The RCPsych Article of the Month for August is ‘Feasibility and acceptability of a solution-focused approach to strengthen lay counselling for common mental disorders (DIALOG+) in Pakistan: mixed methods study‘, written by authors Saniya Saleem, Anayat Baig, Onaiza Qureshi, Sana Sajun, Victoria Bird, Stefan Priebe and Aneeta Pasha. The paper is published in BJPsych International.

Contributors: Onaiza Qureshi (IRD Pakistan), Sana Zehra Sajun (Unit for Social and Community Psychiatry, Queen Mary University London)

In Pakistan and many other low-resource settings, mental health services remain underfunded and understaffed. Lay counsellors, who are individuals with minimal formal psychological training, play an increasingly critical role in bridging the gap. However, traditional approaches to counselling often expect too much from this non-specialist workforce, requiring them to deliver tailored, complex interventions with limited guidance or supervision and amongst other healthcare priorities.

So, how can we support them better?

This question inspired our recent study on DIALOG+, a structured, app-based intervention originally developed for clinicians in the UK. In our study which was recently published in BJPsych International, we examined whether DIALOG+ could be easily delivered by lay counsellors, to support people with depression and anxiety visiting two primary care clinics in Karachi, Pakistan.

How does it work?

DIALOG+ guides structured conversations between clients and counsellors, focusing on improving peoples’ satisfaction across key areas of their life like their health, relationships, and leisure activities. People rate their satisfaction and together with the counsellor, identify actionable goals and leverage existing resources to improve their overall wellbeing. DIALOG+ works because it is rooted in patient-centred, holistic, and solution-focused care. Keeping digital usability in mind, it has also been designed to be delivered via a simple, visual step-by-step user-friendly app.

A key strength of DIALOG+ is its ability to standardise counselling while tailoring sessions to individual needs. By providing a built-in structure, it reduces the burden on lay counsellors, helping them facilitate personalised care with minimal training, and supports sustainability in overstretched mental health systems. DIALOG+ helps individuals identify and use available resources to improve their situation, enhancing their satisfaction in a sustainable way to improve overall quality of life.

Image 1: Reviewing client action points on the DIALOG+ app © IRD Pakistan, 2019

What did we learn?

Feedback from our pilot was strongly positive from both clients and lay counsellors. The latter reported that the tool’s assessment and tracking structure gave them more confidence and focus in delivering sessions e.g. ‘When the patient rated between 1 to 7, we got to know what stage s/he were at and helped us understand them better’. Clients also felt heard and empowered with actionable solutions. As one client put it, DIALOG+ helped him work with his counsellor to develop “a roadmap for me on how to deal with my challenges, and because of this I am able to easily deal now’, shifting the dynamic from passive listening to active and collaborative care planning.

Image 2.DIALOG+ training session with lay counsellor © IRD Pakistan, 2024

Another key advantage is that DIALOG+ can be delivered after minimal training and light supervision. This makes it a scalable intervention well-suited to the realities of integrated mental health care in low- and middle-income countries, where burnout and workload are common barriers to sustained delivery.

We are now exploring opportunities to test this approach at a larger scale and in new populations such as people with psychosis and their carers who require more specialised care. Our goal is to improve the quality of service delivery by strengthening lay counsellors capacity with tools that make their work not only easier, but more impactful in promoting recovery.