Integrating Cognitive Behavioral Therapy-based Interventions and Employment Programs for Youth in Sierra Leone
Evidence suggests that approaches based on cognitive behavioral therapy (CBT) can improve mental health and reduce crime and violence in post-conflict areas. However, delivering CBT programs is a challenge in settings that lack trained staff and therapeutic facilities. Researchers in Sierra Leone are exploring alternate delivery platforms to bring evidence-based mental health interventions to youth facing conflict and adversity in West Africa. This study will integrate a CBT-based intervention into an existing youth employment program and evaluate barriers to implementation and intervention effectiveness, as measured by impact on social functioning (soft skills), emotion regulation and economic stability.
Mental illness is the second-largest contributor to the global burden of disease among youth and adults and is projected to be the highest contributor to the global burden of disease by 2030. The level of untreated mental health problems is especially high in regions where exposure to war, violence, and poverty is prevalent. 1 Psychological distress due to trauma exposure is often expressed in higher rates of traumatic stress reactions, aggression and hostility, leading to difficulty in regulating emotions and social impairments which can further limit the ability of youth to successfully participate in the formal economy.
There is evidence that behavioral change therapy programs can reduce psychological distress and lead to significant reductions in crime, drug use, and violence among high-risk young men. The National Institute of Mental Health (NIMH)-funded Youth FORWARD study adds to this evidence by evaluating the effectiveness of a behavioral intervention designed for at-risk male and female youth affected by violence. While many programs offer treatment for specific diagnoses, such as post-traumatic stress disorder (PTSD), few programs focus on the anger and interpersonal difficulties that impede success in educational and employment programs. To address these issues, the Youth Readiness Intervention (YRI) takes a transdiagnostic focus by targeting deficit areas that occur across a range of mental health disorders related to violence (i.e. conduct problems, depression, anxiety) and adapting common-elements of evidence based treatments for such problems to the context of Sierra Leone in a simple group mental health intervention model that can be delivered by lay health workers under a strong program of training and supervision.
Context of the Evaluation
Sierra Leone has limited health care infrastructure and faces challenges in the delivery of mental health services, with few specialists and facilities.2 The weakened healthcare system and gaps in mental health treatment in the country is similar to that of many other low-income countries that have been affected by decades of war and other adversities. Given the high rates of mental health problems within Sierra Leone, health system constraints and lack of resources, seeking alternate delivery platforms to reach vulnerable youth is critical.
This study will take place in the Kono, Kailahun and Koinadugu districts of Sierra Leone, as a component of GIZ’s (Gesellschaft für Internationale Zusammenarbeit, the German-based development agency) youth employment promotion program (EPP). The youth EPP includes training programs in three areas: agricultural processing, entrepreneurship, and solar power maintenance. Participants for the YRI study will be recruited from youth enrolled in the entrepreneurship program and from control sites where such programs can be launched in the future.
The intervention curriculum was developed by researchers at Boston College, Harvard University and City University of New York, stakeholders with the Government of Sierra Leone and local mental health providers, and will be implemented by a number of local nonprofit service providers, with GIZ providing financial support.
Details of the Intervention
The researchers will evaluate the effects of the group mental health intervention on social functioning, emotion regulation and economic stability. The Youth Readiness Intervention (YRI), is a group-based intervention designed to be delivered by lay workers (such as community health workers and youth employment workers) in areas with little mental health infrastructure.
Twelve hundred youth (ages 18 through 26) participating in GIZ’s employment program or at control sites will be selected to take part in the evaluation. Participants will be selected if their screening test exhibits functional impairment or limitations caused by emotion dysregulation, an inability to control or adjust emotions and difficulties in daily functioning. They will be randomly assigned to one of three groups:
- Group 1: YRI + EPP (entrepreneurship training program and the Youth Readiness Intervention)
- Group 2: EPP only
- Group 3: Comparison group; usual services but not EPP or YRI
Participants assigned to receive the YRI curriculum will be invited to 12 sessions (one session per week). Each session focuses on a particular skill or psychological issue, such as behavioral activation for low mood. Active discussions, role play and skills building are used to reduce the emphasis on literacy and increase engagement with the group. The group format is meant to encourage peer-to-peer learning, share experiences, deepen social connections and practice skills with same-gender peers
The curriculum is delivered in three phases common in trauma-informed interventions: 1) stabilization, which focuses on education about trauma and its effects on interpersonal relationships to help normalize experiences and alleviate feelings of isolation; 2) integration, which emphasizes the reappraisal of negative, hostile, or distorted thinking; and 3) connection to others, which emphasizes a future orientation, building interpersonal relationships by improving communication and problem-solving skills, and the pursuit of positive life goals and activities.
The YRI has been adapted to Sierra Leone’s cultural context. The content is delivered in Krio using both international and local concepts of mental health. The sessions also incorporate Krio proverbs that reflect the skills to be practiced.
Researchers will measure effects three months (post-intervention) and one year after the YRI has been delivered. The research team is interested in whether delivering behavioral therapy in conjunction with an employment program can improve its efficacy and uptake of employment training as well, which is why the evaluation includes groups both with and without the YRI component.
The metrics of success on which the study will be evaluated are improved mental health, reduced functional impairments, improved emotion regulation, and better economic outcomes. Additionally, researchers will conduct a process evaluation to identify internal and external factors influencing the integration of the YRI into the EPP.
Results and Policy Lessons
Study in progress; results forthcoming
This project is made possible through the generous support of the U.S. National Institutes of Mental Health (NIMH).
 “Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016”, The Lancet, 2016. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32130-X/fulltext
 World Health Organization. Sierra Leone Annual Report: A Year in Focus 2017. Available from: http://www.afro.who.int/sites/default/files/2018-03/World%20Health%20Organization%20Sierra%20Leone%20Annual%20Report%202017.pdf.