SJFOETIJQ#FODI5SBJOJOH.BOVBM GPS)FBMUI1SPNPUFST · » Cords, cables, and accessories must be inserted carefully into the tablet to prevent damage. » Health Promoters are responsible

Friendship Bench Training Manual for Health Promoters

ZAPP UZ

This manual can be copied, reproduced and adapted by individuals as part of their work or training needs without permission of the authors. Acknowledgement must be provided and reproduction is QRW�WR�EH�XVHG�IRU�SURÀW�SXUSRVHV��7KLV�PDQXDO�ZLOO�EH�UHYLHZHG�UHJXODUO\�DQG�WKH�ODWHVW�YHUVLRQ�FDQ�be downloaded from the study website www.friendshipbenchzimbabwe.com.

CONTACT :

The Friendship Benchwww.friendshipbenchzimbabwe.comhello@friendshipbenchzimbabwe.com

The Purple House24 Frank Johnson AvenueEastlea, Harare

The Zimbabwe AIDS Prevention Project (ZAPP)92 Prince EdwardMilton ParkHarareZimbabweTel-+263-4-707289/91

MANUAL DEVELOPMENT AND DESIGN :

Ruth VerheyJean TurnerDixon Chibanda

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Tarryn BowersEpiphania MunetsiVongai MunatsiDebra MachandoTarisai BerePercy TaruvingaEthel MandaPeta SearleLloyd DzapasiRicardo ArayaMelanie Abass

Zvidzai SimonLovemore ChinyereAnnah ChitongoIsrael MakwaraNigel JamesAdmire DombojenaSandra MachiriSophia ChipunzaEvans DewaNyaradzai KatenaJuliet Nyamasve

The following have all been contributors in the development of this manual :

TableT care .....................................................................................................01-02chapTer 1 • Friendship Bench Manual for Health Promoters..............03chapTer 2 • Historical background of the Friendship Bench......04chapTer 3 • Psychoeducation......................................................05-08chapTer 4 • Common Mental Disorders...................................................09-15 4.1 Depression 4.2 Anxiety 4.2.1 Anxiety (Generalized Anxiety Disorder) 4.2.2 Panic Disorder 4.2.3 Post Traumatic Stress Disorder 4.2.4 Cognitive Disorders 4.2.5 Substance Abuse

chapTer 5 • The Friendship Bench Intervention............................... 16-17chapTer 6 • Questionnaires for SSQ and PHQ-9...................................18-24 6.1 SSQ 6.1.1 Scoring explanation� � � ��5HG�ÁDJ

6.2 PHQ 96.2.1 Scoring explanation6.2.2 Red Flag

chapTer 7 • Counselling Skills.....................................................................25-31� � � ��&RQÀGHQWLDOLW\� � � ��%UHDNLQJ�FRQÀGHQWLDOLW\ 7.2 What is counselling? 7.3 Qualities of good counsellor 7.4 How to ask Questions

chapTer 8 • Friendship Bench card.....................................................32-33chapTer 9 • Problem Solving Therapy (PST).........................................34-54chapTer 10 • Strong emotional reactions.................................................55-56chapTer 11 • Suicide assessement.............................................................57-60chapTer 12 • Supervision ............................................................................ 61-62chapTer 13 • Home Visits..............................................................................63-64chapTer 14 • Kubatana Tose Circle............................................................65-68chapTer 15 • Self-care...................................................................................69-70

Triaining overview.......................................................................................72-73

shona Training maTerial.....................................................................75-87

Table of contents

the Friendship Bench

page

01


Taking care of Your Tablet

Cleaning » 8VH�RQO\�D�FOHDQ��VRIW�FORWK�VXFK�DV�PLFURÀEHU�WR�FOHDQ�WKH�VFUHHQ��QR�

cleaner of any type – no window cleaners, household cleaners, aerosol sprays, solvents, alcohol, ammonia, or abrasive material.

Caution: Your tablet is not waterproof. Do not pour or spray liquids directly on your tablet or wash your tablet with a heavily soaked cloth.

Daily Use » Avoid putting the tablet computer in places where it could be damaged

such as wet, dusty, dirty, and uneven surfaces.

» Cords, cables, and accessories must be inserted carefully into the tablet to prevent damage.

» Health Promoters are responsible for keeping their tablet battery charged for use each day.

» Waiting to charge the tablet until the charge is low (20% life or red indicator light) extends the battery life.

» The tablet screen can be damaged if subjected to rough treatment.Careful placement in pouch is important.

» Avoid using any sharp object(s) on the tablet. No scratching with pens or pencils or sticks for pointing out important notes on the screen.

» 'R�QRW�´EXPSµ�WKH�WDEOHW�DJDLQVW�ORFNHUV��ZDOOV��GRRUV��ÁRRUV��RU�DQ\�other hard objects.

» Never place a tablet in a bag that contains food, liquids, heavy, or sharp objects.

Appearance » Tablets must remain free of any writing, drawing, stickers, or labels

that are not the property of Friendship Bench

02


» (DFK�FDVH�DQG�WDEOHW�LV�LGHQWLÀDEOH��'R�QRW�UHPRYH�DQ\�)ULHQGVKLS�%HQFK�ID tags or labels.

Safe Keeping » Tablets must never be left in an unlocked locker, unlocked car or any

unsupervised area

» Tablets must NOT be removed from its protective case.

» When not in your personal possession, the tablet should be in a secure, locked environment.

» Unattended tablets will be collected and stored in the Friendship Bench RIÀFH�LQ�WKH�FOLQLF�

» Each tablet has the ability to be remotely located. Modifying, disabling or attempting to disable the locator is a violation of the acceptable use policy and grounds for disciplinary action.

» (DFK�WDEOHW�KDV�D�XQLTXH�LGHQWLÀFDWLRQ�QXPEHU�DQG�DW�QR�WLPH�VKRXOG�WKH�QXPEHUV�RU�ODEHOV�EH�PRGLÀHG�RU�UHPRYHG�

» Do not lend your tablet to another person. Each tablet is assigned to an individual and the responsibility for the care of the tablet solely rests with that individual.

» Never expose a tablet to long-term temperature extremes or direct sunlight. Do not allow the tablet to receive direct sunlight, an excess amount of heat, or extremely cold conditions. If the tablet is placed in cold conditions, the battery life can be decreased.

Repair » The tablet is an electronic device and care must be exercised when

handling the tablet.

» Do not attempt to gain access to the internal electronics or repair your tablet.

» If your tablet fails to work or is damaged, report the problem to ZAPP +263-4-707289/91.

Introduction

This manual was compiled using various resources and drawing from the experience of the Friendship Bench clinical team.

For gender equity purposes, we chose to use the female pronoun throughout the manual. Most of the HPs working for City Health Department are actually women. Where applicable, it includes the male gender.

Aim:This manual aims to enable Health Promoters and their supervisors (District Health Promotors) to IHHO�FRQÀGHQW�LQ�WKHLU�FRXQVHOOLQJ�ZRUN�DQG�EH�DZDUH�RI�WKHLU�FOLHQWV·�DQG�WKHLU�RZQ�QHHGV�WR�GR�WKLV�important work.

Process:We encourage group discussions and exercises as what we learn has to be practiced.


chapter 1

Friendship Bench Manualfor Health Promoters (HPs)

03

Historical background of the Friendship Bench and justification


chapter 2

04

Over 30% of people utilizing primary health care facilities in Zimbabwe suffer from common mental disorders (CMD). This term describes the presentation of anxiety, depressive and

somatic symptoms.The Friendship Bench project was developed in 2006 in response to a stakeholders' meeting that emphasized the need to urgently address the high prevalence of CMD among people ulitizing primary health care facilities in Harare.The Friendship Bench is a task shifted brief intervention that is based on cognitive behavioural therapy (Cognitive behavioral therapy). It is delivered by supervised Health Promoters who have UHFHLYHG�WUDLQLQJ�LQ�WKH�VSHFLÀF�&RJQLWLYH�EHKDYLRUDO�WKHUDS\�DVSHFWV�RI�SUREOHP�VROYLQJ�WKHUDS\�DQG�behaviour scheduling. It consists of six structured 45-minute sessions delivered on a bench within the grounds of the clinic in a discrete area.Our pilot data show that the Bench, which has been running since 2006, is well accepted, feasible and potentially effective (Chibanda, et al. 2011).In this intervention, the counselling will be supported by the use of computer tablets, delivering information and decision support.Furthermore, the Friendship Bench project has the additional feature of Kubatana Tose circles. These circles will be held once a week, at the beginning by trained peer counsellors and later by the SDUWLFLSDQWV�WKHPVHOYHV��$�FLUFOH·V�DLP�LV�WR�FUHDWH�D�VDIH�IRUXP�IRU�SDUWLFLSDQWV�WR�VKDUH�DQG�H[SORUH�strategies for problem solving.

Background


05

Kufungisisa

chapter 3

Psychoeducation

WHAT IS KUFUNGISISA?

Kufungisisa is a common mental disorder (CMD). In the Western context it describes Depression and Anxiety.Kufungisisa is also a common illness that affects many people.Often people do not know that they are suffering from it.If Kufungisisa is not recognized, a suffering person cannot get the right treatment and other conditions such as Hypertension, Diabetes, HIV/AIDS that this person may have can worsen.

CMD is mostly caused by psychosocial stressors such as chronic stress, and negative life events VXFK�DV�ORVV�RI�D�ORYHG�RQH��ORVV�RI�HPSOR\PHQW��WUDXPDWLF�HYHQWV��KLJK�FRQÁLFW�LQ�UHODWLRQVKLSV��

lack of coping strategies and general negative life circumstances such as poverty, chronic illness, ongoing unemployment.There is a genetic component to CMD which means if a parent suffers from kufungisisa, the chances for a child to suffer from depression at some stage in her life are higher than in children whose parents do not have depression.

Kufungisisa affects all areas of life.

.XIXQJLVLVD�DIIHFWV�SHRSOH·V�DELOLW\�WR�WKLQN�DQG�PDNH�GHFLVLRQV�DQG�UHVROYH��SUREOHPV��3HRSOH�ZLWK�NXIXQJLVLVLD�RIWHQ�KDYH�SUREOHPV�ZLWK� VOHHS�� WKH\�PLJKW�RYHUVOHHS�RU�ÀQG� LW�KDUG� WR�VOHHS��7KH\�PLJKW�RYHUHDW�RU�ORVH�DOO�DSSHWLWH��7KH\�PLJKW�ÀQG�LW�GLIÀFXOW�WR�LQWHUDFW�ZLWK�RWKHUV�DQG�withdraw from social activities. They appear sad or angry and tearful and without energy.3UH�H[LVWLQJ�PHGLFDO�FRQGLWLRQV�FDQ�EH�ZRUVHQHG��3HRSOH�VXIIHULQJ�IURP�.XIXQJLVLVD�DOVR�ÀQG�LW�KDUG�to take their medication regularly, a behaviour which will put their health at risk.We speak of the vicious kufungisisa cycle which can be described this way: when people suffering from Kufungisisa have disturbed sleep, they do not get rest and lose the ability to concentrate, they

06

the Friendship Bench psychoeducation

have no interest and motivation. When they lose these important abilities, they cannot perform at work, they cannot solve problems, they withdraw from others and from activities they once liked. They continue to worry and be sad and without energy which will in turn affect their sleep, their eating and their whole behavior and health negatively leading them to have increased symptoms.

Image I: The vicious kufungisisa cycle!!

When Kufungisisa persists for more than two weeks it becomes an illness. It is important to know that Kufungisisa can be treated! A person suffering from Kufungisisa can receive help to develop appropriate coping strategies and problem solving skills.

Friendship Bench • Problem Solving Therapy KUVHURA PFUNGWA ‒ KUSIMUDZIRA ‒ KUSIMBISA ‒ KUSIMBISISA

)��AT THE FRIENDSHIP BENCH, WE WORK WITH A TECHNIQUE CALLED PROBLEM SOLVING THERAPY.

7KH�ÀUVW�SDUW�RI�RXU�VHVVLRQV�LV�FDOOHG�NXYKXUD�SIXQJZD��RSHQLQJ�XS�WKH�PLQG��The counselor helps the client to understand what is happening in their life and encourages her to share what is going on and how she feels about it.The aim is to make a list of all the problems that the client faces.

,Q�WKH�VHFRQG�SDUW�WKH�FRXQVHORU�KHOSV�WR�FKRRVH�RQH�SUREOHP�RI�WKDW�OLVW�It has to be manageable and relevant to you and maybe even practical. $IWHU� WKLV� VWHS� WKH� FOLHQW·V� JRDO� ZLOO� EH� HVWDEOLVKHG� DQG� WKH� SUREOHP� GHÀQHG� LQ� GHWDLO��Brainstorming solutions is the next step.

LACK OF INTEREST,

CONCENTRATION, MOTIVATION

LACK OF SELF-CARE, SLEEP DISTURBANCE

SUICIDAL THOUGHTS

KUFUNGISISA SSQ 14 >8

FEELING RUN DOWN, NOT PERFORMAING AT WORK/ HOME,

WITHDRAWAL FROM OTHERS

This is what we call NXVLPXG]LUD��

7KH�WKLUG�SDUW�IRFXVHV�RQ�D�GHWDLOHG�VROXWLRQ�VHOHFWLRQ�DQG�GHYLVLQJ�D�60$57�DFWLRQ�SODQ�KRZ�WR�UHDOL]H�WKH�VROXWLRQ�This phase is called NXVLPELVD�

7KH�IRXUWK�SKDVH�RI�WKH�)ULHQGVKLS�%HQFK�LQWHUYHQWLRQ�WR�KHOS�ZLWK�NXIXQJLVLVD�LV�FDOOHG�NXVLPELVLVD��Participants are invited to take part in the circle Kubatana Tose where people facing similar life challenges and having gone through the Friendship Bench counselling can share their stories and spend time together in a safe and protected environment.

Session Structure


07

psychoeducation

SESSION 1TABLET COMPUTER CHARGED AND TURNED ON

Greet the client, present yourself, invite client to sit down

$VN�IRU�QDPH�DQG�3,'�QXPEHU�RI�FOLHQW��RSHQ�FOLHQW·V�ÀOH�RQ�WDEOHW�DQG�YHULI\�GDWD

EXPLAIN THE FRIENDSHIP BENCH

START AMBUYA HOPE E-BOOK AND GO THROUGH IT WITH CLIENT

INVITE CLIENT TO SPEAK ��+RZ�FDQ�ZH�KHOS�HDFK�RWKHU"�

Ö &KL�FKLULNXQHG]D�NDQD�FKL�FKLULNXLWLND"

LISTEN EMPATHICALLY

APPLY COMPLETE PROBLEM SOLVING THERAPY

Evaluate and feedback

Make new appointment

SAVE DATA/TURN OFF TABLET

08

the Friendship Bench psychoeducation


Greet the client, invite client to sit down

$VN�IRU�QDPH�DQG�3,'�QXPEHU�RI�FOLHQW��RSHQ�FOLHQW·V�ÀOH�RQ�WDEOHW�DQG�YHULI\�GDWD�

REVIEW 1ST SESSION Ö��+RZ�GLG�WKH�DFWLRQ�SODQ�JR"

WENT WELL: �SUDLVH�UHLQIRUFH�UHDIÀUP�ask for further problem client wants to work on, apply complete PST

DIDN’T GO WELL: explore reasons, discuss obstacles, repeat PST, ��ÀQG�DGMXVWHG�60$57�DFWLRQ�SODQ


Make new appointment



Greet the client, present yourself, invite client to sit down

$VN�IRU�QDPH�DQG�3,'�QXPEHU�RI�FOLHQW��RSHQ�FOLHQW·V�ÀOH�RQ�WDEOHW�DQG�YHULI\�GDWD�

REVIEW 2ND SESSION Ö��+RZ�GLG�WKH�DFWLRQ�SODQ�JR"

WENT WELL: �SUDLVH�UHLQIRUFH�UHDIÀUP�ask for further problem client wants to work on, apply complete PST

DIDN’T GO WELL: explore reasons, discuss obstacles, repeat PST, ��ÀQG�DGMXVWHG�60$57�DFWLRQ�SODQ


Make new appointment, invite to circle Kutabata Tose


Repeat for sessions 4-6 (always reviewing the previous session) :

SESSION 4 • REVIEW 3RD SESSION Ö��+RZ�GLG�WKH�DFWLRQ�SODQ�JR"

SESSION 5 • REVIEW 4TH SESSION Ö��+RZ�GLG�WKH�DFWLRQ�SODQ�JR"

SESSION 6 • REVIEW 5TH SESSION Ö��+RZ�GLG�WKH�DFWLRQ�SODQ�JR"


In Shona we call Depression Kufungisisa. Depression is very common amongst people who seek treatment at the local clinic.

Depression is often not recognized. It is important that we learn to recognize a person who suffers from Depression. Depression is a mood disorder that is characterized by the following symptoms according to DSM V (Diagnostic and Statistical Manual Of Mental Disorders 5th ed.). These symptoms must have been present for a 2-week period.

�� GHSUHVVHG�PRRG�� ODFN�RI�LQWHUHVW�� VLJQLÀFDQW�ZHLJKW�ORVV�RU�JDLQ�� ODFN�RI�VOHHS�RU�RYHU�VOHHSLQJ�� DJLWDWLRQ�RU�ODFN�RI�HQHUJ\��HYHQ�QRWLFHG�E\�RWKHUV�� IHHOLQJV�RI�ZRUWKOHVVQHVV�DQG�JXLOW

4.1 Depression

09

chapter 4

Common Mental DisorderCommon mental disorder is a term that combines both Anxiety and Depression as well as somatic symptoms. Anxiety and Depression are very common disorders. In Shona they are described with the term kufungisisa, embracing the whole concept of CMD.Often, people suffer from both Depression and Anxiety at the same time.They can also present with somatic symptoms such as headaches, heart aches, belly aches.

INTRODUCTION

10

�� SUREOHPV�ZLWK�FRQFHQWUDWLRQ��WKLQNLQJ�DQG�GHFLVLRQ�PDNLQJ�� UHFXUUHQW�WKRXJKWV�RI�GHDWK�RU�VXLFLGDO�LGHDWLRQ

7KH�V\PSWRPV�FDXVH�VLJQLÀFDQW�LPSDLUPHQW�LQ�LPSRUWDQW�DUHDV�RI�IXQFWLRQLQJ��7KH�V\PSWRPV�DUH�not caused by the intake of a substance (alcohol, drugs). The symptoms are not solely explainable by bereavement.

Here is a description of a person who suffers from Depression:

“T. feels very sad most of the days, she does not have any energy to do the things that she has done before, even cooking sadza seems too much of a chore for her. T. finds it very difficult to get out of bed in the morning, often she has spent hours awake worrying about things. she avoids going out now and does not want to see any of her relatives or friends. she has thought about harming herself but would never talk about this to anyone. she feels extremely hopeless. sometimes her mood lifts in the afternoon.”

the Friendship Bench common mental disorders

4.2 Anxiety

Let us look at Anxiety. There are several disorders that belong to the group of Anxiety Disorders. Generalized Anxiety Disorder, Panic Disorder, and Posttraumatic Stress Disorder are the ones

we will look at in more detail, according to DSM V. (GAD, Panic Attacks, PTSD)

4.2.1 Anxiety (Generalized Anxiety Disorder)

Anxiety (Generalized Anxiety Disorder) is a disorder that is characterized by the following symptoms:�� H[FHVVLYH�DQ[LHW\�DQG�ZRUU\�� GLIÀFXOW\�WR�FRQWURO�WKHVH�� DQG�WKUHH�RU�PRUH�RI�WKH�IROORZLQJ�V\PSWRPV��UHVWOHVVQHVV��EHLQJ�HDVLO\�IDWLJXHG�� GLIÀFXOW\�FRQFHQWUDWLQJ�RU�PLQG�JRLQJ�EODQN��LUULWDELOLW\��PXVFOH�WHQVLRQ��VOHHS�� disturbance.

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The symptoms must be present for more days than not during the past 6 months.

Here is a description of a person who suffers from General Anxiety Disorder : “a. has changed. she is constantly worrying about everything and can not make any decisions anymore. she is very worried that she does things wrong and often avoids engaging in any of those activities she did before. she worries a lot that the other people in the community will think badly of her.”

4.2.2 Panic Disorder

Panic Disorder is characterised by recurrent unexpected panic attacks. Panic attacks are brief bouts of intense anxiety. The person suffering from Panic Disorder has continuous worry about re-experiencing further attacks, about the implications of these attacks (fear of having a heart attack, of going crazy) and changes her behaviour massively related to the attacks.

(1) recurrent unexpected Panic Attacks (2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a) persistent concern about having additional attacks (b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going FUD]\µ��F��D�VLJQLÀFDQW�FKDQJH�LQ�EHKDYLRXU�UHODWHG�WR�WKH�DWWDFNV��

Here is a description of a person who suffers from Panic Disorder:

“T. suddenly felt very anxious, her heart was pounding, she felt he could not breathe properly. she thought he would have a heart attack and die. she had to leave the building she was in immediately and is now worried to go back to that same place. in fact, she is so worried about experiencing these same feelings again that she now stays home most of the time.”

common mental disordersthe Friendship Bench

11

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12

common mental disorders

4.2.3 Post Traumatic Stress Disorder

This disorder can occur to persons who have been exposed to a traumatic event. The traumatic event involves actual or threatened death or serious injury to the person or others. The person responds with intense fear, helplessness or horror.

The person re-experiences the event in one or more of the following ways:

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&� ��SK\VLFDO�K\SHUDURXVDO� ��VOHHS�GLVWXUEDQFHV� ��LUULWDELOLW\� ��EHLQJ�VWDUWOHG�HDVLO\� ��K\SHUYLJLODQFH

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Here is a description of a person who suffers from PTSD : “one year ago, s. was walking back from the market when she saw a young girl running across the road and being run over by a commuter bus that was speeding. she heard the sound of the body being hit by the bus and saw the body of the girl being thrown into the air and falling down. The girl was instantly killed. s. heard the brakes of the bus screech and the other people and herself scream. since that day, she can not get the sounds out of her ears and frequently has flashbacks of the scene.



13

4.2.4 Cognitive Disorders

What are cognitive disorders?Mental health also stands for functioning cognitive abilities. Memory, problem solving, planning of complex activities, speed of thinking are examples of cognitive abilities.If these abilities are affected, we speak of cognitive impairment. We will rarely see cases of cognitive impairment at the Friendship Bench. It is still important to know what they are.

What kind of symptoms do patients present with? Some illnesses cause the brain to lose cell functioning, in advanced stages this will have a negative LPSDFW�RQ�WKLQNLQJ�DQG�PHPRU\��$O]KHLPHU·V�'LVHDVH�RU�6HQLOH�'HPHQWLD��)XUWKHUPRUH�� SHRSOH� VXIIHULQJ� IURP� FRJQLWLYH� LPSDLUPHQW� PLJKW� KDYH� GLIÀFXOWLHV� LQ� H[SUHVVLQJ�themselves, in recognizing faces, in controlling their emotions or do things such as putting on clothes.

What can cause cognitive impairment?�� $O]KHLPHU·V�'LVHDVH�� +LJK�EORRG�SUHVVXUH��9DVFXODU�'HPHQWLD�� +,9

HIV and Cognitive Disease:KHQ�VRPHRQH·V�LPPXQLW\�LV�VHYHUHO\�DIIHFWHG�DQG�WKH�&'��FRXQWV�GURS�EHORZ��WKH�EUDLQ�VXIIHUV�from the toxic effects of HIV, the consequence can be cognitive impairment.

Symptoms of HIV related cognitive impairment

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often she wakes up screaming when she has yet again dreamed of the scene. she avoids walking by busy streets and often it takes her a long time to cross a street as she is never sure about the traffic. she does not let her children go out by themselves anymore as she fears something can happen to them.”


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14

the Friendship Bench common mental disorders

� 6HYHUH�V\PSWRPV�� 6ORZ�PRYLQJ�DQG�WKLQNLQJ�� 'LIÀFXOW\�LQ�SODQQLQJ�DQG�FDUU\LQJ�RXW�DQ�DFWLYLW\�VXFK�DV�SUHSDULQJ�D�PHDO�� 6HYHUH�PHPRU\�ORVV�� &RQIXVLRQ��'DWH��WLPH��SODFH�� 'LIÀFXOW\�LQ�YHUEDO�H[SUHVVLRQ�� 'LIÀFXOW\�LQ�UHFRJQLWLRQ�RI�ORYHG�RQHV

Treatment adherence5HPHPEHULQJ�WR�WDNH�PHGLFDWLRQ�UHJXODUO\�LV�GLIÀFXOW�IRU�DQ\ERG\��,PDJLQH�KRZ�PXFK�PRUH�GLIÀFXOW�it becomes for someone who suffers from the above described cognitive impairment. Yet taking the ARVs is the treatment for HIV related cognitive issues. Depending on the severity of the symptoms, the treatment can help a person recover.7DNLQJ�PHGLFDWLRQ�LV�RQH�RI�RXU�LPSRUWDQW�WRSLFV�WKDW�PXVW�EH�EURXJKW�XS�

4.2.5 Substance abuse

People have always been using substances to change their state of mind. Often people will try to self -medicate using easily available substances.Very common substances include alcohol, marihuana/cannabis, medicines you can buy over the counter (cough medicine, pain medication, both can contain codeine!), stimulants (cocaine, methamphetamine), opiates (heroin, codeine, opium, morphine), or inhalants such as glue or petrol.

Effects of substances in general

� ,QWR[LFDWLRQ�� (DFK�VXEVWDQFH�KDV�XVXDO�V\PSWRPV��H[SHULHQFHG�E\�PRVW�SHRSOH��DQG� unpredictable symptoms (experienced by some people). Most people become relaxed when consuming cannabis, but some experience fear and paranoia�� :KHQ�V\PSWRPV�DUH�VHYHUH��LW�LV�KDUG�WR�GLVWLQJXLVK�WKHP�IURP�PHQWDO�LOOQHVV�

:LWKGUDZDO• When people use substances regularly for long periods, they will experience withdrawal symptoms if they stop using suddenly.

3K\VLFDO�HIIHFWV��ORQJ�WHUP�XVH�� 3HUPDQHQW�GDPDJH�SRVVLEOH��WR�OXQJV�IURP�VPRNLQJ��WR�OLYHU�IURP�GULQNLQJ�DOFRKRO�� to the brain from methamphetamine)

0HQWDO�HIIHFWV��ORQJ�WHUP�XVH�� ,QFUHDVHG�DQ[LHW\��SDUDQRLD��GHSUHVVLRQ��SV\FKRVLV


15


Effects of substances and withdrawal symptoms, specific

&DQQDELV�0EDQMH�� 6KRUW�WHUP��UHOD[DWLRQ��DQ[LHW\��ODXJKWHU��KXQJHU��FRQIXVHG�WKLQNLQJ��SDUDQRLD��IHDU�� psychotic symptoms�� /RQJ�WHUP��ORVV�RI�LQWHUHVW�PRWLYDWLRQ��DQ[LHW\��GHSUHVVLRQ��SV\FKRVLV $OFRKRO�� 6KRUW�WHUP��KDSS\�PRRG��UHOD[DWLRQ��ORVV�RI�LQKLELWLRQ��WDONDWLYHQHVV��FRQIXVLRQ�� sleepiness�� /RQJ�WHUP��GHSUHVVLRQ��DQ[LHW\��SV\FKRVLV��GHPHQWLD��OLYHU�GDPDJH�� :LWKGUDZDO�V\PSWRPV��SDOSLWDWLRQV��VKDNHV��VZHDWLQJ��VHL]XUHV��IHDU��DQ[LHW\�� confusion, hallucinations

6WLPXODQWV�� 6KRUW�WHUP��HQHUJ\�DQG�FRQÀGHQFH�LQFUHDVH��GHFUHDVH�RI�QHHG�RI�VOHHS�DQG�DSSHWLWH�� sexual risk-taking, anxiety/paranoia�� /RQJ�WHUP��GHSUHVVLRQ��DQ[LHW\��SV\FKRVLV��FRJQLWLYH�SUREOHPV�� :LWKGUDZDO�V\PSWRPV��DSSHWLWH�LQFUHDVH��WLUHGQHVV��GHSUHVVLRQ��FUDYLQJ

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16


The Friendship Bench Intervention

chapter 5

What is it?

7KH�)ULHQGVKLS�%HQFK�,QWHUYHQWLRQ�XVHV�D�WDVN�VKLIWLQJ�DSSURDFK�WR�GHOLYHU�HIÀFLHQW�KHOS�IRU�SHRSOH�suffering from CMD in a short set of 4-6 sessions with a Health Promoter.� 7KH�WUDLQLQJ�PDQXDO�IRU�WKH�)ULHQGVKLS�%HQFK�,QWHUYHQWLRQ�IRFXVHV�ÀUVWO\�RQ�'60�9�EDVHG�GHÀQLWLRQ�RI�&0'�UHODWHG�FRQGLWLRQV�DQG�LV�XVLQJ�VSHFLÀF�WRROV�WR�DVVHVV�WKH�VHYHULW\�RI�D�FOLHQW·V�condition. Secondly, it engages the Health Promoter being trained in acquiring necessary counselling skills as well as in the use of the Friendship Bench card as a mean of taking short and precise notes. Thirdly, PST is explained in detail, special case scenarios such as suicide intention are being discussed and management of these are described. Fourthly, the psychosocial group support Circle Kubatana Tose offered after having been to a minimum of three sessions is being described in detail. Although several conditions are described in the training manual the main emphasis is on depression (kufungisisa).

�� 7KH�PDQXDO�DLPV�WR�WHDFK�+HDOWK�3URPRWHUV�DQG�'LVWULFW�+HDOWK�3URPRWLRQ�2IÀFHUV�KRZ�WR�UHFRJQL]H�DQG�GLDJQRVH the following conditions that can be combined under the term common mental disorder: Depression, Anxiety (General Anxiety Disorder, Panic disorder, Post Traumatic Stress Disorder). Furthermore, cognitive disorders and substance abuse are being discussed. The care workers are being trained in the use of two locally validated tools, the SSQ 14 and the PHQ 9 in order for them to collect valuable data and use it to base their decision making on.

2. A strong emphasis is placed on training the HPs to HPEUDFH�WKH�VRIW�VNLOOV�RI�FRXQVHOOLQJ� The use of the Friendship Bench card, a simple card that is used to note down the main points of content of the sessions, is taught enabling a precise and short collection of data.


17

3. The actual intervention is delivered using problem solving therapy. Cognitive behavioral therapy based and thus embracing the concept of the interdependence of cognitions, emotions, physical sensations and behavior, the Health Promoter will help the client to FUHDWH�D�SUREOHP�OLVW�E\�VXPPDUL]LQJ�DQG�FROOHFWLQJ�WKH�LPSRUWDQW�LVVXHV�LQ�WKH�FOLHQW·V�QDUUDWLRQ��DV�ZHOO�DV�WR�FKRRVH�D�manageable and meaningful problem and brainstorm possible solutions for it. In the Friendship Bench Intervention this is called .89+85$�3)81*:$�ZKLFK� WUDQVODWHV� OLWHUDOO\� LQWR� ¶23(1,1*�UP THE MIND’� LQ�ZKLFK� WKH�FOLHQW� LV�HQFRXUDJHG� WR�FKRRVH�D�SUREOHP��GHÀQH� WKH�SUREOHP�DQG�brainstorm for possible solutions. Emphasis lies on choosing a feasible solution amongst those and create a SMART action plan to realize it which is called .86,08'=,5$�WUDQVODWLQJ� LQWR�UPLIFTING. In the consecutive sessions, implementation of the action plan is discussed and if necessary adjusted, described by the Shona term .86,0%,6$�PHDQLQJ�675(1*7+(1,1*�

4. The psychosocial support .86,0%,6,6$�WUDQVODWHV�WR�)857+(5�675(1*7+(1,1*. This consists in the participation of a ZHHNO\�JURXS�VXSSRUW which follows strict communication rules and offers a safe environment in which participants can share their experience.

the Friendship Bench intervention

chapter 6

Questionnaires (FOR SSQ and PHQ-9)

6.1 SSQ (Shona Symptoms Questionaire)

HHUH� LQ�=LPEDEZH��ZH�XVH� WKH�6KRQD�6\PSWRP�4XHVWLRQQDLUH� �664�� WR�ÀQG�RXW� LI� VRPHRQH� LV�suffering from CMD.

This is a questionnaire that has been developed and normed for Zimbabwe.

:H�FDQ�DOVR�XVH�WKH�664�WR�ÀQG�RXW�LI�VRPHRQH�LV�JHWWLQJ�EHWWHU��

6.1.1 Scoring explanation

$OO�WKH�TXHVWLRQV�FDQ�EH�DQVZHUHG�ZLWK�¶\HV·�RU�¶QR·�(YHU\� ¶\HV·� DQVZHU� FRXQWV� RQH�SRLQW��7R� VFRUH� WKH� TXHVWLRQQDLUH� UHVXOW��ZH� VLPSO\� DGG� WKH� ¶\HV·�answers. If someone has more than 8 points, we know that this person is very likely to suffer from CMD and needs treatment.

6.1.2 Red flag

4XHVWLRQ� QXPEHU� �� LV� ¶$W� WLPHV� ,� IHOW� OLNH� FRPPLWWLQJ� VXLFLGH·�� ,W� LV� D� YHU\� LPSRUWDQW� TXHVWLRQ�DGGUHVVLQJ� WKH� ULVN� IRU� VXLFLGDOLW\�� ,I� D�FOLHQW�DQVZHUV� WKLV�TXHVWLRQ�ZLWK� ¶\HV·��ZH�FDOO� WKLV�D� UHG�ÁDJ��7KLV�PHDQV�WKDW�WKH�SHUVRQ�LV�HYHQ�PRUH�DW�ULVN�RI�VXIIHULQJ�IURP�&0'��:H�UHIHU�WKLV�SHUVRQ�immediately to our "Helper" Mubatsiri who can then refer to a higher level of care. The Mubatsiri can refer to the nurse who will make a decision about referring on for medication and examination by a doctor.


18

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questionnaires

6.2 PHQ-9 (Patient Health Questionnaire)

The PHQ 9 (patient health questionnaire) is a questionnaire that can be used to assess the severity of Kufungisisa (Depression). If a person scored high (>12) and/or answers 'Yes' to question 11 on

the SSQ (Pane pandaimboita pfungwa dzekuda kuzviuraya. At times I feel like committing suicide.), we need to know how severe the kufungisisa of this patient is. The DHPO will therefore administer the PHQ-9. The 9th question of the PHQ-9 also asks for suicidal intent. The patient will be asked to answer the questions regarding the past 2 weeks.There is an added question 10 asking for the impact of Kufungisisa on the person's functioning at work/home and with other people.

�,I�\RX�FKHFNHG�RII�DQ\�SUREOHPV��KRZ�GLIÀFXOW�KDYH�WKHVH�SUREOHPV�PDGH�LW�IRU�\RX�WR�GR�\RXU�ZRUN��take care of things at home or get along with other people?

Kana muine matambudziko amakasangana nawo ari pamusoro, arikukutadzisai zvakadii kuita basa renyu, kuona kuti zvinhu zviri mugwara kumba kana kuwirirana nevamwe vanenge vakakukomberedzai?)

6.2.1 Scoring explanation

All questions can be answered on a scale with four points: Kwete/not at all - Mamwe Mazuva/several days - Zviri pakati nepakati/more than half the days - Zuva rega rega/nearly every day.

Not at all.ZHWH

Several days0DPZH�PD]XYD

More than half the day=YLUL�SDNDWL�QHSDNDWL

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0 1 2 3

Depending on the answer which is given, a score from 0 to 3 is given. For the total score the individual scores are added up, so a total of 27 points can be reached.

6.2.2 Red flag

The PHQ-9 cut-off score is 20. If a person scores 20 and has at least 1 point on question 9, it is necessary for the DHPO to refer to the nurse for further assessment and possible prescription of anti-depressant medication.

22

the Friendship Bench questionnaires

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For your use…

24


notes …

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» &RQÀGHQWLDOLW\ ��%UHDNLQJ�FRQÀGHQWLDOLW\

» What is counselling?

» Qualities of a good counsellor ��(PSDWK\��$ELOLW\�WR�OLVWHQ��%HLQJ�QRQ�MXGJPHQWDO��3DWLHQFH��.HHSLQJ�DQ�RYHUYLHZ��.HHSLQJ�FDOP��$VVHUWLYHQHVV�WR�JXLGH�WKH client through the session

» How to ask Questions��2SHQ�HQGHG�TXHVWLRQV��&ORVHG�HQGHG�TXHVWLRQV ��&ROOHFWLQJ�LQIRPDWLRQ�

7.1 Confidentiality

One of the most important features of counselling is CONFIDENTIALITY. This means that the information we get from our clients cannot be shared with others. As counsellors we are

ERXQG�WR�FRQÀGHQWLDOLW\��2XU�FOLHQWV�UHO\�RQ�XV�NHHSLQJ�WKHLU�SHUVRQDO�LQIRUPDWLRQ�IRU�RXUVHOYHV��:H�can only create an atmosphere of trust if we can guarantee that a client can speak freely about her


chapter 7

Counselling Skills

25

Contents

thoughts, and feelings etc. when she knows that any information about her is safe with us. Especially when we work in a community where people are linked to many other community members (work, VFKRRO��EHLQJ�UHODWHG��«��ZH�KDYH�WR�IROORZ�WKH�SULQFLSOH�RI�FRQÀGHQWLDOLW\�VWULFWO\�,I�D�FRXQVHOORU�LV�IRXQG�WR�EUHDN�FRQÀGHQWLDOLW\�ZLWKRXW�PDMRU�UHDVRQ��WKH\�ZLOO�ORVH�WKHLU�VWDWXV�DV�counsellor and will give counselling in general a bad name.:H�FDQ�VSHDN�WR�RXU�+HOSHU��¶0XEDWVLUL·��DERXW�RXU�FOLHQWV��HVSHFLDOO\�ZKHQ�ZH�HQFRXQWHU�PRPHQWV�ZKHUH�ZH�QHHG�KHOS��2XU�0XEDWVLUL�DUH�DOVR�ERXQG�WR�FRQÀGHQWLDOLW\��

7.1.1 Breaking confidentiality

7KH�RQO\�UHDVRQ�WR�EUHDN�FRQÀGHQWLDOLW\�LV�JLYHQ�LI�RXU�FOLHQW�WHOOV�XV�WKDW�VKH�LV�DW�ULVN�RI�KDUPLQJ�herself. The SSQ asks for this and we will also assess this with our client every time we speak to her. ,I�WKLV�LV�WKH�FDVH��ZH�UHIHU�WKH�FOLHQW�WR�RXU�0XEDWVLUL�IRU�PRUH�LQWHQVH�WUHDWPHQW��VHH�UHG�ÁDJ�&SWHU��

7.2 What is counselling?

I Q�D�FRXQVHOOLQJ�VLWXDWLRQ�ZH�KHOS�VRPHRQH�WR�ÀQG�D�VROXWLRQ�WR�KHU�SUREOHP��For this, it is important to recognize and understand the problem(s) very well.

Counselling is not the same as giving advice or making decisions for the patient, nor do we judge and blame the patient.In counselling, we want the person to learn how to solve her problems so that in future situations, she is able to help herself and becomes independent of the counsellor.

7.3 Qualities of a good counsellor

GROUP DISCUSSION:��:KDW�TXDOLWLHV�GRHV�D�JRRG�FRXQVHOORU�QHHG�WR�KDYH"��:ULWH�WKHP�GRZQ�IRU�\RXUVHOI�EHIRUH�\RX�GLVFXVV�LQ�WKH�JURXS��'LVFXVV�LQ�WKH�JURXS�DQG�PDNH�D�OLVW�RI�WKH�RQHV�\RX�ÀQG�LPSRUWDQW��:H�SUREDEO\�FDPH�XS�ZLWK�VHYHUDO�FKDUDFWHULVWLFV�WKDW�D�JRRG�FRXQVHOORU�VKRXOG�KDYH�

Let us have a closer look at what we all found and compare them with the following ones:

O Self awareness Knowing oneself is very important. We need to be aware of our own beliefs, values and � DWWLWXGHV�WR�EH��DEOH�WR�DGGUHVV�D�SDWLHQW·V�QHHGV�LQ�DQ�REMHFWLYH�ZD\��

the Friendship Bench counselling techniques

26

exercise: how do you feel when you speak to someone who refuses to go for hiv testing? You might have convinced many people already to go for testing and for you it seems like you know exactly what you need to do, yet it is important to first listen to this particular patient and understand where she is coming from.

O Empathy (PSDWK\�LV�WKH�DELOLW\�WR�SXW�RQHVHOI�LQ�VRPHERG\·V�HOVH·V�VLWXDWLRQ�DQG�UHODWH�WR�ZKDW�WKH\�might feel. It is important for the relationship between the counsellor and the client. The client will feel taken more seriously when she gets the impression that the counsellor is able to understand what the patient feels and why she feels the way she feels. Be genuine, ask before pretending to have understood. Avoid advising the patient to stay strong, not cry, etc. It is good to express emotions.

exercise: There are several ways of showing empathy.how would you show empathy? write down for yourself what you thought of before you discuss in the group.Discuss in the group and make a list of the ones you find important.

(examples are: -you seem upset/…., it sounds as if you are dealing with a lot of anger/frustration/…., if I understood you correctly, you feel…., I am asking myself if you feel….)

O Ability to listen (active listening) The ability to listen actively is a good way of helping a person to feel heard. When a person feels heard, she will also feel safer to speak about what worries her. There are lots of ways

27


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of showing that we listen. We call this active listening. Active listening involves showing nonverbal signs of acknowledgment like nodding, recurrent eye contact (if culturally appropriate), showing an open facial expression or turning the upper body towards the client. $FWLYH�OLVWHQLQJ�DOVR�LQFOXGHV�YHUEDO�DFNQRZOHGJHPHQW�VXFK�DV�H[SUHVVLRQV�OLNH�¶\HV��,�VHH·��¶KDQGLWLND·«��·PPK·��¶DK·��WR�QDPH�D�IHZ��Part of active listening is also summarizing what you have heard in your own words and checking with your clients whether you have really understood what they told you. If you did not understand what they said, let them tell you again and ask questions.

exercise: practice this in pairs with one being the counsellor and one being the client. give yourselves feedback and change roles.

O Being non-judgmental We need to accept a patient just as she is and keep a non-judgmental attitude towards her. If ZH�ÀQG�WKDW�ZH�DUH�YHU\�XQFRPIRUWDEOH�ZKHQ�GHDOLQJ�ZLWK�D�FHUWDLQ�SHUVRQ�ZKR�KDV�YLHZV�and feelings that are very different from our own, it is best to refer to a colleague. We can also share the feelings about a patient with the Mubatsiri. (see Chapter 12 Supervision)

exercise:Think of opinions that you hold about certain things. Do you notice that the stronger your opinion is, the more difficult it is to tolerate a person who believes the opposite?

(examples for strong opinions: A husband has the right to beat his wife. Girls do not need to go to school. It is the wife’s fault if the husband drinks.)

28


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29

O Patience Patience is an important characteristic in counselling. Imagine that a person coming for counselling is anxious and not sure what to expect. Patience will enable you to be able to help the client to open up and to encourage her to look at the issues she is dealing with and at the thoughts and feelings related to those issues.

exercise: Think of a situation when you managed to just patiently listen without offering your opinion or advice. Think about what makes that difficult. Discuss in your mini-group.

O Keeping an overview of what was said/being professional The counsellor is the person in the counselling process who has to keep track of what was said so far. Therefore it is best to take notes. The brief notes help the counsellor to come back to important issues, that although they might be uncomfortable for both client and counsellor, have to be discussed. Taking notes helps the counsellor to follow a counselling structure which is very important to not lose the aim of problem recognition out of sight. exercise: in groups of 2 or 3, let one person speak about an experience and the other two have to take turns to summarize what was said.

counselling techniques

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30


O Keeping calmWhat your client tells you might disturb you. It is important that you keep calm (remain professional) and remember that you are there to help your client now. If something disturbs you, you must talk to your colleagues in the peer supervision sessions or to your Mubatsiri. In the session, the counsellor helps the client to break down the problem(s) into smaller chunks that can actually be addressed. If D�¶SUREOHP�FKXQN·�VWLOO�VHHPV�XQVROYDEOH��LW�KDV�WR�EH�EURNHQ�GRZQ�IXUWKHU�

O Assertiveness to guide the client through the counselling process As the counsellor, we guide the client through the counselling process. We might have to remind the client to come back to the topic by asking further questions. We might have to console the client. We might have to reassure her that we want to hear more. We will always ask more questions to get a good overview of what the client is dealing with.

exercise: work in pairs. role play a session, the client is supposed to keep bringing up new issues and is generally very distraught, the therapist is supposed to stay calm, bring the client back to one main topic and stick to the counselling process.


�

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31


7.4 How to ask Questions

Appropriate and effective questions will allow a person to speak freely and help us gather information. Sometimes, a client is talkative and we do not need to ask a lot. It might still be

LPSRUWDQW�WR�DVN�IRU�VSHFLÀF�LQIRUPDWLRQ�

Open ended questionsOpen ended questions are mostly answered with a few words or sentences. Examples for open ended questions are: How do you feel about this?What happened?

Closed questions&ORVHG�TXHVWLRQV�JHQHUDOO\�FRXOG�EH�DQVZHUHG�ZLWK�¶\HV·�RU�¶QR·��7KH\�FDQ�KHOS�WR�IRFXV�RQ�D�FHUWDLQ�WRSLF��¶'R�\RX�ZDQW�WR�VSHDN�DERXW�WKLV�WRSLF"·��RU�WR�JHW�VRPH�LPSRUWDQW�IDFWV��¶+RZ�ROG�DUH�\RX"·��

Guideline for collecting information�� :KR�LV�RXU�FOLHQW"�:KDW�LV�KHU�KLV�EDFNJURXQG"�:KR�DUH�WKH�VLJQLÀFDQW�SHRSOH�LQ�KHU�KLV�OLIH"�� :KDW�LV�WKH�SUREOHP"�� :KHQ�GRHV�WKH�SUREOHP�KDSSHQ"�:KDW�KDSSHQV�SULRU�DQG�DIWHU�WKH�SUREOHP�RFFXUULQJ"�� :KHUH�DQG�ZKHQ�GRHV�LW�RFFXU"�� :K\�GRHV�LW�KDSSHQ"�:KDW�WULJJHUV�LW�DQG�ZKDW�PDNHV�LW�EHWWHU"�� :KDW�DUH�WKH�FOLHQW·V�UHDFWLRQV�DQG�KRZ�GRHV�VKH�IHHO�DERXW�LW"�� &KLL�FKLUL�NXQHWVD"�� :KR�LV�WKHUH�IRU�WKH�FOLHQW"�� :KDW�LPSDFW�KDV�WKH�LVVXH�KDG�VR�IDU"�� :KDW�GRHV�WKH�FOLHQWW�ZDQW�WR�KDSSHQ"


32

The Friendship Bench card is a way of taking summarized notes. These are necessary for consecutive sessions. Only the most important facts go on the Friendship Bench card. While

we can take as many notes as we like in our book, we will summarize those notes and write them on the card together with our client. In each session, we might add something to our FB cards. Our client will have her own card. The card will help the client to remember what she learned and agreed WR�GR�EHWZHHQ�VHVVLRQV��7KH�FDUG�LV�DOVR�LPSRUWDQW�IRU�WKH�SDUWLFLSDWLRQ�LQ�WKH�¶.XEDWDQD�7RVH·��VHH�Chapter 14). Coming to those meetings will be noted on the back of the card. The card is divided in the 4 sections. Each section has a title, see below to learn how the card looks like.

The Friendship Bench card

chapter 8

Problem that is worked on:

Smart action plan:

Goals:

Next appointment:

DATE PID NUMBER COUNSELLOR CLINIC

ZUVA NZVIMBOZITA RACHIPANGAMAZANO

NHAMBA YEMUPANGWI WEZANO

example:client m. comes to the bench and reports about the many problems she faces at home. amongst not having an income, having difficulties finding the money for school fees for her 2 children, she also mentions her husband using his money to buy alcohol. The counsellor and the client decide that they will choose the husband’s behaviour as the issue to write on both their cards in section 1. They now go about exploring ways how to address this issue. m. is asked to say what goals she has (what would you like to achieve with counselling? what would you like to see happening?...). The most important goals are written down in the ‘goals’-section.During the counselling process, we use a technique (compare chapter 9 on psT) that helps the client to find her own solutions for some of the problems she experience.

Important:�� 7KH�)%�FDUG�KROGV�D�VXPPDU\�RI�RXU�VHVVLRQ�QRWHV�� 7KH�FOLHQW�DQG�WKH�FRXQVHOORU�KDYH�D�)%�FDUG�� 7KH�FOLHQW�KDV�WR�EH�UHPLQGHG�WR�EULQJ�WKH�)%�FDUG�HYHU\�WLPH�VKH�FRPHV�IRU�D�VHVVLRQ�


33

the Friendship Bench card

In this chapter we will learn about a powerful counselling technique and how to use it appropriately.The techniques we use are based on Cognitive-Behavioural Therapy.

Cognitive behavioral therapy is a therapy approach that is problem-oriented, focuses on the ‘here and QRZ·��LV�YHU\�VWUXFWXUHG�DQG�DLPV�WR�WHDFK�WKH�FOLHQW�KRZ�WR�XVH�WKH�WHFKQLTXHV�KHUVHOI�LQ�RUGHU�IRU�KHU�to be independent of the therapist.On the Friendship Bench, we mostly focus on problem solving.After explaining Problem Solving Therapy theory in detail for every step, we will go through a FOLHQW·V�H[DPSOH�WR�VKRZ�KRZ�3UREOHP�6ROYLQJ�7KHUDS\�LV�GRQH�We also watch videos that show examples of how Problem Solving Therapy is used.

chapter 9

Problem Solving Therapy (PST)

34


learn how problem solving Therapy is done!


35

Problem solving should be done in several steps:

�� +RZ�GRHV�WKH�FOLHQW�GHDO�ZLWK�SUREOHPV"2. How to recognize a problem? �� +RZ�WR�VHOHFW�D�SUREOHP��ÀQG�WKH�JRDO�DQG�GHÀQH�WKH�SUREOHP"4. How to brainstorm for solutions? 5. How to select a solution?6. How to make a SMART action plan?7. Did it work?

1. How does the client deal with problems?We ask how the client sees problems in general and what she believes about her ability to address a problem. When someone has an impulsive or careless way of going about problems RU�LV�JHQHUDOO\�DYRLGDQW�RI�SUREOHPV��ZH�QHHG�WR�H[SODLQ�KRZ�LW�LV�PXFK�PRUH�EHQHÀFLDO�WR�WDNH�D�UDWLRQDO�VWDQFH�WR�VROYH�D�SUREOHP�HIÀFLHQWO\�DQG�KRZ�VKH�ZLOO�EHQHÀW�IURP�OHDUQLQJ�the Problem Solving Technique.

)�HOW TO DO IT?

We ask our client: 1. “How have you tried to solve problems in the past?” 2. “What do you do when you have problems?” 3. “How do you feel when you have problems?”

an example:s. had unprotected sex times with a much older man. he had promised her to give her some money and help her out with food from time to time.she felt quite sick lately. she had heard on the radio once that people actually can have flu like symptoms when they contract hiv. she is not sure what is going on and ignores how she is feeling. she goes to church more often and prays every night that she is not hiv positive. she can not imagine talking to the man she is involved with to ask him about his status. what could be a rational way for s. to approach the subject?

The counselor asks s.:1. what do you do when you have problems? s. says: “i don’t know, i try to avoid thinking about it. i can’t solve my problems.”2. how do you feel when you have problems? s. says: “i feel terrible and hopeless. i often can’t sleep and keep thinking.”3. what problems have you managed to solve in the past? s. says: “actually, once my aunt was angry with me, she thought i had taken some of her money, i spoke to my mom about it and my mom and i went to speak to my aunt and we figured out that it could not have been me who took the money.”

proBlem solving therapy (pst)

36


2. How to recognize problems? Sometimes people feel they are not able to tackle problems because they lack the skill to break down a problem into simpler components. Instead of searching for solutions, they might avoid (withdrawal, distraction, playing it down…) or show impulsive reactions and EHKDYH�LQ�D�QRQ�KHOSIXO�ZD\��VWDUW�D�ÀJKW�ZLWK�VRPHRQH��EODPH�RQHVHOI��KDUP�RQHVHOI��JHW�drunk, quit a job, leave the partner…). Negative feelings such as fear, anger, sadness and thoughts that they are worthless or that nobody likes them contribute to this non-helpful behaviour. They might also have body experiences like feeling very run down, headaches, tight chest, feeling like crying. While these symptoms appear like stemming from a medical condition, they are actually caused by Kufungisisa. All these, the feelings, the thoughts, the body experiences and the behavior are indicators that are captured by the SSQ 14.It is our job to help the client to open up about what is happening in her life.


1. How does the client deal with problems?�� +RZ�WR�UHFRJQL]H�D�SUREOHP"�� +RZ�WR�VHOHFW�D�SUREOHP��ÀQG�WKH�JRDO�DQG�GHÀQH�WKH�SUREOHP"4. How to brainstorm for solutions? 5. How to select a solution?6. How to make a SMART action plan?7. Did it work?


remember to lisTen, summarize anD compile a lisT

of problems!


37


saka tingabatsirane

sei muzuva ranhasi?

how can we help each other?

38


)�HOW TO DO IT?

We encourage our client to freely speak about what is going on in her life. 6DND�WLQJDEDWVLUDQH�VHL�PX]XYD�UDQKDVL"�

While we listen, we summarize ever so often and pick out all those things that are problematic for our client. This way, we will compile a SUREOHP�OLVW�We can use the problem category table to help categorize the problems.

1DWXUH�RI�PDLQ��SUREOHP� 6KRQD�WHUPV 7LFN�ZKDW�

DSSOLHV�WR�FOLHQW

relationship ukama

maritalnyaya dzemagariro

mumba

work related nyaya dzekubasa

bereavement NXFKHPD�PXÀ

school zvechikoro

family nyaya dzemumhuri

interpersonal GHÀFLWV��VHOI�

esteem, loneliness)

health related zveutano

money problem nyaya dzemari

accommodation problem

nyaya dzepekugara

legal problem mhosva

sexual problem nyaya dzepabonde

alcohol/drugs nyayadzekudhakwa

other, what?? zvimwe



39

an example:s.’s problem list:had unprotected sexno money



relationship ukama


mumba



school zvechikoro

family nyaya dzemumhuri 9interpersonal GHÀFLWV��VHOI�

esteem, loneliness)

health related zveutano 9money problem nyaya dzemari 9accommodation

problem nyaya dzepekugara





afraid to go for testing, doesn’t want to knowwants to avoid thinking about itnot enough food at the houseafraid that she has contracted an sTi


40


3. How to select and define a problem?SELECTThe next step is to help our client to select one problem of the list to focus on. This problem should be manageable and meaningful and maybe even practical. The client must feel that she has some control over the problem.

FIND GOAL 2QFH�WKH�FOLHQW�VHOHFWHG�D�SUREOHP��ZH�EULHÁ\�GLVFXVV�DQG�IRUPXODWH�WKH�JRDO�DQG�QRWH�LW�down on the FB card.

DEFINE:H�XVH�WKH�IROORZLQJ�TXHVWLRQV�WR�H[SORUH�PRUH�GHWDLOV��2XU�DLP�LV�WR�GHÀQH�WKH�SUREOHP��:KHQ�ZH�KDYH�GHÀQHG�WKH�SUREOHP�UHDOO\�ZHOO��ZH�ZULWH�LW�GRZQ�RQ�WKH�)%�FDUG�


1. How does the client deal with problems?2. How to recognize a problem? �� +RZ�WR�6(/(&7�D�SUREOHP��),1'�7+(�*2$/�DQG�� '(),1(�D�SUREOHP"4. How to brainstorm for solutions? 5. How to select a solution?6. How to make a SMART action plan?7. Did it work?

remember to ask whaT, who, where, when, how

anD summarize!



41

)�HOW TO DO IT?

SELECT:H� WHOO� WKH� FOLHQW�� ´$W� ÀUVW��ZH�PXVW� FKRRVH� RQH� SUREOHP�RI� WKH� SUREOHP� OLVW�� /HW� XV� JR�through it together and select the one that is most meaningful and manageable for you, if it is also practical, even better!”

FIND GOALWe ask the client: “How would you like the situation to be when the problem is solved?” We formulate the goal together with the client and we write it down on the FB card.

DEFINEWe tell our client how important it is to know exactly what problem she deals with. We say:“Tell me all about this problem. It is good and helpful for you to speak about it and the better ZH�NQRZ�\RXU�SUREOHP��WKH�HDVLHU�LW�ZLOO�EH�WR�ÀQG�D�VROXWLRQ�µ

We can use the following questions:�� :KDW�KDSSHQHG"��&KLL�FKDNLWLND�NDQD�FKLQRLWLND"�� :KR�LV�LQYROYHG"�� :KHQ�DQG�ZKHUH��VLWXDWLRQ�HQYLURQPHQW��GRHV�LW�KDSSHQ"��=YLQRZDQ]RLWLND�ULQKL�NXSL"�� :KDW�KDSSHQV�ULJKW�EHIRUH�DQG�ULJKW�DIWHU"�� :K\�GRHV�LW�KDSSHQ"��8\H�FKLNRQ]HUR�FKLUL�FKLL"��:KDW�WULJJHUV�LW"�� +RZ�RIWHQ�GRHV�LW�KDSSHQ"�� :KHQ�LW�KDSSHQV��KRZ�GR�\RX�IHHO�DQG�ZKDW�GR�\RX�WKLQN�RI"�� +RZ�GR�\RX�UHDFW"��8QRQ]ZDVHL"��8QRIXQJHL"�8QRLWDVHL"�� 'R�\RX�KDYH�FRQWURO�RYHU�WKLV"W�

example: selecTThe counselor and s. looked at her list of problems together and s. chose the issue revolving around her fear about her hiv status as the problem she wants to work on. This is a meaningful problem for her, it is practical as one can get tested, and manageable as she also knows other people who have gotten tested.The counselor helps s. to formulate the problem: “i am avoiding to know my about status.”


The better a problem is defined, the easier it is

to find a solution for it.

42


finD goalThe counselor asked: “how would you like the situation to be when the problem is solved?” her goal is to not feel all this fear anymore and not to put herself at risk any longer. her counselor helps her to rephrase this into “to know my status”.Together with her counselor, she puts down the following on the fb card.

DefineThe counselor asks s.: “what happened?”she fears she has gotten infected. “who is involved?” she is involved and maybe her partner. “how does she feel when it happens?” she feels a lot of fear every time she feels a bit sick. “how do you react? (unonzwasei?, unofungei? unoitasei?)”she can see how she avoids thinking about the topic and how she keeps on ignoring her health. especially, ignoring it does not really work, she can lie in bed for hours thinking about all the terrible things that would happen if she were to find out that she were positive.“Do you have control over this problem?”she also says that she has some control over the problem, after all she could theoretically go to the clinic to get tested..

Image II��6�·V�)%�FDUGSee what the counselor has written on the FB card after this step.



Smart action plan:

Goals:

Next appointment:




avoid to know about H I V status.

less fearneed to know my status


43

4. How to brainstorm for solutions?In the next step, we encourage the client to come up with as many ideas for potential solutions as possible. It is important to explain to the client that she should not judge any of her ideas at this moment. The more ideas she has, the higher the chance that one or two will work.We will write all ideas down on our notepad.

)�HOW TO DO IT?

We tell our client that she should come up with any solution idea she can think of:“Please tell me anything that comes up in your mind which could somehow help with your problem. We can discuss later whether the ideas are feasible. We just want to collect as many ideas as possible.”



1. How does the client deal with problems?2. How to recognize a problem? �� +RZ�WR�VHOHFW�D�SUREOHP��ÀQG�WKH�JRDO�DQG�GHÀQH�WKH�SUREOHP"�� +RZ�WR�EUDLQVWRUP�IRU�VROXWLRQV"�5. How to select a solution?6. How to make a SMART action plan?7. Did it work?

we can help the client by asking more questions such as:

��:KR�FRXOG�KHOS"��'R�\RX�NQRZ�VRPHRQH�� with a similar problem? what have they done?��:KDW�ZRXOG�\RXU�EHVW�� friend/mother/ sister/brother/important person…. do?

44

the Friendship Bench proBlem solving therapy (pst)

example: The counselor encourages s. to think of solutions. The counselor writes everything down. at this step, they do not discuss the solutions for their feasibility.

Image III: 6�·�VROXWLRQ�OLVW�

could keep on avoidingcould go to spiritual healer and ask what to docould write letter to the man and ask himask pastor what to doTalk to the friend who told her she is + and ask her how to go about itpray hardernever see the man againleave the city and move kumushajust stay in bed and never wake up againgo to the clinic in the neighbourhoodgo to a testing clinic in towntake a friend and go to the clinictake headache pills for the pain


45



1. How does the client deal with problems?2. How to recognize a problem? �� +RZ�WR�VHOHFW�D�SUREOHP��ÀQG�WKH�JRDO�DQG�GHÀQH�WKH�SUREOHP"4. How to brainstorm for solutions? �� +RZ�WR�VHOHFW�D�VROXWLRQ"6. How to make a SMART action plan?7. Did it work?

5. How to select a solution? (3 SUB-STEPS: first selection, grouping, evaluating)Our client has probably come up with many possible solutions. We have to teach the client to sort through all these solutions.

FIRST SELECTION$W�ÀUVW�� WRJHWKHU�ZLWK�RXU�FOLHQW�ZH�FKHFN�IRU�VROXWLRQV�WKDW�FDQ�EH�GLVFDUGHG�DV� WKH\�DUH�unrealistic, pretty impossible or even dangerous for her.

GROUPINGThe remaining solutions are looked at in terms of similarity and we encourage the client to group them.

EVALUATINGThe clients looks at two or three of the groups (if there are that many) and assesses those according to feasibility, impact on her wellbeing, impact on RWKHUV��WLPH��HIIRUW��FRVWV�DQG�EHQHÀWV�

)�HOW TO DO IT?

FIRST SELECTIONWe ask our client: “Is there any solution here on the list that appears not practical right away? Cross it out.”

GROUPING“Please look at all your solutions and see if any are similar, somehow belong together and can be grouped!”

EVALUATING“Check the group(s) for the best feasible solution! How feasible is it? How would it impact on your own wellbeing? What impact would it have on RWKHUV"�+RZ�ORQJ�ZRXOG�LW�WDNH"�:KDW�ZRXOG�LW�FRVW�\RX"�:KDW�EHQHÀW�ZRXOG�you have from it?”

46


example: firsT selecTionThe counselor discusses with s. if there is any solution on her list that appears not practical or simply not clever.

Image IV:�6�· solution list

could keep on avoidingcould go to spiritual healer and ask what to docould write letter to the man and ask himask pastor what to doTalk to the friend who told her she is + and ask her how to go about itpray hardernever see the man againleave the city and move kumushaJust stay in bed and never wake up againgo to the clinic in the neighbourhoodgo to a testing clinic in townTake a friend and go to the clinicTake headache pills for the pain

groupingThe counselor asks s. to see if any of her solution ideas are similar and can be grouped. s. has found two groups of possible solutions. she decides to leave the other options out. The one group stands for ‘a: going to a clinic and getting tested’, the other group stands for ‘getting help from a spiritual and/or church person whom she trusts’.

Image V:�6�·�VROXWLRQ�OLVW�ZLWK�JURXSHG�RSWLRQV

could keep on avoiding could go to spiritual healer and ask what to do could write letter to the man and ask himask pastor what to do Talk to the friend who told her she is + and ask her how to go about it pray harder never see the man again leave the city and move kumushaJust stay in bed and never wake up again go to the clinic in the neighbourhood go to a testing clinic in town Take a friend and go to the clinic Take headache pills for the pain



47


evaluaTionThe counselor asks her to judge both groups on their disadvantages and advantages. she also poses the following questions for s. to evaluate the solutions in more detail.check the group(s) for the best feasible solution.

��´+RZ�IHDVLEOH�LV�$"µ� s. says she could go to the clinic, she knows where it is. she can walk there.��´+RZ�ZRXOG�LW�LPSDFW�RQ�\RXU�RZQ�ZHOOEHLQJ"µ s. says she is apprehensive, but nothing bad would really happen if she went.��´:KDW�LPSDFW�ZRXOG�LW�KDYH�RQ�RWKHUV"µ� s. says her going to the clinic would not really impact others.��´+RZ�ORQJ�ZRXOG�LW�WDNH"µ� s. says it would probably take her the whole morning.��´:KDW�ZRXOG�LW�FRVW�\RX"µ� s. answers that it would not cost anything.��´:KDW�EHQHILW�ZRXOG�\RX�KDYH�IURP�LW"µ� s. answers that she would be told about her hiv status and could then start taking medication if she had to. she expressed her worry around this topic.

� Her counsellor takes a moment to inform her about HIV and ARVs. This helps S. a little. �

Questions we ask to assess these factors:

�� +RZ�IHDVLEOH�LV�WKLV�VROXWLRQ"�� :KDW�LPSDFW�ZLOO�LW�KDYH�RQ�\RX�DQG�RQ� the people around you?�� +RZ�PXFK�WLPH�ZLOO�LW�WDNH"�� +RZ�PXFK�HIIRUW�ZLOO�LW�WDNH"�)URP�ZKRP"�� $UH�WKHUH�DQ\�FRVWV�LQYROYHG�IRU�\RX"�� +RZ�ZLOO�LW�EHQHILW�\RX"

48


6. How to make a SMART action plan?7KLV� VWHS� HYROYHV� DURXQG�ÀJXULQJ� RXW� H[DFWO\� KRZ� WR� FDUU\� RXW� WKH� FKRVHQ� VROXWLRQ��:H�KDYH� WR�encourage the client to make a very concrete action plan how she will go about solving her problem. :H�ZLOO�DVN�YHU\�VSHFLÀF�TXHVWLRQV�DQG�ZLOO�DOVR�KDYH� WR�GLVFXVV�ZKDW�FRXOG�JHW� LQ� WKH�ZD\�RI�D�possible solution.

Once we have made the SMART action plan, we will write it on the FB card.

The action plan has to be SMART which stands for

�� 6SHFLÀF

�� 0HDVXUDEOH

�� $FKLHYDEOH

�� 5HDOLVWLF�

�� 7LPHO\



1. How does the client deal with problems?2. How to recognize a problem? �� +RZ�WR�VHOHFW�D�SUREOHP��ÀQG�WKH�JRDO�DQG�GHÀQH�WKH�SUREOHP"4. How to brainstorm for solutions? 5. How to select a solution?�� +RZ�WR�PDNH�D�60$57�DFWLRQ�SODQ"7. Did it work?

The more the action plan meets these criteria, the higher

the chances of it being successful.


49


)�HOW TO DO IT?

The following questions help the client to come up with a very precise plan on how to realize the action plan: �� +RZ�FDQ�\RX�GR�LW"�� :KHQ�H[DFWO\�FDQ�\RX�GR�LW"��ZKLFK�GD\��ZKDW�WLPH�� :KHUH�H[DFWO\�FDQ�\RX�GR�LW"�+RZ�GR�\RX�JHW�WKHUH"�� :KR�FDQ�KHOS�\RX"�:KR�FDQ�\RX�GR�LW�ZLWK"�� :KDW�ZLOO�\RX�QHHG�WR�GR�LW"�� :KDW�FRXOG�JHW�LQ�WKH�ZD\�RI�\RXU�SODQ�DQG�ZKDW�FDQ�\RX�GR�WKHQ"

example: The counselor asks s. how exactly she could go about her. Together they discuss all the different aspects.

��´+RZ�FDQ�\RX�GR�LW"µ� s. plans to walk to the clinic. ��´:KHQ�H[DFWO\�FDQ�\RX�GR�LW"µ� she will go on her own on friday morning at 8am and will arrange to meet her friend in the afternoon. she doesn’t need to take anything.��´:KR�FDQ�KHOS�\RX"µ� s. says she wants to meet her friend afterwards.��´:KHUH�H[DFWO\�FDQ�\RX�GR�LW"µ� she plans to go to the clinic in town where nobody knows her.

Together with the counselor, they talk about possible obstacles such as someone seeing her and asking her where she goes – she would say that she goes to visit a friend. another obstacle could be that it rains very heavily on friday in which case she will take some money from her savings and catch a bus. she already knows where to get off the bus and how to get to the clinic.The most important information points are written on the fb card.The counselor is very happy with her progress and tells her so!

50

the Friendship Bench proBlem solving therapy (pst)

After the action plan is done, we make a new appointment and send the client home to carry out the SMART action plan.We will also explain that it is important to come on time to the session and that she can contact us if something comes up and she cannot make her appointment in which case we will make a new one. We stress that we really want to see the client again and hear about how it went for her.

Do you need any more explanation? or do you

have any questions?

let's have a stretch, we've done alot of work getting through the first 6

problem solving steps one more to go!

Friday morning, walk to clinic, meet friend for support in afternoon at

her house


Smart action plan:

Goals:

Next appointment:




avoid to know about H I V status.

less fearneed to know my status

Image VI��6�·V�)%�FDUG

proBlem solving therapy (pst)the Friendship Bench

51

7. Did it work? We can only evaluate how the SMART action plan worked the next time we see the client.

The 2nd session:When we see the client again, we ask how carrying out the plan went?We want to know how it went and encourage the client to tell us details!

If the client says that it went well, we explore the details and praise and reassure the client. We can now choose another problem of the problem list and repeat PST as described above.

If the client says that they failed to carry out the SMART action plan, ZH�H[SORUH�ZKDW�PDGH�LW�GLIÀFXOW�

,W�LV�LPSRUWDQW�WR�IRFXV�RQ�WKH�REVWDFOHV��WUHDW�WKHP�DV�¶SUREOHPV·�DQG�ÀQG�VROXWLRQV�IRU�WKHP��Obstacles can be of practical origin (i.e. the bus did not come) and also of emotional origin (i.e. was too scared). What counts for us is to empower the client enough for her to feel she can try it again.Most probably the SMART action plan has to be revised and discussed again.

)�HOW TO DO IT?

We can ask the client: “How did it go?” “What happened?”


1. How does the client deal with problems?2. How to recognize a problem? �� +RZ�WR�VHOHFW�D�SUREOHP��ÀQG�WKH�JRDO�DQG�GHÀQH�WKH�SUREOHP"4. How to brainstorm for solutions? 5. How to select a solution?6. How to make a SMART action plan?�� 'LG�LW�ZRUN"


52


Special case:Many clients will come to us and say that they have no money.This is a very big issue for all of us. Such a big problem can make us feel very small and helpless, especially when we see how distressed our client is.The Friendship Bench Project does not give money, nor does it have jobs for clients. It is important to state this. We do not want to give false hope.

We need to understand that we cannot solve the problem as it is presented to us. Therefore, we must WDNH�WKLV�SUREOHP�DSDUW�DQG�ÀQG�VPDOOHU��PRUH�VROYDEOH�SUREOHPV�LQ�LW��2QFH�ZH�KDYH�EHHQ�DEOH�WR�GR�this, we can start working with our client using PST strategies.

Questions that are helpful in this context are:1. How have you been paying for your expenses so far?2. What have you tried far to make money?��:KDW�ZRUNHG�DQG�ZKDW�GLGQ·W�ZRUN"��:K\�GLGQ·W�VRPH�WKLQJV�ZRUN��ZKDW�GR�\RX�WKLQN"��

Just because one thing didn’t work once, doesn’t mean it cannot be tried again, maybe it needs to be modified and we can help the client to achieve this!


53

exercise:b. was referred to the bench. The hp welcomes her and explains to her how the bench counselling is done. The counselor then invites her to share what is on her mind.b. is very upset and cries. she speaks about how she has no money for school fees for her children and not enough for food. she also has not paid the rent in two months and the landlord threatens to evict her. There is no income as she does not have a job. her husband has left her for another woman with whom he now has two more children. The counselor asks more questions about how b. has managed so far with no financial means. b. says that she got some money from an aunt ever so often and that she had tried to sell tomatoes but that she felt that it was not worth her while as she still could not make ends meet. she wonders if she maybe gave up too early with the vegetable business. right now she doesn’t know what to do.while b. describes how miserable her life is at the moment, her counselor notices how b. seems very overwhelmed by the amount of problems she faces.she explains that she will teach b. a technique that helps to solve problems.counselor and b. decide that it will help more to break the topic lack of money down into smaller topics and write all these down on a problem list…

1. how does the client deal with problems?2. how to recognize a problem? 3. how to select a problem, find the goal and define the problem?4. how to brainstorm for solutions? 5. how to select a solution?6. how to make a smarT action plan?7. Did it work?

in groups of 2-3 people, please go through the following questions and fill in:

what problems will be on the list? no rent,

choose one problems of the problem list (meaningful, manageable, practical)


�

�

54


come up with a goal

explore all details of the problem

brainstorm solutions

select a solution

smarT action plan


�

�

�

�

�

A person who is suffering from Kufungisisa is vulnerable. She might never have spoken about ZKDW�LV�ZHLJKLQJ�KHU�GRZQ��2QFH�JHWWLQJ�WKH�RSSRUWXQLW\�DQG�ÀQGLQJ�WKH�FRXUDJH�WR�VSHDN�RXW��

our clients might show strong emotions. They might cry, silently or loudly, or express other emotions such as anger or frustration.It is important for us to simply support our client and make sure she feels calmer towards the end of the session.,Q�YHU\�GLIÀFXOW�VLWXDWLRQV��ZH�FDQ�VXJJHVW�WR�FRQWDFW�D�IDPLO\�PHPEHU�WR�FRPH�DQG�VXSSRUW�WKH�FOLHQW�

)��HOW TO DO IT?(PSDWKL]H�FRPSDVVLRQ� �� -XVW�EH�ZLWK�WKH�FOLHQW��7KH�FOLHQW�H[SUHVVHV�KHU�HPRWLRQV�DQG�ZH�OHW�KHU�GR�WKLV�LQ�� safe environment.

$FNQRZOHGJH�� :H�VKRZ�XQGHUVWDQGLQJ�IRU�WKH�FOLHQW�H[SUHVVLQJ�WKHLU�HPRWLRQV��:H�FDQ�GR�WKLV�E\�� nodding, sounds of approval, or paraphrasing which means we repeat what we have � KHDUG�LQ�RXU�RZQ�ZRUGV��:H�FDQ�VD\�´,W�VRXQGV�UHDOO\�GLIÀFXOW�WR�GHDO�ZLWK�WKLV�DOO�µ�� “It must be hard for you.”

6XSSRUW�FRPIRUW�� :H�FDQ�JLYH�WKH�FOLHQW�WLVVXH�SDSHU�ZKHQ�VKH�FULHV��)RU�UHDVVXUDQFH��ZH�FDQ�DOVR�� WRXFK�WKH�FOLHQW·V�DUP�VKRXOGHU�KDQG�LI�LW�LV�FXOWXUDOO\�DSSURSULDWH�IRU�XV�WR�GR�VR�

3UD\�� 0DQ\�RI�RXU�FOLHQWV�ZLOO�IHHO�VXSSRUWHG�ZKHQ�ZH�SUD\�ZLWK�WKHP��:H�FDQ�VXJJHVW�WKLV�

1RUPDOL]H�� :H�H[SODLQ�WKDW�LW�LV�QRUPDO�WR�FU\�ZKHQ�VRPHRQH�IHHOV�RYHUZKHOPHG�DQG�GHVSHUDWH�� crying helps as it releases tension and shows others that we are in need of comfort. It helps as we are expressing our true emotions.


55

chapter 10

Strong emotional reactions

56

strong emotional reactionsthe Friendship Bench

mwana asingacheme anofira mumbereko.

A baby who does not cry will die in a baby sling.

chapter 11

Suicide assessment and management

57


Kufungisisa can make people lose all hope. When people lose hope and only feel despair, they might feel that there is no more point in living.

Definition of suicidal behavioursWe speak of an ATTEMPTED SUICIDE when someone is harming herself but this act is not fatal. Attempted suicides are more common in young women.

COMPLETED SUICIDE is an act of knowingly and intentionally harming oneself resulting in death. Different methods can be used to harming oneself/committing suicide, common are drinking poisonous substances (i.e. pesticides, tablet overdose), hanging, inhaling gas, …

Risk of succeeding

Having attempted suicide in the past increases the risk of a person completing suicide at some stage LQ�KHU�OLIH�VLJQLÀFDQWO\��:H�QHHG�WR�DVVHVV�D�SDWLHQW·V�ULVN�YHU\�FDUHIXOO\�DQG�DVN�IRU�SUHYLRXV�DWWHPSWV�

Myths

We might feel uncomfortable speaking about suicide because we might have heard that this might give the person the idea to commit suicide. This is false.It is very important to get a person to express what she feels.

58

suicide assessment and managementthe Friendship Bench

Suicidal intent - Assessment� SSQ ‒ Question 11

7KH�664�DVNV�D�TXHVWLRQ��4��DERXW�VRPHRQH·V�ULVN�RI�KDUPLQJ�KHUVHOI��,I�D�FOLHQW�DQVZHUV�WKLV�TXHVWLRQ�ZLWK� ¶\HV·��ZH�ZLOO� KDYH� WR� WDON� WR� WKH� FOLHQW� DERXW� WKH� VHULRXVQHVV�RI�KHU� FRQGLWLRQ� �WR�FRPSDUH�WR�&KDSWHU��5HG�ÁDJ��

☆ Questions to ask to assess the seriousness of our client’s suicidal intent:

�� ´+DYH�\RX�WKRXJKW�DERXW�WDNLQJ�\RXU�OLIH"µ�� ´+DYH�\RX�PDGH�DQ\�NLQG�RI�SODQV�RI�KRZ�\RX�ZRXOG�GR�WKLV"µ�� ´+DYH�\RX�SXUFKDVHG�LWHPV�WR�DFWXDOO\�FDUU\�RXW�\RXU�SODQ"µ�� ´+DYH�\RX�PDGH�DQ\�NLQG�RI�DUUDQJHPHQWV�IRU�\RXU�GHSHQGHQWV�IRU�WKH�WLPH�DIWHU�\RXU�GHDWK"µ�

If a client gives precise answers to these questions, we speak of a high suicide intent. The higher the suicide intent, the more important it is to react and get help for the client.

Referral

When someone is suicidal, she needs a lot of intense help. After we have talked to the client and assessed the situation, it is important that we refer the client to the DHPO and to the nurse who will do further assessments and possibly prescribe an Antidepressant.

Management of clients with Suicide Intent

What we need to acknowledge is:

�� 7KH�FOLHQW�QHHGV�D�ORW�RI�VXSSRUW�IURP�D�VWURQJ�FRXQVHORU�FOLHQW�UHODWLRQVKLS�WKDW�LV�EDVHG�RQ�� trust and understanding.�� 7KH�IDFW�WKDW�WKH�SHUVRQ�LV�UHYHDOLQJ�KHU�SODQV�WR�WKH�FRXQVHORU�VKRZV�JRRG�KHOS�VHHNLQJ�� skills.

we might be the first person to whom the client speaks to about her suicide intent.


59

�� :H�ZDQW�WR�IXUWKHU�HQFRXUDJH�WKH�FOLHQW�WR�H[SUHVV�KHU�IHHOLQJV�� :H�DUH�YHU\�VXSSRUWLYH�ZKHQ�WKH�FOLHQW�EHFRPHV�HPRWLRQDO�DQG�WHDUIXO�� :H�ZDQW�WR�HVSHFLDOO\�GLVFXVV�IHHOLQJV�DURXQG�JXLOW��VKDPH�DQG�KRSHOHVVQHVV��:H�H[SODLQ�WKDW� hopelessness is a symptom of kufungisisa.

�� :H�PXVW�GLVFXVV��´:KDW�KDV�VWRSSHG�\RX�VR�IDU�IURP�DWWHPSWLQJ�WR�WDNH�\RXU�OLIH"µ�7KLV�� question aims to make the client aware of reasons to continue living.�� :H�PXVW�H[SORUH�ZKLFK�IDPLO\�PHPEHUV�FDQ�EH�LQYROYHG�WR�VXSSRUW�DQG�SURWHFW�WKH�FOLHQW��

We get all their details and discuss how we can make contact with the chosen family members. Our client should not be left alone and availability of means of suicide needs to be controlled. (Sometimes an inpatient stay at the hospital might be a way to ensure this.)

�� :H�SODQ�WR�VHH�WKH�FOLHQW�UHJXODUO\�WR�IROORZ�XS�FORVHO\��7KLV�FRXOG�DOVR�EH�GRQH�YLD homevisits.

☆ :H�WDNH�WKH�FOLHQW�WR�WKH�'+32�IRU�IXUWKHU�DVVHVVPHQW�DQG�PHGLFDWLRQ�

Checklist

;�Assess suicide intent ;�Encourage the client to express her feelings and be supportive;�Find reasons to continue living that can be seen as protective;�Establish family members who can be contacted and get their details;�Contact the family members ;�Plan further contact with client;�Take client after the session to the DHPO

hopelessness is always part of

kufungisisa.

suicide assessment and management

For your use…

60


notes …


�

chapter 12

Supervision

61


Mubatsiri

A mubatsiri is a person who has had more training and experience in counselling.$�PXEDWVLUL�ZLOO�JXLGH�XV�WKURXJK�GLIÀFXOW�WLPHV�DQG�KHOS�XV�WR�continuously gain more skills.A mubatsiri reminds us how PST is done, what other counselling components we need to keep in mind and how to do our work well.

7KH�PXEDWVLUL�FDQ�RQO\�ZRUN�ZLWK�XV�WKRXJK�ZKHQ�ZH�DUH�KRQHVW�DERXW�ZKDW�LV�KDSSHQLQJ�LQ�WKH�FRXQVHOOLQJ�VHVVLRQV�WKDW�ZH�DUH�FRQGXFWLQJ�DQG�KRZ�ZH�IHHO�DERXW�WKHP��

The mubatsiri helps us and

together we aim to help the client!

62

supervisionthe Friendship Bench

How is supervision done?

We meet our mubatsiri regularly once a week. As we meet the mubatsiri together with our colleagues, we also learn from their experience.We will present cases in the following way. We can prepare this ahead of our supervision meeting:

�� JHQGHU�� DJH�� UHODWLRQVKLS�VWDWXV�� +,9�6WDWXV�RWKHU�FKURQLF�GLVHDVH�DQG�PHGLFDWLRQ�\HV�QR�� (PSOR\PHQW�VWDWXV�� WRSLF�WKDW�FOLHQW�VHHNV�KHOS�IRU�� UHVRXUFHV�RI�WKH�FOLHQW�� ZKDW�KDV�+3�GRQH�LQ�VHVVLRQ��FKHFNOLVW�� +3�TXHVWLRQ�UHJDUGLQJ�WKH�FOLHQW

example: hp sarah has a difficult client. she presents the case like this:

“p. is a 43y old woman, she is a widow. she suffers from Diabetes. she is unemployed. she came to the bench because she was threatened to be kicked out of her room in the flat she shares with her late husband’s relatives. i have worked on the problem list, she chose the problem “find new accommodation” and now we are stuck.her goal was to have a better living environment. she can’t seem to find any solution ideas. my question is what do i do now?”

mubatsiri asks some questions on the process, she asks for the problem list and they discuss the other problems and wonder if they should not rephrase the problem. “find new accommodation” is probably too big a problem, it is not manageable although it is meaningful. The counselor decides she will take her client back to the beginning, define the problem differently and apply the psT technique again.


63

chapter 13

Home visits We will usually see our clients on the Friendship Bench in the clinic.

It is encouraged though to do at least 2 home visits in the time while we see our client. Home YLVLWV�RQO\�KDSSHQ�GXULQJ�WKH�ODWHU�SKDVH�RI�WKH�LQWHUYHQWLRQ��7KH�ÀUVW�WZR��VHVVLRQV�PXVW�EH�KHOG�RQ�the Friendship Bench so that the counselling process can be established and carried out properly.

Why are we doing a home visit?Home visits are done to reassure and reinforce the client.During a home visit, we can give our client words of encouragement (kusimbisa and kusimbisisa).

Sometimes, we might also have to do a home visit as our client has not come to the planned session and we have experienced problems getting hold of the client. In such a case, it is recommended to go to the house of the client.It is best to discuss right in the beginning that you will also see the client in her home.

How to handle the presence of the family in the client’s home?If the client is very uncomfortable with us coming to her home, we should discuss this in detail.:H�FDQ�DFFRPPRGDWH�D�FOLHQW·V�ZLVK�IRU�D�FHUWDLQ�WLPH�RI�WKH�GD\�IRU�WKH�YLVLW�

When we get to the house, we have to follow certain rules:

�� 'R�QRW�DFFHSW�IRRG�DW�D�FOLHQW·V�KRPH�

�� <RX�FDQ�DFFHSW�ZDWHU�RU�QRQ�PDMRU�IRRG�VWXIIV�

�� <RX�ZLOO�LQWURGXFH�\RXUVHOI�DV�DQ�HPSOR\HH�RI�WKH�FLW\�KHDOWK�GHSDUWPHQW�

�� <RX�FDQ�SUD\�ZLWK�WKH�FOLHQW�

�� <RX�PXVW�WDNH�WKH�)%�FDUG�ZLWK�\RX�WR�WKH�KRPH�YLVLW�DQG�\RX�QHHG�WR�PDUN�RQ�LW�WKDW�\RX�are doing a home visit.

64

the Friendship Bench home visits

"Padareidura"In the circle Kubatana Tose people meet to share their experience with others. The circle invites SHUVRQV�ZKR�GHDO�ZLWK�.XIXQJLVLVD� WR� VSHQG� WLPH� LQ�D� VDIH�HQYLURQPHQW�DQG�ÀQG�VXSSRUW� IURP�

others who have similar experiences. A circle meeting takes place once a week and takes about one hour, depending on how many participants the group has. The group is led by two people who will take the responsibility for safety, time management and UHVSHFWLQJ� WKH�JURXQG�UXOHV��7KHVH�DUH�FDOOHG� � ¶KRVW·�DQG�¶JXDUGLDQ·��HYHU\ERG\�FDQ� WDNH�XS� WKHVH�roles, and indeed it is helpful to take turns.The following ground rules are very important for a successful circle meeting and have to be respected:

�� &RQÀGHQWLDOLW\�²�:KDW�LV�VDLG�LQ�WKH�JURXS��VWD\V�LQ�WKH�JURXS�� 2QO\�ZKR�KROGV�WKH�WDONLQJ�SLHFH��FDQ�VSHDN�� 7KH�EHOOV�ZLOO�EH�XVHG�WR�DQQRXQFH�WKH�VWDUW�DQG�WKH�HQG�RI�WKH�PHHWLQJ��PRPHQWV�RI�VLOHQFH�

and general call for order.�� 6LQJLQJ��SUD\LQJ��GUXPPLQJ��GDQFLQJ�DUH�PHDQV�RI�FRPPXQLFDWLRQ��WKH\�RIIHU�D�ZD\�RI�

IRFXVLQJ��RI�UHDFWLQJ�WR�DQ�LQGLYLGXDO·V�SHUVRQDO�WHVWLPRQ\��DQG�FDQ�FKDQJH�D�VWXFN�DWPRVSKHUH�in the group.

Who can take part in the circle Kubantane Tose?We will invite the patients who have come to the Friendship Bench to join the circle after they have had at least 3 sessions of counselling with us.

Where do we meet? The group will meet at a designated place in the local clinic once a week.

Circle Kubatana Tose

chapter 14

65


Community support groups at the local clinic

Who will host the circles?)RU�WKH�ÀUVW��ZHHNV��WKH�¶KRVW·�ZLOO�EH�DQ�H[WHUQDO�H[SHULHQFHG�SHUVRQ�ZKR�KDV�WUDLQLQJ�LQ�WKH�FLUFOH�method. After that time the group can decide who will be the host as everyone will have circle experience. Responsibilities of the Host and GuardianTo arrive early and make sure the room is tidy and swept.To arrange the chairs in a circle.To welcome everyone who arrives.To record the number of participants in the circle diary.To create respect for the ground rules and ensure everyone feels safe.To open and close the circle.To pose the question: “How are you doing today?”.To summarise the themes of the day in the circle diary.

What will happen in the circle?

2QFH��SDUWLFLSDQWV�KDYH�DUULYHG��WKH�¶KRVW·�ZLOO�WDNH�WKH�WDONLQJ�SLHFH��ZHOFRPH�HYHU\ERG\�DQG�RSHQ�the group with the help of the guardian who rings the bells. After a moment of silence, the bells can be rung again, a prayer can be said by a volunteer and songs can be sung, accompanied by clapping, drumming, dancing.After the prayer/songs, the host will explain the ground rules (see above). For the integrity of the circle, it is extremely important to respect these.The host will then ask the question “How are you doing today?” and place the talking piece in the middle of the circle.Anyone is invited to pick up the talking piece and share any amount of personal information. If someone is talking for too long the bells can be rung. If people interrupt or talk amongst themselves the bells will be rung to establish order and remind the group of the rules. If someone arrives late WKH�EHOOV�DUH�UXQJ�WR�ZHOFRPH�WKH�SHUVRQ�DIWHU�WKH�FXUUHQW�VSHDNHU�KDV�ÀQLVKHG��2QFH�VRPHRQH�KDV�ÀQLVKHG�VSHDNLQJ�WKH\�FDQ�SDVV�WKH�WDONLQJ�SLHFH�WR�WKHLU�OHIW��LI�VRPHRQH�LV�QRW�UHDG\�WR�VSHDN�WKH\�can pass it on. If someone shares a lot of emotion, prayer or singing can be used to acknowledge and release the emotions. When everyone has shared, the group can choose to sing, to dance or to pray. The bells will then be rung to close the circle and people get ready to leave.

Each host will carry a laminated card reminding her of the protocol.

circle kuBatana tosethe Friendship Bench

66


67

circle kuBatana tose

Opening Circle Kubatana ToseTinokuchingamidzai kuCircle Kubatana Tose.

Tinganamate

Tinotenda tiripano kuti tizarure moyo yedu tisununguke kuti tikurukure, tivakane, tibatane, titeererane, tiremekedzane.

Our Principles1. What is said in the group, stays in the group. 2. Only who holds the talking piece, can speak. 3. Respect the bells, they signal silence.4. Singing, praying, drumming, dancing are allowed at any time.

)�Laminated Protocol Card

1Ring bells, wait for silence and everybody to settle down, ring bells again

Guardian

2 Welcome Host

3 Welcome prayer and songHost/ volunteer and all

4Explain ground rules and check that they are understood

Host

5Open the forum with the question ´+RZ�DUH�\RX�WRGD\"µ�and place talking piece in the middle

Host

6 All can take talking piece and share, in turns All

7

Optional:��ULQJ�EHOO�IRU�VLOHQW�PRPHQW��HYHU\ERG\�FDQ�DVN��the guardian for a silent moment)��FDOO�IRU�D�VRQJ

Guardian/all

8 Ring bells to announce end Host

9 Final song, closing prayer and good bye All

68


ZeeBAGs

All participants volunteering will be shown by the experienced external host and guardian how to make a ZeeBAG.

They will receive a crochet hook and material. They get to keep their bags.

zee Bags

chapter 15

Self-care

69


Counsellors are exposed to many demands and stressors. They need to practice self-care in order to continue working and stay healthy physically, mentally and emotionally.

Friendship Bench counsellors live in the same environment as their clients, they are also exposed to WKH�PDQ\�VWUHVVRUV�WKHLU�FOLHQWV�KDYH�GLIÀFXOWLHV�GHDOLQJ�ZLWK�

Here are a few suggestions what we can do to keep a healthy body and mind:

�� .QRZ�\RXUVHOI�DQG�OHDUQ�WR�GHWHFW�\RXU�VLJQV�RI�VWUHVV�

�� (DW�KHDOWK\�IRRG�

�� *HW�UHVW�DQG�HQRXJK�VOHHS�

�� ([HUFLVH�

�� 7DNH�\RXU�PHGLFDWLRQ�UHJXODUO\�DQG�DV�SUHVFULEHG�

�� 6XUURXQG�\RXUVHOI�ZLWK�JRRG�SHRSOH�

�� *HW�KHOS�ZKHQ�\RX�DUH�XQVXUH�DERXW�VRPHWKLQJ�

�� 7DON�WR�\RXU�0XEDWVLUL�DQG�\RXU�FROOHDJXHV�UHJXODUO\�WR�GHEULHI�DQG�OHDUQ�PRUH�

70

selF-carethe Friendship Bench

the Friendship Bench For your use …

71

makorokoto

72


Every day first 30 minutes ¢ � �� &LUFOH�.XEDWDQD�7RVH� �� 664��HYHU\�+HDOWK�3URPRWHU�ÀOOV�RXW�6KRQD�6\PSWRPV�4XHVWLRQQDLUH�� *URXS�DFWLYLWLHV

Training overview

Content Training DAY 1 Presenter

Counseling skills

&RQÀGHQWLDOLW\

Preparation

Psychoeducation

Components of the intervention

Screening tools

Introduction of Health Promoter

Reason for referral

Rules for sessions


Kuvhurapfungwa I Client narration

Kuvhurapfungwa II HP summary

Kuvhurapfungwa III Categorizing

Kuvhurapfungwa IV 6HOHFWLQJ�D�SUREOHP�ÀQG�D�JRDOKusimudzira I 'HÀQH�WKH�SUREOHP

73

the Friendship Bench training overview


Kusimudzira II Brainstorm I

Kusimudzira III Brainstorm II

Kusimudzira IV Brainstorm III

Kusimudzira V Brainstorm IV

Roleplay

Feedback

SMART action plan I 'HÀQLWLRQ� ��SMART action plan II Practical

Session evaluation

Roleplay

Feedback

Next appointment plan

Next appointment practical

Circle Kubatana Tose I Aim

Everyday practical

Circle Kubatana Tose II Principles

Circle Kubatana Tose IIIPractical

Content Training DAY Presenter

Practice and repeat

DAY 4DAY 5DAY 6DAY 7DAY 8DAY 9

For your use…

74


notes …

75

SHONA TRAINING MATERIAL

The friendship bench project

Friendship Bench Training Manual for Health Promoters

76

the Friendship Bench shona training material

zvinotarisirwa pamubatsiri akanaka(characteristics of a good counsellor)

1. Anonzwira vamwe ‒ empathy 2. Anochengetedza tsindidzo - confidentiality

3. Anogamuchira munhu sezvaari ‒ non judgmental

4. Anoterera ‒ looking & listening

5. Akagadzikana ‒ calm and patient

6. Anozvinzwisisa ‒ self aware

gadziriro yehurukuro

Mupiwezano anorongedza zvaachashandisa muhurukuro zvakaita sezvinotevera:

» Magwaro ebasa aanozoshandisa muhurukuro (semuenzaniso, FB card, pa clip board)

» Chinyoreso

» Matishu (muzukuru anogona kuzochema muhurukuro)

77


psychoeducation

» Tiri kusangana pano kuti tikurukure maerano nechirwere chekufungisisa. Tiri kuona kuti vanhu vakawanda vari kurarama nechirwere chekufungisisa asi vasingazvizive. Chirwere ichi chinogona NXNRQ]HUHVZD�QHPDWDPEXG]LNR�DNDIDQDQD�QHNXVKD\D�PDUL��NXÀUZD��NXUZDUD�QH]YLPZHZR�

» Mutsvakiridzo dzakaitwa, zvinoratidza kuti kana munhu aine dambudziko rekufungisisa, anogona kubatwa nemamwe matambudziko akafanana nekusuruvara, kutemwa nemusoro, kutadza kurarta, kana kukanganwa kunwa mapiritsi eHIV. Munhu kana achirwara nechirwere che BP, Shuga kana HIV, akazove zvekare nedambudziko rekufungisisa, zvirwere izvi zvinowedzera.

» Tinoda kudzidzisana nzira yatinogona kushandisa kubatsirana kana kubatsira vanenge vachida kubatsirwa/kupangwa mazano. Iyi inzira ye Problem Solving Therapy, zvichireva kubatsirana nevanhu kuti vakwanise kugona kugadzirisa matambudziko avo kuburikidza nehurukuro.

» Hurukuro iyi inotwa muzvikamu zvinotevera: Kuvhura pfungwa, Kusimudzira, Kusimbisa, Kusimbisisa neCircle Kubatana Tose.

» Zvese izvi zvinoitirwa pa Friendship bench muchirongwa chino.

The friendship bench intervention

Components (Zvikamu zvekushanda nazvo)

��.XGRPD�NXWL�GDPEXG]LNR�QGHULSL��SUREOHP�LGHQWLÀFDWLRQ��KUVHURA PFUNGWA)

��.XGRPD�FKLQDQJZD�FKHNXWL�GDPEXG]LNR�ULJDG]LULVLNH��FOHDUO\�GHÀQLQJ�WKH�VHOHFWHG�SUREOHP��goals - KUVHURA PFUNGWA)

3. Kuzeya zvingaitwe kuti dambudziko rigadzirisike (brain storming for solutions - KUSIMUDZIRA)

4. Kusarudza zvatingatange kuita pakugadzirisa dambudziko (decision on what can be done and how a selected solution can be realized - KUSIMUDZIRA)

5. Kuzeya hurongwa hwekugadzirisa dambudziko (SMART implementation plan - KUSIMBISA)

6. Kupenengura hurongwa hwekugadzirisa dambudziko (evaluation - KUSIMBISISA)

7. Kusimbisisa (CIRCLE KUBATANA TOSE – CKT)

shona training material


78

The friendship bench Questionnaires

The Shona Symptom Questionnaire SSQ -14

)�14 questions YES/NO Cut-off score 8 and above Question 11. Suicide intent� 6FRUHV�RYHU�� UHG�ÁDJ� *2�7+528*+�7+(�664��$1'�5($'�($&+�48(67,21�:,7+�+3��*2�7+528*+�THIS SEVERAL TIMES. DISCUSS

The Patient Health Questionnaire PHQ-9

)��9 questions YES/NO - Likert scale

Maximum score 27 Cut-off for referral 20 and above Refer to the clinic nurse to start antidepressants

introduction (how to start a session)

» Taura zita rako kune muzukuru: Ndinonzi nhingi.

» Muudze zvauri: Ndinoshanda saHP pano pa clinic.

» Muchingamidzei: Ndiri kukuchingamidzai pano paFriendship Bench.

» Munoitei: Basa redu ndere kubatsirana nevanhu tichipangana mazano tichionesana kuti tingakwanise sei kukurukura uye kukurira zvingangova zviri kunetsa zvingakonzera kufungisisa. Kazhinji kana munhu achifungisisa anokwanisa kusarara, kutadza kudya kana kurukutika. Munhu kana achirwara necherwere cheBP, Shuga, HIV/AIDS, nezvimwe zvirwere, akazove zvakare nedambudziko rekufungisisa zvirwere izvi zvinowedzera. Kuti tizive kana munhu aine chirwere chekufungisisa tinomubvunza mibvunzo ye SSQ. Imi mabvunzwa mibvunzo iyi.


79


reason for referral(always explain why client has been referred to you)

» Reason for referral: Refer to SSQ. Chikonzero chaatumirwa kwamuri: Dzokerai kuSSQ.

» Matumirwa kuno nekuti pamibvunzo yamabvunzwa ye SSQ zvaratidza kuti munogona kunge muine chirewere chekufungisisa zvichireva kuti pangangova nezviri kunetsa zvatingangoda kukurukura nezvazvo kuti tigadzirise kufungisisa kwenyu.

mashandiro atichaita(explain how you will work with client)

» Tinofanira kudzima mafoni edu (sezvandave kuitawo) kuti tisawane zvinokanganisa muhurukuro yatichaita.

» Tinofanira kukoshesa hurukuro yatichaita iyi.

» Nguva: Hurukuro yedu ingangotora awa rimwe chete.

» Zvakavanzika: Zvese zvatichataura pano zvichasara pano, itsindidzo yedu. Saka wakasununguka kutaura chokwadi chiri pamwoyo pako. Kana zvichikubatsira wakasununguka kutaurira vaunoda. Asi ini ndinosungirwa kuchengetedza tsindidzo. Ndinogona kuzokurukura nevakuru vangu kana taona kuti tingade mamwe mabatsirirwo atingaitwe.

Kuvhura pfungwa

Kuvhura pfungwa (I) » Saka chii chingangove chiri kututambudzai? Kana kuti tingabatsirane sei muzuva ranhasi?

» HP anonyora pasi muchidimbu zvinenge zvichinetsa.

» Izvi zvinonyorwa pa PST Work Sheet* ne paFriendship Bench Card (rakidza PST Work Sheet ne FB card racho).

» Mupuwamazano anotaura kwenguva yakareba asingabvunzwe zvakawanda (empathy, body language from HP). Mupiwezano anorakidza kuteerera nekunzwira muzukuru mudambudziko rake.

* PST worsheet overpage


80


PROBLEM SOLVING WORK SHEET ( SESSION 1 )

ZITA: ZUVA: VISIT: #

1. Kutaura matambudziko arikushungurudza :

a) mwana haana mari yechikoro (school fees)

b) baba vari kunetsa kumba

c) muri kurarama ne hiv

d) hamuna mari ye rent

2. Kudoma dambudziko rekutanga naro nekuridzeya:

3. Kudoma chinanngwa chekuti dambudziko rigadzirisike:

4. Kudzeya zvingaitwe kuti dambudziko rigadzirisike

Mazano Zvaakanakira ZvibingaiidzoA) a) a)

b) b) b)

81


C) c) c)

D) d) d)

5. Kusarudza zano rekutanga naro:

6. Kudzeya hurongwa hwekugadzirisa dambudziko (action plan)

Hurongwa /matanho achatorwa Zvibingaidzo

a)

b)

c)

d)

Mawonero Amupanga mazano

82



relationship ukama


mumba



school zvechikoro

family nyaya dzemumhuri

interpersonal GHÀFLWV��VHOI�

esteem, loneliness)

health related zveutano

money problem nyaya dzemari

accommodation problem

nyaya dzepekugara






83

Kuvhura pfungwa (II) ũ HP: Saka kana ndanzwa zvakanaka muri kuti imi zviri kunetsa nde izvi - (ipai mienzaniso)

1. Mwana haana mari yechikoro (school fees)2. Baba vari kunetsa kumba3. Muri kurarama ne HIV 4. Hamuna mari ye rent

ũ 3$1(�=9$1'$6,<$�+(5("��9(5<�,03257$17�72�$6.�,)�$1<7+,1*�+$6�%((1�/()7�287�

Kuvhura pfungwa (III) » Tinoda kusarudza dambudziko rimwechete ratinotanga kugadzirisa.

» Pamatambudziko aripo aya nderipi ramunofungidzira kuti munoda kutanga naro?

» Chinangwa chenyu?

» Discuss pros and cons. (Ongororai zvakanaka kana kuipa pazviri)

» Dambudziko ramasarudza ………

Kuvhura pfungwa (IV) » Nzira dzamunofunga kuti dzingashandiswe kupedza dambudziko ramasurudza

» Chii chamakamboita?

» Kare maimoboita sei?

» Zvakambotanga sei?

Kusimudzira

Kusimudzira (I) problem definition

» Tarisai nzira dzese dzamapa dzamati dzingapedze dambudziko mundiudze kuti dzinofambidzana/dzakafanana ndedzipi tidziise muchikwata chadzo. (remember to group similar problems together)

» Tarisai muzvikwata zviripo kuti zvinoratidza kuti zvinogona kuitwa nyore ndezvipi?


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Kusimudzira (II) brain storming solution 1 » Ndinoda kuti mukurukure neni zvinenge zvauya mupfungwa dzenyu zvingaite kuti mukwanise

kupedza dambudziko renyu.

» Tichazokurukura kuti zvinokwanisa kuitika muhupenyu ndezvipi mushure meizvi.

» Panguva ino tiri kuda kungoti tikurukure zvinhu zvese zvatingafunge nekuwanda kwazvo.

Kusimudzira (III) brain storming solution 2Nyorai zvese zvichataurwa paFB card.

Mibvunzo ingatibatsire;

» Ndiani angtakubatsire?

» Unoziva mumwe munhu akambosangana nedambudziko rakafanana nerako here?

» Akaita sei kuti ripere?

Kusimudzira (IV) helper questions » Ndezvipi zvingagone kuitwa ne shamwari yako yepamwsoyo / amai / sisi/ hanzvadzi / kana munhu

akakosha kwauri? (What would your best friend / mother / sister / brother / important person…. do?)


Smart action plan:

Goals:

Next appointment:





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Kusimudzira (V) selecting a solution » Zvingashandure hupenyu hwenyu sei?

» Zvingashandure hupenyu hwevamwe sei?

» Zvingatore nguva yakareba sei?

» Zvingade chii kubva kwamuri?

» Ndezvipi zvakanaka zvingabude kwamuri kana mazviita?

role play selecTing soluTions

Ngativei nemunhu ari kuda rubatsiro nemubatsiri tiwone kuti zvinofamba sei.

Role Play:Tsanangura chiitiko nedambudziko (eg. Funga kuti pane munhu ane chirwere cheshuramatongo uye asina mari yechikafu.)

Feedback from role play:'LVFXVVLRQ�DERXW�5ROH�SOD\�

» Ndezvipi zvipingidzo zvamasangana nazvo?

» Ngatikurukurei muzvikwata tozotaura zvabuda muhurukuro.

s.m.a.r.T. action plan

S.M.A.R.T. action plan (I)

» Mungazviite sei?

» Munganyatsozviita rinhi? (musi, nguva)

» Munganyatsozviitira kupi?

» Munosvika sei ikoko?

» Ndiani anga kubatsirei?

» Ndiani wamungaite naye?

» Chii chamungade kuti muzviite?

» Ndezvipi zvingakanganise hurongwa hwenyu?

» Uye zvii zvamungaite kana masangana nezvibingamupinyi zvacho?



S.M.A.R.T. action plan (II)

» Saka, tasarudza dambudziko, tawirirana kuti.

» Mungazviite sei:…

» Mungazviita rinhi? (musi, nguva)…

» Mungazviitira kupi? Muno svika sei ikoko…?

» Ndiani anga kubatsirei…?

» Chii chamungade kuti muzviite…?

» Ndezvipi zvingakanganise hurongwa hwenyu. Uye zvii zvamungaite kana

masangana nazvo?

Session evaluation6XPPDUL]H�NH\�WDNH�KRPH�PHVVDJH�

Zvii zvamadziidza muzuva ranhasi? Ndezvipi zvamuchatakura kumba (mashoko kana shoko guru)?

role play selecTing soluTions

Ngativei nemunhu ari kuda rubatsiro nemubatsiri tiwone kuti zvinofamba sei.

Role Play:Tsanangura chiitiko chine dambudziko (eg. Funga kuti pane munhu ane chirwere cheshuramatongo uye asina mari yechikafu.)

Feedback from role play'LVFXVVLRQ�DERXW�5ROH�SOD\�

» Ndezvipi zvipingidzo zvamasangana nazvo?

» Ngatikurukurei muzvikwata tozotaura zvabuda muhurukuro.

next appointment

» Ungadzoke zvakare here mushure memazuva maviri?

» Ndinogona kukufonera ndichikuyeuchidza nezve kusangana kwedu tichiita hurukuro zvakare here?

» Ndinogona kukushanyira kumba kana kune imwe nzvimbo here?


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sessions 2-6

» How did it go? Zvafamba sei?

» Problem solved? Dambudziko ragadziriswa?

» Encourage/ support. Kurudzira/ tsigira.

» Problem not solved? Dambudziko harina kugadziriswa?

» Go through PST again or consult DHP. Dzokorora zvekugadzirisa dambudziko kana kuti tsvaga rubatsiro kuna DHP.

» After 3 sessions refer to CKT but still continue with PST. Mushure mezvikamu zvitatu endesai muzukuru kuCKT asi fambirai mberi nePST.

circle Kubatana Tose

Aims of Circle Kubatana Tose » Tiripanokuti tizarure moyo yedu tisununguke kutitikurukure, tivakane, tibatane, titeererane,

tiremekedzane.

Principles of Circle Kubatana Tose » 1. What is said in the group, stays in the group.

» 2. Only who holds the talking piece, can speak.

» 3. Respect the bells. They signal silence.

» 4. Singing, praying, drumming, dancing are allowed at any time.

What we do Circle Kubatana Tose » .XYDNDQD - to build each other

» .XEDWDQD - to hold each other

» .XG]LG]LVDQD - to listen to each other with respect

» .XUHPHNHG]DQD - to respect each other

» &KLWVLG]R - to keep secret


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notes …

For your use…

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notes …


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notes …

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, America Psychiatric Association, 2013.

Chibanda D, Mesu P, Kajawu L, Cowan F, Araya R, Abas M: Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. BMC Public Health 2011, 11(1):828.

Patel V, Simunyu E, Gwanzura F, Lewis G, Mann A: The Shona Symptom Questionnaire: the development of an indigenous measure of common mental disorders in Harare. Acta Psychiatrica Scandinavica 1997, 95(6):469.

REFERENCES


Documents

SJFOETIJQ#FODI5SBJOJOH.BOVBM GPS)FBMUI1SPNPUFST · » Cords, cables, and accessories must be inserted carefully into the tablet to prevent damage. » Health Promoters are responsible