Global mental health is an emerging priority in global health initiatives [1, 2]. This body of research suggests that mental health counseling interventions can be adapted and implemented with positive outcomes in the area of mental health and functioning across cultures and in low resource environments [3–8]. The growth of research in this area is critical given the high burden of mental health disorders, which account for approximately one-third of YLD [Years Lived with Disability] among adults . Depression, specifically, is the third leading global health threat. Despite the high prevalence and cost of mental health disorders, 90% of individuals with need do not receive treatment . This is largely due to the scarcity of mental health professionals in LMIC, particularly in the lowest income countries and in rural/low-income regions within countries .
A range of randomized clinical trials testing mental health counseling interventions provided by local lay counselors, with little to no previous mental health training or experience, have demonstrated positive findings in the area of mental health, health, and functioning outcomes [11–13]. In Uganda, Interpersonal Psychotherapy (IPT) was effective in reducing the burden of depressive symptoms among adolescents living in internally-displaced persons camps  and adults in an area severely affected by the HIV epidemic [6, 14]. In rural Pakistan, a CBT intervention for maternal depression was effective in both improving depressive symptoms and infant health (e.g., decreased diarrhea and improved immunization rates) . In the studies where follow-up assessments were conducted (e.g., 6-months post-intervention completion), outcomes were maintained [5, 15]. In a trial of a collaborative stepped-care intervention (i.e., MANAS) that included the provision of IPT for adult anxiety and depression in India, individuals who received the intervention were more likely than those who received enhanced usual care to: 1) recover at 6 months and 2) not meet the criteria for a diagnosable disorder .
Task shifting, employed in all these studies, involves moving the primary provision of the mental health intervention from mental health specialists (e.g., psychiatrists, psychologists, Master level providers) to lay counselors (i.e., limited to no mental health training or experience). This approach is responsive to the reality that addressing the mental health services gap requires an emphasis on a lay counselor workforce. Otherwise, scaling up mental health services for population-level impact is an unrealistic goal, given the limited number and unequal distribution of mental health specialists in LAMIC [16–18].
As evidence for the feasibility and effectiveness of specific interventions begins to accumulate, entities providing and supporting mental health interventions in LMIC (e.g., Ministries of Health, non-governmental organizations, community-based organizations) would benefit from guidelines on how to train and supervise these treatment skills to local providers. As stated in the recommendations from Mental Health Gap Action Programme (mhGAP), "pilot or experimental projects are of little value until they are scaled up to generate a larger policy and programme impact" . Implementation guidelines for training and supervision of lay counselors, as part of task shifting, are an essential element of building mental health programs in LMIC.
The dissemination and implementation literature on building local capacity among lay (or any type of) counselors in low resource countries is relatively limited [for exceptions see [6, 20–23]]. Published randomized trials of intervention outcomes [3, 5, 6, 12, 14, 15] typically provide some detail on training and supervision. However, this information is limited in nature, due to a focus on reporting study procedures and outcomes, rarely sufficient for replication of the training and supervision approach. General guidelines do not currently exist and this gap in the literature is not well addressed in the recently launched mhGAP, due to its broader goals . In the absence of guidelines, programs focused on mental health interventions or psychosocial support provided in LMIC typically consist of "one-off" or "train and hope" approaches (i.e., brief, one-time trainings, with limited pre- or post-training support).
Implementation science research, most of which has been conducted in the United States and other Western countries, clearly indicates that "one-off" training approaches may lead to initial knowledge change, but will not result in behavioral change in practice or counseling approach, even among mental health specialists [24–26]. Increasingly emerging in the implementation literature is the importance of supervision, coaching, and feedback in achieving fidelity, or adherence to the intervention [25–28]. As summarized in a recent paper on recommendations for training of mental health providers , "out of habit, we continue to conceptualize training and continuing professional education as a one-way broadcast from expert to trainee, primarily through didactic lecture, with only minimal feedback loops to learners from instructors regarding learning outcomes... for clinicians to become experts at a particular treatment, rather than achieve the minimal gains we tend to see, they must deliberately engage in target clinical behaviors, often and with feedback" (p. 8, para 3).
The goal of this paper is to elaborate on the training and supervision methods used in our collective work/studies in an attempt to more explicitly provide specific guidelines for lay counselor training and supervision in mental health counseling interventions in LMIC. The recommendations presented here were developed and employed over the last decade in varying low-resource environments, including Sri Lanka, Burundi, Indonesia, Sudan, Cambodia, Uganda, Zambia, Tanzania, Pakistan, Iraq, Nepal, and Thailand, with over 100 lay counselors. The authors are affiliated with different organizations and universities but are connected as scientific colleagues by a common interest in, and overlapping work on, improving outcomes for children, adolescents, and adults with unmet mental health needs in LMIC. In this paper, we have attempted to integrate our collective knowledge and experiences into a framework that can inform future training and supervision attempts.
Our focus is specifically on training and supervision of lay counselors to provide "Advanced Psychosocial Interventions" , defined by the mhGAP Intervention Guide as "interventions that take more than a few hours of a health-care provider's time to learn and typically more than a few hours to implement" (p. 4). We describe the elements of our approach, the underlying logic, and give examples drawn from our experiences. We also describe how this model is consistent with, and draws on, the broader dissemination and implementation (DI) literature. In doing so we hope to contribute to an emerging DI literature for LMIC, and ultimately, to the development of appropriate DI guidelines that can be adapted and used with a range of mental health interventions and populations in LMIC.