Cognitive Behavioral Training to Improve Mental Health Among Conflict-Affected Entrepreneurs in Pakistan

Tasmia Rahman
Priyam Saraf
Fieldwork by:
235 small and medium enterprise (SME) entrepreneurs
2018 - 2018
Target group:
  • Entrepreneurs
  • Communities recovering from conflict
Outcome of interest:
  • Earnings and income
  • Post-conflict recovery
  • Mental health
Intervention type:
  • Cash transfers
  • Unconditional cash transfers
  • Psychosocial support

Mental health, well-being, and lasting economic outcomes are intimately connected, and in conflict-affected areas, entrepreneurs of small- and medium-sized enterprises (SME) experience chronic stress and poor mental health on a regular basis. Researchers evaluated the effects of supplementing a cash grants program with a five-week group cognitive behavioral training (CBT) program on depression, anxiety, and well-being among SME entrepreneurs in conflict-affected areas of Pakistan. Researchers found that the CBT significantly improved mental health outcomes, including reducing the intensity and prevalence of depression and anxiety symptoms and increasing reported levels of well-being, at three months following the intervention.

Policy issue

Mental health, well-being, and lasting economic outcomes are intimately connected. However, in places afflicted by conflict and violence, small- and medium-sized enterprise (SME) entrepreneurs experience chronic stress and poor mental health on a regular basis. Stress is thought to reduce performance, contribute to a more negative work environment, and lead to counterproductive work behavior, all of which can significantly impact firm productivity and economic outcomes. Since SMEs play an important role in job creation and economic growth, it is critical to understand—and reduce—the prevalence and impact of mental health challenges on the health and economic outcomes of SME entrepreneurs.

One way to improve mental health and business outcomes may be to reduce the intensity and prevalence of depression and anxiety via cognitive behavioral therapy (CBT). CBT is a commonly used psychological intervention for youth and adults in areas characterized by fragility, conflict, and violence, and is being used for a novel target group of entrepreneurs in this evaluation.

Context of the evaluation

The increase in conflict and natural disasters around the world has affected nearly 132 million people globally, and parts of Pakistan are no exception. The Khyber Pakhtunkhwa (KPK) province and the Federally Administered Tribal Areas (FATA) of Pakistan have suffered from armed conflict for the last three decades, resulting in large-scale displacement and severe damage to the infrastructure and economy of the region.

Epidemiological studies from these areas in Pakistan have shown high rates of common mental disorders (such as depression and anxiety) among the general population. Among the group of participants in this study, one in three to four entrepreneurs experienced mild to severe symptoms of depression or anxiety. Chronic adversities for these KPK entrepreneurs manifest themselves in the form of “distress,” such as an inability to concentrate on work, poor sleep and appetite, and low self-esteem.

The majority of participants were owners of microenterprises with twenty employees or fewer, concentrating in the manufacturing, service, and retailing sectors, and the majority of whom were men. On average, they had 11.3 years of education, age of 42 years, and monthly household income of US$725 with ten dependents. All had received grants to rehabilitate their businesses within a year prior to the start of the intervention. Overall, the sample selected was representative of the larger population of grantees.

Photo: Naveed Ashraf |

Details of the intervention

Researchers evaluated the effects of supplementing a cash grants program with a five-week group CBT intervention on depression, anxiety, and well-being among SME entrepreneurs in conflict-affected areas of Pakistan.

In 2012, the World-Bank-supported Economic Revitalization of KPK and FATA Project (ERKF) provided support to SMEs in the form of cash transfers in the amount of 2 million Pakistani Rupees each (approximately USD$14,300). Researchers drew a sample of 235 SME entrepreneurs from among participants of the ERKF cash grants program and randomly assigned them into one of two groups:

  1. Training group (118 participants): Participants who received cash grants were invited to join a five-week CBT program. Training was conducted in twelve separate groups based on the gender and location of the participants.
  2. Comparison group (117 participants): Participants received cash grants only.

The CBT training program, called Problem Management Plus for Entrepreneurs (PM+E) and developed by World Health Organization (WHO), consisted of five days of face-to-face training spread over five weeks, facilitated by local non-specialist health providers trained in the PM+E curriculum by master trainers. The training content was designed to provide entrepreneurs with a skillset that could be applied to stressful situations in their everyday life and work to help them negotiate such challenges in an adaptive fashion. The program included modules in stress management, problem solving, behavioral activation, and strengthening social support by including situational simulations relevant to the lived experience of entrepreneurs. The PM+E curriculum was contextualized in leadership and adaptive skills training, in order to circumvent cultural stigma around mental health issues. Participants were sent WhatsApp reminder messages following the training.

To understand the impact of training on mental health, researchers collected data at five weeks and three months after delivery of the last module of the intervention. The prevalence and intensity of depression and anxiety were measured using the Patient Health Questionnaire ‐ Anxiety and Depression Scale (PHQ‐ADS), where lower scores indicate lower intensity of experiencing symptoms of anxiety and depression. Well-being was measured using the WHO-5 Well-Being Index, which documents feelings of good spirits, relaxation, engagement and more.

Results and policy lessons

The study found that cognitive behavioral training led to significant improvements in mental health outcomes in the short run (three months post intervention), with a notable reduction in the intensity and prevalence of depression and anxiety symptoms and higher reported levels of well-being. Across all outcomes measured, impact was larger three months post-intervention than immediately after at five weeks, indicating that the PM+E CBT intervention may have incremental benefits.

Depression and anxiety: Entrepreneurs in the training group experienced a reduction in the intensity of their anxiety and depression three months after the intervention, scoring 1.36 points lower on the PHQ-ADS (a 26 percent decrease from the comparison group average of 5.22) relative to those in the comparison group that received only the cash transfer. Trained entrepreneurs also had 0.46 times the odds of experiencing depression and anxiety symptoms compared to the cash transfer group. The program was most effective for individuals at the onset of depression and anxiety, as well as those experiencing mild to moderate levels of depression and anxiety.

Well-being: While personal well-being among participants was already high just prior to the intervention, there was substantial improvement among SME entrepreneurs in the training group relative to their peers who just received cash grants. Three months after the intervention, CBT-trained participant entrepreneurs scored 4.73 points higher (from a base of 80) on the WHO-5 index.

At USD$300 per trainee, PM+E cognitive behavioral therapy can be a low-cost intervention to further improve mental health and well-being among SME participants of a cash grants program. This study also serves as a positive example of the feasibility of implementing and scaling such interventions in post‐conflict and violence‐affected contexts through use of non-specialist health providers.

To better understand the long-term impact of PM+E cognitive behavioral therapy, researchers also aim evaluate the impact on business outcomes for the SME entrepreneurs. A final follow-up survey will be completed eighteen months after the training, which is expected to provide answers to this question.