“I was convinced this was going to be a complete disaster,” says Udry, an economics professor. “So we’re going to gather very poor people and talk about their problems and somehow change their lives?”
Still, the researchers, who co-direct Kellogg’s Global Poverty Research Laboratory, acknowledged that since mental health care has been largely absent from poverty-fighting efforts, it might be worth exploring. “So much of development policy is focused on job training and skills training and market access,” says Karlan, the Kellogg economics professor. “Mental health is seen almost as a luxury problem that is simply not being addressed in many developing countries.”
With this in mind, Kellogg researchers and collaborators Nathan Barker at Yale, Garrett Brian at the London School of Economics and Angela Ofori-Atta at the University of Ghana designed a study to implement cognitive-behavioral therapy (CBT) in low-income households in Ghana. CBT is a well-established psychotherapeutic approach to depression, anxiety and other conditions that involves helping people identify and deal with ‘cognitive distortions’ that affect the way they interpret and react to events, along with taking strategic actions to solve problems.
Conditions of chronic poverty, where people are “constantly presented with stimuli about their own low status,” may produce negative self-beliefs about one’s talent, worth, or future prospects, the researchers write. The possible results: poor mental and physical health, which could negatively affect financial results. These kinds of compounding difficulties are exactly what those living in poverty do not need.
To evaluate the effects of CBT, researchers conducted a large-scale randomized controlled trial in rural Ghana involving thousands of participants living in hundreds of communities. Research-based measures showed that CBT improved both mental and self-reported physical health, as well as financial outcomes and cognitive skills.
Essentially, the effects occurred regardless of whether a participant had been identified as depressed before starting treatment. This has important implications: although CBT is designed for depression, it can also be beneficial for those struggling with poverty anxiety, which for some will lead to depression. “There’s a lot of movement in and out of depression when you’re living with terrible trade-offs: Which need are you going to put last? Will it be food? Will it be medicine? Will it be training? These are stressful, potentially depressing, decisions to face,” says Karlan.
For those hoping to have an impact on mental health in these contexts, screening for poverty therefore makes more sense than screening for depression. Otherwise, care providers and researchers may miss members of the population who would benefit from treatment, the researchers say.
Changing Cognitive Patterns
The researchers worked in more than 250 communities in Ghana, which they divided into either control communities or communities receiving CBT.
Overall, this is a population experiencing significant stress: At the start of the study, 55 percent of participants reported some form of psychological distress, with 15 percent reporting severe levels—much higher than rates seen in the U.S., note the authors.
CBT was delivered in 2016 in 12 weekly 90-minute sessions in groups of 10 people. Treatment was administered by recent college graduates recruited and trained by Innovations for Poverty Action and the University of Ghana. CBT leaders received two weeks of classroom training and completed a week of CBT pilot work before delivering the intervention.
The program included modules on promoting healthy thinking, solving problems at home and work, managing relationships and setting goals. For example, participants learned how not to dwell on specific issues or to ruin events by thinking, for example, “One week without rain means all my crops will fail this year.” Participants also learned to recognize and mitigate “should statements” such as “I should be doing better in life than I am.”
Researchers collected pre- and post-intervention data from people in both treatment and control villages through surveys that measured mental health, physical health, social-emotional skills, cognitive skills, and economic outcomes. They then compared the results for the CBT group with those of the control group.
Attending the CBT sessions, Udry reconsiders his initial skepticism: “People were so interested in the workouts. They loved it.” For example, he noticed that the participants “seemed excited to talk about problems they were having and that the other people in the group really seemed to be paying attention—they were really listening to each other.” Afterward, participants compared the experience to “conversing with their pastor,” Udry says.
For example, participants discussed challenges they faced with their children. “They talked about strategies for when their kids were out of school and didn’t have a job yet—like if a kid didn’t pass the high school entrance exam,” Udry says. “They had a lively discussion and made a list of strategies on a whiteboard.”
A far reaching intervention
The CBT group did better than the control group on multiple baseline measures.
For example, those who received CBT reported missing fewer days of work due to health problems than the control group. “This translates into real economic changes due to improved mental health,” says Karlan.
Additionally, those receiving CBT were 10 percent less likely to have any psychological distress and 24 percent less likely to have severe psychological distress than their control group peers. They also reported having 11 percent fewer days per month with poor mental health and 20 percent fewer days with poor physical health than the control group.
“We were so happy to see that people had lower levels of stress and symptoms of depression,” says Udry. The study also revealed an unusually large improvement for the treatment group compared to the control group in socioemotional skills, such as those related to self-control.
And the benefits of CBT went far beyond mental health and social-emotional functioning. For example, the intervention also improved people’s cognitive performance, such as their performance on a 10-digit memory test. Importantly, outcomes for health and cognitive skills again did not differ by baseline mental health, suggesting the effectiveness of the program for people with and without diagnosable conditions.
Based on the results, Karlan and Udry conclude that CBT works through two pathways in the communities targeted by the intervention: by reducing the likelihood of poor mental health and directly improving the bandwidth for cognitive tasks, including how mental resources are allocated to solve specific problems. , such as household finances.
The researchers plan to analyze more specific economic effects of the intervention and use measures of income, investment and consumption collected during a follow-up survey.
Access to mental health treatment is not always at the center of anti-poverty efforts. But the researchers say the results of this study call for a major change in attitude. They conclude, “increasing access to mental health treatment in low-income countries should be seen as a key means of increasing human capital in the general population, with relevance well beyond the treatment of people with a diagnosable mental health condition.”