Best Practices in Global Mental Health: An Exploratory Study of Recommendations for Psychologists

Abstract

Recommendations for best practice are useful in guiding the ethical and effective practice of psychology. Global mental health (GMH), which works to improve mental health treatment and access on a worldwide scale, is a growing field with many opportunities for psychologists, though such best practice recommendations have not been articulated. Using a grounded theory approach, this qualitative study recruited and interviewed psychologists identified as leaders in the field. Findings included broad categories of recommendations related to overarching variables (consideration of cultural/contextual variables; collaboration), program level characteristics (sustainability; formative and summative evaluation; flexibility; attention to systems; multidisciplinary teams; clinical knowledge and perspective; attention to spectrum of mental health), and individual level characteristics (perseverance; ongoing mentorship/supervision; self-awareness; boundary setting). Future directions include recommendations to recreate this study with a more geographically diverse sample, as well as with community members and service users of global mental heath projects. Increased attention to individual level competencies that impact global mental health projects are warranted. Recommendations for best practice and implications for training are also considered.

Psychologists have a critical role to play in increasing access to care for the 450 million individuals diagnosed with mental illness worldwide (World Health Organization, 2017). One such route is via greater attention to the field of global mental health (GMH), which is broadly envisioned as a method of improving and achieving universal mental health equity (Patel & Prince, 2010). A relatively new discipline within psychology, GMH developed within the past fifteen years to meet the needs described above and stems in part from the World Health Organization’s global health focus, in part via focus of scaling up mental health services in low- and middle-income countries (LMICs) (Misra, Stevenson, Haroz, de Menil, & Koenen, 2019; Verdeli, 2016). Commitment to this aim is reflected in the 2009 Vision Statement of the American Psychological Association (APA, 2009), which states a goal of advancing psychological science by acting as a “global partner” through efforts to increase knowledge and practice of psychology in diverse communities on an international level. In keeping with this goal, APA’s Committee on International Relations in Psychology (CIRP) works to foster relationships within the psychological community worldwide in order to meet global challenges (APA, 2012). APA has also recently articulated areas of professional competencies for psychologists when working outside of the United States (Morgan-Consoli, Bullock, Inman, & Nolan, 2018). While GMH may not yet be a mainstay of traditional psychological practice, the existing literature illustrates numerous significant contributions to the field of GMH by psychologists and their colleagues, such as mental health program evaluations in post-genocide Rwanda (Ng & Harerimana, 2016), projects in South Africa that advocated for system change and poverty alleviation strategies that work in tandem with mental health services (Burgess & Campbell, 2014), and scaling up mental health services via training lay counselors (Murray, et al., 2011).

While calls for international collaborations are firmly in place (Forrest, 2010; Nilsson, Wang, & Chung, 2019) and professional competencies for international work have been presented (Morgan-Consoli et al, 2018), clearly defined best practices in GMH that are specific to the role of the psychologist have not been fully articulated. Best practices, described as that which has “shown evidence of effectiveness in improving population health when implemented in a specific real-life setting and are likely to be replicable in other settings” (Ng & de Colombani, 2015, p. 159), may be informed by past projects and experiences. Thus, learning from professionals who engage in international work, via discussion of real-world examples of success, may provide a mechanism to fill this gap and may improve subsequent GMH efforts. Further, codified best practices may also serve to acknowledge and respond to some of the common criticisms of the field, such as challenges in recognizing psychopathology in varying cultures and translating mental health interventions meaningfully across contexts (Fernando, 2012; Fernando; 2014; Kirmayer & Pedersen, 2014).

Using combinations of key words international psychology, global mental health, lessons learned, best practices, and case studies highlighted recommendations that appear within the public health, psychology, and psychiatry literature, often with commonalities across disciplines. In the existing international psychology literature, findings have focused on personal characteristics, including curiosity, humility, self-awareness, and openness, that are key for ethical practice (Bullock, 2016; Gerstein, Hurley, & Hutchison, 2015). In particular, self-awareness appears as a critical first step, involving examination of one’s own cultural assumptions that influence how psychological phenomenon are understood; this process requires individuals to consider issues of power and privilege, to recognize that there is much diversity in human behavior, and to accept that interventions do not necessarily seamlessly transition from cultural context to another (Bullock, 2014; Forrest, 2010; Marsella & Pedersen, 2004; Wang & Çiftçi, 2019). Other literature, such as that by Gerstein et al. (2015), offer models that point to the interactive effects between environment and individual, emphasizing that it is these cumulative factors that result in development of international competence. Outside of the individual, competencies related to the incorporation of social justice principles into global contexts exist (Wang & Çiftçi, 2019), with focus on individual awareness, development of culturally appropriate programming, and inclusion of advocacy as vital skills. Similarly, literature also suggests collaboration and sustained engagement as part of competent international engagement (Inman et al., 2019).

Other work, such as that by Khenti et al. (2012), reflected upon successful integration of mental health care into primary care by describing five factors critical to effective GMH practice, including “reciprocity, sustainability, holistic health, cultural competence, and the improvement of overall health and quality of life” (p. 90). In 2015, Khenti et al. updated these factors to include cultural and socioeconomic relevance, partnerships and collaborative, action-based education and learning. While not in the GMH domain, Ng and de Colombani (2015) completed a systematic review that suggested that relevance, community participation, stakeholder collaboration, ethical soundness, replicability, effectiveness, efficiency and sustainability were key guiding factors in public health projects.

Commonalities between these recommendations are evident, which shared focus on sustainability and relevance. Focus on these types of factors is not unique to these specific papers; rather, sustainability is often cited as a critical aim of efforts (Forti, 2005; Raviola, Eustache, Oswald, & Belkin,, 2012; Sapag, Herrera, Trainor, Caldera, & Khenti, 2013; Shah, 2011; van Ommeren, Saxena, & Saraceno, 2005), and relevance (i.e., prioritization of local knowledge) is often emphasized as a critical factor that affects implementation and policy changes (Ravitz et al., 2014; Raviola et al., 2012; Sapag et al., 2013). The similarities across domains suggests that many of these factors may also be critical for psychologists.

Additionally, while other themes identified by Ng and de Colombani (2015) and Khenti et al. (2015) may have differing terminology, interconnected concepts inherent in these variables are easily identified (e.g., community participation and stakeholder collaboration are building blocks to ensuring relevance and craft partnerships). However, aspects of these best practice recommendations also have varying foci (e.g., Ng and de Colombani’s (2015) ethical soundness and replicability domains versus Khenti et al.’s (2015) partnerships and action-based education and learning variables). Assessing these variations, while noting commonalities, is a needed task within best practice literature.

Other recommendations have identified mechanisms that promote capacity building in GMH (Fricchione et al., 2012; Godoy-Ruiz, Cole, Lenters, & McKenzie, 2016), have posited involving interdisciplinary teams (Boutilier et al., 2011; Raviola et al., 2012; Sapag et al., 2013), have described recommendations for specific settings (e.g., humanitarian settings; see Tol et al., 2011), and have emphasized the importance of the roles of respect, empathy, and mutual trust in global partnerships (Forti, 2005; Kayingo, et al., 2016; Sapag, Herrera, Trainor, Caldera, & Khenti, 2013). In addition, it has been argued that awareness of self and the personal attributes of professionals engaged in GMH also are critical moderators of success (Morgan-Consoli et al., 2018). Assessing best practices may include variables that are active at varying levels (e.g., project and individual level variables) to encapsulate these existing concepts.

Finally, a brief review of recommendations from large global health organizations and programs will be reviewed. The Canadian Coalition for Global Mental Health (2015), which works to promote equity in global health, suggest the importance of themes including authentic partnering, inclusion, shared benefits, commitment to the future, responsiveness to causes of inequalities, and humility. Further, the Commission for Research Partnerships with Developing Countries is an organization based in Switzerland that works to promote equitable research collaboration with LMICs to eliminate global problems; their efforts have resulted in a handbook outlining considerations that underscore successful partnerships. These principles include setting the agenda together, interacting with stakeholders, clarifying responsibilities, accounting to beneficiaries, promoting mutual learning, enhancing capacities, sharing data and networks, disseminating results, pooling profits and merits, applying results, and securing outcomes (Swiss Commission for Research Partnerships with Developing Countries, 2014). Of note, while these recommendations come from a variety of sources, similar themes exist in each set of guiding principles.

In order to expand the ability of psychologists to make significant contributions to the field of GMH and to identify what unique contributions psychologists may add to the conversation about best practices in GMH, it is important to leverage what may already be known about effective and successful endeavors from experts who are engaged in the work. Gathering and organizing this type of information is critical to informing education efforts that exist within psychology training programs. The current study adds to the literature on GMH by qualitatively exploring best practice recommendations from psychologists engaged in GMH, given that most of the existing literature examines best practices from the perspective of other professionals (with the exception of Morgan-Consoli et al., 2018). The goal of the present study is to synthesize factors identified as critical to successful practice from experts in GMH and to build on existing literature that highlights necessary competencies (Morgan-Consoli et al., 2018) and recommendations for effective practice (Khenti et al., 2012).

Method

Participants

Participants were initially recruited through identification of significant contributions to the existing literature on GMH and subsequently, through a peer nomination process from initially identified experts. Authors reviewed key GMH articles to initially identify psychologists, as well as hand reviewed reference lists of these key articles to increase the respondent pool. Additionally, psychologists employed by organizations that are active in GMH were specifically recruited, due to a clear portfolio of GMH work. While participants were asked to nominate peers, there were no other participants added via this route. Eligibility criteria included a doctoral degree in psychology, as well as have demonstrated hands-on experience and dedicated time working abroad in a professional capacity. Fifteen initial participants received an email outlining the purpose of the study, an invitation to participate, informed consent forms, and criteria for inclusion in the project. Nine individuals agreed to participate in this study. All participants received the interview questions prior to the interview, in order to allow them to develop thoughts on their involvement tin GMH. Participants also received a demographics questionnaire and questions that were used to describe their history of and current work in GMH.

Seven participants were female, and two were male. Participants ranged from 42 to 64 (M = 53; SD = 8.39) years old. Three individuals identified as White (Caucasian, European American), one individual identified as Asian or Pacific Islander, and one individual identified as Mixed Latina/European American. Four individuals did not identify a racial background. The majority of respondents reported the United States of America as his or her country of origin (n = 8); the remaining participant currently resides in a high-income country. The majority of respondents (n = 8) indicated employment at a university, and the remaining individual reported working for a NGO. Eight participants earned a PhD in clinical or counseling psychology, and one participant held a PsyD. Respondents indicated a range of experience from 12 to 40+ years, as well as job duties typically comprising research, clinical, teaching, and consultation roles. Seven participants reported completing projects in LMICs.

Procedures

The first author conducted individual, semi-structured, audio-recorded interviews with participants, which ranged from 45 to 90 minutes in duration. Interviews were conducted via phone or Skype. Interview questions were designed to seek from participants reflections about their general work in GMH, with additional focus on their past experiences and recommendations for best practices in GMH. Please see Table 1 for a complete list of interview questions. The format of semi-structured interviews allowed for common themes to be explored among participants while offering the flexibility to explore respondent answers as needed (Suzuki, Ahluwalia, Arora, & Mattis, 2007). As a part of the protocol for grounded theory (Corbin & Strauss, 1990), the researcher recorded notes after each interview with impressions about the content and process of the session. Information from the interviews was coded to highlight common themes that emerged across interviews; the first author was the primary coder, and emerging themes and analysis were shared with the second author for review and feedback. Both authors approved the final coding structure. After data were condensed, critical elements of the data were shared with study participants to check for accuracy, to allow for further review, and to check for researcher bias (Morrow, 2005). The authors’ institutional review board approved procedures for the study.

Table 1.

Interview questions. Note that italics indicate follow-up questions.

Number	Question
1	What has your experience been in the practice of global mental health?
1a	What projects have you worked on?
1b	Where have you worked?
1c	How did you get interested in your work?
2	What do you wish you had known when beginning your career in global mental health?
3	As you reflect on your past work, what do you think are your most important “lessons learned”?
4	What has made the projects or interventions that you have worked on successful?
4a	How have you defined “successful”?
5	Tell me about any specific failures or unexpected challenges you have encountered in global mental health work and what you have learned from these experiences.
6	There are some challenges to the practice of global mental health, particularly a.) concerns that it does not truly account for cultural context when attempting to provide interventions and b.) perpetuates issues such as power differentials and lack of involvement of the local community when outside professionals attempt to partner with local communities. How would you respond to these challenges?
7	What would you consider to be essential components of “best practice” when it comes to designing and implementing successful projects?
8	Some recommendations from the existing literature have suggested the importance of considering issues such as “reciprocity, sustainability, holistic health, cultural competence, and improvement of quality of life” in the practice of global mental health.
8a	How would you respond to this statement?
8b	Have these factors been important to you? Have this factors not been important in your work?
8b	What would you add or remove from this list?
9	Are there unique ways that psychology contributes to the field of global mental health to address issues such as mental health disparities?

Researcher Background and Experiences

The primary research and first author completed doctoral level training in counseling psychology in the United Sates of America and identifies as a European American. She is committed to learning more and working towards reducing disparities in mental health on a worldwide level and has been developing this perspective over the last ten years through her volunteer, academic, and clinical work. She is drawn to using qualitative approaches in order to better understand the meanings that individuals ascribe to their experiences, while also believing that such an approach is a useful method for helping traditionally disempowered individuals gain a voice in research endeavors. In this study, she anticipated hearing from respondents descriptions of lessons learned that are culturally responsive, sustainable, and promote a social justice agenda. The second author completed her doctoral training in the United States and identifies as Mexican American. She has participated in several international supervision training efforts in LMICs but was not specifically trained in GMH during her graduate training. In this study, she anticipated hearing about the challenges of conducting culturally responsive projects and the value of learning through making mistakes.

Data Analytic Procedures

Coding themes began broadly and narrowed through the use of subsequently stringent categorization methods utilized in grounded theory (Glaser & Holton, 2007). Grounded theory has three phases of coding: open, axial, and selective (Merriam, 2009). Open coding is based upon identification of any data point that might be relevant to the study (Merriam, 2009). Axial coding then groups related concepts into categories (Merriam, 2009); categories are determined in terms of “properties and dimensions, the conditions which give rise to it, the action/interaction by which it is expressed, and the consequences that result” (Corbin & Strauss, 1990, p. 420). Finally, selective coding develops hypotheses that relate the categories to one another (Merriam, 2009). Selective coding importantly identifies the core variable, which is considered to be the element that connects the categories, accounts for the variation in the study, and offers the basis of the resulting theory (Glaser & Holton, 2007; Merriam, 2009).

After transcribing and identifying themes contained in the individual interview, each participant received an email asking for amendments, additions, or correction of errors of these transcriptions and themes. Of the nine participants, five individuals responded to this invitation. Comments received from the respondents indicated agreement with the transcription and themes, as well as minor modifications to language or naming of themes.

Results

Themes from this study were sorted into three broad categories: overarching variables, program level characteristics, and individual level characteristics (see Table 2). Description of the broad categories and sub-themes are provided below, along with illustrative quotes.

Table 2.

Overview of main findings.

Categories	Themes
Overarching Variables	Consideration of cultural/contextual variables Sub-Themes Cultural relevance Cultural competence Recognizing similarities and differences
	Collaboration Sub-Themes Relationship building Reciprocity Communication
Program Level Variables	Sustainability
	Robust evaluation & research methods
	Flexibility
	Attention to systems
	Multidisciplinary teams
	Clinical knowledge & perspective
	Attention to the spectrum of mental health
Individual Level Variables	Perseverance
	Ongoing mentorship & supervision
	Growth of self-awareness
	Boundary setting

Overarching Themes: Consideration of Cultural/Contextual Variables and Collaboration

Two main categories emerged as common themes with implications for categories within both program and individual level characteristics of successful GMH efforts: consideration of cultural/contextual variables and collaboration. All participants referenced concepts related to these issues. With respect to cultural/contextual variables, subthemes emerged that centered on development of culturally relevant projects, provider cultural competence, and the importance of recognizing both similarities and differences in cultural contexts. Regarding the concept of collaboration, relationship building, reciprocity, and communication emerged as subthemes. Each subtheme will be explored in the following sections.

Cultural Relevance

Crafting GMH programs that have meaning and value in identified communities emerged as a common theme, with eight participants identifying varying aspects of this concept as critical in their work. Generally, comments focused on responding to community needs, following leadership of local colleagues, and modification of interventions. The importance of first ascertaining if proposed projects are needed or are priorities in local communities was described by one participant: “We first want to connect with them - the local population, to find out what the problems are, what already exists, what role can we fill, etc. I think the local implementing partner has a lot to do with that” (Participant #8). As alluded to by this respondent, other participants repeatedly underscored the importance of following the guidance of local colleagues to craft culturally relevant programs and its application in their work. One participant described this concept in greater detail: “So when we work with our colleagues [abroad] in the integration of mental health and primary care, we work with the people on the ground and talk about what has worked in this protocol before and get their expertise on what will or won’t work, and then modify to the extent necessary so that the intervention will have legitimacy and validity locally. So that’s how we do everything, and it makes a huge difference” (Participant #7).

Cultural Competence

Working towards developing cultural competence was identified as key by eight participants. One participant summarized this theme in the following way: “There’s no question that people need to respect the ideas around culture… this is really, really important – really important – you can’t work without an appreciation for the fact that when we work in global health and particularly global mental health, people are exposing themselves and there’s a vulnerability associated with that kind of engagement. To not be culturally competent is a huge problem – it’s not ok” (Participant #7). Nevertheless, a different participant commented on the difficulty of maintain this competency: “I see well-meaning colleagues without a cross-cultural background who want to have an impact… and it’s a bit of a stretch to be able to help in a way that’s relevant by only taking your US or European skill sets over. So I think people are being more and more aware of this… but still a lot of our defaults are to go with what’s culturally familiar” (Participant #3).

To avert difficulties from lack of competence, five individuals identified gaining knowledge as a necessary task within working towards cultural competence. Several participants discussed this idea in the context of cultural immersion and living within different contexts, with one participant describing the following: “It’s almost like get your vaccinations, and you do it, but you don’t really know until you get there that you’re going to be eaten alive by mosquitos. Someone might have told me before I went to [country] ‘well, that’s not going to work’… But until I got there and went to that first therapy session I was doing with that family and it was a total bomb, I probably wouldn’t have made sense of it anyways. It doesn’t register. You don’t hear it” (Participant #5).

However, gaining knowledge via cultural immersion and/or living in different contexts is aided by variables such as respect and humility. Particularly, respect is reflected in appreciation for differing norms, values and beliefs, as well as a willingness to learn about such differences: “The most important thing is respect and being able to appreciate how my colleagues overseas… go about doing their work. Not trying to infuse a US-centric point of view into the way they do things” (Participant #6). Similarly, humility was described as approaching partnerships such that knowledge of one’s limits and importance of hearing the perspective of others is evident. One summarized the following: “Humility – to be able to recognize the limits of your own knowledge and skills and the contributions of other knowledge and skills. I also think to be ok saying ‘I don’t know what to say’ or ‘I didn’t really get that’. You can’t go in with pride” (Participant #5). In sum, working towards cultural competence, a critical aim in best practices, is an ongoing task assisted by supervision and mentorship, gaining knowledge, and developing respect and cultural humility.

Recognizing Similarities and Differences

Six participants discussed learning to identify both similarities and differences, particularly in terms of human experience and manifestations of mental illness. One participant described this concept by stating: “It’s very strange, but at the same time but I’m aware at the same time how different and similar people are. We find some differences, of course, in expression of depression – I mean we call it depression – but expression/state of resignation or hopelessness and helplessness and reactions to loss. So I think the similarities actually may outweigh the differences. But it’s very important to understand the differences” (Participant #1). Another respondent further commented on this idea: “That is absolutely the case that there are cultural differences in the expression of certain mental health conditions and cultural differences in terms of health systems and ideas around etiology. But there’s also an enormous commonly shared platform. And the unique disorders that exist in various parts of the world exist in addition to the globally recognized nature of mental illnesses, like schizophrenia and other forms of psychosis and depression and anxiety and eating disorders. So I think there is a lot we can do by bringing together a global network” (Participant #7).

One respondent cautioned against simply assuming that dissimilarities are most significant and provided an example of feedback received while implementing projects: “One thing that I’ve learned… I’ve literally have had this said to me: “We’re not any different than you. We’re human beings.” So when people first said you can’t take CBT (cognitive behavioral therapy) to Africa, the first time I did it, people were offended, and were like, ‘Why? We think, we behave, we feel. What’s the big issue?’ I think one of the things that I’ve learned is that as a Western culture, we try to be so sensitive to cross-cultural variations, and we don’t want to force it on anyone. But a lot of the people that I’ve talked with are offended the other way. ‘Why would you think we’re so different than you that stuff that works for you as a human being wouldn’t work for us?’ I’ve literally heard it every single place I’ve gone… Even in Africa, they say ‘why wouldn’t you think this works here? The same drugs work for us” (Participant #8).

In sum, finding balance by both accounting for differences while recognizing commonalities emerged as a critical aspect of successful work. Ability to consider both of these factors results in responsive programs that are reflective of both specific cultural variations and methods that have provided effective in other contexts.

Collaboration

Collaboration, with stakeholders, local partners, and service users, was a critical theme that was discussed in eight interviews. One respondent commented “the main thing I have learned is collaboration. You can’t do this work alone” (Participant #4). Below, subthemes that impact successful collaboration will each be addressed.

Relationship Building

Creating relationships emerged as a foundational variable in crafting strong collaborations, with six participants reflecting on aspects of the role of relationships in their interviews. In particular, strong relationships appear to buffer stresses from challenging projects, maintain morale, and improve communication (Participant #5). Additionally, investing in relationships also resulted in improved “buy-in” from community and collaborators (Participants #5 and #8). Similarly, on a systems level, building relationships assists with developing responsive, sustainable programs.

Reciprocity

Creating collaborations that are reciprocal and mutually beneficial was referenced by four participants. One mechanism through which this is expressed is via a perspective of “global knowledge and local expertise. That’s the way to have maximal impact and to insure that people who are working locally and on the ground and have the expertise of the environment and community have access to global knowledge” (Participant #7). Similarly, others reflected on the goal of sharing direction of projects among all team members, such that all team members provide leadership on development and implementation. Attention to creation of opportunities, via publication and support of needs, is another avenue through which to demonstrate this aim.

Communication

Development of meaningful collaborations is directly impacted by regular and ongoing communication and can result in a “shared vision” (Participant #7) between collaborators. One participant warned that even regular communication might still result in misunderstandings due to “differing expectations and mindframes” (Participant #2). Recommendations to support effective communication include “tak[ing] more time rather than less time, even if it’s overkill, to ascertain that we all get this, we all understand what we’re talking about” (Participant #2) and “ask[ing] a lot of questions and listen[ing] more” (Participant #5). Ability to tolerate difficult conversations was also described: “I think one of the great things about international mental health is that those of us who do this are willing to put ourselves in uncomfortable places. It’s great, it’s exciting, but it’s also uncomfortable. I think if we’re willing to be uncomfortable, and we find other people who are willing to be in that space, it also helps to facilitate difficult dialogue. We learn to talk to each other about topics that are uncomfortable because we have been there, and we respect that space. We value the lack of comfort, because we understand it teaches us something, and hopefully our goal is to create a better world” (Participant #5).

Program Level Characteristics

Beyond the two overarching themes described above, respondents also identified multiple variables that operate at the program level in successful GMH projects: sustainability, use of formative and summative evaluation, flexibility, attention to systems, and working inter-disciplinarily. Each will be discussed in more detail below.

Sustainability

Eight participants spoke of attention to long-term sustainability as key, with many noting that sustainability should be a main focus from the initial stages of project design. One participant stated the following: “From the get go, I’m thinking how [my organization] is going to pull out of this so people don’t even know that we’re gone. Things are still existing, and things are still running and running well” (Participant #8). Sustainability serves to leave communities “better off than when we started, with resources to continue to drive changes in their own worlds, even after we’ve left” (Participant #9). In addition to working at the individual and community levels, some respondents also described the importance of involving actors in higher-level systems, such as governments, to continue advancing the agendas of their projects, again reiterating the importance of building these partnerships from the beginning of their endeavors. Conversely, lack of attention to sustainability was described as “unethical” by one participant, particularly if projects are unable to create long-term significant change (Participant #7).

Use of Formative and Summative Evaluation

Evaluation and research methods were another frequently mentioned aspect of successful projects, emerging in eight interviews. One participant stated the following: “Evaluate, don’t leave things without evaluating them. We have so many surprises in this work – things that felt right ended up being not particularly useful. And we always need to see if they’re harmful” (Participant #1). Additionally, the importance of openness to feedback was illustrated through statements describing the need “to accept critical feedback or be redirected if you’re wrong” (Participant #2) and willingness to learn from past mistakes (Participant #8).

Additionally, three participants stressed the importance of ensuring that metrics used in evaluation were both culturally relevant and valid in a given population, noting that revalidation of psychometric tools is an important part of the evaluation process. Similarly, mechanisms to develop and evaluate programs should also be relevant to local contexts; one participant described this by stating: “In the United States, valid research is a clinical trial with a huge sample… a lot of people don’t conceptualize problems in that way, with problems and hypotheses. So I am much more appreciative of the value of information and data even if they don’t look like the kind of information and data that we see in the United States” (Participant #5). Further, one participant suggested that engaging in research that is responsive to context offers benefit to local individuals and communities: “What makes projects like these successful comes down to the methodologies that you use…a lot of the methods I use are participatory in nature…these tools help to engage communities in unpacking and making tangible their views of the world and their own perspectives, so I use that as a way of engaging and asking people about their lives or types of services they might like… I find this shifts the power a bit so people feel like ‘I am doing something, I can do this’” (Participant #9).

Flexibility

Concepts related to flexibility included managing the unknown, adapting and adjusting approaches, and problem solving. One common example of flexibility came through participants’ descriptions of program planning, particularly in regard to issues with funding and changes in partnerships. Other participants described flexibility as a skill that allows psychologists to adapt prior conceptions and plans to realities of the environments where they work. One participant compared flexibility to “stepping back. It’s not plowing through… I need to rethink it, and find a way where we’re all speaking the same language” (Participant #5).

Attention to Systems

The importance of designing programs that consider systemic factors that impact mental health, and not only individual level factors, was a global theme from respondents. Participants referenced both the importance of attending to group dynamics, as well as considerations of higher-level processes (e.g., structural inequality, poverty, sociopolitical context) that affect mental health. At times, as one participant described, these concepts overlapped: “There might be another way to think about psychology, and that is the collective whole. The behaviors and mental processes of collective wholes, of groups… but if we can expand our definition of psychology to include group behavior, and to look at negative life events and poverty, and how poverty is a structural inequality can impact individual and group behavior, then I think psychology has a lot to offer mental health around the world” (Participant #4).

Multidisciplinary Teams

In order to meet the complex needs of GMH and account for the myriad of factors that impact mental health, need for utilizing multidisciplinary teams was common remark from respondents. Participant #7 commented that “we need to engage all disciplines that are associated with this work… in a way that would provide the most comprehensive understanding of mental illness and most comprehensive planning for addressing the needs.” More broadly, a different participant recommended that “we have to be regularly connecting with other sectors – humanitarian development, economic, and so forth” (Participant #3) in order to best well-rounded, impactful projects.

Clinical Knowledge and Perspective

Need for sound clinical knowledge, and use of evidence-based treatment in global settings, was encouraged by participants. Interestingly, one participant discussed the lack of project team members who have explicit attention working with individuals with mental illness on an individual, clinical level, overall advocating for the need of professionals who can use clinical knowledge as a foundation for building relevant treatments: “I’m still surprised how many people do GMH and don’t have someone on their team who has actually seen patients. I think for me, for example in my team – when you haven’t sat in front of 100 depressed people, you have such a different perspective… I think that perspective from us as clinicians is totally missing still from GMH. They treat it as a public health issue – they’re looking at big numbers, massive populations, looking at sustainability. But I think in order to get there, you still need a level of understanding of who are we working with” (Participant #8). While successful projects require input from a variety of disciplines, inclusion of partners with robust clinical knowledge should not be neglected.

Attention to Spectrum of Mental Health

Attention to the entire spectrum of mental health, and not only treatment of mental illness, was suggested by several participants. As an example, one respondent stated that GMH projects should “be very committed to well-being – human well-being – not just mental health. Be committed to the bigger picture” (Participant #3). Related topics, such as considering how to improve quality of life and enhance focus on prevention, was also recommended.

Individual Level Characteristics

Outside of program characteristics, many respondents discussed individual level characteristics that impact the value of their GMH work, specifically perseverance, working with supervision, self-awareness, and boundary setting. The skills and practices identified in this section have ramifications regarding the quality of work that an individual can contribute both to programs and to long-term engagement in advancing the GMH agenda.

Perseverance

Perseverance as a key personality trait was discussed by six participants, with respect to leading GMH efforts despite the challenges of convincing others about the value of the work and difficulties in disseminating work. One individual reported that working in GMH was “not the path of least resistance” (Participant #2), particularly in terms of having to convince others of the usefulness and validity of GMH projects. Similarly, three participants spoke of challenges in publishing and disseminating their work, due to both perceived lack of interest in certain types of projects or use of methodologies that may not be mainstream. As a result, participants noted that there are a missed opportunities for the broader psychological community to benefit from GMH-related insights. One individual stated that if “we can’t share more through our academic publications, then other people who are not traveling are not only not benefitting, but we’re not developing a real emic and epic understanding of human behavior” (Participant #6). Perseverance, then, is needed to face these common obstacles that are expressed above, in order to persist in moving forward the goals of GMH.

Ongoing Mentorship/Supervision

Four participants identified the importance of ongoing mentorship and supervision as an individual professional competency needed for effectiveness within GMH. As described by respondents, this most often took the form of having mentors who could provide recommendations and guidance based upon their own experiences (Participants #5 and #8). Finally, supervision is also an important component of increasing cultural knowledge and competence (Participant #4).

Self-Awareness

Developing self-awareness was addressed by four of the participants, particularly in regards to personal motives that might influence GMH projects, in terms of lack of cultural knowledge, and about learning to recognize and manage power. Of note was one respondent’s statement that there are “many layers of agendas that people have, including ourselves. We need to be very self-reflective and examine ourselves, our motives” (Participant #1).

Boundary Setting

Setting boundaries, both professional and personal, was identified as key by two participants. Boundaries serve to facilitate acceptance of work and experiences, as well as guard against burnout. Participant #4 described this concept by stating “work will chip away at your identity, and all you are is your work. And if your work is draining, where else are you going to go to get replenished?”

Discussion

This study informs the ongoing conversation about best practice recommendations for GMH from the unique perspective of psychologists who work within this domain. Since much of the GMH literature has been based on the experiences of non-psychologists (with the exception of Morgan-Consoli et al., 2018), it is important to determine in what ways psychologists’ commendations may both mirror and supplement what has already been presented in the literature.

Existing literature in psychology, psychiatry, public health and related fields suggest that attention to holistic health, cultural relevance, creating partnerships, working collaboratively, and focusing on sustainability are critical aims of GMH program development (Bullock, 2014; Forrest, 2010; Inman et al., 2019; Khenti et al., 2012; Morgan-Consoli et al., 2018). The themes which emerged in this study are also aligned with the aims of GMH (e.g., creating partnerships, paying explicit attention to cultural, community, and individual factors that impact mental health). For example, the overarching recommendations related to integrating cultural/contextual variables and collaboration are addressed throughout the extant literature, with varying degrees of specification and detail (e.g., Boutilier et al., 2011; Khenti et al., 2015; Ng & de Colombani; 2015; Shah, 2011; Ravitz et al., 2014; Wallcrat et al., 2011), and in many cases, existing literature supports the subthemes found in participants’ responses such as reciprocity (e.g., Godoy-Ruiz et al., 2016; Khenti et al., 2015; Khenti et al., 2012; Raviola et al., 2012) and communication (e.g., Forti, 2005; Kayingo et al., 2016; Larkan, et al., 2016). However, while considerations related to cultural and contextual competence, as well as collaboration, are replete in the general GMH literature, this study highlights these variables as core components are effective project design, implementation, and evaluation, rather than peripheral issues that are tacked-on to projects. For example, many participants in this study addressed the need to understand and respond to expressed community needs, rather than needs that outside professionals might assume exist. In fact, this is one critique leveled in the literature on GMH practice (e.g., Fernando, 2012).

Many of the program-level characteristics of successful programs were articulated in detailed accounts from the expert participants. In particular, developing programs with a clear plan for sustainability was described as a best practice. Of note, data revealed the importance of considering plans for sustainability from the very beginning of project development, and involving higher-level actors (e.g., NGOs, governments) that facilitate handing over interventions to local communities and individuals. Sustainability serves to decrease ineffective behaviors, such as temporarily “parachuting” into communities and leaving without ensuring long-term benefit and is so crucial that one participant described ethical ramifications stemming from lack of sustainability planning. In the existing literature on GMH, sustainability is identified as a core competency (e.g., Forti, 2005; Raviola et al., 2012; Sapag, Herrera, Trainor, Caldera, & Khenti, 2013; Shah, 2011; van Ommeren, Saxena, & Saraceno, 2005).

Using relevant evaluation and research methods was another feature of successful programs stemming from this study (e.g., formative and summative evaluation plans), which is also reflected in existing recommendations (Fernando, 2012; Patel, 2014; Sapag et al., 2013; van Ommeren, Saxena, & Saraceno, 2005). Namely, being culturally and contextually responsive, such that both research design and evaluation methods are relevant to local contexts, was highlighted as a feature of successful GMH. Related to evaluation is the theme of flexibility, particularly managing the unknown, adapting and adjusting approaches, and learning to problem solve. Flexibility serves to assist psychologists in tailoring interventions, as well as evaluations, to communities, instead of rigidly holding on to ineffective approaches. This echoes the need for flexibility, discussed by both participants and other authors (e.g., Fricchione et al., 2012; Godoy-Ruiz et al., 2016; Kayingo et al., 2016).

Several other findings were also echoed in previous literature and mentioned as competencies for international work by Morgan-Consoli et al. (2018). For example, attending to systems (i.e., communities and groups, governments, systemic influences of mental health) is aligned with GMH’s emphasis on addressing inequality (e.g., Patel, 2012); similarly, Khenti et al. (2015) noted the importance of attending to the holistic health, or context, of individuals. Further, psychologists also noted that best practices might include projects that utilize existing methods of community coping, strengthen mental wellbeing as well as attend to mental illness, and attend to systems issues. Given that psychologists, as opposed to other GMH professionals, have specific training as therapists who do applied clinical work, we may bring a unique ability to identify and promote mental well-being in addition to decreasing pathology. Other systemic issues such as those related to power which have been identified in other best practice suggestions (e.g., Campbell & Burgess, 2012; Wang & Çiftçi, 2019), might also be mitigated via the intersections of consideration of cultural and contextual variables combined with self-awareness, reciprocity, and communication.

Projects staffed by multidisciplinary teams were recommended as a best practice, echoing existing sources (Boutilier et al., 2011; Raviola et al., 2012; Sapag et al., 2013). Additionally, successful projects were described as those that involve providers with robust clinical knowledge and in particular, attend to a spectrum of mental health (e.g., Campbell & Burgess, 2012; O’Donnell, 2012; Verdeli, 2016). While participants in this study describe successful projects as those that involve professionals from a variety of disciplines, psychologists nevertheless add specific expertise and clinical background in mental health. This sentiment was reflected by participants in this study, who highlighted the perspective that psychologists bring to projects through their experience of applied clinical work.

While psychosocial approaches (i.e., “talk therapy”) are generally less available worldwide (Hanlon et al., 2014), a growing literature demonstrates potential feasibility and acceptability of such interventions (e.g., Murray et al., 2018). Treatment adaption, to ensure feasibility and acceptability, is a domain where psychologists are able to integrate clinical practice and research acumen, with examples of such roles include work on measure validation (Harroz et al., 2019), integration of cultural context into evidence-based practice (Verdeli et al., 2003), and sensitivity to cultural nuance in diagnosis (Evans et al., 2013). Via such clinical knowledge, psychologists are also in a prime role to provide supervision and consultation, a critical role in successful task shifting interventions (Murray et al., 2011). Lastly, psychologists are able to apply expertise in mental health and illness into other platforms (e.g., understanding of interactions between mental health and medication adherence) (Magidson, Saal, Nel, Remmert, & Kagee, 2016). These tasks are specifically suited to psychologists.

There were several additional findings from this study that are not well articulated in the existing GMH literature and may also reflect the unique perspectives of psychologists who do GMH work, though may appear in the broader literature on training in international psychology (e.g., Gerstein & Ægisdóttir, 2007). Specifically, the participants’ identification of certain key personal characteristics such as perseverance, the emphasis on ongoing mentorship and supervision, and important need for boundary setting were unique contributions to the conversation on best practices. Health service psychology training emphasizes these latter recommended best practices in ways that other GMH professions may not given the intense clinical training and competencies that are cultivated in our graduate programs.

These unique data points illustrate both the commonality that GMH work may have with other types of clinical practice, as well as the unique professional challenges and liabilities that are common in these efforts. For example, one could argue that perseverance is a quality that is beneficial to any type of clinical practitioner, but in many traditional clinical contexts, clients seek out services and issues of buy-in may be less present. Of particular interest are the findings highlighting the fact that GMH as a specialty area may be less well regarded or understood relative to other areas of expertise within the field of psychology. Thus, having the ability to persist in the face of questions about the legitimacy of the work, as well as challenges in disseminating one’s work, and difficulties of moving forward a GMH agenda is critical. In sum, perseverance is a necessity both in terms of a career path, but also in terms of continuing on with programs despite challenges and setbacks that may be frequently encountered.

Implications for Training

Within the health service psychology model that guides the training of accredited doctoral programs within the profession, there are ample opportunities to offer a concentration in GMH and to provide core coursework and practicum experiences. Coursework on international psychology or global mental health could be offered within the competency area of Individual and Cultural Diversity. However, other required GMH competencies would be encompassed within our generalist training as clinicians. As suggested by the rich data that were analyzed for this study, several core implications for training the next generation of GMH psychologists can be articulated. The first implication is that successful GMH professionals must be humble and willing to learn. The concept of cultural humility, which has become a mainstay in the public health arena (Tervalon & Murray-Garcia, 1998), appears to be critical ingredient of success for psychologists doing this important work. Thus, trainees interested in this kind of practice must undergo the necessary self-analysis required to be a competent GMH provider (Morgan-Consoli et al., 2018). Fortunately, health service psychology doctoral training programs focus on developing traits such as humility, openness to feedback, and self-reflection in the competency areas of Professional Values, Attitudes, and Behaviors, as well as Communication and Interpersonal Skills.

Next, successful GMH psychologists must be true collaborators with service recipients, other professionals, and local community experts. This ability to collaborate is related to cultural humility and recognition that community buy-in, which can only come through true collaboration, is a critical ingredient of successful projects. Thus, trainees interested in GMH must be exposed to opportunities to work with health service professionals outside of psychology and to be exposed to projects in communities that are not well known to them. On that particular topic, successful GMH psychologists, while often outsiders to the communities that receive their services, recognize both human universals and cultural uniqueness exists in GMH collaborations. Accordingly, trainees must be able to receive supervision that allows their understanding of cultural context to develop, knowing that the process of learning will be lifelong. Given that health service psychology trainees are educated in competencies of Intervention, as well as Supervision, it can be argued that psychologists are very well positioned to be both practitioners and supervisors of GMH efforts if they chose such a specialization.

One consistent element of being committed to success in the GMH field also appears to be perseverance, whether it be choosing a less traveled professional road, persisting through growing pains of establishing oneself with community members, or being committed to a long-term endeavor. Over and over again, best practice was described as a commitment to take the time to know what is needed and who is being served. The best work is done in collaboration, with professionals from other disciplines, and always in partnership with local community members. Thus, from a training perspective, students who have low tolerance for ambiguity and a high need to see immediate “results” of their work may not be good matches for careers in GMH. This professional disposition of learning to live with ambiguity, whether it be in traditional clinical settings or GMH projects, is often emphasized within the health service psychology competencies of Professional Values, Attitudes, and Behaviors, in addition to Communication and Interpersonal Skills.

Aside from these individual competencies, certain skills will need to be taught to trainees with GMH career interests. For example, to ensure that such true collaborative relationships are fostered, communication with all parties must be clear and consistent, as this is key to developing trust and efficiency. Thus, trainees will need to see role models who have learned how to keep communication lines open and clear, even when it involves having difficult conversations. Communication is often addressed explicitly in health service psychology training as has been mentioned previously. Finally, successful projects are ones that are sustainable, and being able to show what really works (and what does not) is an important part of determining sustainability. Therefore, successful projects require commitment to both formative and summative evaluation efforts. Trainees with GMH career aspirations will need to have solid foundational knowledge in how to evaluate programs and how to create sustainability, which is so critical to GMH success. Given that health service psychologists are also rigorously trained in research and evaluation methodologies, this set of competencies positions psychologists to make important contributions to GMH efforts.

As is implicit in the aforementioned list of recommendations, supervision and mentoring are important components of learning about GMH but also ongoing professional development. Based on the data from this study, while some of the core competencies may be embedded in the general training of health service psychologists, it is likely that not all trainees are a good fit for GMH work, so mentors and program directors have to make sure that they have processes in place that match the appropriate people to ongoing GMH opportunities. From the findings of this study, it is also challenging to learn GMH acontextually since so many of the skillsets involve being flexible and responsive. Thus, to foster the next generation of GMH professionals, it is important to facilitate true partnerships and long-term collaborations as a context for training. While some things can only be learned experientially, making sure that trainees immerse themselves as much as possible and do the self-exploration necessary can be integrated into programs.

Study Limitations

Several limitations should be noted in the interpretation of these data. First, this qualitative study was designed to produce rich, descriptive results that could begin to formulate recommendations of best practice for psychologists who work within the field of GMH. Nevertheless, the findings from this study cannot be generalized to a broader population. Further, the method of recruiting participants (i.e., those identified as experts in the field) was chosen to capture the voices of experienced clinicians and researchers in the GMH field. However, despite their expertise, there were perspectives that were underrepresented in that all participants included in this study were based in high-income countries, and all communications were conducted in English. In response to ideas of reciprocity and cultural relevance described in this manuscript, learning and hearing the perspectives from psychologists in LMICs is a critical aspect of crafting recommendations that are inclusive and reflective of best practice from a global viewpoint. One mechanism through which to meet this goal could be through the use of translators in order to minimize a possible barrier to participation.

Due to the nature of this qualitative study, all data collected was via self-report from participants. While useful, incorporating other data points to triangulate this information could have served to further confirm findings. For example, this process could have occurred through reviewing documentation from past GMH projects directed by participants or confirmatory interviews with participants or service users impacted by these efforts. Finally, while participants were given the opportunity to provide feedback on themes generated from their interviews, some participants did not respond to repeated requests to provide additional clarification.

Suggestions for Further Investigation

The data from this study both reinforce and reiterate some of the core best practice recommendations found in other sources, as well as identify some unique recommendations that are not as frequently discussed in the literature. However, in order to create thorough guidelines for best practice for psychologists in GMH, more research is needed. First, recreating this study with a more geographically diverse sample (i.e., addition of psychologists from LMICs, including non-English speaking participants) would create a more representative compilation of recommendations. It is quite possible that individuals in different contexts, and with potentially varying professional experiences, might offer considerations that were not articulated in this study. Additionally, while these best practice recommendations are specifically designed for psychologists, one area of growth relates to involving community members and service users in the discussion of what constitutes best practice and effective programming. Inclusion of all parties would likely add nuance and dimension to the existing recommendations.

Lastly, future attention to the role of individual level competencies remains an area of exploration for research, and such exploration would build upon and complement recommendations for higher-order systems. Namely, consideration and investigation of the interplay between individual competencies and program level characteristics is of interest. For example, openness, one such individual level characteristic, has implications for adapting research methods and evaluation to be culturally responsive; however, how is this attribute developed in professionals? Similarly, exploring the role of these individual factors in achieving the overarching variables has potential implications, as some of the identified personal variables appear to play a role in developing and utilizing overarching competences (e.g., humility was underscored as critical in developing cultural knowledge and collaboration). Further efforts might also focus on how to develop and refine the individual level competencies that impact effective practice in GMH. Lastly, future research will be very useful in articulating what kind of screening might be helpful in identifying those future psychologists who might be good fits for GMH work. Given its importance to the promotion of global health in general, such individuals will be needed.

Public Significance Statement:

This work highlights parameters for ethical practice in global mental health, with focus on the role that psychologists may play in advancing this agenda. Additionally, key recommendations for training of psychologists that is aligned with these practices are also included. Increasing the number of psychologists who are active in this field, and providing a framework for sound practice, will assist in meeting Sustainable Development Goal 3 (target 4) (United Nations, 2015) via efforts that work to improve mental health worldwide.