Community psychosocial workers

Community Psychosocial Workers have two roles: (1) directly promote mental health and well-being by providing prevention and coping interventions to people living and dealing with distress and stressful circumstances; and (2) identify and facilitate referral for persons needing care for mental health conditions. Community Psychosocial Workers need to be aware of the available services in their communities for people dealing with distress and stressful circumstances (e.g., legal, housing, protection), and how to provide referral information when needed.

Primary Health Care Providers

Primary Health Care Providers are general healthcare providers working in non-specialized healthcare settings. They form the basis of healthcare systems in most countries. In HICs they are usually physicians, physician assistants or nurse practitioners. In many LMICs most Primary Health Care Providers are non-physicians with more limited primary care training. Most Primary Health Care Providers focus on physical health. Our experience is that LMIC Primary Health Care Providers are usually uncomfortable managing mental health conditions. This is due to existing workloads, lack of training, and the greater time required to treat these conditions. Also, psychological counseling skills are different from the typical advice-giving counseling skills of Primary Health Care Providers. Their training typically consists of history taking via closed questions followed by diagnosis and specific disease-focused treatments, requiring fewer visits. Under the C4 Framework we propose building on these existing strengths with management duties assigned to other workers with the requisite training. Primary Health Care Providers remain at the center of patient management, as they do for other health-related issues, since they are usually the most highly trained available care providers and the primary source of pharmacologic treatments. They are also best placed to deal with mental and physical comorbidity (World Health Organization, 2015a, 2018f). Integration of mental health services within primary health care is achievable in LMICs (Jordans et al., Reference Jordans, Luitel, Kohrt, Rathod, Garman, De Silva, Komproe, Patel and Lund2019b).

Primary Mental Health Counselors

Primary Mental Health Counselors focus on in-depth assessment for mental health conditions and provision of psychotherapeutic treatments where appropriate (Jordans et al., Reference Jordans, Luitel, Garman, Kohrt, Rathod, Shrestha, Komproe, Lund and Patel2019a). In the C4 Framework they are primary care workers parallel to Primary Health Care Providers, providing community-based non-pharmacologic mental health services. They may be based in clinics or other service centers or provide services at home or other places accessible within the community and convenient for multiple visits. Ideally, they function as part of the formal, public sector health system. They provide interventions to individuals and small groups. They assess the socio-ecological environment of individuals seeking care and provide interventions for other family members as indicated.

Hospital-Based Care Providers (secondary care in general hospitals)

Hospital-Based Care Providers are physicians and nurses working in inpatient and outpatient secondary care facilities (local or district general hospitals) with access to typical hospital-based diagnostic and patient care services not available in primary care. In LMICs hospital-based mental health services are often limited to a few psychiatric hospitals in the capital or major cities, which is a model of care too often associated with human rights violations. Expanding the role of secondary care facilities to include outpatient psychiatric care and acute inpatient psychiatric care is essential to support efforts to integrate mental health into primary health care, as Primary Health Care Providers are unlikely to commit to mental health care delivery unless care, support and supervision are available at a higher level of the system. This requires psychiatric beds attended by staff trained in a consultation-liaison model of care (medical-psychiatric with additional attention to psychosomatic concerns), to move access to these services closer to communities. Where secondary hospitals do not have psychiatrists, medical and nursing staff can consult with specialists by phone or internet. Since most patients needing psychiatric care cannot get to specialized hospitals, this increases the typical quality of care by making psychiatric care more available and integrated into the health system.

This approach is required to reduce the use of restrictive environments where individuals are locked or chained, resulting in stigma and fear toward persons with severe mental health conditions. Referral from the community would be limited to those who temporarily require protection and psychiatric expertise for safety, stabilization and initiation of medications that cannot be provided locally. Once stabilized, individuals treated by Hospital-Based Care Providers would return to their communities for ongoing intervention and monitoring.

Specialized Mental Health Services Providers

Specialized Mental Health Services Providers include psychiatrists, psychologists and psychiatric nurses. They are not readily available to most LMIC populations, being few in number and usually working in large cities in private practice or psychiatric hospitals. In many countries psychologists do not receive significant clinical training and therefore are generally not able to provide evidence-based psychotherapeutic or psychosocial counseling. The C4 Framework therefore emphasizes community-based management of mental health and psychosocial problems, limiting reliance on Specialized Mental Health Services Providers’ input to only when their expertise is needed. However, under this framework, expanded efforts to reduce stigma and improve identification and screening for problems at the community level will likely result in more referrals and more need for distance consultations. The demand for Specialized Mental Health Services Providers will likely increase in most LMICs, given their current limited supply. The need to improve quality at all levels and push services into communities reinforces the need for national guidelines to implement evidence-based strategies (i.e., in populations concurrently affected by common mental disorders and infectious diseases, or support for caregivers of people living with severe mental disorders).

Evidence-based practice

Mental health interventions must be based on scientific evidence and best practices (World Health Organization, 2013a). Scientific evidence consists of counterfactual trials in similar circumstances to proposed use. This is necessary in LMICs for interventions first developed in HICs.

Collaborative, stepped care approach at all stages of mental health care delivery

The staging model recognizes opportunities for detection and intervention at all stages of mental health problems from stress to common mental health conditions to severe conditions (Berk et al., Reference Berk, Post, Ratheesh, Gliddon, Singh, Vieta, Carvalho, Ashton, Berk, Cotton and McGorry2017). In the early stages, symptoms are often transient and not suggestive of a particular condition. Yet appropriate support and engagement can lead to better outcomes (McGorry and van Os, Reference McGorry and van Os2013) and are therefore preventive. Treating symptomatic persons early is important since common symptoms of mental distress such as anxiety symptoms or low mood are associated with more total population disability than clinical mental health conditions (Das-Munshi et al., Reference Das-Munshi, Goldberg, Bebbington, Bhugra, Brugha, Dewey, Jenkins, Stewart and Prince2008). The C4 Framework is designed to offer services with increasing intensity ranging from stress reactions to severe mental health conditions. It incorporates key components of collaborative care: a population-based approach to prevention including addressing psychosocial determinants of mental health and well-being; valid assessment and screening methods; brief psychotherapeutic interventions; access to mental health specialists for consultation and care supervision; and patient tracking (Kroenke and Unützer, Reference Kroenke and Unützer2017; Jackson-Triche et al., Reference Jackson-Triche, Unützer and Wells2020; Unützer et al., Reference Unützer, Carlo and Collins2020). Collaborative service delivery among providers should be coordinated through case management by the Primary Mental Health Counselor, to ensure individuals get the care and resources they need without gaps or redundancy.

Family-based care across the life cycle

To ensure effective community-based mental health and psychosocial support interventions for all members of the community, services must be tailored for individuals across the life course and designed to be inclusive of people of all genders, ages and abilities. This includes design and implementation of inclusive and developmentally appropriate services for infants, children, adolescents and adults of all ages, including the elderly, as well as for people with physical or mental disabilities. Consideration of the life course includes women who are pregnant, and perinatal mental health for mother and fetus. Comprehensively, this requires a “whole of family” approach that addresses the needs of people in the context of family resources and challenges, as well as potential additional training and supports to ensure adequate service delivery for special population groups. For example, adequate child and adolescent mental health services must consider how best to engage childcare providers, such as parents, extended family and teachers, and how to address the needs of out-of-school or homeless children as well as those with disabilities. How to tailor services to be developmentally appropriate and inclusive must be a part of training curricula and supervision at all levels of service delivery.

Integration of MHPSS into community-based services

The need to integrate mental health services with physical health and other services (including protection, social and education) is well supported (Malone et al., Reference Malone, Marriott, Newton-Howes, Simmonds and Tyrer2007; Chatterjee et al., Reference Chatterjee, Naik, John, Dabholkar, Balaji, Koschorke, Varghese, Thara, Weiss, Williams and McCrone2014; Dieterich et al., Reference Dieterich, Irving, Bergman, Khokhar, Park and Marshall2017; World Health Organization, 2022), and fundamental to the C4 Framework and other models. Some models propose counseling treatments be provided by Primary Health Care Providers. In many settings, however, Primary Health Care Providers are fully occupied with existing medical duties (Kok et al., Reference Kok, Broerse, Theobald, Ormel, Dieleman and Taegtmeyer2017), while effective care requires multiple intervention sessions of an hour or more each. The mhGAP Operations Manual suggests providing mental health services through non-health platforms, including schools, neighborhoods, communities and workplaces, by teachers, police officers, social workers, traditional healers, services users, peers, parents, village elders and the general public (World Health Organization, 2018f). But at the same time considerations apply. Adding time-consuming psychotherapeutic services to their existing responsibilities makes it likely that these services will be a low priority, to be interrupted or set aside when other duties or urgent concerns intervene. Instead, it requires full time or “most of the time” commitment by dedicated providers. Other non-health providers can be trained in basic psychosocial support (such as psychological first aid) and referral. For example, teachers may benefit from learning how to better create safe and healing learning environments that aim to improve both mental health and psychosocial well-being, as well as learning outcomes, for children.

The C4 Framework splits community-based MHPSS into three types of elements: brief psychosocial interventions; evidence-based psychotherapeutic interventions; and pharmacologic interventions. Both the brief psychosocial and pharmacologic elements are integrated into the duties of existing workers. The psychosocial elements include group educational and skills building activities to be conducted several times a month or less frequently, to minimize the additional burden. These services are provided by the Community Psychosocial Workers which is preferably a part-time position for persons already engaged in social, educational or other community-based services as well as within, religious and cultural institutions that bring providers into contact with persons with MNS concerns. Integration can also occur within and across services for other co-occurring problems that risk complicating MNS concerns. This includes maternal health, nutrition, HIV, tuberculosis, early childhood development, child health and other conditions requiring behavioral change. Community Psychosocial Workers are therefore embedded to identify, assist and refer persons with MNS issues. More time-consuming psychotherapeutic treatments are provided by the separate group of dedicated Primary Mental Health Counselors.

The central role of Primary Health Care Providers

According to the WHO mhGAP Operations Manual, “Caring for people with MNS conditions and chronic diseases must be provided in a person-centered, integrated approach, with integration at various levels, from screening and early detection of physical health conditions…and management of established physical and mental health conditions” (World Health Organization, 2018h). Some of the authors have previously promoted an integrated, patient-centered approach through greatly expanded training of Primary Health Care Providers in assessment and intervention (Thornicroft et al., Reference Thornicroft, Ahuja, Barber, Chisholm, Collins, Docrat, Fairall, Lempp, Niaz, Ngo and Patel2019). The C4 Framework proposes expanding their training by building on their existing skills. Psychotherapeutic interventions, which use a very different skillset, are instead delivered by separate specialized providers with counseling-specific training. Primary Health Care Providers remain at the center of this framework, as they do for other physical and general medical care issues: receiving referrals; providing medication-based interventions; and consulting with and referring to other workers and providers as needed. This reduces the siloing of mental health from other general medical health services, which risks misdiagnosis and mismanagement. For example, persons with symptoms due to anemia and nutritional deficiencies can be misdiagnosed with depression when based solely on mental health assessments without a physical health assessment. It therefore helps to ensure that persons with mental health conditions receive adequate physical health care, and vice versa.

The C4 Framework expands the role of Primary Health Care Providers in dealing with severe conditions. Primary Health Care Providers not only assess and refer individuals with severe mental health conditions to hospitals, but also monitor and maintain treatment upon their return. This would provide for earlier discharge from hospitals and specialist care. This role is enhanced significantly by collaboration with Community Psychosocial Workers, facilitating better follow-up in the community.

Dedicated local mental health workers treat multiple and comorbid conditions

Time-consuming care is provided by Primary Mental Health Counselors. As a new cadre of health workers, they require official recognition, including defined training curricula and requirements, pay scales and working conditions.

Since comorbidity is common, interventions should be transdiagnostic, using a single, flexible approach to address a variety of conditions. Workers learn a variety of intervention elements and how to tailor varying element combinations to each individual to either treat a single problem or varying patterns of comorbidity (Murray et al., Reference Murray, Dorsey, Haroz, Lee, Alsiary, Haydary, Weiss and Bolton2014). This is more feasible than training in multiple evidence-based psychotherapies that each focus on one or two conditions (e.g., Posttraumatic Stress Disorder (PTSD) and depression) (Kazdin and Blase, Reference Kazdin and Blase2011), particularly in LMICs (Murray et al., Reference Murray, Dorsey, Haroz, Lee, Alsiary, Haydary, Weiss and Bolton2014).

Support of roles for people living with illness and families in clinical decision making

People living with illness and caregivers are typically not accustomed to providing input on their care and support (Lempp et al., Reference Lempp, Abayneh, Gurung, Kola, Abdulmalik, Evans-Lacko, Semrau, Alem, Thornicroft and Hanlon2018). Individuals with severe conditions are thought to have reduced capacity to make decisions. Families may not trust mental health services or fear using them due to stigma. Persons with MNS problems and their families have the right to make decisions regarding their own care in collaboration with mental healthcare providers, which can also improve services (World Health Organization, 2013b). Client input can make services more acceptable while family members can be instrumental in accessing important resources such as social support, recommended coping strategies, and self-help programs (Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton and Herrman2018). The C4 Framework promotes client and caretaker involvement by education on the nature of mental health conditions and intervention options which can normalize mental health conditions and reduce stigma, and provide hope of effective management. Apprenticeship-type training (Murray et al., Reference Murray, Dorsey, Bolton, Jordans, Rahman, Bass and Verdeli2011) involves feedback from people living with illness, family and providers. Providers maintain communication with supervisors and supervisors with trainers/experts. The result is an ongoing four level conversation (person living with illness/caregivers, provider, supervisor and trainer/expert), producing iterative adaptations that improve care.

Engaging persons with lived experience as providers

This increases the interest and understanding of mental health by providers even prior to training. It also enhances their credibility as mental health providers and makes them more approachable in the community. Engaging persons with lived experience as providers themselves also reduces stigma by challenging the common myth that they have reduced capacity to lead or take on responsible roles and more formal positions in their communities. The existing literature suggests that positive exposure to persons with lived experience is effective in reducing the stigma of mental health conditions.

Workforce care, maintenance and development

Each type of worker requires supervision as well as training that includes attention to well-being, to maintain quality of care and reduce turnover. Community Psychosocial Workers receive a limited version of the training provided to Primary Mental Health Counselors. This enables Primary Mental Health Counselors to act as their trainers and supervisors, and to monitor and address the mental health of the Community Psychosocial Workers. Those Community Psychosocial Workers who are interested can be trained and become Primary Mental Health Counselors, providing professional development and more formal career advancement. Similarly, Primary Mental Health Counselors can become supervisors and ultimately trainers. The intent is to promote staff quality and retention by provision of a career pathway for workers at each level, and to reduce staff turnover by selecting committed persons already within the framework for further training. This minimizes extra training and resource needs. Workers also learn from the extensive referral, back-referral and consultations built into the framework, which makes referrals, consultations and, ultimately, care, more efficient. This incorporation of professional development is missing from most service models.

With regard to supervision of providers by others with the same role, designated supervisors would have additional training and report to trainers. Community Psychosocial Workers would, however, be the exception to this and be supervised by Primary Mental Health Counselors who report to trainers.

Monitoring the well-being of workers as part of supervision and addressing their mental health needs are critical to sustainability. Mental health workers are subject to significant stresses and should not be harmed by their work. This represents an extension of “do no harm” and “self-care” principles to the mental health workforce.

Severe mental health conditions must be addressed

Vulnerable to stigma and fear, persons living with severe mental health conditions may be abandoned or receive poor care, including acute and chronic physical restraint. These conditions include chronic schizophrenia, bipolar disorder, severe depression, severe substance use disorders or other debilitating conditions which can cause substantial disability. Individuals living with these problems are often the first to present to mental health programs. They are best initially assessed and managed by Primary Health Care Workers (who have received appropriate training and supervision on treating these conditions in line with the WHO mhGAP Intervention Guide or mgGAP Humanitarian Intervention Guide, for example) and require close monitoring and frequent follow-up. Consultation and, if possible, referral and stabilization under specialist care, may be needed for persons who do not respond to treatment, who experience serious side effects with pharmacological interventions, who have comorbid physical or MNS conditions, or who are at acute risk for suicide or self-harm. If in-person care is not possible, these individuals must be supported at home with support from Community Psychosocial Workers and Primary Mental Health Counselors, under specialist advice by phone or internet. The WHO QualityRights Initiative and Toolkit are key resources in assisting these populations in ways that protect human rights and are community-based as well as rehabilitation- and recovery-oriented (World Health Organization, 2012).

Intellectual disabilities and developmental disorders must be supported

While specific treatments for intellectual disabilities and developmental disorders may not be available, those affected as well as their families and caregivers can benefit from the psychoeducation, training for caregivers, psychosocial support and referral (to other services when needed) offered by Community Psychosocial Workers. This includes identifying and treating associated mental health conditions that would not otherwise be recognized.

This approach will require a large increase in spending, both to set up and to maintain, which is currently not available in many LMICs

The WHO has recognized that substantial increases in global access to mental health services require a substantial increase in funding, and have consistently called for LMICs to substantially increase their funding for mental health services. Therefore, the requirement for greater resources is not specific to this framework. Resource limitations were a major consideration in the structure of the proposed framework. The authors believe that this approach would be a much lower cost option to universal access than simply calling for an increase in the number of psychiatrists, psychologists and other more specialized mental health staff employed in Western models of care.

Some work has been carried out to assess the costs associated with delivering a basic package of mental health care, based on similar approaches to those proposed in this paper; that is, based on decentralization, task sharing, and provision of basic medical and psychological interventions for major mental health conditions in primary care. Some of this work has been based on pilot programs, and some using modeling. In Nigeria, a package of care for psychosis, depression, anxiety, alcohol use and epilepsy was estimated to produce one extra year of healthy life at a cost of less than US $320, which is the Nigerian average per capita income (Chisholm et al., Reference Chisholm, Sweeny, Sheehan, Rasmussen, Smit, Cuijpers and Saxena2016). A return on investment analysis of services for depression and anxiety, using approaches similar to those included in the framework in LICs, estimated that for every USD 1 invested in mental health services, there was a return of US $3-5 (Gureje et al., Reference Gureje, Chisholm, Kola, Lasebikan and Saxena2007). This was deemed to be a conservative figure, as treatment outcomes were restricted to economic impacts at the individual and family levels. Mental health services have also been incorporated into the OneHealth Tool for costing and national health strategic planning in LMICs (Chisholm et al., Reference Chisholm, Heslin, Docrat, Nanda, Shidhaye, Upadhaya, Jordans, Abdulmalik, Olayiwola, Gureje and Kizza2017). Such work has led to the development of a methodology for supporting national investment decisions in mental health (“Investment Cases”) (World Health Organization, 2021d).

Even with evidence of substantial cost-benefits for mental health, it is clear that these considerations are only one part of the equation to mobilize resources for mental health services reform. In LMICs, investments in mental health services have historically been pitifully low compared to the very high relative burden of diseases, with the limited mental health budgets tending to be inefficiently allocated, and with estimates that many countries with unreformed services spend over 80% of their budgets on outdated specialist hospitals (Saxena et al., Reference Saxena, Thornicroft, Knapp and Whiteford2007). Reallocation of resources toward more efficient, decentralized, community-based services has long been accepted as a logical approach, but political considerations often prevent reduction in funding to established services. Ideally, community-based alternatives need to be in place in advance of reform or closure of existing institutions; hence the need for “bridging funds” and clear commitments to reinvest funds saved from specialist hospitals to community-based services (World Health Organization, 2014).

This approach assumes that the health system will have the willingness and human resources at specialist hospitals for implementation

In many LMICs both general and specialty hospitals do not routinely have adequate services of psychiatrists, psychologists, social workers or mental health nurses to carry out the designated roles outlined in this paper. In recognition of this challenge we stress that this framework is aspirational, suggesting what we are building toward as we advocate for more resources for mental health, while recognizing that not every locality or country currently has the required resources. Regarding resources at specialist hospitals, this proposed approach has already been successfully implemented in some countries. For example, in Sri Lanka after the 2004 tsunami, there were no services. Psychiatrists typically covered populations of a million people or more. Other than a few inpatient units, there were no staff trained in psychiatry so a model of full-time Medical Officers of Mental Health and non-professional Community Support Officers was implemented and proved to be highly effective (Mahoney et al., Reference Mahoney, Chandra, Gambheera, Silva and Suveendran2006).

The framework assumes a high level of local leadership and governance mechanisms for the progressive implementation, refinement, local adaptation and scaling up of care

This is most often not the case. While high levels of local leadership and governance are often lacking in some places, they are present in others. The primary goal of this framework is to offer an approach for those places where there are effective leaders who are interested in seeking guidance to improve access to mental health services. They do not necessarily need to be knowledgeable about mental health. For example, in Sri Lanka service development was successfully led by the Regional Directors of Health, none of whom had any prior experience in providing community-based mental health services (Mahoney et al., Reference Mahoney, Chandra, Gambheera, Silva and Suveendran2006; Saraceno et al., Reference Saraceno, van Ommeren, Batniji, Cohen, Gureje, Mahoney, Sridhar and Underhill2007; Kakuma et al., Reference Kakuma, Minas, Van Ginneken, Dal Poz, Desiraju, Morris, Saxena and Scheffler2011).

While the demand for mental health services worldwide has increased considerably, the COVID pandemic has disrupted the already low levels of in-person mental health services

These challenges enhance the need for efficient mental health services through task-shifting to non-professional providers, better access by training local workers, and use of telemedicine, teletherapy and other innovative virtual services or social media applications. Mobile phones, which are increasingly available worldwide, have been used to facilitate access to training, supervision, consultation and support among care providers and to make records available remotely. However, low digital literacy, low smartphone penetration in some places, digital data costs, and limited internet connection continue to make online mental health services a limited option in some locations.