If There Are No Therapists In Your Area, Can a Lay Professional Do?

Deepali Vishwakarma is a lay counselor in the state of Madhya Pradesh, India — a well-trained community member who provides mental health treatment to  people in India and to show that people with much less training than a psychiatrist or psychologist can deliver effective care, according to a segment on NPR.

It’s a controversial approach. Critics say the use of lay counselors means that patients receive substandard care.

In a typical week, she may meet with 25 people, and in her several years as a counselor, patients who’ve stuck with her, as most have, have done well. The patients have been diagnosed with serious depression (or anxiety or tension, as it’s more often called in India), or alcoholism, and every so often, someone with schizophrenia. She’s been trained to listen and to assign specific tasks to her patients. She might tell someone who’s feeling really low to go for a daily walk, or go out and play soccer, or work in the garden or listen to the radio. For depression, it means thinking about anything other than that paralyzing howling tempest. For schizophrenia, it means helping people, many of whom are on medication, adjust to living in society.

Vishwakarma’s biggest challenge is educating her patients. Worldwide, most people with depression don’t seek help, and Deepali’s patients are no different. “The people don’t know they have depression because they don’t understand what depression is,” she says. “They come in seeking help for not sleeping, not eating. We tell them no, when we cure your mental issues the symptoms go away. Then they accept treatment.”

Most of the old research showed that lay counselors were just as effective for depression as counselors with lots more education — sometimes even more effective. A 1979 review paper in Psychological Bulletin analyzed 42 papers and concluded so-called paraprofessionals got results “equal to or significantly better than those obtained by professionals.”

In a 1985 rebuttal in the same journal, the best the opponents could come up with was that professionals did just as well, but not better.

In India, the establishment of lay counselors was pioneered by psychiatrist Vikram Patel and colleagues at Sangath. The idea sprang from something Patel saw in Zimbabwe, where he worked as a psychiatrist in the mid-1990s. Community members were being trained to give care to people with AIDS. Patel figured that maybe the same approach could be used for people with mental illness.

Years into the project, someone at Sangath came across the U.S. research and told Patel about it. “It completely blew my mind,” says Patel. “There was an entire research enterprise.”

The approach has American proponents such as Alan Kazdin, former head of the American Psychological Association. “Seventy percent of the people in this country who need psychiatric services receive nothing,” he says. That number comes from several studies, including two published in the Annual Review of Public Health and JAMA Internal Medicine. “The truth is that today, we are not treating everyone in need, and we cannot do so if we insist on one-to-one therapy, at a clinic, with a mental health professional.” Kazdin is an expert on parenting but has been interested in lay counselors as a way of expanding access to care for years.

So why no change? “There’s no incentive,” says Kazdin. “The individuals who suffer from mental illness are not the best lobbyists, and there’s no industry behind this.”

Terry Wilson, a psychology professor at Rutgers University, says it’s always challenging to introduce a culture shift. “The problem is professionals here are concerned or worried that lay counselors are not going to be able to provide the expert level of care that they’d want.”

But he thinks lay counselors could catch on here. “Change takes time,” he cautions.

Read the full article here.