Using lay staff to help problem
drinkers in India
NDSAG Conference, Birmingham
29th April 2013
Richard Velleman
Emeritus Professor of Mental Health Research,
University of Bath
Senior Research Consultant,
Sangath Community Health NGO, Goa, India
SETTING
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SETTING
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SETTING
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Lay Staff, Drinkers, India
Vikram Patel: world leader in global mental health, leads an NGO
in Goa, and Prof. of Global Mental Health at LSHTM
http://www.lshtm.ac.uk/aboutus/people/patel.vikram
http://www.ted.com/speakers/vikram_patel.html
Decided to mount a project looking at both Depression, and Alc
Probs in India
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Why Alc? Traditionally, low alc country, but now, India is
one of the fastest growing alcohol markets in the world
and one of the largest consumer of whiskey (which
accounts for almost 80 per cent of the entire liquor
market in India). [http://www.financialexpress.com/news/liquorconsumption-in-india-to-jump-30-/869641]
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High abstention rates, high rates of AUD amongst those
who drink, no normative drinking culture, and high
rates of alcohol-attributable mortality and prevalence
of AUDs, relative to the per capita alcohol consumption
The Goan Story
• Prevalence of AUD in
men- 5-21%
• 1/3 who consume
alcohol have AUD
• Associated with CMD,
injuries, economic
difficulties & spousal
physical violence
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Lay Staff, Drinkers, India
• NOW in India, Alc is second only to depressive
disorders as the leading neuropsychiatric cause
of disease burden
• Remains low on Indian health policy agenda
• No services for alcohol (policy = ATUs; reality –
very few. Satara – 10+ million catchment area)
• Treatment gap amongst the largest for all
mental disorders
• Lack of trained professionals
Lay Staff, Drinkers, India
The PREMIUM project (plan!) 5 year project, October 2010September 2015
• Develop an alcohol [& depression] treatment
• a) best evidenced using Western research
• b) change it to fit with India (Context!)
• Get professional practitioners to deliver the intervention,
and change and adapt it according to their experiences to
make it Indian-appropriate
• Once trained and competent, use these practitioners to
train lay people to deliver the intervention (s), supervised
by a) the trained practitioners and then b) peer
supervision
• Plan to deliver it in primary care, following screening
(AUDIT – scores of 12-19)
• Do an RCT (vs ‘enhanced usual care’) 2013-2015, to see if
it works.
• Focus on Harmful Drinking (AUDIT) not Dependent (20+)
Lay Staff, Drinkers, India
VERY exciting for me –
a) obviously interested in Counselling for Alc Problems;
plus
b) my work in developing the VACTS scheme in the UK –
still running well in Scotland, and
c) related to VACTS, in reviewing research on the relative
effectiveness of lay and lesser-trained staff vs Highly
trained and very expensive staff.
SO …. What had been done in PREMIUM in the 14months
before I joined, in December 2011 (17 months ago)
• Developed the alc [and depression] treatment
Lay Staff, Drinkers, India
Lay Staff, Drinkers, India
• Best evidence seemed to be for Motivational
Approaches (Although recognising that CBT and
Personalised Feedback might also be useful,
alongside of host of other ideas, including
utilising social support, religious and spiritual
practices, relapse prevention work, etc)
• Got Jeff Allison out to run a MI training workshop
• Selected 4 professionals to deliver the therapy: 2
x Consultant Psychiatrists, 1 senior psychiatric
SW, one trained professional counsellor (came in
via Lay work – previous project MANOS delivering to MH services in tandem with primary
care in India).
• 2 based in Goa, 2 based in Maharashtra (6-8 hour
drive or an overnight train away)
Lay Staff, Drinkers, India
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My role: year 1 (December 2011-November 2012)
I was asked to provide weekly supervision to the
professionals, and get them to a level that they’d be
able to train and supervise the lay workers. Did that
December – March in Goa (and Maharashtra) and then
weekly by Skype/phone until October
•
PLUS to co-write an overall generic counselling manual ,
and also the developing Manual for the Alc treatment –
the PREMIUM Approach to Counselling Treatment:
Harmful Drinking (PACT-HD); name being changed –
probably to CAP - Counselling for Alcohol Problems
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PLUS to run a generic counselling course for the
professionals – more on that later
Lay Staff, Drinkers, India
My role: Year 2 (Dec 2012- end of project)
• Continue the writing / revising of the
manuals;
• continue the supervision;
• help with the recruitment and the
training of the lay workers;
• help with developing the RCT.
Lay Staff, Drinkers, India
Issues and challenges
Supervision: Complicated, as they delivered the treatment in
local languages (Konkani or Marathi) and I don’t speak either
of them (and the two from Maharashtra don’t speak Konkani)
Solution: transcribe the sessions; then translate them –
ISSUES – awful translations! And lose so much information.
Rating of Competence: Develop a systematic way of rating
(tried MITS (Motivational Interviewing Target Scheme) and
MIA-STEP (Motivational Interviewing Assessment –
Supervisory Tools for Enhanced Proficiency). Both measured
various aspects (eg Empathy, collaboration, independence,
navigation, evocation etc)
Lay Staff, Drinkers, India
The Psychological Treatment
Motivational Interviewing (Behavioural Activation):
Indian Professionals found MET Very difficult
• Deceptively simple
• Very antithetical to India – hierarchical systems
• Even trained professionals are not trained - No
training in counselling – all from books
• MI = mix of core person-centred skills, PLUS
structure / direction. COULD do warmth
empathy etc; Started by being authoritarian in a
warm way; could learn to stop being
authoritarian, but then, complete mess and drift,
and no structure or control! Found the mix of
warmth PLUS structure – collaboration ;
independence; all v difficult.
Lay Staff, Drinkers, India
Solution: I trained all their staff; plus supervised
‘My Four’ with extremely detailed annotations and
role-plays to get them to gradually ‘get it’.
But Problem: if THEY find it so difficult (1 year of
detailed supervision and training) can we expect
lay people to get it vastly faster?
* Plus, I soon realised that a MI approach would
not be enough. Many people needed far more
than a motivational nudge. Many people had no
drink-refusal skills, felt hugely pressurised, had no
alternative social networks, etc etc.
Lay Staff, Drinkers, India
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Plus the original idea to see only Harmful drinkers and NOT
see Dependent ones was deeply flawed – the work is to be
done in Primary Care, and we can’t simply refuse to see the most
severely problematic of their patients and still retain our credibility
with the PC Centres. We have to offer DD something. My idea –
offer the same; Jim Mc – offer a brief session plus referral on.
Problem – nowhere to refer them on to.
Modifications of treatments and in language:
• Patient’s participation in agenda setting difficult – They need help
to realise that they are ‘allowed’ and wanted to to participate
• Use culturally appropriate terms in the Manuals:
• Use ‘Counsellor’ instead of therapist; ‘patient’ instead of client’
• Terms such as ‘practice’, ‘exercise’ rather than ‘homework’;
• ‘meetings’ instead of ‘sessions’;
• Terms such as ‘stress’ and ‘tension’ explain the illness rather than
‘depression’, ‘mental illness’
Current Treatment Manual looks something like this:
Lay Staff, Drinkers, India
Page
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Understanding Harmful Drinking
An Introduction to the PREMIUM Approach to Counselling Treatment for
Harmful Drinking (PACT-HD)
The style of PACT HD counsellor
PACT-HD SESSION BY SESSION GUIDE –
A:
THE GENERAL FORMAT OF ALL THE SESSIONS:
 Four Tasks: Developing an engaged relationship; Working together;
Helping to set the agenda; and Building the patient’s motivation to
change.
 Structure of each session
B:
INITIAL PHASE (SESSION ONE – GETTING STARTED)
 Introduce PACT-HD to our patient
 Set the agenda
 Help our patient to better understand his drinking, based on initial AUDIT
assessment
 Give personalized feedback to our patient about his drinking
 Help our patient to decide on his drinking and other goals
 Working with our patient on developing a change plan
 Special Situation: providing a very short version of Session One
Lay Staff, Drinkers, India
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C:
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D:
MIDDLE PHASE (SESSION TWO – HELPING THE PATIENT TO CHANGE):
Reviewing Progress
Problem solving
Drink refusal skills
Handling urge to drink
Handling your difficult emotions
ENDING PHASE (SESSIONS THREE AND FOUR – DEALING WITH RELAPSES
AND ENDING WELL)
 Preventing and dealing with relapse
 Ending well
Telephone Counselling and Home Visits
Dealing with challenging situations
Dealing with patients having Tobacco problem as well as drinking problems
Dealing with patients having Depression as well as drinking problems
Dealing with Domestic Violence
APPENDICES
Lay Staff, Drinkers, India
The Lay Workers
• Recruited and Trained 16 in June 2012. Only 3 left
by December.
• Recruited and trained new cohort, much more
attention paid to engaging them, so far, few dropouts.
• We are developing an assessment and competency
framework.
Piloting the interventions:
Engagement: huge problems: Barriers and solutions
at patient, facility and interventionist levels
Lay Staff, Drinkers, India
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PHC Patient refuses screening, does not see screening as a
part of the PHC services, does not think it is important
• Does not have time for screening – will lose place in the
queue to see doctor
• Lack of space for screening/privacy
• Refuses counselling due to practical barriers
• SO does not allow counselling
• Patient has no time to wait for first session
Solutions:
• Spend greater efforts in engagement, recognising that
patients comes to PHC seeking medical treatment for
physical health problem
• Engagement of significant others, family early in counselling
– identify support person and develop information materials
• Develop optional Short brief session (covering key
engagement, and assessment and personalised feedback)
Lay Staff, Drinkers, India
Opportunities: If ‘works’, will probably be rolled out over
whole of India, and maybe much of the developing world:
Lay Staff, Drinkers, India