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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

be downloaded from the study website www.friendshipbenchzimbabwe.com.

CONTACT : @
The Friendship Bench
www.friendshipbenchzimbabwe.com
hello@friendshipbenchzimbabwe.com

The Purple House


24 Frank Johnson Avenue
Eastlea, Harare

The Zimbabwe AIDS Prevention Project (ZAPP)


92 Prince Edward
Milton Park
Harare
Zimbabwe
Tel-+263-4-707289/91

MANUAL DEVELOPMENT AND DESIGN :

Ruth Verhey
Jean Turner
Dixon Chibanda

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

Tarryn Bowers Zvidzai Simon


Epiphania Munetsi Lovemore Chinyere
Vongai Munatsi Annah Chitongo
Debra Machando Israel Makwara
Tarisai Bere Nigel James
Percy Taruvinga Admire Dombojena
Ethel Manda Sandra Machiri
Peta Searle Sophia Chipunza
Lloyd Dzapasi Evans Dewa
Ricardo Araya Nyaradzai Katena
Melanie Abass Juliet Nyamasve
the Friendship Bench

Table of contents page

TableT care .....................................................................................................01-02


chapTer 1 Friendship Bench Manual for Health Promoters..............03
chapTer 2 Historical background of the Friendship Bench......04
chapTer 3 Psychoeducation......................................................05-08
chapTer 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............................... 16-17
chapTer 6 Questionnaires for SSQ and PHQ-9...................................18-24
6.1 SSQ
6.1.1 Scoring explanation

6.2 PHQ 9
6.2.1 Scoring explanation
6.2.2 Red Flag
chapTer 7 Counselling Skills.....................................................................25-31

7.2 What is counselling?


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

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

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


the Friendship Bench

Taking care of Your Tablet

Cleaning


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.

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

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the Friendship Bench


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

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.

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.

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the Friendship Bench

chapter 1

Friendship Bench Manual


for Health Promoters ( HPs)
Introduction

T his 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

important work.

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

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the Friendship Bench

chapter 2

Historical background
of the Friendship Bench
and justication

Background

O ver 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

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

strategies for problem solving.

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the Friendship Bench

chapter 3

Psychoeducation
Kufungisisa
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.

C MD is mostly caused by psychosocial stressors such as chronic stress, and negative life events

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.

withdraw from social activities. They appear sad or angry and tearful and without energy.

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
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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!!

LACK OF
KUFUNGISISA INTEREST,
SSQ 14 >8 CONCENTRATION,
MOTIVATION

SUICIDAL LACK OF SELF-CARE,


THOUGHTS SLEEP DISTURBANCE

FEELING RUN DOWN,


NOT PERFORMAING AT WORK/ HOME,
WITHDRAWAL FROM OTHERS

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.

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.

It has to be manageable and relevant to you and maybe even practical.

Brainstorming solutions is the next step.


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the Friendship Bench psychoeducation

This is what we call

This phase is called

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

SESSION 1
TABLET COMPUTER CHARGED AND TURNED ON
Greet the client, present yourself, invite client to sit down

EXPLAIN THE FRIENDSHIP BENCH

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

INVITE CLIENT TO SPEAK

LISTEN EMPATHICALLY

APPLY COMPLETE PROBLEM SOLVING THERAPY


Evaluate and feedback

Make new appointment

SAVE DATA/TURN OFF TABLET

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the Friendship Bench psychoeducation

SESSION 2
TABLET COMPUTER CHARGED AND TURNED ON
Greet the client, invite client to sit down

REVIEW 1ST SESSION


ask for further problem
WENT WELL: client wants to work on, apply complete PST
explore reasons, discuss obstacles, repeat PST,
DIDNT GO WELL:
Evaluate and feedback
Make new appointment
SAVE DATA/TURN OFF TABLET

SESSION 3
TABLET COMPUTER CHARGED AND TURNED ON
Greet the client, present yourself, invite client to sit down

REVIEW 2ND SESSION


ask for further problem
WENT WELL: client wants to work on, apply complete PST
explore reasons, discuss obstacles, repeat PST,
DIDNT GO WELL:
Evaluate and feedback
Make new appointment, invite to circle Kutabata Tose
SAVE DATA/TURN OFF TABLET

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


SESSION 4 REVIEW 3RD SESSION
SESSION 5 REVIEW 4TH SESSION
SESSION 6 REVIEW 5TH SESSION

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chapter 4

Common
Mental Disorder
INTRODUCTION

Common 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.

4.1 Depression

I n 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.

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the Friendship Bench common mental disorders

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.

4.2 Anxiety

L et 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:

disturbance.

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the Friendship Bench common mental disorders

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

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.

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the Friendship Bench 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:

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.

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the Friendship Bench common mental disorders

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.

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

themselves, in recognizing faces, in controlling their emotions or do things such as putting on clothes.

What can cause cognitive impairment?

HIV and Cognitive Disease

from the toxic effects of HIV, the consequence can be cognitive impairment.

Symptoms of HIV related cognitive impairment

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the Friendship Bench common mental disorders

Treatment adherence

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.

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

unpredictable symptoms (experienced by some people). Most people become


relaxed when consuming cannabis, but some experience fear and paranoia

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

to the brain from methamphetamine)

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the Friendship Bench common mental disorders

Effects of substances and withdrawal symptoms, specic

psychotic symptoms

sleepiness

confusion, hallucinations

sexual risk-taking, anxiety/paranoia

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chapter 5

The Friendship Bench


Intervention
What is it?

suffering from CMD in a short set of 4-6 sessions with a Health Promoter.

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).

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


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.

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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

manageable and meaningful problem and brainstorm possible solutions for it. In the Friendship Bench
Intervention this is called
UP THE MIND
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
UPLIFTING. In the consecutive sessions, implementation of the action plan is discussed and if
necessary adjusted, described by the Shona term

4. The psychosocial support .


This consists in the participation of a which follows strict communication
rules and offers a safe environment in which participants can share their experience.

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chapter 6

Questionnaires
(FOR SSQ and PHQ-9)

6.1 SSQ (Shona Symptoms Questionaire)

H suffering from CMD.


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

6.1.1 Scoring explanation

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 ag

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.

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the Friendship Bench questionnaires
chapter title

25 19
the Friendship Bench questionnaires

10

11

12

13

14

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the Friendship Bench questionnaires

6.2 PHQ-9 (Patient Health Questionnaire)

T he 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.

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 Several days More than half the day Nearly every day

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 ag

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.

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the Friendship Bench questionnaires

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the Friendship Bench questionnaires

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the Friendship Bench For your use

notes

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the Friendship Bench

chapter 7

Counselling
Skills
Contents

What is counselling?
Qualities of a good counsellor

client through the session


How to ask Questions

7.1 Condentiality

O ne 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

can only create an atmosphere of trust if we can guarantee that a client can speak freely about her

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the Friendship Bench counselling techniques

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,

counsellor and will give counselling in general a bad name.

7.1.1 Breaking condentiality

herself. The SSQ asks for this and we will also assess this with our client every time we speak to her.

7.2 What is counselling?

I 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:

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

Self awareness
Knowing oneself is very important. We need to be aware of our own beliefs, values and

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the Friendship Bench counselling techniques

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.

Empathy

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.)

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
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the Friendship Bench counselling techniques

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.

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.

Being non-judgmental
We need to accept a patient just as she is and keep a non-judgmental attitude towards her. If

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 wifes fault if the husband drinks.)

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the Friendship Bench counselling techniques

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.

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.

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the Friendship Bench counselling techniques

Keeping calm
What 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

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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the Friendship Bench counselling techniques

7.4 How to ask Questions

A ppropriate 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

Open ended questions

Open 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

Guideline for collecting information

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chapter 8

The Friendship
Bench card
T he 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

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.

DATE PID NUMBER COUNSELLOR CLINIC


NHAMBA YEMUPANGWI ZITA
ZUVA WEZANO RACHIPANGAMAZANO
NZVIMBO
Problem that is worked on: Goals:

Smart action plan: Next appointment:

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the Friendship Bench the Friendship Bench card

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 husbands
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 w h a t
g o a l s s h e h a s ( w h a t w o u l d y o u l i k e t o a c h i e v e w i t h c o u n s e l l i n g ? 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:

33
the Friendship Bench

chapter 9

Problem Solving
Therapy (PST)
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

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

We also watch videos that show examples of how Problem Solving Therapy is used.

learn how problem solving


Therapy is done!

34
the Friendship Bench proBlem solving therapy (pst)

Problem solving should be done in several steps:

2. How to recognize a 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?

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

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 dont know, i try to avoid thinking about it. i cant solve my problems.
2. how do you feel when you have problems?
s. says: i feel terrible and hopeless. i often cant 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.

35
the Friendship Bench proBlem solving therapy (pst)

Problem solving should be done in several steps:

1. How does the client deal with problems?

4. How to brainstorm for solutions?


5. How to select a solution?
6. How to make a SMART action plan?
7. Did it work?

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

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.

remember to
lisTen, summarize
anD compile a lisT
of problems!

36
the Friendship Bench proBlem solving therapy (pst)

saka
tingabatsirane
sei muzuva
ranhasi?

how can we help


each other?

37
the Friendship Bench proBlem solving therapy (pst)

HOW TO DO IT?

We encourage our client to freely speak about what is going on in her life.

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
We can use the problem category table to help categorize the problems.

relationship ukama

nyaya dzemagariro
marital
mumba

work related nyaya dzekubasa

bereavement

school zvechikoro

family nyaya dzemumhuri


interpersonal

esteem, loneliness)
health related zveutano

money problem nyaya dzemari

accommodation
nyaya dzepekugara
problem

legal problem mhosva

sexual problem nyaya dzepabonde

alcohol/drugs nyayadzekudhakwa

other, what?? zvimwe

38
the Friendship Bench proBlem solving therapy (pst)

an example: afraid to go for testing, doesnt want to know


s.s problem list: wants to avoid thinking about it
had unprotected sex not enough food at the house
no money afraid that she has contracted an sTi

relationship ukama

nyaya dzemagariro
marital
mumba
work related nyaya dzekubasa

bereavement

school zvechikoro

family nyaya dzemumhuri


interpersonal

esteem, loneliness)
health related zveutano

money problem nyaya dzemari

accommodation
nyaya dzepekugara
problem

legal problem mhosva

sexual problem nyaya dzepabonde

alcohol/drugs nyayadzekudhakwa

other, what?? zvimwe

39
the Friendship Bench proBlem solving therapy (pst)

Problem solving should be done in several steps:

1. How does the client deal with problems?


2. How to recognize a 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?

3. How to select and dene a problem?

SELECT
The 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

down on the FB card.

DEFINE

remember to ask
whaT, who, where, when, how
anD summarize!

40
the Friendship Bench proBlem solving therapy (pst)

HOW TO DO IT?

SELECT

through it together and select the one that is most meaningful and manageable for you, if it is
also practical, even better!

FIND GOAL
We 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.

DEFINE
We 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

We can use the following questions:

The better a problem is defined,


the easier it is
to find a solution for it.

example:
selecT
The 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.

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the Friendship Bench proBlem solving therapy (pst)

finD goal
The 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.

Define
The 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
See what the counselor has written on the FB card after this step.

DATE PID NUMBER COUNSELLOR CLINIC


NHAMBA YEMUPANGWI ZITA
ZUVA WEZANO RACHIPANGAMAZANO
NZVIMBO
Problem that is worked on: Goals:
avoid to know about less fear
H I V status. need to know my status

Smart action plan: Next appointment:

42
the Friendship Bench proBlem solving therapy (pst)

Problem solving should be done in several steps:

1. How does the client deal with problems?


2. How to recognize a problem?

5. How to select a solution?


6. How to make a SMART action plan?
7. Did it work?

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.

we can help the client by


asking more questions
such as:

with a similar
problem? what have they
done?

friend/mother/
sister/brother/important
person. do?

43
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:

could keep on avoiding


could go to spiritual healer and ask what to do
could write letter to the man and ask him
ask 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 kumusha
just 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

44
the Friendship Bench proBlem solving therapy (pst)

Problem solving should be done in several steps:

1. How does the client deal with problems?


2. How to recognize a problem?

4. How to brainstorm for solutions?

6. How to make a SMART action plan?


7. Did it work?

5. How to select a solution?


(3 S UB-STE PS : rst 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

unrealistic, pretty impossible or even dangerous for her.

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

EVALUATING
The 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

HOW TO DO IT?

FIRST SELECTION
We 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

you have from it?

45
the Friendship Bench proBlem solving therapy (pst)

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

Image IV: solution list

could keep on avoiding


could go to spiritual healer and ask what to do
could write letter to the man and ask him
ask 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 kumusha
Just 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

grouping
The 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:

could keep on avoiding


could go to spiritual healer and ask what to do
could write letter to the man and ask him
ask 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 kumusha
Just 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

46
the Friendship Bench proBlem solving therapy (pst)

evaluaTion
The 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.

s. says she could go to the clinic, she knows where it is. she can walk there.

s. says she is apprehensive, but nothing bad would really happen if she went.

s. says her going to the clinic would not really impact others.

s. says it would probably take her the whole morning.

s. answers that it would not cost anything.

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:

the people around you?

47
the Friendship Bench proBlem solving therapy (pst)

Problem solving should be done in several steps:

1. How does the client deal with problems?


2. How to recognize a problem?

4. How to brainstorm for solutions?


5. How to select a solution?

7. Did it work?

6. How to make a SMART action plan?

encourage the client to make a very concrete action plan how she will go about solving her problem.

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

The more the action plan


meets these criteria, the higher
the chances of it being
successful.

48
the Friendship Bench proBlem solving therapy (pst)

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:

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

s. plans to walk to the clinic.

she will go on her own on friday morning at 8am and will arrange to meet
her friend in the afternoon. she doesnt need to take anything.

s. says she wants to meet her friend afterwards.

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!

49
the Friendship Bench proBlem solving therapy (pst)

Image VI

DATE PID NUMBER COUNSELLOR CLINIC


NHAMBA YEMUPANGWI ZITA
ZUVA WEZANO RACHIPANGAMAZANO
NZVIMBO
Problem that is worked on: Goals:
avoid to know about less fear
H I V status. need to know my status

Smart action plan: Next appointment:

Friday morning, walk to


clinic, meet friend for
support in afternoon at
her house

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!

50
the Friendship Bench proBlem solving therapy (pst)

Problem solving should be done in several steps:

1. How does the client deal with problems?


2. How to recognize a 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?

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,

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?

51
the Friendship Bench proBlem solving therapy (pst)

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

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?

Just because one thing


didnt work once, doesnt
mean it cannot be tried
again, maybe it needs to be
modified and we can help
the client to achieve this!

52
the Friendship Bench proBlem solving therapy (pst)

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 doesnt 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)

53
the Friendship Bench proBlem solving therapy (pst)

come up with a goal

explore all details of the problem

brainstorm solutions

select a solution

smarT action plan

54
the Friendship Bench

chapter 10

Strong emotional
reactions
A person who is suffering from Kufungisisa is vulnerable. She might never have spoken about

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.

HOW TO DO IT?

safe environment.

nodding, sounds of approval, or paraphrasing which means we repeat what we have

It must be hard for you.

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
the Friendship Bench strong emotional reactions

mwana asingacheme
anofira mumbereko.

A baby who does not cry will die


in a baby sling.

56
the Friendship Bench

chapter 11

Suicide
assessment and management

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.

Denition of suicidal behaviours


We 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

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.

57
the Friendship Bench suicide assessment and management

Suicidal intent - Assessment


SSQ Question 11

Questions to ask to assess the seriousness of our client s

suicidal intent:

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:

trust and understanding.

skills.

we might be the first person to whom the


client speaks to about her suicide intent.

58
the Friendship Bench suicide assessment and management

hopelessness is a symptom of kufungisisa.

hopelessness
is always part of
kufungisisa.

question aims to make the client aware of reasons to continue living.

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.)

homevisits.

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

59
the Friendship
the Friendship Bench
Bench For your use

notes

60
the Friendship Bench

chapter 12

Supervision
Mubatsiri

The mubatsiri
helps us and
together we aim
to help the client!

A mubatsiri is a person who has had more training and


experience in counselling.

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.

61
the Friendship Bench supervision

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:

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 husbands 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 cant 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.

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the Friendship Bench

chapter 13

Home visits
W e 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

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.

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

are doing a home visit.

63
the Friendship Bench home visits

64
the Friendship Bench

chapter 14

Circle Kubatana
Tose
Community support groups at the local clinic

"Padareidura"
I n the circle Kubatana Tose people meet to share their experience with others. The circle invites

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

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:

and general call for order.

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.

65
the Friendship Bench circle kuBatana tose

Who will host the circles?

method. After that time the group can decide who will be the host as everyone will have circle
experience.

Responsibilities of the Host and Guardian


To 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?

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

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.

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Laminated Protocol Card

Opening Circle Kubatana Tose

Tinokuchingamidzai kuCircle Kubatana Tose.

Tinganamate

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

Our Principles
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.

Ring bells, wait for silence and


1 Guardian
everybody to settle down, ring bells again

2 Welcome Host
Host/ volunteer
3 Welcome prayer and song
and all
Explain ground rules and check that they are
4 Host
understood

Open the forum with the question


5 Host
and place talking piece in the middle

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

Optional:
7 Guardian/all
the guardian for a silent moment)

8 Ring bells to announce end Host

9 Final song, closing prayer and good bye All

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the Friendship Bench zee Bags

ZeeBAGs

A ll 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.

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chapter 15

Self-care
C ounsellors 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

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

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makorokoto

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Training overview

Every day rst 30 minutes

Content Training DAY 1 Presenter

Counseling skills

Preparation
Psychoeducation
Components of the intervention
Screening tools
Introduction of Health Promoter
Reason for referral
Rules for sessions

Content Training DAY 2 Presenter

Kuvhurapfungwa I
Client narration
Kuvhurapfungwa II
HP summary
Kuvhurapfungwa III
Categorizing
Kuvhurapfungwa IV

Kusimudzira I

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Content Training DAY 3 Presenter

Kusimudzira II
Brainstorm I
Kusimudzira III
Brainstorm II
Kusimudzira IV
Brainstorm III
Kusimudzira V
Brainstorm IV
Roleplay
Feedback
SMART action plan I

SMART action plan II


Practical
Session evaluation
Roleplay
Feedback
Next appointment plan
Next appointment practical
Circle Kubatana Tose I
Everyday practical
Aim
Circle Kubatana Tose II
Principles
Circle Kubatana Tose III
Practical

Content Training DAY Presenter


DAY 4
DAY 5

Practice DAY 6
and repeat DAY 7
DAY 8
DAY 9

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notes

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The friendship bench project
Friendship Bench Training Manual
for Health Promoters

SHONA TRAINING MATERIAL

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zvinotarisirwa pamubatsiri akanaka


(characteristics of a good counsellor)

1. Anonzwira vamwe empathy

2. Anochengetedza tsindidzo - condentiality

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)

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psychoeducation

Tiri kusangana pano kuti tikurukure maerano nechirwere chekufungisisa. Tiri kuona kuti vanhu
vakawanda vari kurarama nechirwere chekufungisisa asi vasingazvizive. Chirwere ichi chinogona

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)

KUVHURA PFUNGWA)

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)

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The friendship bench Questionnaires

The Shona Symptom Questionnaire SSQ -14

14 questions YES/NO
Cut-off score 8 and above
Question 11. Suicide intent

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.

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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

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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 Zvibingaiidzo


A) a) a)

b) b) b)

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C) c) c)

D) d) d)

5. Kusarudza zano rekutanga naro:

6. Kudzeya hurongwa hwekugadzirisa dambudziko (action plan)

Hurongwa /
Zvibingaidzo
matanho achatorwa
a)

b)

c)

d)

Mawonero Amupanga mazano

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relationship ukama

nyaya dzemagariro
marital
mumba

work related nyaya dzekubasa

bereavement

school zvechikoro

family nyaya dzemumhuri


interpersonal

esteem, loneliness)
health related zveutano

money problem nyaya dzemari

accommodation
nyaya dzepekugara
problem

legal problem mhosva

sexual problem nyaya dzepabonde

alcohol/drugs nyayadzekudhakwa

other, what?? zvimwe

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Kuvhura pfungwa (II)

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 kumba
3. Muri kurarama ne HIV
4. Hamuna mari ye rent

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 denition

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 2

Nyorai 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?)

DATE PID NUMBER COUNSELLOR CLINIC


NHAMBA YEMUPANGWI ZITA
ZUVA WEZANO RACHIPANGAMAZANO
NZVIMBO
Problem that is worked on: Goals:

Smart action plan: 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:

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?

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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 evaluation

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

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

- to build each other


- to hold each other
- to listen to each other with respect
- to respect each other
- to keep secret

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notes

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REFERENCES

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.