The Experiences of Counsellors Offering Problem-Solving Therapy for Common Mental Health Issues at the Youth Friendship Bench in Zimbabwe

Abstract

There is growing evidence that lay health workers providing counselling is a feasible approach of addressing the universally large treatment gap for mental disorders. This study illuminates the experiences of the counsellors in the Youth Friendship Bench in Zimbabwe, a pilot project where students provide problem-solving therapy to adolescents with common mental disorders. Twelve interviews were analysed using content analysis. The first theme “Working in a meaningful project” describes how the counsellors managed to create an alliance with the clients. The project was perceived as helpful, meaningful and urgent, and the counsellors’ experienced a professional and individual development through the support of the Friendship Bench organization. The second theme “Encountering obstacles” illuminates how counsellors experienced situations where they failed to reach out to clients, felt unprepared and inadequate, and how they combated preconceptions and taboos. In the third theme, “Carrying an emotional burden,” the counsellors described experiences of recognising own problems and empathising with the client.

Introduction

The treatment gap in mental health is universally large, and even larger in low-income countries like Zimbabwe. In average, there are less than two mental health care workers per 100,000 inhabitants in low-income countries compared to more than 70 in high-income countries (World Health Organization [WHO], 2018). This is concerning since nearly three quarters of the global burden of psychiatric disorders including depression and anxiety are attributed to low- and low middle-income countries where treatment gaps larger than 75% have been reported (WHO, 2008). This treatment gap and shortage of specialised health care personnel is even more prominent in mental health care for children and adolescents, once again most prominent in low-income countries (WHO, 2005). Although the right to psychiatric care for children and adolescents is recognised and endorsed by the United Nations, the statistics are disheartening. World-wide, 20% of children and adolescents are affected by disabling mental illness (WHO, 2003). Suicide is the second leading cause of death among young adults and 75% of the suicides in this population occur in low-income countries (WHO, 2014). Left untreated mental illness is associated with reduced compliance to other medical treatments as well as inability to maintain relations, work, studies, and quality of life. On this basis, treatment of mental illness is paramount both for individuals and nations, and to diminish that global treatment gap is one of the WHO’s core goals (WHO, 2013a; 2013b).

In order to address the shortage of professionals, task shifting in mental health care to more available and affordable personnel, so called lay health workers, have been tried in low-income countries with promising results (Patel et al., 2011; van Ginneken et al., 2013). The definition of a lay health worker according to the WHO is a person from the local community who performs some health care intervention and who has received training in the local context of the specific intervention. However, the lay health workers are not professional health care workers and they have no formal professional training or tertiary education degree (WHO, 2013a; 2013b). Most interventions and screening forms are developed in high-income settings and not always attuned for low-income settings (Patel et al., 2011). To increase compliance to treatment in low-income settings, contextually validated screening tools and culturally appropriate language are essential.

Mental health in Zimbabwe

With a population of 14.8 million of which 70% live below the poverty line, studies suggest a prevalence of depression and anxiety above 20% in the adult population (Abas & Broadhead, 1997; Chibanda, Cowan, et al., 2016; Chibanda, Verhey, et al., 2016) as well as in rural youth (Langhaug et al., 2010). The estimated treatment gap for major depression in Zimbabwe is 67% (Kohn et al., 2004). The primary health clinics are intended to provide the initial and basic care for psychiatric patients, including screenings, referral to one of the six psychiatric hospitals and follow up treatments. Zimbabwe has only 16 psychiatrists of which one is specialised in children. The standard care for common mental disorders in Zimbabwe consists of nurse-led evaluation and psychoeducation. If needed, the nurse will prescribe antidepressant medications or/and refer the patient to a psychiatric facility (Chibanda et al., 2015). However, the reliance on healers and spirit mediums is still high, and for a third of the patients they constitute the first contact with a care provider (Patel, Simunyu, & Gwanzura, 1997).

The Friendship Bench

The Friendship Bench (FB) program is a Zimbabwean intervention, developed in 2006, where problem-solving therapy (PST) is provided by a trained lay health worker (The Friendship Bench Organization, 2020a). The program was originally designed to address mild to moderate mental health conditions in the adult population at primary care level. The intervention PST, a cornerstone in FB, is a psychosocial brief therapy based on cognitive behavioural therapy (CBT). More than 50,000 persons have received the service, making FB the largest mental health program integrated in primary health care in Africa. FB is supported by the Zimbabwean Ministry of Health and the City Health Departments. PST has shown to be successful in helping adult patients with a range of different health and mental problems to handle emotions, from depression and anxiety to cancer and heart diseases (Nezu et al., 2012). Furthermore, PST has been effective in enhancing patients’ adherence in medical as well as other psychological treatments (Nezu et al., 2012).

Clients visiting the local primary care units are screened with the Shona Symptom Questionnaire (SSQ). The SSQ is a non-specific screening instrument which has been developed and validated in Zimbabwe’s local context (Chibanda, Verhey, et al., 2016; Patel, Simunyu, Gwanzura, et al., 1997). The questionnaire includes both items common in psychiatric screening questionnaires, such as problems with concentration and suicidal thoughts, but also idioms for distress in the local language Shona, such as kufungisisa (thinking too much; Patel, Simunyu, Gwanzura, et al., 1997). Clients scoring nine or higher in SSQ will be referred to a lay health worker from the FB specially trained in PST. Those at the risk of harming themselves or showing psychotic symptoms will instead be referred to health care professionals. The lay health workers in the adult FB are referred to as “Grandmothers” since all of them are senior women, with an average age of 58. They have received 3 weeks of training and are supervised by qualified health professionals. The training is manual-based and consists of culturally adapted information of depression and anxiety, role playing exercises and group discussions (The Friendship Bench Organization, 2020a).

Clients referred to a lay health worker at FB will receive six sessions of PST carried out on a bench outside the local clinic. The six sessions last for 30–45 min each, except for the first session which is 60 min, and are completed within 4–6 weeks (The Friendship Bench Organization, 2020a).

PST focuses on enhancing the patient’s ability to cope with setbacks and stressors, from daily hassles to major traumas. The idea is to let the client identify their most significant problem, then to support problem-solving by breaking down the issue into smaller components, and finally to help exploring possible solutions. The counsellor helps the client to find a solution without giving advice, making decisions for them, blaming or judging them. The long-term goal is to teach clients to adopt a problem-solving approach enabling them to solve their problems in the future, independent of their counsellor. The first session focuses on problem identification. The lay health worker listens as the client tells his story. She asks the client to select one manageable and meaningful, maybe practical problem from the list and to formulate a measurable and achievable goal. She then asks the client to come up with possible solutions and to select a realistic solution. In the next sessions, progress in the plan agreed upon will be evaluated. If improvements have been made, the lay health worker will reassure and encourage further development. On the contrary, if no progress has been made or if new obstacles have emerged, the lay health worker and the client will start over again, identifying problems and possible solutions (The Friendship Bench Organization, 2020a). After four sessions, the clients will be invited to a peer support group with two fundamental functions: sharing experiences and behavioural activation (The Friendship Bench Organization, 2020b).

The results from the FB intervention have so far been promising, including a recent randomised controlled trial showing an improvement in symptoms in patients going to the FB compared to patients receiving the standard care in Zimbabwe (Chibanda, Weiss, et al., 2016). The results as well as the cost-effectiveness has given the FB intervention an international reputation. Since the start in 2006 in Zimbabwe, mental health programs based on the FB have been organised in neighbouring countries as well as in New York (Rosenberg, 2019).

The youth FB

In 2016, a cluster-randomised trial of the FB was conducted in Zimbabwe. The results indicated similar effects among youth aged 18–22 as in older adults (Chibanda et al., 2015). However, the trial showed difficulties in reaching young people. To increase the availability to youth aged 16–19, a modified version of the FB called the Youth Friendship Bench (YouFB) was implemented as a pilot project. The YouFB shares basic concepts with the original FB with some essential differences. The counsellors of the YouFB are referred to as “buddies” and are university students, usually psychology or sociology students on their third year of university studies. After spending 1 year working at the YouFB as interns, they return to university to finish their final year to reach a bachelor’s degree. They are trained in the same way as the lay health workers in the program for adults, with focus on young adult issues such as addiction, domestic violence, sex, and relationships. During their internship, they receive a salary of 100USD a month.

Additionally, the YouFB differs from the FB also by delivering interventions not only at health clinics but also at schools and other community settings. The activities in the peer support groups differ as well, football and dance are the main activities in the YouFB, whereas handicraft is predominant in the original program (The Friendship Bench Organization, 2020c). A further aim of the YouFB is to identify and provide service to specific groups of adolescents with high risk of common mental disorders, such as pregnant teenagers and young offenders. Furthermore, the intention of YouFB is to raise awareness of adolescents’ mental health and possible support.

Studies evaluating the effect of the YouFB are ongoing but are yet to be published. Qualitative studies containing in-depths interviews with senior counsellors working with the original FB intervention for adults has previously been conducted (Chibanda et al., 2017; Verhey et al., 2020). As no previous study has focussed on the experiences of the YouFB counsellors, it is of interest to investigate what lessons can be learned from the experience of the YouFB.

Aim

The aim was to illuminate the experiences of the counsellors at the Youth Friendship Bench.

Method

Design

This study is a part of a process evaluation of the YouFB. In order to extract and capture a spectra of experiences of the YouFB counsellors, a qualitative method with interviews and content analysis on a latent level was used (Lindgren et al., 2020).

Participants

The participants were purposefully selected by the YouFB manager at the FB office in Harare, to ensure an adequate number of participants and heterogeneity among the participants. They were selected regarding age, gender, and educational background to include as many differences in the demographic variables as possible. All 14 counsellors who were invited, seven males and seven females, agreed to participate. They were asked for consent by the study manager and the interview was scheduled. Due to the Corona pandemic and national lockdown in Zimbabwe, the last two scheduled interviews could not be performed.

Data collection

An interview guide was constructed at Lund University, Sweden, by AW, with inputs from the co-authors as well as from the researchers at the FB office in Harare, Zimbabwe. All interviews started with the question “Can you tell me about your experience of being a counsellor in YouFB?” and continued with open-ended questions, such as “Are there certain problems in the client’s life that you find hard to talk about? “and “How has working as counsellor affected you?” The semi-structured interviews were conducted face to face at a bench in the garden of the FB office. All interviews were conducted by AW in March 2020 in English and lasted between 20 and 89 min each. The interviews were recorded.

Analysis

Initially all entire interviews were transcribed verbatim. By doing so word by word, the uniqueness of the interviews was preserved. Then the transcript was divided into meaning units (Lindgren et al., 2020). A meaning unit is a part of the text which conveys a specific message related to the study aim. It could not only be few words but also a complete sentence or paragraph; what is essential is that the unit is referring to a single central meaning. Afterwards, the meaning units were condensed, whereby the units were shortened while still preserving their core. Then, the condensed meaning units were abstracted and coded, in other words the content was de-contextualized. In the next step, the re-contextualization begun (Lindgren et al., 2020). The codes were sorted into subthemes; a group of codes which share a commonality. Finally, subthemes merged into themes, which in this context can be described as a thread of meaning being pervasive through numerous domains and bringing meaning to recurrent topic (Graneheim et al., 2017). In this latter part of the analysis, the latent content was interpreted.

Ethics

Permissions to conduct studies, including qualitative interviews on YouFB was granted by the Medical Research Council of Zimbabwe, the Director of Health Services in the City of Harare and London School of Hygiene and Tropical Medicine. All participants received both written and oral information about the study in accordance with the principles of the Declaration of Helsinki and they were informed that they could withdraw consent at any given point without motivation or reprisal (World Medical Association, 2013). The participants were given time to consider and ask questions about the study and participation before giving consent regarding participation and recording. Interviews were recorded on offline devices and handled according to the research policies at the FB office. The counsellors were reimbursed for their participation in the interviews in accordance with local regulatory research and ethics bodies, in this case with soft drinks.

Results

Twelve counsellors, five males and seven females were interviewed. The age of the participants varied from 21 to 23 years, and nine of the participants studied psychology, two social studies, and one development studies. When the interviews were conducted, all of them had been on attachment as counsellors at the YouFB for 9–10 months. The interviews lasted from 20 to 89 min, with a median length of 31 min.

Three themes, “Working in a meaningful project,” “Encountering obstacles” and “Carrying an emotional burden” along with eleven subthemes emerged from the data analysis. The themes and subthemes are shown in Table 1 and further described below along with quotes.

Table 1. Themes and subthemes.

Working in a meaningful project	Encountering obstacles	Carrying an emotional burden
Contributing and solving problems	Facing others’ preconceptions	Empathising with the client
Growing as a professional and individual	Dealing with taboos	Seeing oneself in the client
Creating an alliance	Having to be flexible	Feeling inadequate
Being strengthened by the team	Failing to reach out to people

Working in a meaningful project

The counsellors agreed on being working and thriving in a helpful and much needed project. They expressed in various ways how they experienced educating and solving problems together with the clients as meaningful for the clients, and even for the whole nation. The counsellors also pointed out how they themselves had acquired skills useful for their future profession and life in general along the way. The supportive and professional environment of YouFB was described as important for their development.

Contributing and solving problems

The participants experienced how their efforts made a difference when they reached out to the clients in the suburbs. Working in one of the first mental health projects aimed at adolescents in Zimbabwe, the counsellors described how they were filling a gap which had not been addressed before.

So let’s be the first ones to go there and tell them depression is real, depression is normal and it’s something that you can pull out from if we work together. (C1)

Educating the clients about mental or sexual health, and teaching them about their human rights was by the counsellors perceived as empowering clients in making changes in their lives, and seen d as meaningful l and important, and overall regarded as one of the most important outcomes of the project.

Because most girls they end up realizing they were raped after you talk to them. She doesn’t even know that she was raped. She doesn’t know that her consent is important. That her saying yes is important, that her enjoying it is important. (C1)

Reaching out to the clients in their communities instead of waiting for the adolescents to search for help at the YouFB was described as a necessity to be able to help by the counsellors. They overall described the field work in positive words—meeting the adolescents in the suburbs and taking part of their living conditions was perceived as meaningful, and the counsellors felt that they were doing something for real, contrary to reading books or sitting in an office.

The strength that I may say is in the way we deliver PST, in that we do not wait for… for the youth to come to us, we go into the communities. (C10)

In order to preserve the problem-solving focus with the client when a problem was identified, the counsellors sometimes had to curb their impulse to give the client straight advises.

So you should really really really not give anyone advice because what worked for you might not work for them.[…] So yeah, it’s really to start suggesting and start giving them ideas. (C1)

Helping someone else to solve their problem and experiencing the effects of one’s help in positive feedback from the clients evoked feelings of proudness and joy in the counsellors.

I feel like I’m a hero. Especially when the participant managed to overcome the situation. It feels so good knowing that you’re helping someone out there. (C4)

Seeing the positive effects of the intervention led many counsellors to urge for further expansions. The counsellors suggested several measures to help more people, i.e. that YouFB should include a broader age span, educate about mental health in elementary schools and churches and spread the project to other nations. The counsellors were enthusiastic regarding the thought of coming back to YouFB after their graduation, being a part of this possible expansion.

Growing as a professional and individual

The counsellors expressed how their view on mental health was challenged during their internship at YouFB. They spoke of how their understanding of how mental illness affects people had progressed, giving them a more holistic understanding of the subject. The attachment to YouFB facilitated a process of learning. The counsellors described feeling proud, confident, and empowered having managed to solve problems together with people of their age. Beside growing skills in PST the counsellors noted that other abilities improved, such as being able to talk to different and large groups of people, and lending an ear.

I now understand more of mental problems/…/, associated maybe with being abused. You’d be affected psychologically, mentally, having low income, bad economy. So before I didn’t know that those problems can affect mental health. (C5)

YouFB made the counsellors reflect also on mental health problems they had previously experienced, themselves or in a family member, which they now perceived in a different light. The participants witnessed how the work in YouFB had helped them to solve personal problems, managing own emotions, taking better care of themselves and feeling more confident, giving them new insights regarding future life paths.

Before I was someone… when there was something that was troubling me, I could go sleep and cry. But now I'm someone who is strong, who believe in myself. I do believe in myself! (C12)

Creating an alliance

Maintaining the client-counsellor relationship and trying to adapt the clients’ perspective (put on their shoes) was experienced as of utmost importance. Striving to act professionally the counsellors experienced how they had to tone down personal beliefs and opinions. They stressed how important confidentiality was, and how making the clients feel at home was a crucial part to make the client open up. The counsellors emphasised the importance of a dynamic interaction between the client and counsellor, in which the client came up with solutions and the counsellor helped them pick the most suitable. When this worked well, the counsellor described it as if the client and counsellor were one and how they were brainstorming and solving problems together.

We create that judgement free zone where you’re talking to the youth and that person see that whatever perceptions they had about the certain problems that they are facing, they are able to say “okay, this a place where I can actually open up and say everything that I’ve experienced.” (C10)

The counsellors emphasised the advantages of maintaining a professional relationship. By making the clients come up with their own solutions, the counsellors recognised the potential effect of empowering the client, making them the masters of their own lives, which also was perceived as making them more resilient to future problems. Additionally, this made the clients unable to blame the counsellors when a solution failed.

Being strengthened by the team

Different obstacles and problems were encountered by the counsellors. By the help of other team members in YouFB, these problems could appear less heavy or even disappear. The counsellors spoke of how the training and education provided by the YouFB was helpful and how the support of mentors and staff members improved coping when clients’ problems seemed too big. The counsellors described how they were able to support each other, leading to a feeling of control when they could handle the situations they faced together. They found comfort in each other and felt secure and confident when being together in unfamiliar neighbourhoods. The friendly working environment at the FB office was highly appreciated and made going to work not seem like a chore. The office was described as a safe hub of confidentiality.

Here is a place where everyone is accepted, you know, everyone, no matter what level you are, no matter what you have, no matter what your background is, everyone is really accepted. (C2)

Encountering obstacles

The counsellors experienced different forms of failing to reach the target group, adolescents with common mental disorders. Hinderances and difficulties experienced included combating taboos and preconceptions regarding mental illness described to hamper recruitment of clients and the implementation of the therapy. The counsellors mentioned how the reality differed from theory in the manual and how they had to adapt in order to get on with the PST sessions. Situations where solutions failed or when the counsellors did not manage to reach clients in need were also perceived as tough.

Facing others’ preconceptions

The counsellors spoke of preconceptions, experienced to hinder young people from engaging in YouFB. One preconception concerned superstitious explanatory models for mental illness, perceived to hold clients back since it made the clients suspicious of the counsellors’ intentions.

Africans… when it comes to mental health, maybe you understand or you know, the witchcraft,/other religious faiths/, you know a lot of things that are associated with the evil spirits. (C8)

Furthermore, the counsellors had to deal with presumptions that mental illness was a Western thing not affecting Africans, and of mental illness not affecting young people, expressed like “they don’t have problems at all since they’re just kids” (C6).

Dealing with taboos

Although receiving training and support from the YouFB organisation some problems remained difficult to discuss and bring up with the client according to the counsellors. Sensitive matters were regarded as difficult to talk about by the counsellors, as the client was uncomfortable and could not talk about it, and the counsellors sometimes felt that they lacked the knowledge to address the subject properly. Sensitive topics usually involved sex and relationships but were sometimes further specified as other topics stigmatised by society such as abortions and homosexuality.

So then at first when a client, they wouldn’t feel comfortable sharing things that’s associated with sex. I would find out that they want to tell you something but they just can’t say it out loud. (C7)

Having to be flexible

The structure of the PST sessions was not always perceived as suitable by the counsellors. The sessions often took place in uncomfortable and stressful environments which differed from the training scenarios. Due to this, the counsellors experienced that the structure could not always be fully applied. The reality of working in the field and having to adapt to different people and situations meant that the structure was sometimes perceived as rigid. If the counsellors followed the method rigorously, they ran the risk of losing a sense of presence with the client. The method of not giving straight advises in the therapy was emphasised by many of the counsellors. However, in cases where the client was unable of rendering own solutions, they experienced that hints or suggestions might be necessary.

Well, of course sometimes you feel limited. Cause there’re some times when you have something like a solution that you think it might work to your client, but then you can’t tell them to do it.[…] So just find a nice way of suggesting to them, that way it will be easier for you. (C7)

The counsellors told of situations where the clients honestly admitted that they did not come for therapy but simply for the 5 dollars they were reimbursed with for participating, while other clients had been revealed to lie about their problems to generate more sessions or because they didn’t trust the counsellor. The counsellors expressed how they had to adapt to these unpredictable and frustrating situations in order to find an approach, whether this would be to nicely dismiss the client or offering extended sessions.

Failing to reach out to people

The counsellors described a frustration when they could not reach out to adolescents who needed help. The counsellors spoke of the potential risk of relapses and what might happen when the clients did not have anyone to talk to anymore. They expressed concerns regarding suicidality and lives destroyed by drug addictions. In some cases, practical issues such as the lack of a correct phone number to the client, or unreimbursed transportation fees complicated follow ups.

We were doing six sessions but I actually think it was limited. Cause you might get to the sixth session, but the client still has unsolved problems. (C7)

It was perceived as stressful by the counsellors when they had to say no to clients younger than 16 or older than 19, and to clients who lacked an identification card or birth certificate, as these clients did not fit in the study’s inclusion criteria. Having to reject clients was not an easy task, since the counsellors experienced these groups to be in need of the intervention.

There’s a lot of youths who are suffering out there. (C6)

As most of the clients were younger than 18, they needed their parents’ consent to participate in the intervention. According to the counsellors, some parents were reluctant to consent due to pride, superstition, or lack of information. Having to comply to the will of the parent when the child was searching for help was experienced as frustrating and unfortunate.

Because sometimes you call a parent for a follow up. […] and they’ll be like: “What’s about Friendship Bench? What counselling does he need? He’s still a kid.” (C9)

The counsellors experienced that it could be hard for clients to grasp the concept of therapy initially, affecting the willingness to get involved in the project. These potential clients were perceived as unwilling to approach YouFB, and clients who had not understood the concept could get stuck or angry during the sessions, making the work difficult for the counsellors. The counsellors also experienced how some potential clients showing signs of depressions were not captured by the SSQ, as the client was answering “No” on all questions.

The counsellors experienced both how the reimbursement money that clients got for participation in the sessions could attract people not in need of the intervention, while sometimes the money was conceived as insufficient for the clients’ need. The counsellors both suggested an increase as well as an abolition of the reimbursement to counteract these problems. The counsellors also called for collaboration with the police and with other organisations.

Carrying an emotional burden

The counsellors talked about the burden of carrying emotions, and how this could be a consequence of picking up the problems of other’s, carrying own unprocessed problems or facing new ones. The counsellors mentioned how these emotions could interfere with their professional role. The experience of recognising oneself or one’s problem in the client was perceived as helpful or unpleasant.

Empathising with the client

Meeting young persons with big problems affected the counsellors on an emotional level. The counsellors stated how they could reflect on the emotions of the clients. The counsellors expressed how they had to struggle to keep a professional attitude. Thoughts and feelings could flare up when the sessions with the clients were over and interfere with sleep and making it harder to maintain a professional focus on the client’s problem and experiences. When the nature of the problems was confidential, the counsellors could feel alone in the burden. The counsellors expressed how they themselves could sometimes be in the need of a PST session after giving one to a client.

And sometimes I could feel like, I could feel like crying in front of the participant or in front of the client like this is happening to you. (C8)

Seeing oneself in the client

The counsellors easily recognised some of their own problems in those of the client’s. The counsellors mentioned how their life and the client’s could intertwine and how talking about the client’s problem made them confront their own unsolved problems, making it harder to help the clients efficiently.

You know that triggers both people, you know, you say you are actually trying to counsel a client and help them out of a problem that they are facing but again you yourself have been triggered back to those emotions you once felt when your parent or your… someone you loved died. (C10)

Yet, his experience was also perceived as something positive. The counsellors expressed how having personal experience of handling a specific problem might facilitate the processes of finding feasible solutions.

… the person can open up more because they think you’re, you’re of their age and you’ve, you’ve maybe used, maybe you’re facing the same problems.[…] They feel you understand them more because we’re probably going through the same stages and the same problems in life. (C9)

Feeling inadequate

Dealing with clients’ major, sometimes unfamiliar problems was perceived as overwhelming when the counsellors found themselves in situations which they did not know how to handle. They felt responsible to guide clients to solve their problems and combined with a hectic working schedule some counsellors feared being burned out. When the suggested solutions had failed and problems remained unsolved, the counsellors experienced distress and frustration.

Someone could come to you, telling you about the father who died and then she starts telling me she misses her father. The solution may be beyond my control. (C2)

The counsellors expressed how they felt unprepared in situations where they had worked with clients who suffered from hallucinations or had other problems not included in the YouFB manual. They expressed how they did not know what to do in these situations and they experienced the intervention as insufficient. This could also be the case in situations where the problem was more of a materialistic nature, for example when the client was lacking money for school fees.

Discussion

This study is the first to illuminate the experiences of young lay health workers delivering PST to adolescents with mental health problems in a low income setting. The counsellors emphasised how the positive and pleasant experiences overshadowed the negative or difficult and they were excited regarding the idea of continuing the work at YouFB after having completed their studies. While highlighting the value of the intervention and the need for continuance and expansion, they also identified room for improvement.

The results from the present study are in line with interviews illuminating the experience of senior lay health workers, so called grandmothers, supporting adults in a FB program (Chibanda et al., 2017; Verhey et al., 2020). Both the younger counsellors in YouFB and the grandmothers’ described experiences of having to tone down personal beliefs and to be non-judgmental to make the clients open up, and reported how sharing similar experiences with the clients made it easier for the clients to talk about their problems. Sharing environment and life conditions created trust between the client and counsellor. Problems concerning financial situations were perceived as difficult according to the grandmothers (Chibanda et al., 2017). This was also mentioned in the interviews with the counsellors of the YouFB as they described how they could feel inadequate in dealing with economic problems, and in the counsellors’ suggestions on how the YouFB should expand in order to better help the clients materialistically. Verhey et al. reported how the older lay health workers could feel overwhelmed by the problems of the clients as they live under the same conditions (Verhey et al., 2020). Correspondingly, recognising or projecting own problems onto the client sometimes made it harder for the counsellors in the present study to perform their duties. However, both the YouFB counsellors and the grandmothers recognised the empowering impact of their work and wished for the intervention to continue (Verhey et al., 2020). Similar results have been reported from South Africa, where counsellors reported how PST was generally accepted although the clients lacked an understanding of what they might expect from the therapy (Myers et al., 2019). Counsellors belonging to the same generation might facilitate sharing experiences, as suggested by the findings of Roach et al., where adolescents struggling with depression and thoughts of suicide were perceived to be more likely to seek support in a peer than in an older counsellor (Roach et al., 2020). In FB, older clients are counselled by mature counsellors, so-called Grandmothers. YouFB enables younger clients, more comfortable to talk about personal problems with a peer, to discuss things they hesitate to bring up with a Grandmother or an older professional healthcare worker. Adolescents may use electronic communication and social media when expressing concerns and support (Roach et al., 2020). This was a source of distress for the YouFB counsellors as electronic communication was not always possible due to technical or economic reasons.

A difference worth mentioning between the younger lay health workers in YouFB and the Grandmothers is that the Grandmothers only received a brief training in PST, while the YouFB counsellors had studied relevant subjects at the university ahead of their internship as lay health workers in YouFB. Thus, they might be better prepared for counselling, on the other hand, their previous training might make them establish more of professional relationships and less of a peer support approach.

The counsellors in the present study experienced interactions with parents as troublesome, as they sometimes did not acknowledge their child’s mental health problems. This experience is shared by professional health care workers, for example school nurses in Sweden described the difficulties when dealing with uncooperative parents to children with mental health problems as one of the hardest (Dina & Pajalic, 2014). The feelings of not being enough, as well as contributing and developing in one’s profession were experienced by both counsellors of the YouFB and Swedish school nurses (Dina & Pajalic, 2014; Jönsson et al., 2019).

Thus, the results in the present study highlight several similarities in experiences of lay health workers in low-income settings and of professional health care personnel in high-income settings.

The participants in the present study described sex as a difficult topic to discuss with clients, either due to lack of knowledge or due to sex being a sensitive subject in the cultural context. This is concerning since the prevalence of HIV is high in Zimbabwe and its negative impact on mental well-being is well documented (Brandt, 2009). The experience of dealing with sexual education in Zimbabwe has previously been explored (Gudyanga et al., 2019). Secondary school teachers called for support from politicians and other community workers in order to overcome challenges and to break the taboo of speaking about sexual health (Gudyanga et al., 2019). Sex was considered a difficult topic by the counsellors in the present study as well as in Gudyanga et al., and further interventions might be necessary to normalise sexual education and increase knowledge regarding sexual health.

The experience of failing to reach some clients made the counsellors suggest improvements such as increased number of sessions and the inclusion of a broader age span to enable more to benefit from PST. The counsellors also called for collaboration with other organisation, such as the police, social services as well as NGOs, in order to broaden potential support for clients at risk. The counsellors felt inadequate, when clients presented problems beyond the scope of the intervention. They described that they happened to meet clients with psychotic symptoms despite previous SSQ-testing. Clear guidelines regarding when and where to refer a client to YouFB, and who should be offered PST were suggested to reduce the risk of clients with inappropriate diagnoses being included.

Compared to CBT, PST requires no extensive education, making it feasible in low-income settings (Zhang et al., 2018). As the ratio of mental health workers/general population is higher in high-income countries, the need of interventions like YouFB might be smaller in countries where some of the demand is already met by existing interventions. However, the treatment gap of mental illness is a challenge in high-income settings as well and an affiliation of the FB has been established in New York. Programs such as Mental Health First Aid (MHFA) and similar initiatives with the purpose of educating about and normalising mental illness exist in numerous high-income countries (Kitchener & Jorm, 2008). The public acceptance of these programs has generally been good and the results have been promising (Kitchener & Jorm, 2008; Morgan et al., 2018). This indicates that interventions with task shifting and education might have a place in high-incoming settings as well. The active recruitment of clients out in the communities, rarely applied by health care providers in high-income countries, was mentioned as one of the strengths of YouFB in the present study. PST as used in YouFB is a brief therapy, not meant to replace more qualified psychiatric care performed by psychiatrists, nurses, and psychologists with longer university educations. Brief therapies might be successful provided that the lay health workers are properly trained and properly supervised as in YouFB. Thus, YouFB might be a cost-effective, well-functioning “first aid,” preventing mild cases from deterioration, and saving sparse resources for severe cases.

Strengths and limitations

The research team consisted of individuals with different professions, gender, and ages, enhancing different perspectives. AW had a different cultural background than the participants which might have influenced data collection and interpretation in a negative way. The data collection was facilitated through the cooperation with the local research team at FB, who gave valuable input regarding approaches suitable in the Zimbabwean context. A limitation is that all interviews were conducted in English, a second language for both the researcher and the participants. To gain a better understanding of the setting and thereby further strengthen the credibility, AW lived at the FB office in Harare during the process of collecting and analysis of the data.

All participants in the present study were purposefully invited by the project manager at the FB office in Harare to ensure feasibility and variability. An adequate number of participants were recruited, and the collected data was rich, increasing credibility (Graneheim et al., 2017).

To enable future researchers to repeat the work and ensure transparency, all steps in the analysis process were documented. The use of an interview guide assured that all interviews were conducted within the same framework of questions (Graneheim et al., 2017). To enhance credibility, the data were systematically and meticulously analysed and discussed between the researchers. No theme was fixed until consensus was reached. To address the confirmability and authenticity of the findings quotes from the participants are included in the results.

To enable the reader to decide whether the results are transferable to different settings and groups or not an accurate and distinct description of the studied population and cultural context have been strived for (Graneheim et al., 2017).

Conclusion

The treatment gap in mental health is especially high amongst adolescents in low-income countries such as the African region, adding to the significance of the YouFB project. Neglecting the mental health of adolescents will have severe consequences not only for the adolescents but for whole nations. The YouFB has the potential to become one of the first scalable and effective mental health program addressing common mental disorders among adolescents in Africa, and the program could possibly provide a way to narrow the existing treatment gap. The present study captures the experiences of young counsellors providing PST to adolescents in the YouFB in Zimbabwe. These results might guide future research and contribute to the development of the YouFB within and beyond Zimbabwe. Further studies are needed to further investigate client’s experiences, effects of the intervention in high- and low-income settings, and potential improvements enhancing the YouFB intervention as a tool in optimising mental health care for adolescents.

Author contribution

The interviews and preliminary analysis were performed by AW as a part of his master thesis in the medical program at Lund University, Sweden. KL supervised all phases of the analysis. SE supervised mainly the psychiatric aspects. Having lived in Zimbabwe, SE also contributed with knowledge regarding the cultural context. All authors took part in finalising the script.

Abbreviations
FB	=	Friendship Bench Organisation
CBT	=	Cognitive behavioural therapy
SSQ	=	Shona Symptom Questionnaire
PST	=	problem-solving therapy
YouFB	=	Youth Friendship Bench
NGO	=	Non Governmental Organisation

Acknowledgments

Thanks to Ruth Verhey, clinical psychologist, and researcher at the FB in Harare, who mediated the contact with several researchers involved in the FB and provided invaluable information about the local context and setting. Thanks to the YouFB managers Kelly Muzariri and Rhulani Chauke for input and feedback.

Declaration of interest

The authors report no conflict of interest.

Funding

None.