Common Elements Treatment Approach (CETA)
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The Common Elements Treatment Approach (CETA), is based on evidence-based treatments for depression, anxiety, substance use and trauma and stress related disorders. The CETA model was developed specifically for LMIC settings that rely on non-mental health providers working within sustained supervisory systems. We currently have studies completed or ongoing Iraq, Thailand, Zambia. Ethiopia, Ukraine and Myanmar. This treatment can be used to treat individuals with any of these mental health problems and with any combination of these problems. CETA expands upon traditional treatment approaches that are designed to focus on one specific disorder and has been proven through multiple rigorous trials to reduce the burden of multiple common mental health problems and improve functionality among men and women living in low resource settings. CETA can be provided to people in their own communities by trained and supervised lay providers, for example community health workers. CETA is a proven, inexpensive, widely accessible approach that can reduce the burden of disability due to common mental problems.
Murray LK, Dorsey S, Haroz E, Lee C, Alyasiry MM, Haydary A, Weiss W, Bolton P. ‘A common elements treatment approach for adult mental health problems in low- and middle income countries.’ Cognitive and Behavioral Practice May 2014. 21(2):111-123. doi:10.1016/j.cbpra.2013.06.005
How it Works
Table 1: CETA Elements
- Attention to perceptual & concrete obstacles to engagement;
- Links program to assisting with client's problems;
- Includes family when appropriate participation
- Program information (duration, content, expectations); often use analogies;
- Normalization/validation of current symptoms/problems
|Anxiety Management Strategies**||Relaxation|
- Learn strategies to improve physiological tension/stress
- Employ strategies for tension/stress
- Offer deep breathing, meditation, progressive muscle relaxation, and imagery
|Behavior Activation**||Getting Active|
- Identifying and engaging in pleasurable, mood-boosting, or efficacy-increasing activities
|Cognitive Coping/Restructuring* (2 elements)||Thinking in a Different Way - Part I & II|
- Understand association among thoughts, feelings & behavior;
- Learn to evaluate and restructure thinking to be more accurate and/or helpful
|Imaginal Gradual Exposure**||Talking about Trauma Memories|
- Facing feared and avoided memories (details and associated thoughts and feelings)
- Gradual desensitization/exposure
|In Vivo Exposure**||Live Exposure|
- Facing innocuous triggers/reminders in the client's environment
- Gradual desensitization/exposure
|Suicide/Homicide/Danger Assessment and Planning*||Safety|
- Assess client for suicide, homicide, and domestic violence
- Develop focused plan with the client and client's family (when appropriate)
- Additional referral/reporting when needed
|CBT for Harm Reduction for Substance Use**||Alcohol Intervention|
- Utilize concepts of CBT to get client buy-in to change substance use/abuse behavior
In contrast with transdiagnostic approaches in high-income countries, CETA has: a) A more limited number of elements, b) Simplified language, c) Step-by-step guides for each element, and d) Training and supervision materials that ultimately place the decisions about element selection, sequencing, and dosing in the hands of providers (versus higher order algorithms).
Common mental health problems such as depression, posttraumatic stress, and anxiety, are among the greatest contributors to global health disability. These common mental health problems, along with behavior problems such as alcohol and drug use, exist in all populations around the world. Unlike many other causes of disability, these health conditions are not only treatable but reversible. For people whose problems require their families to expend time and resources on their care, treatment can improve their ability to take care of themselves and to recover their social functioning and economic productivity for their family and community. CETA is a program that is scientifically proven to address a range of common mental health problems in different parts of the world. It does not require drugs, equipment, or large numbers of expensive mental health professionals, and it can be made widely accessible even in low resource settings. CETA can help people who experience disability or low productivity due to mental health problems strengthen their ability to contribute to the well-being of their families and communities.
To become a CETA provider, training and initial supervision is required by certified CETA trainers. Below is an overview of the training and supervision process. An apprenticeship model is used to ensure quality and support.
- Two week initial training in CETA
- 10 2-hour practice sessions for reviewing components
- 8-12 sessions for a pilot/practice client with supervision
- Weekly supervision and ongoing training from a trained supervisor and distance trainers
- Use CETA manual as a reference
- Clients receive 8 – 12 sessions (60 minutes per session)
- Clients learn and practice activities in session with homework
The CETA program includes counselors and supervisors, together referred to as CETA providers. Supervisors are identified from the participants in the 2-week initial CETA training and are provided with additional supervisory training. The Supervisors provide group supervision to the counselors. Typically, a CETA team consists of one supervisor and 3 to 5 counselors. Both supervisors and counselors provide services to clients (though supervisors generally have fewer clients because of their supervision time). Supervisors receive regular supervision from the CETA trainers via web/phone until their competence and skill-level is strong.Murray LK, Dorsey S, Bolton P, Jordans MJ, Rahman A, Bass J, Verdeli H. Building Capacity in Mental Health Interventions in Low-resource Countries: An Apprenticeship Model for Training Local Providers. International Journal of Mental Health Systems . 2011; Nov 18;5(1):30. doi: 10.1186/1752-4458-5-30. PMID:22099582. PMCID: PMC3284435.
In Karbala, Najaf and Hilla, Iraq, we completed a trial with adult survivors of systematic violence who were randomly allocated to receive CETA or be in a wait-control condition. CETA was provided by 12 community mental health workers (CMHWs) who were medics or nurses who worked in rural Ministry of Health primary health care centers. CETA supervisors were Iraqi psychiatrists. Compared with the wait-control condition, participants in CETA showed large, statistically significant improvements for all outcomes. Effect sizes were 2.40 for trauma symptoms, 1.60 for anxiety, 1.82 for depression, and 0.88 for dysfunction.
Weiss W, Murray L, Zangana G, Mahmooth Z, Kaysen D, Dorsey S, Lindgren K, Gross A, Murray S, Bass J, Bolton P. (2015) Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial. BMC Psychiatry. Oct 14; 15(1):249.
In Mae Sot, Thailand, we completed a trial with adult survivors of systematic violence from Myanmar who were randomly allocated to receive CETA or be in a wait-control condition. CETA was provided by 20 counselors who had worked previously as teachers or health workers, two had prior “general counseling” experience. Three CETA supervisors were selected who had at least a high school education and were bilingual in English and Burmese. One had prior “general counseling” experience. Compared with the wait-control condition, participants in CETA showed large, statistically significant improvements in depression and posttraumatic symptoms and moderate, statistically significant improvements in anxiety and aggression symptoms and functional impairment. Effect sizes were 1.16 for depression symptoms, 1.19 for trauma symptoms, 0.79 for anxiety, 0.58 for aggression, and 0.63 for impaired functioning.
Bolton, P, Lee C, Haroz EE, Murray L, Dorsey S, Robinson C, Ugueto A, Bass J. (2014) A Randomized Controlled Trial of a Transdiagnostic Community-Based Mental Health Treatment for Comorbid Disorders among Burmese Refugees in Thailand. PLOS Medicine. Nov 11.
In Ethiopia, we conducted an open trial of CETA with youth and caregivers. This study had two objectives: 1) to conduct an open trial of a common elements treatment approach (CETA) developed for comorbid presentations of depression, anxiety, traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border, and 2) to evaluate implementation factors from the perspective of staff, lay providers, and families who engaged in the intervention. The study was conducted in three refugee camps and utilized locally validated mental health instruments for internalizing, externalizing, and PTS symptoms. Lay providers delivered a common elements treatment approach (CETA) to youth and families, and symptoms were re-assessed post-treatment. Providers and families responded to a semi-structured interview to assess implementation factors. Children who participated in the CETA-Youth open trial reported significant decreases in symptoms of internalizing (d=1.37), externalizing (d=.85), and posttraumatic stress (d=1.71), and improvements in well-being (d=.75). Caregivers also reported significant decreases in child symptoms. Qualitative results were positive toward the acceptability and appropriateness of treatment, and its feasibility. In conclusion, this study is the first to examine a common elements approach (CETA: defined as flexible delivery of elements, order and dosing) with children and caregivers in a low-resource setting with delivery by lay providers. CETA-Youth may offer an effective treatment that is easier to implement and scale-up versus multiple focal interventions.
In Zambia, we are investigating the effectiveness of CETA compared to treatment as usual in reducing intimate partner violence (IPV) and alcohol abuse within family units. CETA is being provided by 63 lay counselors (20 male/43 female) who are overseen by 7 local supervisors. CETA is provided in separate, individual sessions for 8-12 weeks to three family members: 1) an adult female who has reported recent, severe experiences of IPV perpetrated by her male partner; 2) the adult male partner who has also self-reported hazardous alcohol use (or the female has reported that he drinks at hazardous levels); and 3) a child within the family whom the mother identifies as being most affected by the ongoing violence. CETA was adapted for this trial to include a CBT-based substance use reduction element. The component was drafted by our team, reviewed by other CETA trainers, substance use treatment experts, and local counselors from Zambia who had provided other CBT treatments. The CETA SU element includes: 1) motivational statements, including asking participants at multiple time points throughout the session to determine a behaviorally specific goal and rate their motivation to complete that goal; 2) asking participants to identify all of the drivers that underlie their drinking behavior; 3) teaching and practicing specific interventions and strategies that counter these individualized reasons listed; and 4) revisiting the individual goals and the motivation to work toward or complete that goal. Utilization of a family support system, including family-based approaches, has been shown to be an efficacious approach to decreasing substance use and relapse in other populations, therefore we also developed a “substance use support” component for this adaptation of CETA. The SU support element is designed to: a) provide psychoeducation about the substance use to the partner of the substance abuser, b) to have the partner help in identifying the users’ drivers, and c) help the partner identify ways in which she can support the reduction of use. Upon completion of the trial, we will compare the effectiveness of CETA to treatment as usual in reducing IPV and alcohol abuse at three timepoints: 1) immediately following the end of treatment; 12 months post-baseline; and 24 months post-baseline.J. C. Kane, S. Skavenski Van Wyk, S. M. Murray, P. Bolton, F. Melendez, C. K. Danielson, P. Chimponda, S. Munthali and L. K. Murray (2017) Testing the effectiveness of a transdiagnostic treatment approach in reducing violence and alcohol abuse among families in Zambia: study protocol of the Violence and Alcohol Treatment (VATU) trial. Global Mental Health, 4. doi:10.1017/gmh.2017.10
In Ukraine, we are conducting a three-armed blinded randomized control trial examining the effectiveness of CETA in reducing depression posttraumatic stress, and improving functioning for veterans of the Ukrainian military, internally displaced persons (IDPs), and their adult family members. The three arms include standard CETA, a brief 5-session CETA, and a wait list group. In this study we are simultaneously measuring the effectiveness for both versions of CETA to the wait-control condition, as well as, comparing the standard and brief 5-session version using a non-inferiority design. CETA is being provided by 29 counselors and 5 supervisors representing a range of professional backgrounds including psychologists, volunteers, medical doctors, program managers, teachers, and a lawyer. Standard CETA will be delivered in at least 8 individual sessions , while brief CETA will be delivered in 5 individual sessions. Brief CETA was developed to try to increase the public health reach of evidence-based treatments with shorter treatments. The 5 sessions include introduction, a cognitive element (coping/restructuring), and a behavioral component (either exposure or behavioral activation). These were chosen based on research suggesting that these elements may be particularly effective in reducing symptoms.
All clients, counselors and supervisors are blinded to whether the client is in standard or brief, with un-blinding happening after the fourth CETA session. All participants complete a symptom monitoring form on a weekly basis while in treatment. Primary outcomes will be measured at the 6-month post baseline time-point for all participants enrolled in the trial.
In Kachin state, Myanmar, we are researching the effectiveness of CETA for children and adolescents aged 8-17 years who have experienced stressful life events including displacement from conflict and who have elevated symptoms of mental health and/or behavior problems on the initial assessment. In this study, enrolled participants are randomized to receive CETA right away or placed on a wait list to be offered services later. Participants receiving CETA meet with a counselor one time per week to receive counseling sessions and wait list participants are visited by a data collector weekly. Both groups of participants complete a symptom monitoring form on a weekly basis. The CETA treatment participants will receive approximately 8-12 sessions and the wait list group will be met by the data collector for 10 weeks. CETA is being provided by 9 counselors and 3 supervisors. Primary outcomes will be measured using a comparison of pre- and post-assessments and will look specifically at changes in mental health and behavior problem scores. Mental health symptoms will be measured using a modified, locally validated version of the assessment instrument consisting of items from 1) the Child PTSD Symptom Scale (CPSS); 2) the Moods and Feelings Questionnaire (MFQ); and 3) items developed from qualitative research in this population. Behavior problems will be assessed using a behavior problem checklist developed using qualitative data collected from this population. In addition, we will analyze changes in functioning using a functioning scale developed using qualitative data collected from this population.
For more information about related to international application of CETA or for international adaptations or trainings, please contact the Global Mental Health group at Johns Hopkins Bloomberg School of Public Health.