Abstract
The large burden of mental health disorders among young people worldwide calls for scalable prevention and treatment models that reach children and families in low-resource settings. This paper describes the development of an evidence-informed family therapy intervention designed for lay counselor delivery in low-resource settings and presents findings on the feasibility and acceptability of implementation in Kenya. Qualitative data guided the development of a components-based family therapy that integrates multiple strategies from solution-focused and systems-based therapies, as well as those from parenting skills training and cognitive behavioral therapies. Eight lay counselors delivered the intervention, with 10 families completing treatment. Lay counselors demonstrated adequate fidelity and clinical competency when treating families with a wide range of presenting clinical problems. Unique elements of the implementation model proved feasible and acceptable, including recruiting “natural” lay counselors from communities already engaged in informal counseling for families; participants indicated trust and respect in the counseling relationship that facilitated their participation. Both counselors and families reported positive perceptions of intervention content and strategies, including those least similar to local counseling practices. Results support the potential of this implementation strategy that aims to add evidence-based practices to local practices and routines rather than creating new cadres of lay counselors or health workers. Supervision, provided by psychology student trainees, also proved feasible and mutually beneficial, with phone-based supervision as acceptable as in-person meetings; this suggests the potential feasibility of this model for use in remote locations. Future directions include integrating these delivery approaches into existing social structures to develop and evaluate a comprehensive implementation model for scale-up.
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References
Annan, J., Sim, A., Puffer, E. S., Salhi, C., & Betancourt, T. S. (2016). Improving mental health outcomes of Burmese migrant and displaced children in Thailand: a community-based randomized controlled trial of a parenting and family skills intervention. Prevention Science, 18(7), 1–11. https://doi.org/10.1007/s11121-016-0728-2.
Barry, M. M., Clarke, A. M., Jenkins, R., & Patel, V. (2013). A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health, 13(835). https://doi.org/10.1186/1471-2458-13-835.
Bass, J. K., Annan, J., McIvor Murray, S., Kaysen, D., Griffiths, S., Cetinoglu, T., Wachter, K., Murray, L. K., & Bolton, P. A. (2013). Controlled trial of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine, 368(23), 2182–2191. https://doi.org/10.1056/NEJMoa1211853.
Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation of treatments: a resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40(4), 361–368. https://doi.org/10.1037/a0016401.
Bolton, P. (2001). Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. The Journal of Nervous and Mental Disease, 189(4), 238–242.
Bond, C., Woods, K., Humphrey, N., Symes, W., & Green, L. (2013). Practitioner review: the effectiveness of solution focused brief therapy with children and families: a systematic and critical evaluation of the literature from 1990–2010. Journal of Child Psychology and Psychiatry, 54(7), 707–723. https://doi.org/10.1111/jcpp.12058.
Boudreault-Bouchard, A.-M., Dion, J., Hains, J., Vandermeerschen, J., Laberge, L., & Perron, M. (2013). Impact of parental emotional support and coercive control on adolescents’ self-esteem and psychological distress: results of a four-year longitudinal study. Journal of Adolescence, 36(4), 695–704. https://doi.org/10.1016/j.adolescence.2013.05.002.
Carr, A. (2000). Evidence-based practice in family therapy and systemic consultation. Journal of Family Therapy, 22(1), 29–60.
Castro, F. G., Barrera, M., & Martinez, C. R. (2004). The cultural adaptation of prevention interventions: resolving tensions between fidelity and fit. Prevention Science, 5(1), 41–45. https://doi.org/10.1023/B:PREV.0000013980.12412.cd.
Chorpita, B. F., Daleiden, E. L., & Weisz, J. R. (2005). Modularity in the design and application of therapeutic interventions. Applied and Preventive Psychology, 11(3), 141–156. https://doi.org/10.1016/j.appsy.2005.05.002.
Cummings, E. M., & Davies, P. T. (2002). Effects of marital conflict on children: recent advances and emerging themes in process-oriented research. Journal of Child Psychology and Psychiatry, 43(1), 31–63. https://doi.org/10.1111/1469-7610.00003.
Dobson, K. S. (2009). Handbook of cognitive-behavioral therapies (Third ed.). Guilford Press.
Eaton, J., McCay, L., Semrau, M., Chatterjee, S., Baingana, F., Araya, R., Ntulo, C., Thornicroft, G., & Saxena, S. (2011). Scale up of services for mental health in low-income and middle-income countries. Lancet, 378(9802), 1592–1603. https://doi.org/10.1016/S0140-6736(11)60891-X.
Edwards, T. M., & Vakili, S. (2017). Global mental health: a call for increased awareness and action for family therapists. Family Process, 57(1), 70–82. https://doi.org/10.1111/famp.12281.
Erskine, H. E., Moffitt, T. E., Copeland, W. E., Costello, E. J., Ferrari, A. J., Patton, G., Degenhardt, L., Vos, T., Whiteford, H. A., & Scott, J. G. (2015). A heavy burden on young minds: the global burden of mental and substance use disorders in children and youth. Psychological Medicine, 45(7), 1551–1563. https://doi.org/10.1017/S0033291714002888.
Fazel, M., Patel, V., Thomas, S., & Tol, W. (2014). Mental health interventions in schools in low-income and middle-income countries. The Lancet Psychiatry, 1(5), 388–398. https://doi.org/10.1016/S2215-0366(14)70357-8.
Gardner, F., Montgomery, P., & Knerr, W. (2016). Transporting evidence-based parenting programs for child problem behavior (age 3–10) between countries: systematic review and meta-analysis. Journal of Clinical Child & Adolescent Psychology, 45(6), 749–762. https://doi.org/10.1080/15374416.2015.1015134.
Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: the RE-AIM framework. American Journal of Public Health, 89(9), 1322–1327. https://doi.org/10.2105/AJPH.89.9.1322.
Jewkes, R., Flood, M., & Lang, J. (2015). From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. The Lancet, 385(9977), 1580–1589. https://doi.org/10.1016/S0140-6736(14)61683-4.
Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36(4), 567–589. https://doi.org/10.1007/s10802-007-9201-9.
Kerr, M. E. (1981). Family systems theory and therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Family systems theory and therapy (Vol. 1). New York: Routledge.
Khasakhala, L. I., Ndetei, D. M., Mathai, M., & Harder, V. (2013). Major depressive disorder in a Kenyan youth sample: relationship with parenting behavior and parental psychiatric disorders. Annals of General Psychiatry, 12(1), 15. https://doi.org/10.1186/1744-859X-12-15.
Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., Rohde, L. A., Srinath, S., Ulkuer, N., & Rahman, A. (2011). Child and adolescent mental health worldwide: evidence for action. The Lancet, 378(9801), 1515–1525. https://doi.org/10.1016/S0140-6736(11)60827-1.
Klasen, H., & Crombag, A.-C. (2013). What works where? A systematic review of child and adolescent mental health interventions for low and middle income countries. Social Psychiatry and Psychiatric Epidemiology, 48(4), 595–611. https://doi.org/10.1007/s00127-012-0566-x.
Knerr, W., Gardner, F., & Cluver, L. (2013). Improving positive parenting skills and reducing harsh and abusive parenting in low- and middle-income countries: a systematic review. Prevention Science, 14(4), 352–363. https://doi.org/10.1007/s11121-012-0314-1.
Kohrt, B. A., Jordans, M. J., Rai, S., Shrestha, P., Luitel, N. P., Ramaiya, M. K., & Patel, V. (2015). Therapist competence in global mental health: development of the ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale. Behaviour research and therapy, 69, 11-21
Liddle, H. A., Dakof, G. A., Parker, K., Diamond, G. S., Barrett, K., & Tejeda, M. (2001). Multidimensional family therapy for adolescent drug abuse: results of a randomized clinical trial. The American Journal of Drug and Alcohol Abuse, 27(4), 651–688.
Lund, C., Tomlinson, M., Silva, M. D., Fekadu, A., Shidhaye, R., Jordans, M., et al. (2012). PRIME: a programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Medicine, 9(12), e1001359. https://doi.org/10.1371/journal.pmed.1001359.
Mejia, A., Calam, R., & Sanders, M. R. (2012). A review of parenting programs in developing countries: opportunities and challenges for preventing emotional and behavioral difficulties in children. Clinical Child and Family Psychology Review, 15(2), 163–175. https://doi.org/10.1007/s10567-012-0116-9.
Minuchin, S., & Nichols, M. P. (1998). Structural family therapy. In Case studies in couple and family therapy: systemic and cognitive perspectives (pp. 108–131). New York: Guilford Press.
Murray, L. K., Dorsey, S., Bolton, P., Jordans, M. J., Rahman, A., Bass, J., & Verdeli, H. (2011). Building capacity in mental health interventions in low resource countries: an apprenticeship model for training local providers. International Journal of Mental Health Systems, 5(1), 30. https://doi.org/10.1186/1752-4458-5-30.
Naslund, J. A., Aschbrenner, K. A., Araya, R., Marsch, L. A., Unützer, J., Patel, V., & Bartels, S. J. (2017). Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature. The Lancet Psychiatry, 4(6), 486–500. https://doi.org/10.1016/S2215-0366(17)30096-2.
Panter-Brick, C., Burgess, A., Eggerman, M., McAllister, F., Pruett, K., & Leckman, J. F. (2014). Practitioner review: engaging fathers - recommendations for a game change in parenting interventions based on a systematic review of the global evidence. Journal of Child Psychology and Psychiatry, 55(11), 1187–1212. https://doi.org/10.1111/jcpp.12280.
Patel, V., Flisher, A. J., Nikapota, A., & Malhotra, S. (2008a). Promoting child and adolescent mental health in low and middle income countries. Journal of Child Psychology and Psychiatry, 49(3), 313–334. https://doi.org/10.1111/j.1469-7610.2007.01824.x.
Patel, V. H., Kirkwood, B. R., Pednekar, S., Araya, R., King, M., Chisholm, D., Simon, G., & Weiss, H. (2008b). Improving the outcomes of primary care attenders with common mental disorders in developing countries: a cluster randomized controlled trial of a collaborative stepped care intervention in Goa, India. Trials, 9(4). https://doi.org/10.1186/1745-6215-9-4.
Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health, 36(1), 24–34. https://doi.org/10.1007/s10488-008-0197-4.
Proulx, C. M., Helms, H. M., & Buehler, C. (2007). Marital quality and personal well-being: a meta-analysis. Journal of Marriage and Family, 69(3), 576–593. https://doi.org/10.1111/j.1741-3737.2007.00393.x.
Puffer, E. S., Friis, E., Green, E. P., & Giusto, A. (2018). Family functioning and mental health changes following a family therapy intervention in Kenya: Results of a pilot trial. https://doi.org/10.17605/OSF.IO/2KUST.
Repetti, R. L., Taylor, S. E., & Seeman, T. E. (2002). Risky families: family social environments and the mental and physical health of offspring. Psychological Bulletin, 128(2), 330–366.
Schmit, E. L., Schmit, M. K., & Lenz, A. S. (2016). Meta-analysis of solution-focused brief therapy for treating symptoms of internalizing disorders. Counseling Outcome Research and Evaluation, 7(1), 21–39. https://doi.org/10.1177/2150137815623836.
Vachon, D. D., Krueger, R. F., Rogosch, F. A., & Cicchetti, D. (2015). Assessment of the harmful psychiatric and behavioral effects of different forms of child maltreatment. JAMA Psychiatry, 72(11), 1135–1142. https://doi.org/10.1001/jamapsychiatry.2015.1792.
van Ginneken, N., Tharyan, P., Lewin, S., Rao, G. N., Meera, S., Pian, J., … Patel, V. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. In Cochrane Database of Systematic Reviews. Wiley. https://doi.org/10.1002/14651858.CD009149.pub2
Vu, N. L., Jouriles, E. N., McDonald, R., & Rosenfield, D. (2016). Children’s exposure to intimate partner violence: a meta-analysis of longitudinal associations with child adjustment problems. Clinical Psychology Review, 46, 25–33. https://doi.org/10.1016/j.cpr.2016.04.003.
World Health Organization. (2010). MhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: Version 1.0. Geneva: World Health Organization.
Acknowledgements
The authors acknowledge Wilter Rono and Katherine King for the project management; the local TP supervisors (Daisy Malinga, Valarie Kosgei, Mercy Korir, and Julius Barasa); the Tuko Pamoja lay counselors; the Tuko Pamoja survey enumerators; the participating families; Puja Patel for the qualitative data coding; and Bonnie Kaiser for the qualitative analysis consultation. This research was conducted in collaboration with the AMPATH consortium.
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This study was funded by Grand Challenges Canada.
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Puffer, E.S., Friis-Healy, E.A., Giusto, A. et al. Development and Implementation of a Family Therapy Intervention in Kenya: a Community-Embedded Lay Provider Model. Glob Soc Welf 8, 11–28 (2021). https://doi.org/10.1007/s40609-019-00151-6
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DOI: https://doi.org/10.1007/s40609-019-00151-6