocial services for non-specific outcomes • i.e. psycho-education and de-stigmatization programs, programs that reduce social isolation, self-help groups Do not replicate without permission

17. Qualitative results provide guidance. Collaborative process with locals – What is already being done; where is the need? Start with evidence-based Adapt for culture/Structure with flexibility Choosing an Intervention Do not replicate without permission

18. Why start with Evidence-Based Treatments? • Literature strongly suggests that EBTs are more effective than non-specific programs. • Why re-invent the wheel? • Research is showing that cultural modifications are minor. • Growing research demonstrating implementation success of EBTs. Do not replicate without permission

19. Examples: Interventions/Programs AMHR is evaluating • Trauma-Focused CBT (children/youth) • Sex-Trafficked youth in Cambodia • Abused/trauma, HIV-affected, community populations in Zambia • Interpersonal Therapy for Depression • Adolescents, Northern Uganda • Superior to Psychosocial program • Adults, Southern Uganda • Cognitive Processing Therapy (CPT) • Northern and Southern Iraq • Eastern DRC • Behavioral Activation (BA) • Northern Iraq • Components-Based Intervention (CBI) • Southern Iraq • Thailand/Burma border Do not replicate without permission

20. Why Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in Zambia? • Hybrid model • Over 10 randomized controlled trials • Used with youth 3-18 years • Adapted and shown effective across different cultures • Current use of CBT here in Zambia, showing good results • Effective for multiple types of trauma histories: • Sexual Abuse Domestic Violence • Physical Abuse Traumatic Grief • Post-disaster Community Violence Do not replicate without permission

21. EXTENSIVE LITERATURE SHOWS THAT TF-CBT… • Helps reduce: • Mental health symptoms • Relationships (caregiver child/social support) • Mitigate the violence cycle • HIV risk-related behaviors (e.g., sexualized behaviors, interpersonal/social skills) • Prevention of adult mental health problems commonly found in those that were sexually abused as a child: • Drug and/or Alcohol use and/or abuse • Violent relationships • Depression Do not replicate without permission

22. Do not replicate without permission OVERVIEW OF TRAUMA FOCUSED-COGNITIVE BEHAVIORAL THERAPY (TF-CBT) Developers: Judith Cohen, Anthony Mannarino & Esther Deblinger www.musc.edu/tfcbt

23. What is TF-CBT? A hybrid treatment model that integrates: • Trauma sensitive interventions • Cognitive-behavioral principles • Attachment theory • Developmental Neurobiology • Family Therapy • Empowerment Therapy • Humanistic Therapy Do not replicate without permission

24. Treatment Research for TF-CBT • Trauma-Focused CBT is currently the most rigorously tested treatment for abused children • Over 10 randomized trials • Improves PTSD, depression, anxiety, shame and behavior problems compared to supportive treatments • PTSD improved more with direct child treatment • Improved parental distress, parental support, and parental depression compared to supportive treatment Do not replicate without permission

25. TF-CBT Skills • PRACTICE • Psychoeducation and Parenting Skills • Relaxation • Affective Modulation • Cognitive Processing • Trauma Narrative • In Vivo Desensitization • Conjoint parent-child sessions • Enhancing safety and social skills Do not replicate without permission

26. What does TF-CBT involve? • Psychoeducation. The child/youth and parent/caregiver learn about traumatic stress, typical reactions, why they happen, and what is involved in the therapy. • Emotion regulation. The child/youth and parent/caregiver identify typical trauma-related emotions and learn specific skills to handle these negative emotions in constructive ways. • Correcting unhelpful thoughts. The child/youth and parent/caregiver identify unhelpful trauma-related thoughts/beliefs such as: “this is all my fault”; “I am not worth anything”. They learn more accurate and helpful ways to think about what happened. • Trauma narrative. The therapist helps the child/youth to talk about what happened in a slow, safe way. This allows the child and family to stop avoiding the trauma and learn how to handle trauma reminders. • Positive parenting. The therapist will help them learn to handle the child/youth’s difficult to manage behaviors and behaviors that interfere with family relationships. Do not replicate without permission

27. TF-CBT Training:Apprenticeship Model Supervisory Training • 3 TF-CBT therapists trained as “leaders” • Co-led supervision groups • Attended training 2 hours/week • Therapist training: • 39 Zambians (2 cohorts) • 8 day live training • Small groups for 4 hrs/month • Local supervision and feedback Do not replicate without permission

28. Supervision of TF-CBT • 3 local “leaders” identified • The more “skilled” during the training • Conducted supervision groups • 1x per week with 6-7 counselors • Followed agenda prepared by trainer • Had weekly calls with the trainer • Each leader paired with a supervisor for support and overall clinical issues (suicide, legal...etc.) • Built for sustainability in the future Do not replicate without permission

29. Examples of Cultural Adaptations • Local languages: tribal languages more simple • Trauma narratives done in pictures • Markers/Colors become sticks/plants/rocks • Witchcraft/Spirits and cognitive restructuring • Bread-winning often prioritized over safety so extensive safety plans were developed when sending kids home Do not replicate without permission

30. Quotes from Zambian Therapists • “Thanks for giving us skills to truly help children!” • “It is easier to know what we might need to adapt after learning the model as it should be…then let us see what works with our kids.” • “We have had to work religion and witchcraft beliefs into the T part of the triangle.” Do not replicate without permission

31. Findings from Zambia Feasibility Study • Overall receptiveness from local counselors • Strong feeling that the local counselors need to know the model themselves first, then they can modify. • Cultural modifications are minimal; more in implementation rather than concepts • Practice-practice-practice…this is the way to learn. The Apprenticeship Model. • Families are positive about TF-CBT • Need ongoing close supervision • Clear need for this type of trauma program Do not replicate without permission

32. Findings from Zambia Pilot Project • Trauma/Violence IS an issue that needs to be addressed. • 99.7% of the entire sample reported experiencing at least 1 trauma • 58.9% of those assessed met “criteria” for TF-CBT • The problem extends to boys and girls • There is a significant lack of services. Do not replicate without permission

33. Evaluations as Controlled Trials • Uses wait-list control model for comparison • Acceptable to service providers and populations because consistent with their normal program experiences • Allows for continuing improvement of services based on initial results Do not replicate without permission

34. Example from Northern Uganda • 3-armed RCT of two different interventions for depression problems among adolescents living in IDP camps • Collaboration between World Vision and War Child • Allowed us to compare a psychological approach (IPT) with a psychosocial approach (play and activities) Do not replicate without permission

35. Training and Service Providers • Interpersonal Psychotherapy in Groups (IPT-G) • US-Based trainer: 2-week live training • 2 Ugandan supervisors previously trained in IPT-G • Local counselors; all had at least a HS education • Creative Play (CP) • Already being implemented by local NGO • Training and supervision provided by NGO staff • Local facilitators; all had at least a HS education Do not replicate without permission

36. Reduction of depression symptoms by group Depression Symptom Scores Do not replicate without permission

37. N. Uganda RCT Conclusions • IPT-G effective in reducing depression severity - particularly girls • CP model not effective in reducing depression • Psychological interventions based on Western-models can be feasible and efficacious when adapted locally. • Starting to identify what works/what does not work • Evidence from Indonesia indicates problem solving program alone did not reduce symptoms either Do not replicate without permission

38. Summary • Integration of Mental health into existing infrastructures and points of entry… • Is Feasible • Allows for Community-based work • Increases access to services • Able to train people with limited to no mental health background to treat trauma/violence • Supervision and M&E processes are critical Do not replicate without permission

39. CHALLENGES SOLUTIONS Do not replicate without permission

40. Current thinking… • Evidence from developed countries and our experience tells us current methods of dissemination will not be feasible. • Solution: Use of Components-Based Intervention approach Do not replicate without permission

41. What is Components-Based Treatment? • Based on the fact that most evidence-based mental health treatments (EBTs) (most of which are cognitive behavioral) are made of similar components. • Train counselors in a range of different components that are similar across EBTs, and then teach them how to choose different “flows” of components based on a client’s presenting problems. • CBI is NOT a new treatment but instead is a new way of teaching counselors how to treat multiple problems with the same components that have already been shown to be effective. Do not replicate without permission

42. What is CBI made of? • Encouraging Participation (Engagement) • Psychoeducation • Cognitive Coping (linking thoughts, feelings, behaviors) • Exposure (imaginal or live) • Cognitive Restructuring • Behavioral Activation • Relaxation • Safety Do not replicate without permission

43. A sample “flow” of CBI Do not replicate without permission

44. Summary • Mental Health is a significant but neglected issue in international development. • Rigorous needs and impact assessments are feasible in the program context. • These methods are critical since solid outputs are often lacking. • Results using these method so far suggest that psychological interventions based on Western-models can be feasible and efficacious when adapted to local problems and conditions. • CBT in particular is showing strong evidence across all our studies • Policy – Use of evidence-based practices makes sense as a starting point. Do not replicate without permission

45. Contact Information JHU Applied Mental Health Research Group Laura Murray: lamurray@jhsph.edu Paul Bolton: pbolton@jhsph.edu Judy Bass: jbass@jhsph.edu Do not replicate without permission

46. Acknowledgements USAID Victims of Torture and Displaced Children’s and Orphans Funds for supporting the development and dissemination of these methods NIH and CDC for supporting the Zambia, Kinshasa DRC and ongoing Brazil work World Vision and War Child for providing financial and logistical support the Uganda trials Do not replicate without permission