Establishing a System for Cognitive Therapy Training, Research, and Practice in Pakistan: Implementation-More Art Than Science

Building a sustainable mental health system in low and middle-income countries (LMICs) has been a long-term concern.1 There is an increasing international recognition for the need to build capacity to strengthen mental health systems in LMICs. However, the primary focus of global mental health research has traditionally been at a public health level, with an emphasis on delivering therapy by non-specialist therapists after a short period of training. 2 Although the population in these countries is mainly based in rural areas, most of the studies have been conducted in rural areas. However, ironically, the health services in most LMICs are located in large urban centers, and people have to travel a long way to these centers to seek the mental health care they need.3 Also, there is a limited provision of psychotherapeutic interventions in many LMICs due to lack of resources; inadequate training; different explanatory health models; and the religious and political landscape.4 LMICs differ widely in income, scientific and social development, and their relationship with the West.5 This diversity requires individual solutions rather than a broad-brush approach to improve access to mental health care. One shoe does not fit all. Health care in Pakistan is provided by a mix of public and private sectors, with additional support from alternative health practitioners and traditional faith healers.6 Pakistan is at this moment recovering from a near economic default situation. The country’s health budget allocation to mental health has drastically declined over time, leaving the present situation even more dire than when it stood at just 0.4%.7 Since there are only a few hundred psychiatrists, now estimated at over 600, and around 500 practicing psychologists for a population of around 250 million,8 we have trained more than 300 CBT therapists to cope with this dire lack of resources, who provide low-cost psychotherapy in Pakistan (typically 10-15 USD per session). Pakistan is the first low-income nation in the global south to produce locally trained CBT therapists. Pakistan Association of Cognitive Therapists (PACT) was launched 15 years ago. FN trained nine CBT master trainers in Pakistan between 2006 and 2009. In 2008, six of the master trainers, along with FN, founded the PACT and then the Pakistan Institute of Cognitive Therapies (PICT) in 2013. In 2019, PACT launched the first national CBT service in any low- and middle-income country, called Dil ki baat, to provide low-cost online therapy as well as in-person services. This service was launched on a non-profit, no-cost basis.9 The implementation process was divided into three phases; the First Phase (2009) focused on awareness, training, and accreditation. Public information campaigns and the publication of therapy materials made CBT popular in Pakistan. The Second Phase (2014) aimed at developing local therapists. A one-year CBT diploma was launched in Lahore and Karachi, and later as a hybrid model during the COVID pandemic.10 The third Phase (2019) focused on developing clinical services. Initial centres were developed in collaboration with local hospitals, and an online CBT support service was launched during the COVID pandemic. The organization decided not to rely on foreign funding or local philanthropy. Initial funding was generated through conducting CBT training in Pakistan and other countries in the region. Additionally, funds were raised by selling hard copies of self-help manuals, which are otherwise available for free on the website.11 In this process, several barriers were identified, including a lack of awareness, funding, government interest, trained professionals, and access to therapy materials.12 Facilitators towards said barriers included increased mental health awareness; engagement of all stakeholders including psychiatrists, psychologists etc.; interventions aimed at engaging both patients and caregivers; the use of the internet and social media; and the development of a workforce not dependent on government structures.13 It is possible to disseminate and implement CBT on a national scale in a low- and middle-income country by working closely with all stakeholders, gathering a team of dedicated professionals, and implementing careful long-term planning. Such an ambitious undertaking demands not only strategic foresight but also unwavering commitment, creativity, and innovation in order to ensure sustainability. From the outset, careful consideration of an appropriate business model is essential, as sustainability cannot be achieved without a structured financial framework. However, culturally adapting CBT provided us with the common language that helped in buidling a stronger therapeutic relationship, without merely concentrating only on financial framework, because our broader aim was to create a workforce of therapists in Pakistan, drawing from the large pool of psychology graduates produced by national universities each year.14 Since Pakistan is recovering from a financial crisis and is currently not in a position to further support mental health services as physical health takes precedence, the only possible way to revive an evidence-based therapy is to provide it at low cost by producing local therapists. However, this requires setting up systems to support the training and supervision of therapists, with the hope that in the future, with economic improvement, these therapists can provide CBT at subsidized rates. Even in most high-income countries, free CBT services are rarely available. Also, the people of Pakistan are accustomed to a healthcare model that blends public and private services. In conclusion, our approach can be considered as field research; we learned as we progressed and we progressed as we learned, and the journey continues.

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