EMPOWER: Toward the Global Dissemination of Psychosocial Interventions

Even before the COVID-19 pandemic, the needs of persons with mental illness were largely unmet, both in the United States and globally (1). More than one billion people worldwide are estimated to be living with a mental illness, and this burden is rising in the shadow of the pandemic (2). Furthermore, the burden of psychiatric problems affects certain groups disproportionately—young people, racial and ethnic minority populations, low-income populations, sexual minority populations, indigenous peoples, refugee and displaced populations, and the otherwise disadvantaged. In an unequal world, the rising burden of mental illness represents a global crisis further amplified by lack of access to quality, evidence-based care. Virtually every country in the world has failed to shift the needle, regardless of their resources, testifying to the inadequacy of current approaches to mental health care and their unsuitability for the rising demand.

One major hurdle to improved quality of care is the lack of access to evidence-based psychosocial interventions, considered among the most effective treatments for mood, anxiety, trauma-related, substance use, and childhood psychiatric problems (3). Yet, the vast majority of affected people cannot access these interventions. In the United States, for example, among patients who do receive treatment for depression, only about a quarter receive psychotherapy (4). This circumstance has developed despite the fact that patients, particularly those from racial and ethnic minority groups, overwhelmingly express preference for psychological treatments and that patients who receive their preferred treatment report greater satisfaction, higher rates of treatment completion, and superior clinical outcomes ( 5). Among the greatest barriers to dissemination of evidence-based psychosocial interventions are the shortage of trained mental health professionals, their high cost, and reliance on resource-intensive in-person training and expert supervision. Traditional approaches to training and treatment delivery are inadequate, requiring a radically different approach that emphasizes science, scalability, and equity (3).

The Opportunity

Task sharing of evidence-based psychosocial interventions with nonspecialist providers (NSPs), such as community health workers, peers, or lay counselors, is the most transformative innovation to emerge from global health care. The large body of evidence on task sharing for the delivery of mental health interventions, now composed of nearly 100 randomized controlled trials (RCTs) from more than 40 countries, has demonstrated the effectiveness of task sharing for prevention and care of a range of mental health conditions (6, 7). These interventions are generally built around known psychological core elements or “active ingredients,” but they also address accompanying social determinants. Typically, they are delivered in as few as six-to-eight face-to-face sessions in community or primary care settings (or, increasingly during the pandemic, remotely, by using digital technology) (8, 9). Notably, this method of treatment delivery not only increases coverage but also reaches those who may not be able to, or who are reluctant to, access care because of varying structural, economic, and social barriers. The global relevance of this work has been evidenced by increasing calls for its use in global policy and in high-income countries (10).

Apart from a few notable examples, such as the Improving Access to Psychological Treatments (IAPT) program in England (11), there has been limited implementation at scale of psychosocial interventions in most countries. One major barrier is the difficulty training the army of providers needed. In addition, there is the nontrivial matter of assuring the quality of the treatment delivered. Technological advances, such as the widespread availability of smartphones, enhanced mobile network connectivity, improved teleconferencing, and new digital tools for learning management, offer potential ways to address these barriers—enabling the training and supervision of therapists at scale. In addition to IAPT, such tools are also being used to scale-up psychological treatments for eating disorders worldwide (12), for maternal depression in Pakistan (the Thinking Healthy Program) (13, 14), and for depression in India (the Healthy Activity Program [HAP]) (15, 16).

Empower

EMPOWER (www.empower.care) is a not-for-profit program led by Harvard Medical School and by Sangath, a nongovernmental, not-for-profit organization in India founded in 1996 and engaged in mental health implementation science across diverse states in India. EMPOWER is building on the above-mentioned technological and scientific advances by deploying a suite of digital tools to increase the capacity of a nonspecialist frontline-care workforce. By using digital tools for training and supervision, EMPOWER aims to efficiently train and support a wide range of NSPs in learning, mastering, and delivering evidence-based psychosocial interventions. The program builds on and converges three strands of science: clinical science demonstrating the effectiveness of brief psychosocial interventions; implementation science demonstrating the effectiveness of the delivery of such interventions by community health workers or other cadres of NSPs; and pedagogical science demonstrating the effectiveness of digital approaches for training and quality assurance.

How Empower Works

Selection of Interventions

A critical feature of EMPOWER is that it emphasizes the scale-up of evidence-based interventions, defined as psychosocial interventions evaluated in at least two adequately powered RCTs, and found to be effective when delivered by NSPs. The manuals used in these trials serve as the basis for the design of the digital curriculum. All potential interventions are reviewed by a panel of leading psychological treatment scientists ( www.empower.care/about-us) before being selected for use in the program. A foundational skills course, covering evidence-based common factors in psychotherapy, has been designed as the first training step for each NSP, before the learner advances to disorder-specific treatment components. To date, the two interventions that have been chosen are behavioral activation (following the manual of the HAP) (15, 16) and problem-solving for adolescent mental health problems (following the Premium for Adolescents problem-solving manual) (17). Other interventions that have been identified as potentially eligible for dissemination by EMPOWER are parenting interventions for promoting early child development, brief motivational enhancement interventions for alcohol use disorders, and parent-mediated communication interventions for children with autism.

Digital Content Development

In creating a digital ( 18) EMPOWER course, a training syllabus or blueprint is created from the intervention manual. The blueprint contains two parts: The first part focuses on content and has specific modules for various topics and lessons, including objectives for each lesson and source material. The second part focuses on the skills and competencies needed to deliver the intervention. Once the blueprint has been developed, the content from the manual is adapted into video scripts. On average, each video is 5–8 minutes long, and each lesson contains one video. These may be didactic, lecture-style videos or dynamic role-plays between a client and a counselor illustrating a particular skill. The videos are then placed within a learning management system (LMS), which organizes the information in an easy-to-use, interactive format. Textual explanations of key concepts are added before and after videos to reinforce learning. These explanations also prepare learners for knowledge checks (i.e., multiple-choice quizzes) designed to emphasize key points and enhance engagement. Finally, optional supplemental material is provided for learners to enhance their knowledge on particular concepts. Importantly, at each stage (blueprint, scripting, video production, and the final product), the content is peer-reviewed by a panel of experts with clinical expertise in the relevant interventions. The adaptation of existing curricula to other languages or for use in different contexts follows a systematic procedure (as was done for adapting the HAP for use in the United States). Focus groups of NSPs also provide feedback and pilot test the course before implementation and scale-up.

Assessment of NSP Competencies

Although few psychological treatment delivery programs for NSPs have described the process for assessment of competency (8), EMPOWER has built on the experiences of these programs to design a suite of competency assessments suitable for remote delivery. For knowledge application competencies, we use questionnaires assessing responses to specific treatment scenarios, such as the ones developed to evaluate competencies for behavioral activation and general counseling skills (the HAP) in India (19). In addition, tools are available for the observational rating of provider skills. These tools allow observers to document demonstrated behaviors and classify each skill level as potentially harmful, basic, or advanced. Our plan is to conduct these assessments remotely as well. Once providers have attained a specified level of competency, they can graduate to delivering the intervention, and the focus can shift to ongoing quality assurance.

Quality Assurance

Supervision is key to effective delivery of high-quality psychological treatments (20, 21) that contribute to improved patient outcomes (22, 23, 24) and to therapist self-efficacy (25). Relying on mental health specialists to supervise NSPs in person is neither scalable nor sustainable, as this is expensive, time-intensive, and lacks generalizable metrics. Our previous work in India (26, 27) has demonstrated the acceptability, feasibility, and efficacy of measurement-based peer supervision models for NSPs to facilitate quality-assured mental health care. The EMPOWER approach emphasizes scalability and replicability through digital, measurement-based peer supervision (Figure 1). There are three components to this approach: First, therapists with similar levels of training monitor, evaluate, and support one another, typically in a group context (28, 29). This approach contributes to shared learning, skill building, and enhanced self-efficacy, and it strengthens the collective practice of ethical standards (30, 31). Second, there is peer assessment of the quality of audio-recorded therapy sessions using therapy quality rating scales, complemented by group discussion and narrative comments. Third, supervision is conducted through the use of custom-made digital tools, powered by the CommCare platform, the most widely used digital platform aimed specifically to support frontline, community health workers (https://www.dimagi.com/commcare). Our aim is to provide both asynchronous feedback as well as synchronous group supervision sessions with peers and specialist clinicians. The use of digital technology enables us to engage NSPs from diverse geographic areas and to accommodate their busy workloads.

System Integration and Evaluation

It is crucial that the treatments enabled by EMPOWER are integrated within the local broader health system. Ideally, the EMPOWER NSP workforce delivers care within the framework of a collaborative, stepped-care model, in which patients receive the appropriate intensity of care. Within such a system, the NSPs represent the front line, with seamless pathways for referral (in both directions) to or from more specialized mental health providers.

The provider-level data generated by EMPOWER can be used to evaluate the progress of each NSP within the EMPOWER platform and, when aggregated with data from other providers, can offer opportunities to address questions related to the interrelationships between these variables (i.e., provider characteristics, competencies, and quality of therapy sessions). Importantly, when these metrics are supplemented by patient-level clinical outcomes data, there is the potential to determine which NSP characteristics or competencies may predict better patient outcomes. Such data, in turn, could be used to enhance the effectiveness of the psychosocial interventions themselves and of the EMPOWER program overall. As the bank of audio-recorded therapy sessions, which have been manually coded by NSPs, grows, natural language processing and machine learning may enable real-time assessments of the quality of all therapy sessions (not only of the ones manually coded by peers). Such data science approaches could also inform precision medicine approaches to tailor treatments to specific patient profiles.

Implementation of Empower

Madhya Pradesh, India

Much of the foundational work that has led to EMPOWER has been conducted in India, led by Sangath in partnership with an array of local and international institutions. EMPOWER’s first offering, the scale-up of the HAP, is now underway in the central state of Madhya Pradesh, one of the least resourced states in India. The program is being implemented in partnership with the state government’s health department and involves the training of more than 1,000 NSPs (called accredited social health activists [ASHAs]), all of whom are women who serve as the frontline providers of the country’s National Health Mission. These 1,000 ASHAs serve a population of approximately 1.4 million persons. Although these front-line providers were originally intended to help improve maternal and child health outcomes in rural communities, their role has now expanded to addressing issues related to noncommunicable diseases and, most recently, to the door-to-door COVID-19 vaccination campaign.

The Hindi digital curriculum of HAP is composed of 16 modules integrating foundational and treatment-specific skills, hosted on a customized LMS. The LMS is accessed through a smartphone-based application, which allows course facilitators to track learners’ progress, manage access to course activities, and generate performance reports. Created to meet the needs of the ASHAs, who are located in remote areas with intermittent Internet access, the entire curriculum can be downloaded and accessed offline, with the LMS syncing data with the server whenever connected to the Internet. Remote technical support and coaching (by experts in HAP), delivered through LMS notifications and telephone calls, motivates learners and helps resolve both technical and content queries. The acceptability and feasibility of this digital form of training is high, with over 65% of ASHAs completing the training (16). The overall feedback has been generally positive, with ASHAs reporting that the training has provided them with valuable insights into mental health more generally and of depression in particular. Many ASHAs reported personal transformation—being empowered with knowledge to respond to needs they frequently observed in their clients and among themselves. This mode of delivery of mental health training makes it possible for the ASHAs to learn at a self-guided pace, where and when it suits them, integrating the learning with their other professional and personal responsibilities, and avoiding the disruptions and costs associated with in-person training. As these NSPs complete training, we are putting in place systems of case-based learning and therapy quality assurance, by way of peer supervision, to support their journey toward becoming credentialed (i.e., certified by the local health system) providers of the HAP for people with depression.

Texas, United States

Building on our experience in expanding the NSP workforce in India, we are now extending this work to Texas. As in Madhya Pradesh, there are significant gaps in access and availability of quality treatment for people with mental disorders in Texas. Over 80% of the state’s 254 counties are designated as Mental Health Professional Shortage Areas (HPSAs), defined as having more than 30,000 Texans per mental health clinician (31). In partnership with the Meadows Mental Health Policy Institute and the University of Texas Southwestern Medical Center, we have been awarded the Lone Star Prize to scale up depression care in underresourced communities in Texas. Over the next 4 years, through EMPOWER, we expect to recruit, train, and support hundreds of NSPs to deliver behavioral activation for depression. We have completed the tailoring of the program content and are currently engaged in culturally adapting the program content so that it will be available in Spanish as well as English and will meet the needs of the significant Hispanic population in Texas. This effort is a rare example of “reverse engineering” of innovations developed in low-resource countries for delivery in wealthy countries. We are also working closely with key stakeholders to iteratively assess and address acceptability and feasibility barriers to NSPs’ engagement and completion of the digital training. We aim to train 300 NSPs, which will include community health workers already embedded within health systems in the state, as well as new providers recruited from the communities we are seeking to serve. By recruiting directly from these communities, we wish to develop a workforce reflective of the neighborhoods, with a priority on recruitment of Black and Latino NSPs, those with physical disabilities, and especially people who have personal experience with depression. These providers will be trained to deliver behavioral activation in English or Spanish, thereby affording opportunities to help bridge cultural and language barriers to accessing care, with emphasis on reaching vulnerable communities and individuals without health insurance and linking those who need more specialized care to formal health systems where they can receive it. As described earlier, we will leverage web- and mobile-based technologies to observe, supervise, and support the NSPs as they start delivering treatment.

Role of Mental Health Professionals and Services

It is important to stress that EMPOWER is a means of scaling up the delivery of evidence-based psychosocial interventions by building the capacity of NSPs working in community and primary care settings. As such, it is an extension of the existing mental health care system, not a replacement for it (8). In the two implementation sites described above, EMPOWER is closely linked with existing health care systems, seeking to expand its footprint deep into the community to reach those whose needs have been unmet. This linkage ensures that there is coordination between services, so that those who need more specialized care can easily access it. The involvement of mental health professionals is central to the successful delivery of EMPOWER. In our experience, mental health professionals have at least three crucial roles in this program. First, and arguably the most important, is to embrace the EMPOWER mission. This translates not only into championing the scale-up effort, but also into advocating for adequate resource mobilization to support it. The second role is to provide clinical leadership of the program, both by ensuring that patients with more complex and refractory needs are able to seamlessly access specialist care and by supervising and supporting the NSPs so they can confidently engage with the mental health needs of their communities. The third role is to engage with the evaluation of the scale-up and the associated data analytic opportunities by leveraging grants dedicated to the implementation of mental health care.

The Future

The pandemic has offered an unprecedented opportunity to rethink the provision of mental health care. By building on the increased recognition of the importance of mental health, the widespread acceptance of digital tools in health care, and by leveraging major technological advances (including the increased acceptance, familiarity, and ubiquity of digital tools in health care settings) to disseminate evidence-based psychosocial interventions, the EMPOWER approach has the potential to play a critical role in the scale-up of mental health services. The design of the platform enables widely available human resources to learn, deliver, and master specific psychological treatments, enhancing treatment coverage while also building a quality-assured community-based mental health workforce (Figure 2). It is our hope that our work in Madhya Pradesh and Texas will offer real-world case studies replete with learning opportunities to inform and refine our implementation strategies. This vision, together with our plan to expand the curricula to address a wider range of mental health problems, has the potential to markedly increase the availability of evidence-based psychosocial interventions worldwide.