Common Elements Treatment Approach (CETA)

1. Introduction

Version followed: adult CETA as published by Murray, Dorsey, Haroz, Lee, Alsiary, Haydary, Weiss & Bolton (2014, Cognitive and Behavioral Practice; Iraq and Thailand–Myanmar border version, with the lay-friendly element names used there), updated with the current element list and delivery rules in the South Africa HIV trial protocol (NCT04242992), the CETA Global listing on the MHPSS Network, and the CETA Psychosocial Support (CPSS) and telephone-CETA (t-CETA) publications; youth content follows CETA-Youth as evaluated in Somali refugee camps (Murray et al. 2018). The full CETA manual and steps sheets are not public: CETA Global sends them to organisations that sign up for training [source: MHPSS listing]. Element-level steps below are therefore reconstructed from the published descriptions and marked [synthesis] where they go beyond them. Sources include the open-access Iraq trial (Weiss et al. 2015), the Zambia VATU trial protocol (Kane et al. 2017), the CETA-Youth evaluation (Murray et al. 2018), the Zambia ZCAP pilot protocol (NCT03966885) and the author and abstract records of Bolton et al. 2014 and Murray et al. 2019. These support the element list, session formats, training model, supervisor decision rules, the substance-use element and partner support element, the VATU safety protocol, the youth trauma flow and caregiver role, and the published roles of the developers and of Judith K. Bass. [uncertain: default element orders for anxiety-primary and substance-use-primary cases (no published text; the CETA Flows handout is not drawn on), most step-by-step element content, and child-specific element steps].

CETA is not a new single therapy. It is a transdiagnostic, modular, cognitive-behavioural system of care assembled from elements shared by evidence-based treatments for depression, trauma, anxiety and (later) substance use and behaviour problems, built for delivery by lay counsellors in low-resource settings and now used with adults, children and caregivers [source: Murray et al. 2014; Kane et al. 2017; MHPSS listing; Murray CDC handout 2019]. It was developed in the Applied Mental Health Research Group at the Johns Hopkins Bloomberg School of Public Health by Laura K. Murray with Paul Bolton, Shannon Dorsey and the other authors of the 2014 description [source: Murray et al. 2014; UW RISE CETA page]. Dr Judith K. Bass of Johns Hopkins is not an author of the 2014 development paper; the published record shows Dr Bass as an investigator in the CETA trials and projects: principal investigator of the 2011–2013 Colombia community mental health worker training and supervision project, senior (last) author of the Thailand–Burma border RCT (Bolton et al. 2014), co-author who helped conceive and design the Iraq RCT (Weiss et al. 2015), and co-author of the CETA-Youth evaluation (Murray et al. 2018) [source: UW RISE CETA page; DOAJ record of Bolton et al. 2014; Weiss et al. 2015; Murray et al. 2018]. The pairing "Murray, Bolton, Bass, Johns Hopkins" therefore reflects the Hopkins development and trial team, not three co-authors of the original treatment description. Today CETA is disseminated by CETA Global, Inc. [source: MHPSS listing].

How change happens: the counsellor identifies the client's primary problem, then delivers the matching CBT elements (psychoeducation, cognitive coping and restructuring, behavioural activation, gradual exposure, relaxation, problem solving, motivational substance-use work) in a chosen order and dose. Each element teaches a skill through rationale, modelling, role-play and home practice; weekly symptom monitoring tells the counsellor whether to move on, repeat or add an element. Safety is assessed in every case [source: Murray et al. 2014; CETA Description, UW 2017].

2. Framework

Overall structure. CETA has no fixed phase sequence; it has (a) an assessment and triage step, (b) a set of elements, (c) default flows (orders of elements) per primary problem, and (d) decision rules for selection, sequence and dose. Lay providers are trained to make three choices: which primary problem to treat, in what order (including what to do about "interference"), and how many sessions per element [source: t-CETA webinar 2021; Murray et al. 2014].

Levels of care (current CETA Global system) [source: MHPSS listing; Nguyen et al. 2023; CDC handout]:

Prevention / mild: CETA Psychosocial Support (CPSS), a single group session (5–10 people, about 2 hours) with psychoeducation, self-assessment, safety identification and planning, one cognitive-coping skill, and finishing steps; referral to full CETA if symptoms stay elevated or any safety risk is reported.
Mild problems: about 3–5 sessions.
Moderate to severe: about 8–12 sessions (average about 8).
Format: individual or group, in person or remote (phone, video).

Session count, length, format. Weekly (sometimes biweekly) sessions. Published designs: about 8–12 weekly individual sessions of 50–60 minutes in the Iraq RCT (mean 9.94 sessions, range 7–14) [source: Weiss et al. 2015]; 6–12 weekly sessions of 60–90 minutes for CETA-Youth (completers averaged 8.81, range 4–13) [source: Murray et al. 2018]; a suggested 6–12 weekly sessions of about an hour in the Zambia and South Africa protocols [source: Kane et al. 2017; ZCAP protocol; SA protocol]; 20–60+ minutes per CETA Global; t-CETA splits content into more sessions of about 30 minutes. Pilot clients in Iraq averaged 10.8 sessions (range 5–13) and in Thailand 9.5 (range 4–15) [source: Murray et al. 2014]. Group format: the Zambia VATU trial began with groups of 5–7 of the same participant type (men, women, youth by age), 90–120 minutes, two providers, opening with a "tea time" for cohesion, but switched to individual delivery because of missed sessions, travel and scheduling problems; the authors would not recommend group CETA in that urban setting [source: Kane et al. 2017]. Usually one element per session; some elements take more than one session [source: Murray et al. 2014; CETA Description].

Standard session format (every element) [source: Murray et al. 2014; SA protocol]:

Client Monitoring Form (CMF): brief symptom checklist at the start of each session (12 items in the 2014 adult version; later versions also track externalising behaviour and substance use).
Safety check if any safety concern exists (then every session).
Review of last week's homework, problem-solving any barriers.
The element: rationale, counsellor modelling, guided practice/role-play.
New homework.
Counsellor records which element steps were completed (fidelity log).

Default flows (2014 adult version) [source: Murray et al. 2014, Figure 1]:

Traumatic stress primary: Safety → Encouraging Participation (Engagement) → Introduction (Psychoeducation) → Thinking in a Different Way I (Cognitive Coping) → Talking about Difficult Memories (Imaginal Exposure, usually 2+ sessions) → Thinking in a Different Way II (Cognitive Restructuring) → Finishing Steps.
Depression primary: Encouraging Participation → Introduction → Getting Active (Behavioural Activation) → Thinking I → Thinking II → Finishing Steps.
Anxiety-primary and substance-use flows: current training names further flows (e.g. "Substance Misuse" and "Child/Adolescent") [source: t-CETA webinar], but no published default order for anxiety-primary or substance-use-primary cases was found [uncertain]. What the trials report: in the Iraq RCT there was no separate anxiety flow; every CETA client received Encouraging Participation/psychoeducation, cognitive coping/restructuring, imaginal exposure, safety and finishing, and anxiety or inactivity was handled by adding Relaxation (26 clients), Behavioural Activation (12) or In Vivo Exposure (1) [source: Weiss et al. 2015]. In the Zambia VATU trial the substance-use element was given to all men and to women reporting substance abuse, but the flow figure is an image and the order is not stated in the text [source: Kane et al. 2017]; the ZCAP pilot protocol also lists elements without an order [source: ZCAP protocol]. The youth trauma flow is in 4.15. Until you have the CETA Flows sheet from a trainer, place the substance element where your supervisor decides [synthesis].
Safety is assessed at intake in every case regardless of flow [source: CETA Description].

Criteria for adding, repeating or moving on [source: Murray et al. 2014; CETA Description]:

Add Getting Active early when "interference" (e.g. very low energy) would block other elements.
Add Relaxation when physiological anxiety symptoms impair functioning or block other work.
Add Live Exposure when the client avoids situations that are actually safe.
Add the Alcohol/Substance element where hazardous use is identified (Thailand originally; in the Zambia VATU trial given to all men and to any woman reporting substance abuse; in HIV-care versions guided by a past-7-day alcohol timeline follow-back each session) [source: Murray et al. 2014; Kane et al. 2017; ZCAP protocol].
Repeat an element when weekly monitoring shows distress is still high (the 2014 vignette repeats imaginal exposure when distress stays around 7 after two sessions).
Change the primary target or elements as treatment progresses if response is poor.
Decisions draw on three inputs: selected items from the validated assessment instruments, the client's presentation and statements, and discussion with the supervisor, who consults a CETA trainer [source: Weiss et al. 2015]. In CETA-Youth an Elements Decision Making Table grouped assessment items by problem area; the flow was agreed with the supervisor after the first session and approved by the trainer [source: Murray et al. 2018]. A second session of an element is given if its steps were not all completed, the client has not learned the skill, homework was not done, or symptoms have not improved enough [source: Murray et al. 2018].
Move to Finishing Steps when the primary flow is complete and CMF scores have fallen [synthesis: exact discharge thresholds were not found].

Training, certification and fidelity before delivering "CETA" [source: MHPSS listing; SA protocol; Murray et al. 2014; t-CETA webinar; CDC handout]:

Training only from a CETA trainer, via the Apprenticeship Model: about 10 days of in-person training (8–10 days per CETA Global; two weeks in 2014; remote options now), role-plays with coaching and "card sort" flow practice, then weekly small-group practice with a local supervisor and at least one supervised pilot case (or pilot group) before taking clients; in CETA-Youth this was followed by 6 months of weekly small-group practice and case supervision [source: Weiss et al. 2015; Kane et al. 2017; Murray et al. 2018; MHPSS listing; Murray et al. 2014].
Weekly local supervision (groups of about 5–6 providers, about 2 hours); local supervisors have weekly calls with CETA trainers (1–2 hours in CETA-Youth, 2–3 hours in VATU) to review every case or role-plays [source: CDC handout; Weiss et al. 2015; Kane et al. 2017; Murray et al. 2018].
Provider certification first; supervisors must be certified providers coached to supervise; trainers must be certified provider and supervisor, complete train-the-trainer, and co-train 1–2 times with certified trainers.
Fidelity by "triangulation": counsellor step logs, supervisor case database, weekly trainer review; missed steps are completed or redone. A competency rating has been used (Lebanon). Organisations set up a written safety protocol (who to call, when, what to share) before launch.
Contact: info@cetaglobal.org. A licensed clinician who has not been trained and supervised by CETA Global should not describe their work as CETA [synthesis from the stated requirement].

3. Guiding principles

[source: Murray et al. 2014 unless noted]

Common elements, not a new therapy: use components shared by proven CBT treatments. Practically: you are delivering familiar CBT skills in plain language, not inventing new techniques.
"Flexibility within fidelity": choose and order elements per client, but deliver every chosen element's steps fully. Practically: individualise the flow, never skip steps within an element.
Match elements to symptoms: the treatment elements "that match the symptoms" are chosen [source: CETA Description]. Practically: start from the CMF/assessment, not from your favourite technique.
Treat the primary problem first; clear interference: practically, ask what most distresses or impairs the client, and add only what blocks progress on it.
Measurement-based care: weekly CMF drives dosing [source: MHPSS listing]. Practically: look at the trend before deciding to move on.
Safety first, every time: safety is assessed at the start and, if a concern exists, at every session [source: CETA Description]. Practically: a safety concern pre-empts the planned element.
Same micro-structure in every element: rationale, guided practice with modelling and role-play, homework review with barrier problem-solving, weekly monitoring. Practically: never just explain a skill; rehearse it in session.
Simple, concrete, local: simplified element names, steps sheets with example wording, local analogies (a bread-making fear analogy in Iraq; a broken sandal in Thailand), building on local practices (Buddhist meditation in Thailand). Practically: translate every concept into the client's idioms.
Engagement as an active element: address stigma and doubts and involve family where locally appropriate. Practically: deal with "is this for crazy people?" before teaching skills.
Task-sharing under supervision: lay providers deliver; decisions are made with supervisors [source: CDC handout; SA protocol]. Practically: bring every flow change and safety case to supervision.
Client autonomy in substance work: the client decides whether to change drinking (MI stance). Practically: give feedback, do not lecture or prescribe abstinence.
Precision-based levels of care: match intensity (CPSS, brief, full CETA) to need [source: MHPSS listing]. Practically: not everyone needs 12 sessions.
Culture- and gender-sensitive logistics: e.g. same-gender or chaperoned arrangements in Iraq. Practically: plan staffing and setting around local norms.

4. Intervention inventory

Element names: lay name used in the 2014 version, then the technical name. Purposes and inclusion rules are sourced; numbered steps are the published components where stated and otherwise [synthesis] reconstructions in standard CBT form, because the CETA steps sheets are not public [source: Murray et al. 2014; SA protocol; CETA Description]. All example wording is my own (illustrative).

4.1 Multi-problem assessment, triage and the Client Monitoring Form (CMF)

Purpose / when: at intake, identify the primary problem, co-occurring problems, impairment and safety risk; then at the start of every session track symptoms to guide dosing and spot interference [source: Murray et al. 2014; SA protocol; MHPSS listing]. Trials used locally validated measures (e.g. depression, trauma, functioning, AUDIT for alcohol) at intake; the CMF is a short weekly checklist [source: Murray et al. 2014; CDC handout; t-CETA webinar].
Steps: (1) Administer the intake assessment (in person, phone or group self-assessment). (2) Score domains; note the highest-impact problem and any safety items. (3) If any safety item is positive, go straight to the Safety element. (4) Choose the default flow for the primary problem and write a provisional element plan with supervisor. (5) Each session, give the CMF first, compare with prior weeks, and decide: continue, repeat, add, or change target. [steps 2–5 partly synthesis] (Do not reproduce CMF items; use the version your CETA trainer provides.)
Example language (illustrative): "Before we start, I ask the same short questions every week so we can both see whether things are changing."
Watch for: scores that fall on the primary problem but rise elsewhere (e.g. drinking), indicating a change of target; social-desirability bias when the counsellor administers the CMF (noted by the developers) [source: Murray et al. 2014].

4.2 Encouraging Participation (Engagement)

Purpose / when: early in every flow; address practical and perceptual barriers (stigma, doubts that talking helps), link the programme to the client's own problems, and involve family when appropriate; linked to retention [source: Murray et al. 2014; SA protocol].
Steps (the element's published aims are: discuss how the programme helps, identify obstacles to engagement, promote buy-in [source: ZCAP protocol]; the step order is [synthesis]): (1) Ask what the client hopes will be different. (2) Link those hopes to what the programme offers. (3) Elicit practical obstacles (time, transport, childcare, phone access, permission from family) and problem-solve each. (4) Elicit perceptual obstacles ("is this for crazy people?", "talking cannot fix my life") and respond with normalising information. (5) Decide with the client whether and how a family member should be involved. (6) Agree attendance plan.
Example language (illustrative): "Many people here worry that coming means something is wrong with their mind. This is a programme to build skills for stress and sadness, the kind most people face after hard times."
Watch for: missed second sessions, a family member who opposes attendance, or a client agreeing only to please you; revisit engagement whenever attendance slips.

4.3 Safety (suicide, homicide, intimate partner violence, abuse)

Purpose / when: assessed at the start of every case; if a concern exists, addressed at every session; includes risk of harm to self or others, domestic/intimate partner violence and abuse, a focused safety plan with the client (and family when appropriate), referral and mandated reporting [source: Murray et al. 2014; CETA Description; SA protocol]. In IPV-focused versions, safety planning starts in session 1 and covers both preventing violence and what to do when a partner becomes violent [source: SA protocol].
Steps (1–6 paraphrase the published trial safety protocols): (1) Ask the screening questions about thoughts of harming self or others and about current violence or abuse [source: Kane et al. 2017; ZCAP protocol]. (2) Suicide risk endorsed: contact the supervisor immediately and agree a plan before the client leaves; published options include a safety agreement, identifying warning signs, and referral to a facility for closer monitoring [source: Kane et al. 2017]. (3) Homicide risk: inform the clinical supervisor immediately; staff arrange for the person to be accompanied to a safe place; options include a safety agreement, safety watch and reporting to local authorities [source: Kane et al. 2017]. (4) Intimate partner violence: consult the supervisor during the session and agree a plan before the client leaves; options depend on local law (police victim-support reporting, shelter or one-stop-centre referral, in-home safety planning) [source: Kane et al. 2017]. (5) A child reports unreported abuse by a known person living with them: contact child welfare and the police child-protection unit immediately, then the supervisor; arrange a safe placement during investigation if needed [source: Kane et al. 2017]. (6) Psychosis or danger to self or others: refer and contact the supervising clinician at once; in the Iraq trial an adverse event involved a counsellor who did not notify the supervisor immediately as the protocol required [source: Weiss et al. 2015]. (7) For lower risk, build a concrete written plan (warning signs, coping steps, people to contact, safe places, securing or removing means, emergency numbers); current practice favours such a plan over a bare no-harm agreement [synthesis]. (8) Re-check at every session while a concern exists [source: CETA Description]. The SA trial adds weekly SMS safety checks with escalation to a supervisor, and a 7-day safety agreement for minimal risk [source: SA protocol]. Follow your own organisation's written safety protocol and reporting law; these are trial protocols, not a universal standard.
Example language (illustrative): "I ask everyone this: in the last week, have you had thoughts of ending your life or of hurting someone else?"
Watch for: risk disclosed late in treatment; partner participation increasing a woman's risk (in the SA trial the partner's participation ended and he was referred elsewhere) [source: SA protocol]. Lay providers need a reachable supervisor for every safety case [source: CDC handout; t-CETA webinar].

4.4 Introduction (Psychoeducation)

Purpose / when: at least one session in every course; explain the programme (duration, content, what is expected), the presenting problems and their impact, normalise and validate symptoms, reduce stigma; use local analogies [source: Murray et al. 2014; CETA Description; SA protocol]. CPSS adds simple brain-science and stress-normalisation content [source: Nguyen et al. 2023].
Steps [synthesis]: (1) Name the client's symptoms in their own words. (2) Explain that these are common reactions to stress, loss or trauma. (3) Explain how symptoms keep themselves going (e.g. avoidance, withdrawal). (4) Describe the programme: number of sessions, weekly checklist, practice at home, what will be asked. (5) Use a local analogy (the 2014 teams used a bread-making analogy in Iraq). (6) Answer questions and summarise.
Example language (illustrative): "What you describe, the nightmares and feeling on edge, happens to many people after what you went through. It is the mind still trying to protect you."
Watch for: client feeling understood and less ashamed; misunderstandings about what the programme can fix (housing, money) that need referral.

4.5 Relaxation (Anxiety management)

Purpose / when: an add-on element for physiological tension or anxiety that interferes with functioning or other elements (added for 26 CETA clients in the Iraq RCT); published content is breathing exercises and imagery, with meditation and progressive muscle relaxation also described, building on local practices (e.g. Buddhist practices in Thailand) [source: Murray et al. 2014; Weiss et al. 2015; ZCAP protocol; CETA Description; SA protocol].
Steps [synthesis]: (1) Explain the body's stress response and the rationale. (2) Ask what the client already does to calm down (prayer, meditation) and build on it. (3) Teach one technique: slow breathing with a longer out-breath; or tensing and releasing muscle groups; or a calm-place image. (4) Practise in session; rate tension before and after (0–10). (5) Assign daily practice and use in stressful moments.
Example language (illustrative): "Breathe in slowly while I count to four, now out slowly to six. Let's do that five times and then rate how tense you feel."
Watch for: relaxation used as avoidance in exposure work; breathing that triggers panic (switch technique); drop in tension ratings across sessions.

4.6 Getting Active (Behavioural activation)

Purpose / when: core for depression; added early when low energy or withdrawal interferes; identify and do pleasurable, mood-boosting or mastery activities; in HIV versions includes care-related activities [source: Murray et al. 2014; CETA Description; SA protocol].
Steps [synthesis]: (1) Explain the link between doing less and feeling worse. (2) List activities the client used to enjoy or that give a sense of achievement, adapted to current resources. (3) Choose one or two small, specific activities; schedule day and time. (4) Rate mood before and after. (5) Review next week; problem-solve barriers; build up gradually.
Example language (illustrative): "When we feel low we stop doing things, and then we feel lower. Let's pick one small thing you could do this week, like visiting your neighbour on Thursday."
Watch for: activities too large (shrink them); activities blocked by cost or safety; mood ratings after activities.

4.7 Thinking in a Different Way, Part I (Cognitive coping)

Purpose / when: in every default flow; teach the connection between thoughts, feelings and behaviour (the "cognitive triangle", which trainees also apply to their own lives in training) and that changing how we think about a situation can change how we feel and act; also the one skill taught in CPSS [source: Murray et al. 2014; CETA Description; Nguyen et al. 2023].
Steps [synthesis]: (1) Use an everyday neutral example (CPSS added examples such as being refused a free bus ride) to separate situation, thought, feeling, action. (2) Show how a different thought about the same event leads to a different feeling and action. (3) Practise with a mild event from the client's week. (4) Introduce questions for checking whether a thought is accurate or helpful. (5) Homework: notice one upsetting moment a day and record situation, thought, feeling, action (orally or with pictures if the client does not read).
Example language (illustrative): "Two people are refused a seat on the bus. One thinks 'he hates people like me' and feels angry; the other thinks 'the bus is full' and feels calm. Same event, different thought."
Watch for: confusing thoughts and feelings (keep practising labelling); client applying the triangle spontaneously between sessions is a good sign. Do not start on trauma thoughts in Part I [synthesis].

4.8 Thinking in a Different Way, Part II (Cognitive restructuring)

Purpose / when: after Part I (and after imaginal exposure in the trauma flow); evaluate and change "stuck" thoughts that maintain distress so they become more accurate or helpful; in trauma, often thoughts about blame, safety, trust; in HIV versions, negative thoughts about care [source: Murray et al. 2014; CETA Description; SA protocol]. A CETA handout titled "Socratic Techniques for Changing Unhelpful Thoughts" is hosted by the UW Harborview trauma centre but its content is not drawn on [uncertain].
Steps [synthesis]: (1) Choose a stuck thought identified in Part I or in the trauma narrative. (2) Rate belief 0–100%. (3) Ask Socratic questions: evidence for and against; what you would tell a friend; what else could explain it; what was actually within your control. (4) Help the client write or say a more balanced thought. (5) Re-rate belief and the feeling. (6) Practise with further stuck thoughts; assign daily practice.
Example language (illustrative): "You said 'it was my fault he was killed.' What could you actually have done in those few seconds, with the gun pointed at you?"
Watch for: arguing or persuading instead of questioning; a replacement thought that is merely positive and not believed; decreases in guilt and shame ratings.

4.9 Talking about Difficult Memories (Imaginal gradual exposure)

Purpose / when: included in all trauma-primary cases in the pilots; gradual exposure to feared memories, including details and associated thoughts and feelings, in a safe setting; usually two or more sessions, repeated while distress stays high [source: Murray et al. 2014; CETA Description].
Consent, safety and contraindications [synthesis]: obtain explicit consent after explaining rationale and expected temporary distress; delay while active suicide risk, ongoing violence from the perpetrator, acute psychosis or severe substance intoxication are unresolved; make sure Thinking I (and Relaxation if needed) are in place; ensure the client has a plan for after the session; staff must have supervisor backup.
Steps [synthesis based on the published description]: (1) Explain why avoiding memories keeps them powerful. (2) Start with the less distressing parts or a general outline, then move to the worst moments over sessions (gradual). (3) Ask the client to describe what happened in the first person, slowly, including what they saw, heard, thought, felt in their body. (4) Take distress ratings (0–10) at start, at the worst point and at the end. (5) Note stuck thoughts that emerge for Part II. (6) Close with grounding and a review of what the client managed. (7) Repeat in the next session; dose by the CMF and in-session ratings (the 2014 vignette repeated exposure when distress stayed around 7).
Example language (illustrative): "Tell me what happened when you reached the checkpoint, as if it's happening now. What do you see? What are you thinking?"
Watch for: dissociation or overwhelming distress (slow down, ground, shift to a less intense part); skipping the worst moment; within- and between-session drop in distress ratings; fewer nightmares and avoidance on the CMF.

4.10 Live Exposure (In vivo gradual exposure)

Purpose / when: added when the client avoids harmless triggers or safe places (e.g. an Iraqi torture survivor avoiding checkpoints); gradual exposure to these in daily life [source: Murray et al. 2014; CETA Description].
Steps [synthesis]: (1) Confirm together that the situation is objectively safe (not, e.g., a real danger zone or a violent partner). (2) Build a ladder of 5–10 steps from least to most feared, rated 0–10. (3) Start with a low step; stay until distress comes down; repeat several times that week. (4) Review, move up the ladder. (5) Use coping skills before and after, not to escape.
Example language (illustrative): "First step: stand across the street from the market for ten minutes and notice your fear rise and then settle."
Watch for: safety behaviours and escape; steps too big; never use live exposure for situations with genuine current danger.

4.11 Alcohol / Substance Use Reduction

Purpose / when: added for hazardous alcohol or drug use. Original Thailand version: a brief intervention based on Screening and Brief Intervention and Motivational Interviewing with personalised AUDIT feedback, the client deciding whether to change [source: Murray et al. 2014]. Zambia version (VATU): a CBT-based substance-use reduction element drawing on motivational enhancement, contingency management and relapse prevention [source: Kane et al. 2017]. HIV-care versions describe an integrated CBT and MI element to set goals, reduce use and address "drivers of use" [source: ZCAP protocol; SA protocol; CDC handout].
Steps (Zambia VATU version, paraphrased from the published description) [source: Kane et al. 2017]: (1) Elicit motivational statements and set a specific goal for use; have the client rate motivation to reach it, and repeat the rating at several points in the session. (2) Identify the client's own drinking triggers (e.g. boredom, stress, passing a bar on the way home). (3) Teach and rehearse strategies that counter each trigger, such as replacing the behaviour with another activity or avoiding the trigger. (4) At the end of the session revisit the goal and re-rate motivation. Monitor with a brief past-7-day alcohol timeline follow-back each session [source: Kane et al. 2017; ZCAP protocol]. Thailand brief-intervention version: ask permission, give neutral feedback on the AUDIT score compared with low-risk levels, and let the client decide whether to change [source: Murray et al. 2014]. Exploring pros and cons and using other CETA skills (relaxation, problem solving) against drivers is [synthesis].
Example language (illustrative): "It's your decision what you do with this. What do you think about the score?"
Watch for: counsellors slipping into persuasion (CBT-trained counsellors found the MI stance hard); withdrawal risk with heavy dependence needs medical referral [synthesis].

4.11a Substance Use Support (partner element)

Purpose / when: in the Zambia VATU trial, a support element for the partner of the person using alcohol, when applicable; rationale from family-based approaches, because the main aim was preventing violence [source: Kane et al. 2017].
Steps (paraphrased from the published aims) [source: Kane et al. 2017]: (1) give the partner psychoeducation about the substance use; (2) help the partner identify the drinker's drivers of use; (3) work out ways the partner can support reduced use. Anything further (e.g. how to respond safely to intoxication, not taking on blame for the drinking) is [synthesis].
Example language (illustrative): "Let's look at when your partner's drinking tends to start, and which of those times you could make easier without putting yourself at risk."
Watch for: any sign that the support role raises violence risk; check the partner's safety privately each session and follow the IPV steps in 4.3 [synthesis consistent with the Kane et al. 2017 safety protocol].

4.12 Problem Solving

Purpose / when: in 2014, used only for homework barriers; in later versions a full element that teaches a stepwise process to solve problems and make healthy decisions, including medication-adherence problems in HIV care [source: Murray et al. 2014; ZCAP protocol; CETA Description; SA protocol].
Steps [synthesis]: (1) Define one specific problem. (2) Brainstorm all possible solutions without judging. (3) Weigh pros and cons of each. (4) Choose one and plan who, what, when. (5) Try it, then review and adjust.
Example language (illustrative): "Let's list every way you could get to the clinic, even the silly ones, then pick the best."
Watch for: problems that are unsolvable (shift to coping or cognitive work); solutions that rely on others' cooperation.

4.13 Finishing Steps

Purpose / when: last element in every flow [source: Murray et al. 2014]; content not described in the sources. In CPSS, finishing steps include planning a later follow-up contact [source: Nguyen et al. 2023].
Steps [synthesis]: (1) Review CMF change since intake. (2) Review each skill learned and when to use it. (3) Identify warning signs of relapse and which skill to use. (4) Plan follow-up and how to re-contact services. (5) Acknowledge progress.
Example language (illustrative): "Which of the skills will you reach for if the nightmares come back?"
Watch for: residual safety concerns (update safety plan); need for referral.

4.14 Homework and guided practice routine (cross-cutting)

Purpose / when: every element includes guided practice (modelling, role-play) and weekly homework review with barrier problem-solving [source: Murray et al. 2014; MHPSS listing].
Steps [synthesis]: model the skill, role-play it with the client, assign one specific practice, check understanding, review and problem-solve next week.
Example language (illustrative): "Let me show you first, then you try it with me."
Watch for: homework not done (see section 5).

4.15 Child, adolescent and caregiver components

Purpose / when: CETA-Youth targets co-occurring depression, anxiety, traumatic stress and externalising (behaviour) problems in children and adolescents, delivered individually to the child with the caregiver where possible [source: Murray et al. 2018]. Caregivers, if available, are taught the same skills as the child so they can support the child, in joint child–caregiver sessions; parenting skills are added when the child has behaviour problems [source: Murray et al. 2018]. Youth trauma default flow: Introduction/Encouraging Participation → an element listed as "Learning" [uncertain: its content is not described in the text read] → Thinking in a Different Way Part 1 (cognitive coping) → Talking about Difficult Memories (imaginal exposure) → Thinking in a Different Way Part 2 (cognitive processing) → Finishing; weekly 60–90 minute sessions, 6–12 suggested [source: Murray et al. 2018]. Other uses: youth groups by age (children 8–17, with assent) in the Zambia VATU trial before the switch to individual delivery [source: Kane et al. 2017]; orphans and vulnerable children (Zambia) and Syrian refugee children by phone (Lebanon), with separate caregiver sessions in some cases (e.g. 10 child and 8 caregiver sessions) [source: t-CETA webinar; CDC handout; MHPSS listing].
Steps: the published decision rules apply (flow agreed with the supervisor after session 1 and approved by the trainer; a second session of an element when steps are incomplete, the skill is not learned, homework is not done or symptoms have not improved) [source: Murray et al. 2018]. Child-specific element steps and the content of the parenting-skills element are not given in the sources [uncertain]. In practice [synthesis]: teach each skill to the child first, then have the child show it to the caregiver with your help; give the caregiver a specific role in home practice; for trauma narratives, agree with the child beforehand what, if anything, will be shared with the caregiver. Use only after CETA child training.
Watch for: privacy for the child during caregiver contact; caregivers correcting answers.

4.16 CETA Psychosocial Support (CPSS) single group session

Purpose / when: prevention and referral for mild symptoms; developed for veterans and families in Ukraine [source: Nguyen et al. 2023].
Steps: (1) Introduction and psychoeducation with brain science and stress normalisation. (2) Self-assessment across mental health, functioning, safety, alcohol, social disconnection, aggression and communication. (3) Safety identification and planning, immediate referral for anyone at risk. (4) One cognitive coping skill (Thinking I). (5) Finishing steps and follow-up; referral to full CETA if scores remain above threshold. Groups of 5–10, about 2 hours with a break.
Example language (illustrative): "Today is one meeting to learn one skill and check how you're doing."
Watch for: heterogeneous groups are harder to manage; keep size small enough to screen and refer quickly.

4.17 Telephone and remote delivery (t-CETA)

Purpose / when: when clinic attendance is impossible [source: t-CETA webinar; SA protocol].
Steps: shorter (about 30 minute) sessions spread over more contacts; visual-aid booklet sent in advance; agree privacy arrangements and coded check-in questions in the first contact; "call me" text when safe; plan for overheard conversations (change topic or reschedule); verify identity before disclosing anything; backup numbers and call-back plan; extra verbal warmth and validation; games and breaks for children; on-call supervisor for safety.
Example language (illustrative): "If someone comes into the room, say 'I'll call you about the delivery later' and we'll stop."
Watch for: hesitancy, sudden noises or changes in voice (check safety).

5. Handling problems

From the sources

Stigma and engagement ("only for crazy people"): call it a "programme", not treatment; use community outreach (the Thailand team used radio shows and community drama); spend a full session on Encouraging Participation [source: Murray et al. 2014].
Distress not decreasing: repeat the element rather than moving on (e.g. extra imaginal exposure sessions when distress stays high); review in supervision; consider changing the primary target [source: Murray et al. 2014; CETA Description].
Interference (low energy, high physiological anxiety, avoidance): insert Getting Active, Relaxation or Live Exposure before continuing the flow [source: Murray et al. 2014].
Counsellor difficulty with MI stance in substance work: extra role-play and supervision on giving feedback without persuading [source: Murray et al. 2014].
Counsellor not yet competent: extra practice time and additional pilot cases; training continues "until competency is reached" [source: Murray et al. 2014; SA protocol].
Gender norms and logistics: arrange chaperones or same-gender counsellors where required; plan travel accordingly [source: Murray et al. 2014].
Partner involvement increasing violence risk: check the woman's safety after each partner session; end the partner's participation and refer him elsewhere if risk rises [source: SA protocol].
No response to safety check-ins: re-text, then call; home visit if the client previously showed distress [source: SA protocol]. Missed sessions: up to three phone follow-ups within a week, then one home visit [source: ZCAP protocol]. Groups failing because members miss sessions or cannot travel: switch to individual delivery, as the Zambia VATU trial did [source: Kane et al. 2017].
Phone delivery problems (cost, single family phone, no privacy, poor network, children bored or reluctant): shorter sessions, flexible scheduling, call-back plans, games and breaks, more verbal warmth, repeat and re-explain content [source: t-CETA webinar].
Unmet practical needs (money, housing, school, family separation) undermining outcomes: link to services alongside CETA [source: t-CETA webinar].

Clinician synthesis (not found in CETA sources) [synthesis]

Homework non-adherence: ask what got in the way; shrink the task; practise it in session; use oral or picture-based records for clients who do not read; link the task to a daily routine. Treat non-completion as data, not failure.
Exposure avoidance or refusal: revisit the rationale, start lower on the gradient, do more of the narrative in session rather than at home, offer choice of starting point; never force exposure; if refusal persists, discuss with supervisor and consider cognitive work alone.
Overwhelm or dissociation in exposure: pause, ground (name things in the room, feet on floor, slow breathing), resume at a less intense part; end with distress lower than peak where possible; review readiness and safety at the next session.
Multiple shifting crises: run Safety and Problem Solving first; avoid changing flows weekly; agree with supervisor on one primary target for at least two to three sessions before reconsidering.
Ruptures (client feels judged, misunderstood or pushed): name it, invite feedback, acknowledge your part, adjust pace; especially check after exposure or cognitive challenge sessions.
Fidelity drift (skipping steps, turning sessions into general support): use the step log each session and bring it to supervision; redo missed steps.
Suicide risk emerging mid-treatment: switch to the Safety element that session; follow the organisation's escalation protocol; means counselling limited to safe storage or removal; involve family or emergency services as the protocol requires.
Specialist clinician using CETA: do not add techniques from outside CETA under the CETA name; if the client needs more (e.g. psychosis, severe dependence, complex medical issues), refer or step up care.

Sources

Sources:

Further reading (not drawn on) [uncertain]: the CETA manual and steps sheets (available only via CETA Global training); the CETA Global website; the UW Harborview "CETA Flows" handout and "Socratic Techniques for Changing Unhelpful Thoughts" handout; the full texts of Bolton et al. 2014 (PLoS Medicine; abstract only) and Murray et al. 2019 (abstract only); the Murray et al. 2020 VATU trial results paper (PLoS Medicine) and the PMC copy of Murray et al. 2014.

Books and papers cited: Murray LK, Dorsey S, Haroz E, Lee C, Alsiary MM, Haydary A, Weiss WM, Bolton P (2014). A common elements treatment approach for adult mental health problems in low- and middle-income countries. Cognitive and Behavioral Practice, 21, 111–123. Bolton P, Lee C, Haroz EE, Murray L, Dorsey S, Robinson C, Ugueto AM, Bass J (2014). A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand. PLoS Medicine, 11(11), e1001757 (record and abstract read). Weiss WM, Murray LK, et al., including Bass JK (2015). Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial. BMC Psychiatry. Kane JC, Skavenski Van Wyk S, Murray SM, Bolton P, Melendez F, Danielson CK, Chimponda P, Munthali S, Murray LK (2017). VATU trial protocol. Global Mental Health, 4, e18. Murray LK, Hall BJ, Dorsey S, Ugueto AM, Puffer ES, Sim A, Ismael A, Bass J, et al. (2018). An evaluation of a common elements treatment approach for youth in Somali refugee camps. Global Mental Health, 5, e16. Murray LK, Haroz EE, Pullmann MD, Dorsey S, Kane J, Augustinavicius J, Lee C, Bolton P (2019). Under the hood. the Cognitive Behaviour Therapist, 12, e6. Murray LK et al. (2020). Effectiveness of CETA in reducing intimate partner violence and hazardous alcohol use in Zambia (VATU): a randomized controlled trial. PLoS Medicine.

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