Despite the need to disseminate effective psychological treatments, they are inherently difficult to scale up. In this overview, we describe strategies for increasing the availability of psychological treatments, which include increasing the number of therapists through task shifting, providing training via the Internet, and promoting the use of therapist-free forms of treatment delivery.
Mental disorders are common, yet even in resource-rich countries most people who have them are not receiving treatment (1). In resource-poor countries, the proportion not in treatment is even higher (1, 2). This discrepancy needs to be rectified, as reasonably effective pharmacological and psychological treatments are available for many disorders. This commentary considers strategies for increasing the availability of psychological treatments and proposes a road map for research and practice.
Increasing the Number of Therapists
The evidence supporting most psychological treatments has come from studies in which the intervention has been delivered by highly trained health care professionals (generally clinical psychologists or psychiatrists). Therapists of this type are in short supply in resource-rich countries (3); in resource-poor settings they barely exist at all. In India, for example, with its population of 1.2 billion, there are approximately 5,000 mental health professionals, the majority of whom have not been trained to deliver psychological treatments.
The worldwide shortage of therapists is being addressed in various ways. The obvious solution is to train more of them. This is the main strategy of the Improving Access to Psychological Treatments (IAPT) program being implemented across England (4). A strategy that is likely to have a far greater impact is a more contentious one: “task shifting” or “task sharing.” This strategy involves training less-qualified people, including peers, to take on tasks that have previously been undertaken by more highly qualified individuals (5). As applied to mental health interventions, task shifting is being used mainly in resource-poor settings, although it is of relevance to health care delivery everywhere. One concern about task shifting is that it risks compromising quality of care. However, studies of task-shifting in medicine and surgery indicate that this need not be the case, and the same appears to be true of psychological treatments (6).
Scaling Up Therapist Training
Both training more therapists and task shifting have the potential to increase the availability of psychological treatments. One major barrier that remains is training the therapists, be they mental health professionals of the type employed by IAPT or community health workers in rural Pakistan. The method currently used to train therapists is not scalable.
Training therapists how to implement psychological treatments typically involves three components, all of which are thought to be necessary (7–9). The first is attending an introductory workshop given by an expert in the treatment. This introduction provides an overview of the intervention and its strategies and procedures. The second component is reading written material describing the treatment. The third component is thought to be particularly important: implementing the treatment under the supervision of someone proficient in it. The first and third components are simply not scalable, least of all in the global context. Few experts are available to give workshops, and not many people are sufficiently experienced to provide supervision.
Two solutions have been proposed. The first is the “train the trainer” model, in which certain therapists are trained to be future trainers (10). This solution is nowhere near capable of training the number of therapists required worldwide, let alone in a reasonable period of time. The other solution is “web-centered training” (11), which is designed to be capable of training large numbers of therapists simultaneously. In this form of training, a specially designed training web site describes and illustrates the treatment in great detail and incorporates features to help trainees grasp key concepts and master the main procedures. Web-centered training may be used alone or accompanied by support from a nonspecialist (guided training). Thus, even with guidance, web-centered training is highly scalable. Web-centered training is currently being tested in a pilot study involving all eligible therapists across a country in Europe.
Promoting Program-Led Treatments
Even if therapist training can be successfully scaled up, therapist-led interventions will always be limited in their impact (Figure 1). It is unlikely there will ever be sufficient therapists, who are appropriately trained and distributed, to meet the needs of individuals with detected mental disorders. Moreover, therapist-led interventions will never reach those who do not seek help. How can psychological treatments benefit them?
FIGURE 1.Forms of Treatment Delivery and Their Influence on the Availability of a Psychological Treatment
The answer may lie in the development and promotion of “program-led” forms of treatment, in which the intervention is delivered by the program itself rather than by a therapist. These therapist-free interventions involve self-help (i.e., individuals treating themselves) and thus there is no need for them to present for treatment. Self-help versions of many of the evidence-based psychological treatments are available, and some have good evidence to support them (12, 13). Until recently, these treatments have been delivered in the form of self-help books, but increasingly they are being provided via the Internet. These two forms of delivery have their pros and cons. Printed material is potentially accessible everywhere, whereas online treatments have more limited penetration, even in resource-rich countries, although this is changing fast. What is particularly attractive about the online mode of delivery (web-centered treatment) is the fact that the treatment can be personalized to match the characteristics of the individual and his or her specific problems, something that cannot be achieved with a one-size-fits-all self-help book. Online treatments can also be designed to exchange real-time information with compatible smartphone applications (apps), a feature that might enhance their effectiveness.
If psychological treatments are to have the greatest penetration, priority must be given to the optimization of program-led interventions. Until recently, this has been a relatively neglected research area, but interest in online self-help is burgeoning, and empirically supported online treatments for depression and most of the anxiety disorders are now available (14, 15). However, the take-up and completion rates are modest, as is adherence (16). If there is a consistent finding, it is that these problems are reduced if the program is accompanied by some form of external support (15), but herein lies a danger. If the support has to be provided by someone with specialist experience, scalability will be seriously compromised. Instead, and in common with web-centered training, the support should be from a nonspecialist so that the intervention remains program led. Ideally, support should be provided remotely over the telephone or Internet (i.e., via a voice over IP service), as this would open up the possibility of a call center model of providing guidance, in which support is centrally provided.
The optimization of program-led treatments will not be enough on its own. It needs to be accompanied by research on how to maximize treatment penetration. Mental health literacy needs to be enhanced, especially in developing countries, and greater appreciation of the value of self-help is needed by both the general public and mental health professionals. This will require responsible marketing of the approach. It will also be important for health care systems to integrate program-led (i.e., therapist free) and therapist-led forms of treatment so that individuals who do not or cannot benefit from the former can move smoothly on to the latter.
To achieve these ambitious goals, collaboration needs to be forged between individuals who develop psychological treatments and those in the fields of public mental health and global mental health in particular. With such collaboration, and given recent advances in treatment, training, and technology, much might be achieved.