DRAFT_manual_15.01.16

the Friendship Bench ZAPP UZ 1

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the Friendship BenchDetails and AcknowledgementsThis manual can be copied, reproduced and adapted by individuals as part of their work or trainingneeds without permission of the authors. Acknowledgement must be provided and reproduction isnot to be used for profit purposes. This manual will be reviewed regularly and the latest version canbe downloaded from the study website www.friendshipbenchzimbabwe.com.@ Contact : The Friendship Bench www.friendshipbenchzimbabwe.com [email protected] Zimbabwe AIDS Prevention Project (ZAPP) 92 Prince Edward Milton Park Harare Zimbabwe Tel-+263-4-707289/91  Manual development and design :Ruth VerheyJean TurnerDixon ChibandaAcknowledgement goes to the whole Friendship Bench team, ZAPP and MSF. 3

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the Friendship Bench TABLET/phone care Cleaning »» Use only a clean, soft cloth such as microfiber to clean the screen, no cleaner of any type – no window cleaners, household cleaners, aerosol sprays, solvents, alcohol, ammonia, or abrasive material. »» Caution: Your device is not waterproof. Do not pour or spray liquids directly on your device or wash your device with a heavily soaked cloth. Daily Use »» Avoid putting the device 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 device to prevent damage. »» Health Promoters are responsible for keeping their tablet and phone battery charged for use each day. »» Waiting to charge the tablet/ phone until the charge is low (20% life or red indicator light) extends the battery life. »» The tablet/ phone screen can be damaged if subjected to rough treatment. Careful placement in pouch is important. »» Avoid using any sharp object(s) on thedevice No scratching with pens or pencils or sticks for pointing out important notes on the screen. »» Do not “bump” the tablet against lockers, walls, doors, floors, or any other hard objects. »» Never place a tablet/ phone in a bag that contains food, liquids, heavy, or sharp objects. 6

the Friendship Bench Appearance »» Tablets/ phones must remain free of any writing, drawing, stickers, or labels that are not the property of Friendship Bench »» Each case and table/ phonet is identifiable. Do not remove any Friendship Bench ID tags or labels. Safe Keeping »» Tablets and phones must never be left in an unlocked locker, unlocked car or any unsupervised area. »» Tablets and phones 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 and phones will be collected and stored in the Friendship Bench office in the clinic. »» Each tablet and phone 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. »» Each tablet and phone has a unique identification number and at no time should the numbers or labels be modified or removed. »» Do not lend your tablet/ phone to another person. Each tablet is assigned to an individual and the responsibility for the care of the tablet/ phone solely rests with that individual. »» Never expose a tablet/ phone 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 phone is placed in cold conditions, the battery life can be decreased. Repair »» The tablet and phone are electronic devices and care must be exercised when handling them. »» Do not attempt to gain access to the internal electronics or repair your tablet/ phone. »» If your tablet/ phone fails to work or is damaged, report the problem to ZAPP +263-4-707289/91. 7

the Friendship Benchacronyms GlossaryART: anti-retroviral therapyARV: anti-retro virusCBT: cognitive behavioural therapyCKT: circle kubatana toseFB: Friendship BenchGAD: generalized anxiety disorderHIV: human immunodeficiency virusLHW: lay health workermhGAP : mental health global action planPHQ: patient health questionnairePLWH: people living with HIVPND: postnatal depressionPST: problem solving therapyPTSD: posttraumatic stress disorderSSQ: shona symptom questionnaireSTD: sexually transmitted diseaseSTI: sexually transmitted infectionSUD: substance use disorderUNAIDS: United Nations AIDsWHO: World health organization 8

the Friendship BenchFriendship Bench Manualfor Lay health workers (LHW)IntroductionThis training manual was compiled using various resources and we drew from the experience of the Friendship Bench clinical trial and our clinical expertise.For gender equity purposes, we chose to use both the female and male pronouns throughout the manual. Aim:This manual aims to enable LHW and their supervisors to feel confident in their counseling work and be awareof their clients’and their own needs to do this important work. Training process:We encourage group discussions and exercises during the training as what we learn has to be understood andpracticed. All of us can use the simple and effective method of problem solving in our work and private life. 9

the Friendship BenchHistorical backgroundof the Friendship Benchand justificationBackgroundOver 30% of people utilizing primary care facilities in Zimbabwe suffer from common mental disorder (CMD). This term describes the presentation of anxiety, depressive and somaticsymptoms.According to UNAIDS 16.7% of Zimbabweans are living with HIV, 40% of these people living with HIV(PLWH) are also prone to suffer from CMD.The Friendship Bench (FB) was developed in 2006 in response to a stakeholders’meeting that emphasized theneed to urgently address the high prevalence of CMD among people seeking primary health care.The FB is a task-shifted brief and culturally-adapted intervention that is based on cognitive behaviouraltherapy (CBT). It is delivered by lay health workers (LHW) who have received training in problem solvingtherapy (PST) and behavior scheduling and are supervised by higher cadres. The intervention consists of upto six structured 45-minute sessions delivered on a bench within the grounds of the primary care clinic in adiscrete area, with the first session lasting up to an hour.A clinical trial showed that the Friendship Bench project, which has been running since 2006, is well accepted,feasible and effective (Chibanda et al. 2011).Furthermore, the FB has the additional feature of Kubatana Tose circles (CKT). These circles will be held oncea week led by LHWs and active participants. A circle’s aim is to create a safe forum for participants to shareand explore personal experiences and to enhance the learned problem solving skills.Within Harare’s City Health Department, the FB is being scaled up to all primary health care clinics and itis expected to address the mental health needs of these communities. A whole range of mental, neurologicaland substance use disorders (MNS) as identified by the World Health Organization (WHO) will be managedthrough a stepped care approach on the Friendship Bench. These MNS conditions are highly prevalent amongpeople presenting at local clinics with conditions such as hypertension, diabetes, arthritis and HIV relatedillnesses.In 2015, the FB started to cooperate with Médicins sans frontières (MSF) who have been actively involvedin addressing the mental health needs of inmates within the Zimbabwe prison services. This work by MSFhas involved providing outreach support to inmates upon discharge from prison. The FB will help in themonitoring of those with MNS upon discharge from prison services by ensuring they continue to get theirmedications and community support through the LHWS. MSF will also through this initiative provide supportto the tertiary care facility of Harare central Hospital Psychiatry. 10

the Friendship Bench proverb “Kana uchidakuenda nekukurumidza enda wega asi kanauchida kuenda kure enda nevamwe.”(If you want to go fast go alone, if you want to go far go together.) 11

the Friendship BenchChapter 1psychoeducationKufungisisaWhat is Kufungisisa? Kufungisisa is a common mental disorder (CMD). In the Western context it describes depression and anxiety. Kufungisisa is an illness that affects many people, men and women and especially those living with HIV. Most people do not even know that they are suffering from it. If kufungisisa is not recognized, as suffering person cannot get the right treatment and other chronic conditions such as hypertension, diabetes, HIV, TB that this person might have can worsen. It was also found that suffering from a chronic condition as those named above and mental illness such as epilepsy or psychosis makes people more vulnerable to kufungisisa.CMD is mostly caused by psychosocial stressors such as chronic stress, and negative life events such as loss of a loved one, loss of employment, experiencing traumatic events, being exposedto high conflict in relationships, lack of coping and self soothing strategies and general negative lifecircumstances such as poverty, chronic illness and longstanding lack of resources and income.There is a genetic component to CMD which means if a parent suffers from kufungisisa the chances for a child 12

the Friendship Bench psychoeducationto suffer from depression at some stage in his or her life are higher than in children whose parents have not eversuffered from depression.Kufungisisa affects all areas of life.Kufungisisa affects people’s ability to think and make decisions and resolve problems. People withkufungisisa often have problems with sleep, they might oversleep or find it hard to sleep. They mightover eat or lose all appetite. They might find it difficult to interact with others and withdraw fromsocial activities. They appear sad or angry and tearful and without energy.Depressed people might also find it hard to take their medication regularly, a behavior which will puttheir 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 concentrate, they loseinterest.When they lose these important skills, they cannot perform at work, home or school. They cannotsolve problems, will withdraw from others and from those activities they once liked. They continue toworry and be sad and without hope and motivation. This will affect their sleep, their eating and theirwhole social behavior and overall health which will lead to them experiencing increasing symptoms.Image I: The vicious kufungisisa cycle!! kufungisisa lack of interest, SSQ 14 >9 concentration, motivation suicidal lack of self-care,thoughts non-adherence to prescribed medication, sleep disturbance feeling run down, not performaing at work or home, withdrawal from others, worsening of physical illness related symptomsWhen Kufungisisa persists for more than two weeks it becomes an illness.It is important to know that depression can be treated!A depressed woman or man can receive help to develop appropriate coping strategies and problemsolving skills. 13

the Friendship Bench psychoeducationFriendship Bench•Problem Solving TherapyKuvhura pfungwa – kusimudzira – kusimbisa – kusimbisisa At the Friendship Bench, we work with a technique called Problem Solving Therapy.The first part of our sessions is called kuvhura pfungwa (opening up the mind).The counselor helps the client to understand what is happening in her or his life and encouragesher or him to share what is going on and how she or he feel about it.The aim is to make a list of all the problems the client faces.In the second part the counselor helps to choose one problem of that list.It has to be manageable and relevant to the client and maybe even practical.After this step the client’s goal will be established and the problem defined by inviting theclient to speak about it in great detail.Brainstorming possible solutions is the next step.This is what we call kusimudzira.The third part focuses on a detailed solution selection and devising a SMART actionplan how to realize the solution. This phase is called kusimbisa.The fourth phase of the Friendship Bench intervention addressing kufungisisa is calledkusimbisisa.Participants are invited to take part in the Circle Kubatana Tose (CKT) where people facingsimilar life challenges and all having gone through the Friendship Bench counselling canshare their stories and spend time together in a safe and protected environment. 14

the Friendship Bench psychoeducationSession Structuresession 1PHONE/TABLET computer charged and turned onGreet the client, present yourself, invite client to sit downAsk for client’s nameExplain The Friendship BenchInvite client to speak How can we help each other? Chi chirikunedza kana chii chirikuitika? Listen empathically Apply complete Problem Solving TherapyEvaluate and feedbackMake new appointmentSave Data/turn off PHONE/TABLET session 2PHONE/TABLET computer charged and turned onGreet the client, invite client to sit downAsk for client’s nameReview 1st session  How did the action plan go?Went well: praise/reinforce/reaffirm ask for further problem client wants to work on, apply complete PSTDidn’t go well: explore reasons, discuss obstacles, repeat PST, find adjusted SMART action planEvaluate and feedbackMake new appointmentSave Data/turn off PHONE/TABLET 15

the Friendship Bench psychoeducationsession 3PHONE/TABLET computer charged and turned onGreet the client, present yourself, invite client to sit downAsk for client’s name Review 2nd session  How did the action plan go?Went well: praise/reinforce/reaffirm ask for further problem client wants to work on, apply complete PSTDidn’t go well: explore reasons, discuss obstacles, repeat PST, find adjusted SMART action planEvaluate and feedbackMake new appointment, invite to circle Kubata ToseSave Data/turn off PHONE/TABLET Repeat for sessions 4-6 (always reviewing the previous session) :session 4 Review 3rd session How did the action plan go and how is CKT going?session 5 Review 4th session How did the action plan go and how is CKT going?session 6 Review 5th session How did the action plan go and how is CKT going? 16

the Friendship BenchChapter 2Core competenciesor lay health workers (LHW)The FB program aims to increase capacity in the group of non-specialized health workers. We are aiming toempower LHW in following aspects:»» To possess knowledge of MNS (mental, neurological and substance use disorders)»» To be able to Screen with SSQ and identify who could benefit from FB»» To possess knowledge of best We are aiming to counseling practices empower health»» To be able to actively seek out members of the community who promoters show signs of MNS»» To be able to adequately deliver PST and stabilization adequately to the client 17

the Friendship Bench Core competencies»» To be able to decide when to refer one level up»» To be able to provide education about MNS and support to the client and family, caretakers, colleagues»» To understand stigma, its impact and ways of stigma reduction»» To have knowledge about support systems within clinic and district»» To be able to identify barriers to access of care, treatment and recovery»» To be able to monitor mental state, stages of recovery, adherence, and side effects»» To be able to make use of supervision and ongoing education offers»» To understand and use the concept of peer-supervision and debriefing»» To understand and using the concept of self-care»» To be able to make use of technology to improve treatment outcomes, for supervision and self-care These are the skills that we will acquire during our training and ongoing work. 18

the Friendship BenchChapter 3mentalillnessIn this chapter we will learn about common mentaldisorders such as depression, postnatal depressionand anxiety, mental disorders such as psychosisas well as epilepsy, and Cognitive Disorders andSubstance Use Disorders.We use the mental health global action plan (mhGAP) composed by the World Health Organization (WHO) tohighlight the features of the various mental, neurological andsubstance use disorders we come across. The mhGAP is a veryhelpful tool for healthcare providers.Common mental disorder is a term that combines both anxiety anddepression and somatic symptoms. Anxiety and depression are verycommon, especially among people with chronic illnesses such as HIV,TB, Diabetes or other non-communicable diseases.Often people suffer from both depression and anxiety at the same time.They might present with somatic symptoms such as headaches, heartaches, belly aches. 19

the Friendship Bench mental illnessWe learn about these signs of mental illness These signs are indicating that someone is most likely suffering from impaired mental health and might need help! Not all signs will be present in the same person.»» Abnormal mood: elated, irritable, sad»» Not functioning in daily life»» Neglect of children»» Multiple unexplained physical complaints»» Use of substances»» Bizarre behaviors»» Incoherent speech»» Suicidal ideation»» Concerned familyi) DepressionIn Shona we call depression kufungisisa. Depression is very common amongst people who seek treatment atthe local clinic.Depression is often not recognized. It is important that we learn to recognize a person who suffers fromDepression. Depression is a mood disorder that is characterized by the following symptoms according to themhGAP. A lot of people do not know that they actually suffer from depression. We need to ask them about these symptoms. 20

the Friendship Bench mental illnessThe symptoms must have been present for a 2-week period.When all 3 questions are answered with ‘Yes’, we can assumethat the person is suffering from Kufungisisa.1) Core Depression symptoms are these three of which at least two have to be present: »» Depressed mood most of the day and almost every day »» Loss of interest in those activities that the person used to like »» Decreased energy2) Further characteristics of Depression are these seven of which at least three have to be present: »» Reduced concentration and problems with thinking and decision making »» Reduced self esteem and confidence »» Feelings of guilt and unworthiness »» Feeling hopeless for the future »» Recurrent thoughts of self-harm or suicide »» Disturbed sleep »» Disturbed appetite (weight gain or weight loss)3) This last question is added as it is very important for the diagnosis of kufungisisa: »» Does the person find it difficult to carry out the usual work, school, home or other activities?The symptoms are not caused by the intake of a substance(alcohol or drugs) and they are not solely explained by be-reavement! In the first two months of bereavement these symptoms are normal and do not have to be treated. 21

the Friendship Bench mental illness CASE of 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.”ii) Postnatal depressionWhat is it?Many young mothers go through a phase of ‘babyblues’right after having given birth. They feel sadand confused of what they are feeling and how theyshould react to it. They find it difficult to look aftertheir newborn baby.Some of these young mothers experience moresevere and ongoing sadness (for longer than 2weeks, very much like kufungisisa).They might feel very out of control when they havethoughts of self-harming or thoughts of harming thebaby which will stress them tremendously.Financial, health related, housing or relationshipstress make things even worse. 22

the Friendship Bench mental illnessPostnatal Depression (PND) might be a reaction to the difficult circumstances they live in or just simply bemade worse by those circumstances.Signs for PostNatal Depression»» Ongoing sadness and tearfulness All young mothers need a lot of support»» Inability to feel joy over the baby or other things and those who show signs of kufungisisa»» Indifference towards the baby and therefore not engaging in bonding need even more support. Any young»» Guilt feelings mother can be affected by PND.»» Lack of motivation»» Irritability and very low tolerance towards stress»» Social withdrawal»» Changes in appetite»» Sleep problems (with newborn nobody will expect to get full night of sleep)»» Extreme fear about the baby’s health»» Helplessness»» Self-harming thoughts»» Thoughts of harming the baby 23

the Friendship Bench mental illnessNot being able to look after her baby can make a young mother feel extremely guilty which will leave her feelinghopeless and helpless.Being accused of not looking after her baby will make things even worse. Everybody surrounding the youngmother should understand this.We should rather encourage contact with the baby, help her look after the baby, speak to her family so theysupport, encourage regular breastfeeding, self-care and resting and make sure she eats and drinks enough andmost of all: LISTEN to her.Post partum psychosisA woman can also develop post partum psychosis after having given birth, usually within 2 weeks with verysudden onset of a wide range of disorganized symptoms. This illness needs immediate medical attention inorder to protect mother and baby from harm. The risk for maternal suicide or infanticide is real! The close contact when breastfeeding is extremely important for both mother and baby. 24

the Friendship Bench mental illnessCaseW. is a 25y old woman who has three children. Her first child is 4, thesecond child is 3 y old. Her little son was born just 6 weeks ago.Since then she felt very low and everything seemed too difficult andtoo hard. She had some help from her mother in law but also felt quitecontrolled and criticized by her. She missed her own mother terriblywho had died 1 year ago and had been a big help with her other children.W. remembers that she had felt like this before with her other childrenbut never paid attention to it. The family of her husband had beenvery disappointed with her for not functioning well then.She felt breastfeeding was too much and she wanted it done fast. Atthe same time, she worried about her baby and whether he got enough toeat. He had colics and reflux, cried a lot and threw up even more. Peoplemade comments that something must be wrong with her breastmilkwhich made her worry a lot. She felt like a bad mother. She experiencedhis crying as almost impossible to deal with. Often she just let himcry.W. did not get more than 2h sleep at once and soon was so tired, shecould not concentrate on anything.She could not make herself go to the clinic for the baby check-up.She felt very guilty and cried a lot herself. Sometimes she felt sooverwhelmed and tired that all she wanted was for her baby to be quiet.She had even hit her baby and shaken it.Luckily, the lay health worker came to her house and wanted to knowhow she and the baby were.The Ambuya Utano recognized that W. was not doing well and spoketo her intensively. Ambuya asked her a lot about how she felt andwhat she was thinking.W. realized that it helped her to speak about what she went through andto be explained what her sadness and loss of energy was all about.Ambuya took her and her baby to the clinic and she was offeredmedication which she started taking. 25

the Friendship Bench mental illnessWhat intervention is needed?1. We encourage a young mother to talk about her feelings, we normalize those and do PST where we can. If we suspect she suffers from PND then we refer her to the clinic.2. We always assess for suicidal thoughts and thoughts of harming the baby.3. We help the young mother to establish a routine with her baby and her own life and stick to it. We encourage particularly to breastfeed and to interact with the baby.4. We educate her and her family about PND and make everyone aware of how important it is for mother and baby to be together so that they can form a strong and healthy bond. We explain to the family that a trusted person should always be with the young mother.5. We teach the young mother how to communicate with her baby and explain to her what her baby needs.6. We will follow up very closely on the young mother and her family. She needs to be reassured, supported and always encouraged to stay in close contact with her baby.What happens at the clinic?If you suspect a young mother is suffering from Postnatal Depression, refer her to the clinic. Make sure she willgo with a trusted person and takes her baby so breastfeeding is not interrupted.At the clinic, the young mother will be assessed and, if needed, given anti-depressant medication or referred onfor further psychiatric/psychological support.There is no need to stop breastfeeding when put on anti-depressant medication.At the clinic, the health care providers use a questionnaire called the Edinborough Postnatal Depression Scale(EPDS) to find out if she is suffering from PND. Mother and baby need to stay together. This is most important for the baby’s healthy development. If the mother has PND, she needs treatment. 26

the Friendship Bench mental illnessFatherhoodMaking children is a task for women and men.Raising children is a task for women and men.Every child has a father. So we want to get fathers more involved giventhat both children and fathers benefit from being together.Children of any age need the love, affection and support a father or father figure can give.Right from conception, the father should be encouraged to take part in the prenatal care and support his pregnantpartner. She needs a lot of support and love and just wants to know he is going to be there for her.We can talk to the young fathers-to-be and encourage them to talk about their worries and hopes.The father must be encouraged, shown how to and reassured to bond with the baby. This is especially importantin the case when a mother is not available due to health issues.A father’s involvement makes childrenfeel more confident and secure, theywill thrive better. Children of engagedand responsible father will have a betterfuture. A father is a role model for hischild and by being involved he can alsoprotect his child from being abused.Where parents share chores in the family,less violence is happening and the overallfamily wellbeing is increased.Fathers benefit from being engaged inraising their children as they will be moreactively seeking to generate an income,be more respected in the community andexperience being part of a family. 27

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the Friendship Bench mental illnessPartner/familyPartner and family might react with frustration, anger and fear when a young mother is not fulfilling expectations.They might shout at her, threaten her and express their disappointment in her not functioning.It is easy to imagine how that can make the situation worse.They need information in order to understand what is going on. Especially, the young father will benefit frombeing explained what his partner is going through and how he can help. He is probably also anxious and worriedand has no one to talk to.Anxiety can show in the form of poor sleep, feeling stressed, irritability, lack of appetiteand kufungisisa. We need to talk to the young father too!When a person who suffers from kufungisisa fallspregnant...The risk of suffering from PND is higher for someone who already suffered from depression. We need toexplain this and look out for the pregnant woman and her family even more throughout the whole pregnancyand after the baby is born.What does a baby need? A baby needs soothing and nurturing so it feels safe and secure. A baby needs to be held so it can hear mom’s heartbeat. A baby needs skin contact so it can smell mom’s body scent. 32

the Friendship Bench mental illness The baby needs to be responded to when it cries. We might not know what is wrong with the baby but in responding, the baby learns that it can trust and rely on it mother/ caretaker and thus bond with her. It needs to bond with the adult(s) who look after it. The brain of a baby with a safe bond will be able to develop and grow normally, both physically and emotionally. A baby needs to be looked at so it can learn how to communicate. While feeding, baby and mother or caretaker can look at each other and interact. 33

the Friendship Bench mental illnessA baby needs to be talked or sung to so it can hear He-e huu-u-u we-e-e!mom’s or dad’s voice (which the baby has heard Nyarara nhanha-a. Nhanha anochema. while being in its mother’s tummy). Anochemerei? Anochemera bota. Bota nderaani? Bota nderekacheche. Kacheche kari kupi? Kari kumusana. Amai nekacheche vanofara-a-a!A baby can never get toomuch physical contact.Touch and cuddle thebaby and speak to it.Do you have any questionsor can we continue on ourjourney to grow and learn? 34

the Friendship Bench mental illnessiii) AnxietyLet us look at anxiety.There are several disorders that belong to the group of anxiety disorders: generalized anxiety disorder, panicdisorder, and posttraumatic stress disorder.Anxiety (generalized anxiety disorder – GAD)Anxiety is a disorder that is characterized by the following symptoms and has been present for moredays than not during the past 6 months: »» Excessive anxiety and worry »» Difficulty to control the anxiety and worry And three or more of the following symptoms: »» Restlessness »» Being easily fatigued »» Difficulty concentrating or mind going blank »» Irritability »» Muscle tension »» Sleep disturbanceCASE of generalized anxiety disorder“A. has changed. She is constantly worrying about everythingand can not make any decisions anymore. She is very worriedthat she does things wrong and often avoids engaging in anyof the activities she used to enjoy before. She worries a lot aboutwhat the other people in her community think about her. She alsoworries about what would happen if the landlord raises the rent,if her husband lost his work, if the price for mealie meal went up,if someone got hurt. She can stay up whole nights not being ableto sleep and just ruminate. She finds it hard to concentrate andsnaps easily when someone approaches her. She does not find anycalm moment in her life.” 35

the Friendship Bench mental illnessiv) Panic DisorderPanic Disorder is characterised by recurrent unexpected panic attacks. Panic attacks are brief bouts ofintense anxiety. The person suffering from Panic Disorder has continuous worry about re-experiencingfurther 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 attackor its consequences (e.g., losing control, having a heart attack, “going crazy”) (c) a significant changein behaviour related to the attacks. 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.”v) Post Traumatic Stress DisorderThis disorder can occur to persons who have been exposed to a traumatic event. The traumatic eventinvolves actual or threatened death or serious injury to the person or others. The person responds withintense fear, helplessness or horror. 36

the Friendship Bench mental illnessThe person re-experiences the event in one or more of the following ways:A • Recollection of the event (images, thoughts, perceptions) • Dreams • Acting or feeling as if the traumatic event happened again • Intense fear and distress when being reminded of the traumatic event or parts of itB • Avoidance of reminders (conversations, activities, places associated with the traumatic event • Inability to recall memories of the traumatic event • Decreased interest in activities • Feeling of detachment and estrangement from others • Reduced ability to feel • Foreshortened sense of futureC • Physical hyperarousal • Sleep disturbances • Irritability • Being startled easily • HypervigilanceD • The person suffered from these symptoms for more than 1 month.E • The person is significantly distressed and impaired in their functioning.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 runningacross the road and being run over by a commuter bus that was speeding. She heardthe sound of the body being hit by the bus and saw the body of the girl being throwninto the air and falling down. The girl was instantly killed. S. heard the brakes of thebus screech and the other people and herself scream. Since that day, she can not getthe sounds out of her ears and frequently has flashbacks of the scene. Often she wakesup screaming when she has yet again dreamed of the scene. She avoids walking bybusy streets and often it takes her a long time to cross a street as she is never sure aboutthe traffic. She does not let her children go out by themselves anymore as she fearssomething can happen to them.” 37

the Friendship Bench mental illnessCognitive DisordersWhat 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 cognitiveimpairment at the Friendship Bench. It is still important to know what cognitive disorders are.Especially, as we might need to help family members of persons who suffer from cognitive impairmentor dementia.What can cause cognitive impairment?Some illnesses cause the brain to cell functioning to change and become disturbed, in advancedstages this will have a negative impact on thinking, and memory and behaviour. »» Alzheimer’s Disease »» High blood pressure (Vascular Dementia) »» HIV »» Traumatic brain injuryvi) DementiaDementia is a syndrome characterized by memory loss, loss of skills, change in cognitive functioning,personality and behavior. It is caused by illness of the brain and is chronic and progressive.People with Dementia might present with symptoms of depression and will complain aboutforgetfulness. They develop problems with daily tasks such as dressing, eating, and personal hygiene.Over time, they will become more and more confused and unable to look after themselves.Often, we will be approached by members of the family of someone with dementia. It is very hard tocare for a person with dementia.Dementia can be caused by HIV.As there are often symptoms of depression present, we have to talk to the client and his or herrelatives and carers to assess whether dementia is present. »» Have there been difficulties with memory, orientation, speech, language and the ability to perform normal duties? »» Have these difficulties had a gradual onset? »» Does the person have problems with social functioning? 38

the Friendship Bench mental illnessvii) HIV and Cognitive DisorderWhen someone’s immunity is severely affected and the CD4 counts drop below 200, the brain suf-fers from the toxic effects of HIV, the consequence can be cognitive impairment.Symptoms of HIV related cognitive impairment Subtle symptoms: »» Slight clumsiness »» Forgetfulness (more than usual) »» Slow thinking Severe symptoms: »» Slow moving and thinking »» Difficulty in planning and carrying out an activity such as preparing a meal »» Severe memory loss »» Confusion (Date, time, place,..) »» Difficulty in verbal expression »» Difficulty in recognition of loved onesTreatment adherenceRemembering to take medication regularly is difficult for anybody. Imagine how much more difficultit becomes for someone who suffers from the above described cognitive impairment. Yet taking theARVs is the treatment for HIV related cognitive issues. Depending on the severity of the symptoms,the treatment can help a person recover.Taking medication is one of our important topics that must be brought up! Taking medication is one of the most important topics that we must bring up! 39

the Friendship BenchChapter 4epilepsytsviyo or kugwinaWhat is it? FACTS (World Health Organisation) »» »» Having two or more seizures warrants a diagnosis of epilepsy. »» Epilepsy is chronic. »» Epilepsy is non-communicable. »» Epilepsy can affect people of all ages. »» Epilepsy is the most common neurological disease worldwide. Epilepsy is treatable. And »» The majority of people suffering from epilepsy live in low and middle income countries like Zimbabwe or its neighboring countries. »» And many of those people do not get the treatment they need (treatment gap). »» Epilepsy is a cause for many unnecessary deaths! 40

the Friendship Bench epilepsyEpilepsy is a condition that affects the electrical activity ofthe brain. It is also called seizure disorder.Epilepsy affects consciousness, movement, perception ofsensations, thinking and memory as well as mood (moreanxiety and depression).Having a seizure causes a person to behave very differentlyfor a period of time.Seizures can happen only sometimes or very often such asseveral times a day. People suffering from epilepsy mentiona feeling they get just before the seizure. This is called Aura.What happens during a seizure?Some people might just go blank, their mind is absent for a short while and then they carry on as if nothing hashappened. They might not even notice themselves that they were “absent”. People do not remember as they areunconscious during the seizure.Another person might actually lose all control of her or his body, fall to the ground be really stiff and then shakeuncontrollably for several minutes.When she or he regains consciousness, the person will feel very tired, confused and scared.She or he can also hurt herself very badly (get bruised or cut, break bones, sustain burns, or even drown) if noone comes to protect her or him. When someone has such a severe seizure, she or he must be supported and helped. Untreated epilepsy is very dangerous and causes unnecessary deaths.Epilepsy can be treated with medication (anti-epileptic drugs).A person with epilepsy must be taken to the clinic so she or he can get the right medication to stop the seizuresfrom happening. She or he then has to be reminded to take her or his medication regularly. If a person suffers from epilepsy, he or she can get medication and become seizure free. The medication is given out for free at our local clinic. 41

the Friendship Bench epilepsyCauses for epilepsy»» In the majority of the cases, no causes can be identified.»» Prenatal or perinatal brain injury (i.e. prolonged loss of oxygen supply to the baby or very low birth weight).»» Traumatic brain injury that causes bleeding in the brain (i.e. in a traffic or work accident).»» Infections that affect the brain (cerebral malaria, meningitis, encephalitis).»» A stroke that leaves part of the brain without oxygen supply.»» Tumors in the brain.»» HIV when the person does not take the medication as prescribed and the virus grows strong.»» Chronic and excessive substance abuse.CaseN. is a 45y old woman. She is now taking medication for her epilepsy and hasno seizures anymore.She has big burn scars on her arm and leg. She explains that she fell in thefire place when she was 8y old while she had a seizure. She does not activelyremember this but says that her relatives told her what happened then. She onlyremembers the pain that she suffered from the burns and how long it took to heal.She had many seizures as a child and nobody ever had any explanation for it.She reports that her family often just tied her to a tree or locked her up insidewhen they had to go somewhere and could not look after her.She remembers that people laughed at her and that neighbors whispered aboutthe family being cursed. Many neighbors did not want to have anything to dowith her.She was only taken to the clinic in her early twenties when her husband wasworried that she would not take care properly of their children.She was then given the right medication. N. still does not like to speak aboutthe fact that she suffered from epilepsy. She is afraid of the stigma. At firsther husband was very scared of what happened to N., now he understands moreabout what epilepsy means. 42

the Friendship Bench epilepsy Ambuya: Always remember: young or old, men or women, all can suffer from seizures! This illness can affect people from any age and any background.When you witness someone having aseizureFamilies of persons who suffer from epilepsy need to know how to handle the person who has a seizure:»» Save the person from the dangers of fire, traffic, water to prevent harm.»» Remove any dangerous objects from around the person.»» Support her or his head, remove glasses.»» Secure her or him on the side so that the air passage ways stay clear of saliva, vomit, mucus.»» Do not put anything in the mouth, not even water, the person might choke!»» Do not try to stop the jerking.»» Stay with the person until she or he recovers.Recovery Position 43

the Friendship Bench epilepsyLHW and referring to the clinicIt is our job to visit our client regularly and talk about how important it is to take the medication as prescribed sothey can stay seizure free.If our client is still suffering from seizures, we will refer them to the clinic for an assessment. Remember, the more knowledge people have, the less they will think superstitious beliefs are true. This way we reduce STIGMA!We talk to the family and explain what epilepsy is and how it can be treated. We encourage the client and thefamily to ask lots of questions. We listen very well to how it can affect people to watch their loved one having aseizure. We reassure everybody that epilepsy can be treated.We will raise these important points:»» Has our client understood the importance of the right medication? • The medication takes a while (days to weeks) before it is working. • Medication has to be taken as prescribed. Not taking the medication can result in having seizures again. • Medication can cause side effects. • Herbal remedies should be avoided, they can interact badly and unpredictably with the right medication.»» Epilepsy is not contagious, it is non-communicable just like Diabetes or high blood pressure (Hypertension). We can and must actively protect the person who has a seizure.»» People who suffer from epilepsy can live normal family lives.»» Children with epilepsy can go to school just like other children.»» Epilepsy must be talked about in the community, workplace, school, and church so that STIGMA is reduced and the risk for a person who experiences a seizure is minimized.»» Someone suffering from epilepsy should avoid these stressors: • Lack of sleep • Lack of regular food • Getting drunk • Physical and emotional stress • Flashing lights (can trigger a seizure) 44

the Friendship Bench epilepsy Epilepsy is an illness of the brain. It is not caused by evil spirits. Only the right medication can help the person suffering from epilepsy.We now understand that epilepsy is a brain illness that requires treatment.We can address people’s questions and worries, we can explain that epilepsy has nothing to do with beingbewitched or being possessed by evil spirits. We are knowledgeable and can stand up to wrong beliefs andignorance.In setting these myths right, we ensure that our clients are treated correctly, with respect and in line with humanrights. 45

the Friendship BenchChapter 51medicationAll medications (and this includes all herbal medicines as well) have effects and side effects. Effects are wanted and side effects are not.Therefore the dose of a medication has to be carefully balanced to have enough effect but as little as possible sideeffect. Taking many different medications can increase the risk of side effects.Side effects should always be discussed with the health care provider.There is no reason to just endure side effects.We want to encourage our clients to learn about their condition and about the medication they are being given.Nobody expects us to know as much as a nurse or a doctor, our strength lies in helping our clients to findinformation. We can suggest to them who to ask or to use the internet to find out about medication. 46

the Friendship Bench medication Take the medication regularly as the health provider prescribed and best take with food. And remember, medication may take some time before it actually starts to work! ART (Anti-retro viral therapy)ART are the class of drugs that help to keep the viral load (CD4count) low.Everybody who tested positive for HIV should take ART.If no anti-retroviral therapy is initiated, the virus will just reproducefreely, weaken the body and the disease will progress to death.There are several ways of how these drugs work, and most peopleare started on two different drugs to get the best effect in fightingthe virus.Side effects caused by ARTs mostly happen at the beginning ofthe treatment and decrease or stop after some time.Most common side effects: »» Headaches »» Dizziness »» Nausea »» Vomiting »» Diarrhea »» Tiredness »» Abnormal dreamsSudden onset of rash and fevers should be immediately reported to the clinic/doctor/nurse.If tiredness and dizziness occur, it can be recommended to take the medication at night.ARTs can also interact with some forms of family planning and weaken their effectiveness. Clientsshould always ask about the effect of the ART when they are taking it with other medication.Not taking the medication as prescribed can cause the drug to become ineffective which means thatthe virus becomes resistant to it and will start growing strong again. 47

the Friendship Bench medication Antidepressants (Amitriptyline, Fluoxetine)Antidepressants are a class of drugs that aim to treat depressive disorders/mood disorderssuch as kufungisisa and are prescribed by the doctor/clinic.They are affecting levels of so called neurotransmitters (neuro = nerve/nerve cell andtransmitter = communicator) in the brain. These are chemicals that brain cells use tocommunicate. If these chemicals are not sufficiently present, this imbalance can affect moodand behavior.Antidepressants take about 3-6 weeks before becoming effective. When a person is startedon an Antidepressant, she or he must be closely monitored for signs of getting worse, forsuicidal thoughts or any unusual changes in behavior. This kind of medication can make aperson’s suicidal thoughts worse.Tablets Usual daily dose (mg) Max. daily dose (mg)Amitriptyline 50 150Fluoxetine   20 60Antidepressants must be weaned off gradually, if they are stopped abruptly withdrawal symptomscan occur.Withdrawal symptoms of antidepressants: »» Headaches »» Dizziness »» Nausea »» Vomiting »» Irritability »» Sleep disturbance »» Nightmares »» Psychosis »» Seizures 48

the Friendship Bench medication Potential side effects: Fluoxetine: Selective serotonin reuptake inhibitorsAmitriptyline (SSRIs)(Tricyclic antidepressants) »» Abnormal thinking »» Sedation »» Agitation »» Dry mouth »» Anxiety »» Blurred vision »» Dizziness »» Constipation »» Headache »» Urinary retention »» Insomnia »» Increased pressure in the eye »» Sexual dysfunction »» Hypertension »» Sedation »» Abnormal heart rhythms »» Tremor »» Anxiety »» Sweating »» Insomnia »» Weight loss »» Seizures »» Diarrhea »» Headache »» Constipation »» Rash »» Dry mouth »» Nausea »» Rash »» Vomiting »» Nausea »» Abdominal cramps »» Rarely hyponatremia (low »» Weight loss »» Sexual dysfunction sodium) and hypoglycemia »» Tricyclic antidepressants rarely (low blood glucose) »» Rarely seizures cause liver failure AntipsychoticsAntipsychotics are a class of drugs that treat mental disorderssuch as psychosis, schizophrenia and bipolar disorder. They arealso given in cases of very severe anxiety or depression.These drugs also work on the above mentioned brain chemicalscalled neurotransmitters, amongst these Dopamine is especiallyaimed at, they block too high Dopamine action.Dopamine is involved in us having feelings such as beinginterested, satisfied, motivated as well in having control overour muscle movements.Too much Dopamine means that the system is overactive andcan produce hallucinations (visual, auditive or tactile perceptionof what is not there), delusions (ideas about oneself and the 49

the Friendship Bench medicationworld that are not real) or thought disorder. When a person is very agitated and overactive, ahigher dosis of antipsychotics can be given for a short time. (see psychosis chapter)Antipsychotics have to be weaned off as the brain gets used to them. They are not addictive assuch (compare with tranquilizers).Most common side effects of antipsychotics are: »» Feeling sleepy, drowsy, drugged up, weight gain, libido decrease Because of the side effects a lot of people do not like to take these medications and will stop them and risk relapsing. The right dose for every individual has to be carefully managed and adherence encouraged at all times. For these kind of disorders, nothing else works as well as antipsychotic medication.Tablets Usual daily dose (mg) Max. daily dose (mg)Chlorpromazine 50-300 400Haloperidol       1.5-15 20Trifluoperazine 5-15 20Sulpiride 200-800 2400These are common medications given to patients in the clinics. They were designed in the 1950s and aretherefore called first generation or typical antipsychotics. When these side effects occur, it is importantto check the patient’s dose with the health care provider! The dose might be too high. Sometimes she/he will be given another medication to counteract the side effects, if the antipsychotic medication has tobe taken in a high dose so that our patient stays well.Side-effects include: Long term side effect:»» Stiffness and shakinests, like Parkinson’s disease Tardive dyskinesia is an muscle disor-»» Feeling sluggish and slow in thinking der that causes involuntary continuous»» Dry mouth movements of lips, tongue and jaw»» Uncomfortable restlessness (akathisia) muscles or of the limbs (rarely).»» Blood pressure changes and caused dizziness It is irreversible and has to be avoided»» Changes in libido by carefully balancing the antipsychotic»» Problems with breast swelling or tenderness dosage given to a client. 50