Q: How do you describe EMPOWER?

A: What EMPOWER does is it brings together three different strands of science that have developed quite independently. You have the clinical science that has demonstrated the effectiveness of brief psychological treatments. Implementation science that has demonstrated that, with carefully designed training and supervision efforts, non-specialists such as community health workers or nurses can deliver these treatments in routine settings. And pedagogical science, learning science, which has shown that digitally delivered online learning programs are just as effective as in-person, classroom-based programs to enable people to learn new skills and, with continuing peer supervision, are just as effective to sustain the quality of skills.

If a frontline worker is delivering care for a patient’s diabetes, equipping them with the skills to deal with their mental health problems means the same people can support the patient in a holistic way. This is the hallmark of person-centered care. EMPOWER seeks to strengthen the foundation of mental health care in a person-centered way.

Q: You’ve long been an advocate of training non-specialists to provide basic mental health care. Is this a case of technology catching up to your ideas?

A: EMPOWER would not have been possible 15 or 10 years ago, and the technology certainly has been a game-changer. But make no mistake, the technology is only a platform for the science because the science is also pretty recent. When I first wrote my book—Where There Is No Psychiatrist: A Mental Health Care Manual—in 2003, there wasn’t a single shred of science that demonstrated that non-specialist workers could effectively treat any mental health condition. The first randomized controlled trials emerged in 2003. That’s how new the science is. So, I think clinical and implementation science and the technology both coincided over the last 10 years.

Q: EMPOWER appears to represent a major shift in the way people think about mental health care. Can you talk about that?

A: What’s novel is the treatments we are working with now are very brief. If you ask most Americans how long they thought psychotherapy would take, …most people would think it lasts a long time, even a year or more, and you have to go every week for expensive sessions. Global mental health practitioners have designed brief interventions, an average of six-to-eight sessions even for severe mental health problems, as a way to optimize acceptability and recovery in a short time. These interventions typically target specific mediators of mental health problems, and I think that’s pretty novel science as well.

Q: It seems that, beyond helping people in Texas, the Lone Star Prize presents an opportunity to show how EMPOWER works on a large scale in the United States. Is that correct?

A: It’s a real privilege to be doing this in Texas. Especially, it’s a privilege that we are bringing science that came from some of the world’s least resourced countries to the world’s most resourced country. There’s something very captivating about that idea. It’s also been a privilege to find so many colleagues in Texas, not least in the university system and of course at Meadows, who with very open arms have embraced my team and this idea.

It’s an enormously exciting opportunity to test this model going to scale in the U.S. And why I say it’s exciting is because we have the backing of universities, the backing of local health care organizations, the backing of payors, and …most excitingly …we have the backing of the community health workers who are going to be engaged in this process.

Q: Can you speak a bit about how EMPOWER helps address issues of mental health equity?

A: Robust knowledge has emerged in the last decade that has shown that people from racial minority groups, as well as low-income communities, are systematically disadvantaged in their access to quality mental health care …and especially to good quality psychotherapy.

The irony is that these are the very groups who actually want therapy. There are surveys that ask people, “Would you prefer medication or psychotherapy?” People from disadvantaged groups overwhelmingly prefer psychotherapy. Ironically, they are overwhelmingly less likely to receive it.

So, by creating a new workforce that is affordable, that is accessible, and that delivers care in these communities, you are now bringing the care people want and need directly to them.

Q: If stigma and hesitancy to talk about mental illness were still the rule and not the exception, programs like EMPOWER would be much harder to implement. How have you seen attitudes about mental health change?

A: When I was trained in psychiatry back in the late ‘80s, honestly, you were embarrassed to even tell people that you’re a psychiatrist. The stigma was not only attached to people with mental illness, it was also attached to people who worked with people who had mental illness. It would have been impossible to imagine the President of the United States or the Prime Minister of India talk about mental health problems as a national issue.

Between then and now, there has been a polar transformation. Now is quite an amazing moment. The political will is enormous. There are conversations about mental health in every sector of society, and they’re not stigmatizing conversations. They’re conversations about compassion, about dignity, about respect, and about parity. We’ve come a long way, and it presents a unique opportunity for the mental health sector to respond. This could be the historic moment we’ve all been waiting for, not only to invest in mental health care, but to reimagine the entire system with a renewed focus on care delivery in the community by resources available in the community.