Using Group‐ Based Cognitive The Project Behavioral Therapy (CBT) Training The World Bank carried out a randomized controlled trial (RCT) to study the incremental effects of a five‐week CBT- to Improve Mental based group intervention for SME entrepreneurs combined Health of SME with cash grants, compared to receiving cash grants alone. CBT centers on the idea that people’s unique patterns Entrepreneurs of thinking, feeling, and behaving are significant factors in how they experience their surroundings and the type of in Pakistan actions they take. CBT helps people i) identify patterns of negative thoughts about themselves or others, ii) gather new data from the world to challenge these patterns and iii) engage with prior beliefs and preconceptions. A rapid needs assessment revealed high levels of psychological distress among the target population of SME entrepre- neurs in Pakistan. Given this, a CBT-based approach was deemed suitable to ameliorate symptoms and improve productivity of SME entrepreneurs in this context. The intervention curricula - Problem Management Plus for Entrepreneurs (PM+E)- adapted existing CBT curricula by pairing stress and problem management strategies with In regions marked by fragility, conflict, and business-focused leadership and adaptive skill building. The violence (FCV), entrepreneurs of small and medi- training included modules in stress management, prob- um-sized enterprises (SMEs) face increased risk lem solving, behavioral activation, strengthening support of experiencing chronic stress and poor mental network, and self-care. This approach helped circumvent health. In turn, this can lead to poor psycho- cultural reservations around mental health programming logical outcomes, hamper their business per- and improved acceptability of the training among target formance, and weaken the benefits of existing participants. Other adaptations included delivering training financial and business assistance programs. in the local language, forming “affinity” groups (based on characteristics such as gender, education, and business The World Bank’s Finance, Competitiveness, and Inno- type), and holding sessions in accessible, acceptable, and vation (FCI) Global Practice, in collaboration with the safe locations for both male and female entrepreneurs. Mind, Behavior, and Development Unit, launched a pilot intervention to explore the effects of group cognitive Training was conducted with 235 SME entrepreneurs, all behavioral therapy (CBT) training - over and above the of whom were beneficiaries of the World Bank-supported effect of receiving cash grants - on reducing depres- Economic Revitalization of Khyber Pakhtunkhwa and FATA sion and anxiety and improving wellbeing among SME (ERKF) program. All participants received a cash grant of entrepreneurs in conflict-affected parts of Pakistan. two million Pakistani Rupees (approx. US$14,000). Those randomized into the intervention group received cash This exploration provides much needed evidence of the grants plus five weekly face-to-face PM+E group sessions. feasibility of implementing and evaluating interventions The control group received cash grants only. At baseline, at the nexus of mental health and business performance. demographic characteristics and symptoms of depression Where preceding interventions focus on the functioning and anxiety were balanced across both groups. In addition of SMEs, reducing psychological stressors may provide to measuring impact, the pilot also tested whether rapidly a path to improved productivity in post-conflict and trained non-specialist providers could successfully execute FCV settings. psychosocial wellbeing interventions in FCV contexts. Results CBT leads to short-run improve- The intervention is cost effective Targeting specific population ments in mental health outcomes and measurable, allowing for fu- groups leads to greater engage- that persist and increase beyond ture scalability. This model of train- ment and improved wellbeing. Vari- the immediate post-intervention ing, supervision, and evaluation may ability among workshop participants period. Treated entrepreneurs ex- be adapted for other beneficiary influenced engagement and partic- perienced a statistically significant groups. The project demonstrated ipation. For example, participants reduction in the intensity and prev- that empirical research, including from urban areas, with high educa- alence of depression and anxiety RCTs, can be conducted in challeng- tional backgrounds and advanced symptoms. They also experienced ing settings through the appropriate business skills, found it difficult to improvements in levels of wellbeing. rapid training of local researchers. commit to the workshops amidst The impact is larger three months Because the intervention was de- competing business demands. In after the intervention, compared to livered by non-specialist providers, contrast, entrepreneurs who oper- immediately after, suggesting that knowledge of the local context was ated smaller businesses, were from the impact of such psychosocial significant and the need for spe- lower socioeconomic strata and ge- interventions may be incremental cialist resources was circumvented. ographical areas which were directly over time. This low-touch interven- Additionally, the cost of training impacted by humanitarian crises tion is particularly meaningful for was low- US$300 per trainee. had the best participation rates. those experiencing mild to moder- ate levels of depression and anxiety. Saraf, P. 2019. A Study of Fragility, Entrepreneurship and Mental Health : Investing in Better Cognitive and Behavioral Skills for Small Medium Enterprise Entrepreneurs to Thrive in Conflict-Affected Areas of Pakistan. Washington, DC. © World Bank. Saraf, P., Rahman, T., & Jamison, J. 2019. Group-Based Cognitive Behavioral Therapy (CBT) Training Improves Mental Health of SME Entrepreneurs : Experimental Evidence from Conflict-Affected Areas of Pakistan. Policy Research Working Paper Series 8872. World Bank Group. Policy Implications sociological and/or anthropological qualitative interviews Conflict, the main driver of growing humanitar- with quantitative methods allows for an experiment design ian needs (UNOCHA, 2019), is associated with that is better framed and more culturally acceptable. Par- psychological consequences that may negatively ticipants and trainers viewed the intervention as applicable impact the social and economic fabric of entire re- to their real-life problems and as an opportunity to gain gions. Thus, this pilot may inform and stimulate iter- new skills. Future success will stem from ensuring trainings ations of similar programs in other FCV regions. are easily accessible in terms of the physical proximity of Early psychosocial interventions workshops to where entrepreneurs may mitigate the risk of chronic Early psychosocial interventions live and the means with which and severe distress in the future. may mitigate the risk of chronic and the information is presented. This could result in healthcare severe distress in the future. This could Policymakers can mitigate these cost savings in the long term result in healthcare cost savings in challenges by focusing on specific and improvements in business the long term and improvements groups. It appears that low-income productivity. Complementary in business productivity. entrepreneurs tend to attend dil- efforts, such as mental health in igently, as they likely do not have the workplace, may also be informed by these findings. substitute networks and resources. Additional opportunities The rapid training of local researchers and non‐specialist include piloting how to reach those who may find it difficult providers can result in cost savings as well as more effec- to attend the workshops. The evidence on phone-adminis- tive program delivery. For example, trainers who are familiar tered CBT is also encouraging, and it might be worthwhile with the contextual factors are better able to help partic- to try a hybrid of face-to-face and telephone sessions. ipants discuss their problems and brainstorm solutions. Adapting the program with a gender-sensitive lens, includ- ing gender matching of trainers and trainees and encour- Carefully assessing a population’s needs is an essential aging family members of female entrepreneurs to attend, precursor to behavior change, and towards this, combining can increase the participation of female entrepreneurs. About eMBeD The Mind, Behavior, and Development Unit (eMBeD), the World Bank’s behavioral science team in the Poverty and Equity Global Practice, works closely with project teams, governments, and other partners to diagnose, design, and evaluate behaviorally informed interventions. By collaborating with a worldwide network of scientists and practitioners, the eMBeD team provides answers to important economic and social questions, and contributes to the global effort to eliminate poverty and enhance equity. Stay Connected eMBeD@worldbank.org #embed_wb worldbank.org/embed bit.ly/eMBeDNews Last Update: January 29th, 2020