The volunteers delivering life-saving mental health support

Time was already running out when Texas pastor Veron Blue heard that a young woman in her community was contemplating suicide.

“She had a plan that night, while her mom was at work, to take her own life,” said Blue, co-founder of a non-denominational church in San Antonio. Searching out professional care was not an option at such short notice. “We had to help her that day.”

Blue, who is part of a project that gives pastors and other church members the tools to support people with deteriorating mental health in their communities, was able to guide the 25-year-old through her crisis.

“So that’s one person who’s alive now, who wouldn’t have been had we not been trained.”

Amid a surge in demand for psychological support that has been exacerbated by the Covid-19 pandemic, Blue is one of many people without formal psychiatric qualifications — including volunteers and health workers — who are stepping in to deliver interventions.

Known as task-shifting or task-sharing, the trend has grown across healthcare as services grapple with a stark mismatch between resources and demand. The World Health Organization estimates that there is a global average of 13 mental health workers per 100,000 people, but in low-income countries this can fall to fewer than two.

But a number of studies suggest that simple interventions, such as benches where people can sit with a sympathetic listener, can be at least as powerful as expensive clinical approaches, easing the burden on specialist workers.

Blue said before joining the Congregational Collective programme, which aims to make San Antonio’s congregations safe places for people “seeking mental wellness”, she would see “maybe one or two people every six months about mental health. Now it’s one or two people a day.”

Health policymakers are increasingly seeking to replicate projects pioneered in the developing world, a process that has been dubbed “frugal innovation”.

The project in Texas, a wealthy state in one of the world’s richest countries, was inspired by the Sangath programme in India where less than 6,000 psychiatrists serve the 1.45bn population, according to Abhijit Nadkarni, professor of global mental health at the London School of Hygiene and Tropical Medicine (LSHTM).

Nadkarni, a director of the Sangath programme, said where once it was assumed “that low-resource settings were in some ways synonymous with low and middle-income countries . . . people are increasingly realising that when it comes to mental health, all countries are poorly resourced.” 

Sangath became one of the first projects to run a randomised control trial (RCT) of task-sharing in mental health in 2007. “It’s not a compromise,” said Nadkarni, “it’s an idea backed by solid research evidence.”

Global crisis in mental health

This is the third in a series examining how employers and governments are tackling the rise in depression and other conditions — and the new therapies being developed

Part 1: Financial services among hardest-hit in the crisis

Part 2: The new generation of treatments

Part 3: Mental health support on the cheap

Part 4: Which nations are getting it right? (coming Monday)

Soumitra Pathare, a consultant psychiatrist who directs the Centre for Mental Health Law and Policy in Pune, India, analysed the return on investment of a project called Atmiyata, or “shared compassion”, which uses lay volunteers to provide “psychosocial” support. Participants showed increased productivity at work or school, while reducing dependence on health and welfare services.

“Every $1 invested in a service like this gives you about $9 in return — both for the individual and the society combined,” he added.

Only around 16 paid Atmiyata staff members are required to supervise and mentor 800 lay people. These “community champions” end up “helping anywhere between 25,000 and 30,000 people each year”, said Pathare.

An RCT which compared the outcomes of those receiving psychiatrist treatment with those receiving care from lay “champions”, found that the latter group were two and a half times more likely to recover, he added.

Pathare attributes the findings to the greater likelihood of patients completing treatment when it is offered by someone from their own community. “With our champions they get someone coming to their doorstep, rather than them having to travel to a health centre or hospital to see a psychiatrist,” he said. 

Conventional psychiatry often falls short on this front. Texas pastor Blue said only around 4 per cent of therapists in the US are African-American, adding a lack of access to trusted providers to the numerous disparities that already exist in minority communities.

A similar determination to tackle not just workforce shortages but other barriers to clinical care led Dixon Chibanda, a consultant psychiatrist in Zimbabwe and professor of psychiatry at LSHTM, to found The Friendship Bench. “Grandmothers” are trained to sit with those who seek support and listen without judgment. A small number of men are also involved.

The idea was born from tragedy. Chibanda lost a patient called Erica, who died by suicide. “Erica’s parents knew that [she] had a relapse and needed to go back to the hospital. Erica herself knew she needed help, but because they lived 200 miles away they didn’t have the bus fare to bring her to where I worked.

“That was the beginning of this idea of taking mental health out of the hospital and into the community.”

A clinical diagnosis has a place, he said, “but it shouldn’t be the primary driving factor in an interaction between two human beings”. Instead of referring to depression, for example, the grandmothers speak of “thinking too much” or kufungisisa, a term in the Shona language that ensures the encounter is not over-medicalised.

Sesedzai Chipiro sought help after her husband died by suicide, which some neighbours blamed her for. 

The “grandmother” who supported her, Betty Siachitubuka, made her “feel welcome in the community” again, Chipiro said, noting that the care was free and easy to access. The nearest hospital able to provide formal psychiatric help is a 45-minute journey away, requiring an expensive bus fare and consultation fee.

Spontaneously hugging Siachitubuka during a video call with the Financial Times, Chipiro added: “I pray that God keeps her safe, she is very important.”

In Washington DC, where charity HelpAge USA has placed friendship benches in several locations, chief executive Cindy Cox-Roman underlines the importance of access to a trusted figure.

“There is a tremendous stigma around mental health that endures overall, but certainly in the African-American community,” she said.

One concern about using non-specialists is the risk of people receiving insufficient treatment.

However, John Naslund, leader of the Harvard-based Empower project, which trains the participants in the Texas programme in collaboration with San Antonio’s University Health System, said such initiatives do not “replace or circumvent” the formal mental health support system. Rather, they act as a partner “so that we can actually get individuals who need a higher level of care referred and access to specialists”.

Angela Jasper, a retired educator who volunteers in the Washington programme, said herself and her colleagues always make it clear that they do not have medical training. She tells visitors to the scheme: “We are not fixers. We’re here to support you in any way we can.”

Daisy Singla, a Toronto-based clinical psychologist, aims to improve mental healthcare for pregnant women and new mothers. She is carrying out a large study comparing “talk therapy” sessions by trained non-specialist providers, such as nurses, midwives and childbirth assistants, with those delivered by psychiatrists, psychologists and social workers.

Her research will not be published until March, but she said early findings suggested high satisfaction irrespective of whether participants received treatment from a non-specialist or specialist provider, high treatment completion rates and fewer than 3 per cent requiring additional referrals.

The evidence on “talk therapies” pointed to a “very, very low” potential for harm, Singla said, adding that people with suicidal intent or substance abuse problems were not selected.

However, while task-sharing models have taken root around the world, scaling them is often a bigger challenge, said Kana Enomoto, partner and director of brain health at McKinsey Health Institute.

Initiatives such as the Friendship Bench and the Common Elements Treatment Approach devised by Johns Hopkins University, a mental health intervention that can be delivered by trained and supervised lay providers in low and middle-income countries, are collectively reaching millions of people and have proved their worth in multiple studies.

But funders still tended to focus on setting up clinical projects rather than bringing about systemic change in resource allocation or medical payment models that would drive widespread adoption.

“We don’t step back and say, ‘Well, what’s the change that would be necessary to get this to everybody in Kenya, in Brazil?’ Even in developed countries [such as] the US, [donors] just want to fund the local implementation,” Enomoto added. 

Back in San Antonio, Blue has no doubt about the value of her work. The project is “saving the lives of people in my community”, she said.

“For the first time, I feel equipped to minister to the human soul.”

Data visualisation by Amy Borrett