DRAFT_manual_15.01.16

the Friendship Bench medication IMPORTANT:This is a life-threatening condition!Neuroleptic malignant syndrome:It can occur at beginning of anti-psychotic treatment. Symptoms are fever, muscle rigidity, alteredmental status, difficulty breathing, increased heart rate, difficulties swallowing, paleness, incontinence,abnormal walkingThe medication has to be stopped immediately and the person has to be treated symptomaticallywith paracetamol to bring down the fever, blood pressure has to be monitored and the client has to bereferred to the hospital.»» RisperidoneA common ‘atypical’ antipsychoticTablets Usual daily dose (mg) Max. daily dose (mg)Risperidone 4-6 16This is a newer antipsychotic which has fewer side effects.It works the same way as described above. They are several of these second generation antipsychotics,mostly patients will be given Risperidone in the clinics.Sometimes it is also given to people to treat severe depression.Newer antipsychotics are seen to help with low motivation, lack of interest, poor self-care of our clients(so called negative symptoms). Side-effects »» Sleepiness and slowness »» Weight gain »» Libido changes »» Increased chance of developing diabetes »» Blood pressure changes and possible dizziness »» In high doses, some have the same Parkinsonian side-effects as the older medications (stiffness of the limbs). »» Long-term use can produce tardive dyskinesia (see above). Anti-psychotics in depot formDepot medication is giving by an injection every 4-6 weeks instead of taking daily tablets. The medicationis especially designed to release over this time and will have the same effects and side effects. 51

the Friendship Bench medicationBut….The person will need to be okwith getting an injection.And adjusting the dose willtake more time than it wouldif someone is taking the dailydose in tablet form.Some common depot antipsychotics.Depot injections Normal 2-weekly Usual max. IntervalHaloperidol decanoate dose (mg) (mg) 4 weeksFlupenthixol decanoate 2 weeksFluphenazine decanoate 50 300 2 weeksPipothiazine palmitate 4 weeksZuclopenthixol decanoate 40 400 2 weeksNewerRisperidone 12.5 25 2 weeks 50 200 200 600 25 50 Tranquilizers (Diazepam)Tranquilizers are used to relieve anxiety, make a person calmer (sedate),relax muscles, induce sleep and have an anti-convulsant effect. They can also cause a mildmemory loss.Tranquilizers work in the brain by suppressing thewhole central nervous activity. They impact on abrain chemical called GABA and make the bodyvery tired and slow.This class of drugs should only be given underthe care of a health professional. When takenregularly, tolerance to the drug and dependencyon it is created quite rapidly. This means thedose has to be increased to have the same effect.Tranquilizers are often abused: the person takingthem might be in denial about the medicationdependency/addiction, and once ready, needs tobe weaned off (compare substance use disorder). 52

the Friendship Bench medicationwarning: these drugs are addictive I can’t live without these. Me neither.Side-effects of Tranquilizers: Warnings: »» Lethargy »» Drowsiness, and fatigue People should not operate machinery while »» Dizziness on tranquilizers. »» Confusion »» Dry mouth As they are widely available, tranquilizers »» Slurred speech are often used for suicide attempts (over »» Blurred vision dosing) in combination with alcohol and/ »» Impaired thinking or other medication. Because of their effect »» Impaired coordination (over-sedation, depression of breathing until »» Nausea and loss of appetite breathing even stops, unconsciousness or »» Headache coma), an overdose can be lethal when taken in combination with other drugs. Avoid taking many different tablets. Medication can interact with one another. The health care provider needs to know about all the medication someone takes (including herbal remedies) to minimize medication interaction effects. A substance like alcohol will also interact with medication! 53

the Friendship Bench medication AntiepilepticThis class of drug works on the brain cells activity level, or more precise theircommunication with one another. Under a seizure, the brain cells are required to work fasterthan normal and this medication stops this process.The medication has to be taken very regularly. If a client has difficulties remembering totake the medication, discuss with her/him what makes it difficult and problem solve aroundthis topic.Tablets Usual daily dose (mg) Max. daily dose (mg)Carbamazepine 600 1200Phenobarbitone    30 150Sodium Valproate 400 1200Phenytoin 300 500 If your client notices side effects, they must to go back to the clinic to get help from the health provider.»» CarbamazepineThis drug is a very common drug for epilepsy. It is used for Temporal lobe epilepsy, for complex andsimple partial seizures, and general seizures.Side effects: Medication interaction:»» Sleepiness Effect of Carbamazepine on other»» Dizziness»» Unsteadiness medication:»» Headaches»» Blurred vision Carbamazepine makes birth control pills/»» Upset stomach depot injections less effective. A woman might thus be at higher risk to fall pregnant if she relies only on this form of contraception! 54

the Friendship Bench medication»» PhenobarbitalThis drug has been around for more than 100 years, it is very common and given for all the differentseizure disorders. If any of the following side effects occur in your client, send them to the clinic todiscuss with the health provider.Side effects: »» Sleepiness »» Depression »» Hyperactivity (in children) »» Trouble paying attention (in children and adults) »» Dizziness »» Memory problems »» Decreased sexual interest »» For males, inability to have an erection »» Slurred speech »» Upset stomach »» Anemia »» Deficiency of the vitamin folic acid »» Rash »» Fever »» Low calcium levels, bone density lossEffect of Phenobarbital on other medication:Phenobarbital makes birth control pills/depot injections less effective. A woman might thus be athigher risk to fall pregnant if she relies only on this form of contraception!Phenobarbital creates a physical dependence on the drug. It should always be weaned off. If it isstopped abruptly, people can experience withdrawal symptoms.Withdrawal symptoms: »» Anxiety »» Increased heart rate »» Sweating »» Confusion »» Seizures »» Depression (especially if depression was present in the past) »» Suicidal thoughts 55

the Friendship Bench medication»» Sodium ValproateSide effects: »» Tiredness (sometimes with slower thinking) »» Dizziness »» Upset stomach »» Vomiting »» Tremor (shaking of the hands or other parts of the body »» Hair loss »» Weight gain »» Behavior change (depression in adults, irritability in children)»» PhenytoinThis drug is a very common drug for epilepsy. It is given for all kinds of seizures.Side effects: »» Jerking movements of the eyes »» Decreased coordination »» Shaking of the hands »» Slowed thinking and movement »» Memory problems »» Slurred speech »» Poor concentrationEffect of Phenytoin on other medication:Phenytoin makes birth control pills/ depot injections less effective. A woman might thus be at higherrisk to fall pregnant if she relies only on this form of contraception! 56

the Friendship BenchChapter 6HIV andmental healthWhat is HIV? HIV stands for: HUMAN – it only infects humans IMMUNODEFICIENCY – it weakens the body’s immune system VIRUS – a virus is a very, very small infectious microorganism that needs to take over a body cell to make more of itself (reproduce)HIV is widespread in southern Africa. In Zimbabwe, UNAIDS estimates that in the year 2014 16.7% of the population isinfected, this means that 1.4 million of people have the HI-Virus.Compared to the rest of the world, this is a very high number ofinfected people. When a person is infected with HIV, we say she orhe is HIV positive.HIV exists everywhere in the world. 57

the Friendship Bench hivWhat does HIV do to my body?A virus needs to hijack the body’s cells to reproduce. The HI-virus wants to become very strong and wants toreproduce a lot.It attacks those cells that a person’s immune system consists of (T-cells and CD4 cells) and destroys them. Thesecells are normally the ones that help us fight an infection. When we get a flu or a cold (dzihwa) and the immunecells are strong, we will recover from it within a few days.When HIV has taken over a person’s immune cells, she or he cannot fight off diseases anymore. She or he willget sick more often. In fact, she or he can get very sick and might die. That is why it is so important to preventgetting infected and to get the right medical treatment. Always remember: One can live with HIV when on treatment.How do I find out if I am HIV infected?There are tests that look for HIV-related signs in a person’s blood. A tiny bit of blood is screened for antibodies,a type of cell the human body makes when it was in contact with a virus. This test is called rapid test and it takesabout half an hour before the results are out.There are many places where a person can get tested.All these places will offer a brief counselling session beforethe test is done and after the results are being given.Often the counselling is given to a whole group of people.HIV is an infection for life. The human body is not able to get rid of the HI-virus. 58

the Friendship Bench hivIt can be quite a shock for a person to receive thenews that she or he is HIV-positive, and she or hemight need a lot more support than just pre- andpost-test counselling.Therefore, people who learned that they are HIVpositive need to speak and learn about their fears,their hopes, and also practical issues such as howto get treatment, how to stay on their medication,how to talk to their families, how to stay safe andhow to protect others from getting infected bythem. People often feel shock, denial, fear, guilt, despair and depression and need help!CD4 countAt the clinic, the blood gets checked for the CD4 count. The CD4 count gives an idea of how strong the immunesystem’s response is by counting the number of immune system cells. The CD4 cells are the ones that fight HIV.The higher the CD4 count is, the stronger is someone’s immune response. A low CD4 count means thatthe body’s immune system is weakened, this can also be due to other medical conditions including somenon-HIV related infections.  What is a window period?There is a time between the moment an HIV-infection took place and the moment that the screening test can pickup the antibodies (those cells that are made by the body when it was in contact with the HI-virus) or the viral load(the amount of virus in a person’s body) which is called window period. In this window period, a test can comeback as negative but this test result is false. The window period for the rapid test is about 3 months.This means a person has to come back after 3 months to really be sure. If the test says ‘negative’, this could be afalse result, and the person could infect other people.* In the appendix you find a list of places that offer HIV testing. 59

the Friendship Bench hiv How I cannot get infected: -- Sharing a cup or -- Kissing and glass or eating hugging utensils -- Tears-- Sharing a towel, -- Saliva washing water, a toilet -- Insect bites -- Shaking hands 60

the Friendship Bench hiv How I can get infected: ++ Unsafe sex ++ From mother to child++ Through blood transfusion and organ transplants ++ Injection drug use++ Through occupational risks for health professionals61

the Friendship Bench hivHIV is found in body fluids such as semen, pre-semen, blood, vaginal fluids, rectal fluids, breast milk.Transmission can happen when any of these fluids from a HIV positive person get in touch with the soft moistmembrane (special type of skin) that is found in the body’s openings (mouth, vagina, rectum, opening of thepenis) or with any damaged tissue (wounds, however small).The HI-virus does not live long outside the human body.The most common way of becoming infected is Unprotected sexWomen are more at risk of contracting HIV and there are actually more women than men who are HIV positive.Both, infected men and infected women can infect another person. You have seen posters and flyers around thecountry making us aware of the risks of unprotected sex.The best protection is to use a condom when having penetrative sex. There are male and female condomsavailable at the clinic or at any shop.A condom has to be used correctly and only once. It is important that especially both young men and womenlearn how to use condoms. Safe sex means using a condom and being protected.Condoms also protect us from other sexually transmitted diseases (STDs) or from falling pregnant whensomeone does not want to fall pregnant. 62

the Friendship Bench hivlargest risk groupYoung women and adolescent girls are most at risk for getting infected!HIV is the leading cause for death in adolescents and 3x more adolescent girls and young women are infectedwith HIV compared to adolescent boys and young men according to UNAIDS.This means we have to put a stop to sexual abuse (i.e. rape), intimate partner violence, sexual exploitation (i.e.relationship with a sugar daddy, prostitution…), child or teenage marriage and early and unintended pregnancies.Adolescent girls and young women must be empowered to protect themselves (i.e. how to negotiate whento have sex and make it safe and insist on using a condom). We must continuously support them todo so. If we help adolescent girls andyoung women to protect themselves,we will reduce the rate of HIV in ourcommunity.By speaking with adolescentboys and young men we canhelp change the dangeroustraditional ideas that only aman with early onset sexualactivity and many partnersis a real man. As LHW we are very important for our community. We have the power to make people understand that we all have to educate our daughters and sons about safe sex. 63

the Friendship Bench hivRape or sexual assaultIn the case of rape, the woman has to be taken to the clinicimmediately, preferably a clinic that specializes in helpingvictims of rape.She needs to be examined and will be given emergencymedication to prevent her from getting infected with HIV orother STDs and from falling pregnant.Rape and sexual assault are crimes that should be reported to thepolice.Perpetrators need to be stopped or they will continue to harmothers.A person who has been assaulted or raped needs a lot of support. What happens if both partners areHIV positive?If both partners are HIV positive they will still need to protect ++themselves from getting re-infected.A virus can change its shape (a new strain of the virus develops)fast and that will affect our immune system. It can also lead tothe HIV medication not being effective anymore.Both partners need to be on HIV medication to stay healthy andstrong.Prevention of Mother to Childtransmission (PMTCT)All HIV positive pregnant or breastfeeding women need to receive HIV treatment (ART – antiretroviraltreatment).All mothers are offered voluntary pre- and post-test counselling and testing when they register at thematernity clinics. They are given treatment, for life, and get counselled how to take the medication regularly.We must encourage an HIV positive pregnant woman to protect her health and the health of the baby she carries.Let us answer all her questions, address her worries and fears and reassure her that getting tested and going onmedication is the only way to keep her baby and herself healthy.The newborn will also be started on medication and together with her or hisz mother will be followed closelyso that both stay healthy and strong. 64

the Friendship Bench hivA mother whose HIV infection is well managed andwho is taking her medication regularly, will have alower viral load which is very important as babiescan also get infected through breast milk.In our environment, exclusive breastfeeding is stillthe best way to feed a newborn baby. Exclusivemeans that the baby only gets breast milk for the first6 months of baby’s life. This is also described in theChild Health Card.Babies do cry out of many reasons, not only becausethey are hungry. They might cry because they aresuffering from colic or because they feel lonely or justbecause they have no other way of communicatingthat they are uncomfortable.Exclusively breastfeeding a baby is the right thing todo. A young mother needs to be supported as she isoften told her baby cries because she does not haveenough milk. 65

the Friendship Bench hivCaseS. is a young woman who is pregnant for the first time. When shewent to the antenatal clinic to register for the first time, she wastested for HIV and found out she was positive.She had suspected but never wanted to get tested. She was veryscared when she was told she was positive, she worried about how shewould tell her husband about this.She spoke to Ambuya about this and learned how her being positivewill affect her baby. She had not known about this.Ambuya helped her to realize that she needs to go on the medicationto protect her baby.She spoke ttoo AAmmbbuuyyaaaaloltotananddlelaeranrnededtotlooofkacaettthheeffeeaarr sshhee hadaround talking to her husband and her family.She felt empowered enough to find solutions now to whatever wouldhappen. It is very important that a mother knows her HIV status so she can protect her baby. 66

the Friendship Bench hivTreatment ARTHIV treatment is for life!ART = antiretroviral therapyMedications for HIV are called ART (anti-retroviral therapy) and they are actually a combination of medicines.The human body is not able to get rid of HIV.An HIV-positive person needs medication to keep the amount of virus, the viral load, low.We need the medication for life!On the right medication, we can continue to live our life being HIV positive.When our HI-virus load is high, our immune system becomes weak. We are at a much higher risk of falling sick,and we will eventually die of opportunistic infections (OIs) or AIDS. Everybody who is HIV positive needs to be on treatment for life.How to take your ART?ART has to be taken regularly just as prescribed.The pills have to be daily and preferably with food. 67

the Friendship Bench hivMedication adherenceIt can be difficult to take one’s medication regularly and therefore it is so important to talk about what stops usfrom taking our ART and/or other medications regularly and as prescribed.»» Make sure the client understands why adherence is so important.»» Discuss what the client feels about successful ART and a low viral load. (“What would you be able to do when you are feeling stronger?”, “Why is it important for you to feel better?”)»» Find out exactly what reasons have lead to not taking the medication in the past. (This could be topics around forgetting, fear of disclosure, non-availability of medication, financial issues, non-availability of food, denial, side effects)»» Apply PSTSTIGMA – DisclosureWhy are people afraid of getting tested and why are people ashamed of telling others that they are HIV positive?Stigma means that someone thinks lesser of another person due to something this other person has or does. Wemight stigmatize people for how they look, where they come from, or for the fact that they are HIV-positive.Disclosure means that a person will tell family, friends, colleagues about her or his HIV status. The Stigma around HIV makes us afraid to seek support and act in the right way.The more STIGMA, the less a person will DISCLOSE!To fight HIV stigma, people need to know more about HIV. Knowledge is power against stigma.Everybody can get infected with HIV, especially if people do not know how to protect themselves.Feeling judged for being HIV-positive is very unhelpful!It makes people avoid:»» getting tested»» going to the clinic and taking the right medication»» protecting themselves and others»» disclosing 68

the Friendship Bench hiv “Chinokanganwa idemo asi muti watemwa haukanganwi.” (The one who wronged might forget bet the one who has been wronged will never forget.)misleading suggestions from some church leadersSometimes we will meet clients that say to us that they were told at church to stop taking their medication andinstead pray.We will always explain that taking the medication is the most important part of the treatment that we need tosurvive.We must follow up with a person who stops taking the ART. We need to get him or her back on track. We havelearned that stopping the ART is like a slow death penalty.What can we do?»» Reach out to the person whom you suspect has stopped the medication.»» Even go to the house of the person.»» Discuss his or her reasons for stopping the medication.»» Apply problem solving. 69

the Friendship Bench hivHIV and Human rightsWe all have human rights. Sometimes, we have to make sure our rights are respected and ask for them.Especially in our line of work, the right to confidentiality is very important. We will not share our clients’information with anybody.When we speak with our clients we can also teach them about their rights.Often people do not even know.We have rights to:»» The right to gender equality»» The right to rights to information and education»» The right to confidentiality»» The right to protect oneself from unwanted unsafe sex (within and without marriage)»» The right to protection from discrimination against vulnerable groups such people living with HIV or people living with mental illness»» The right to access to affordable treatment We need to make sure that our human rights are being respected. For our clients and for us!Family and HIVFamilies are affected by HIV on all levels.They have extra costs for health care, they are worried about illness, suffering and death. They are stressed aboutthe consequences of stigma.Children who grow up with very worried parents, will also worry a lot.We know that there are many things a family affected by HIV needs.We are limited in what we can do but we can make sure that the family members learn how to solve problems.We can support them in adhering to the medication they need to take. We help to find out what makes it difficultto take the medication and find solutions to those difficulties.By visiting and speaking to our clients and their families, we show that we respect and care for them. They aremembers of our community just like us. 70

the Friendship Bench hiv We need to Do you have any support the whole questions or a family. They story you would need and deserve like to share on our support! this chapter? 71

the Friendship Bench for your use…Notes … 72

the Friendship BenchChapter 7substanceuse disorder(SUD)In this chapter we will learn about the effects of alcohol use and substanceuse disorder. 73

the Friendship Bench substance use disorderALCOHOL CASEM. is a father of 4 children, he is 35y old and works in a factory. Work is hard, hedoes not earn a good income. His wife can not make ends meet, she sells tomatoesand looks after the children. M. is frustrated. He likes to meet his friends at thebottle store Fridays after work and on Saturdays as well.On Fridays, he gets his pay, and he is tired of the week, he thinks a few drinkswill help him to relax. When he comes to the bottle store, some of his mates are therealready, some colleagues go too, they congratulate each other to having survivedthe hard week. They agree that going home would be miserable. They would justget complaints from their wives or other female relatives. And especially the wivesare so ungrateful, the men find. And there are too many children around.The men have a few drinks, M. buys another round for his friends. He feels strongand happy, he laughs and dances. There are a few women outside the bottle storeas well. He likes dancing with them.Not one thought crosses his mind about how he is just spending what was intendedfor food, the rent, the rates. They are behindwith the rent anyways, forget the schoolfees.When he finally goes home, he gets ina bad mood when his wife asks forthe money. He ignores her andgoes to bed. On Saturday, M.does not feel so good. He getsangry with his family andleaves the house. He meets hisfriends at the bottle store. OnSunday, M. goes to churchwith his family.On Monday, he goes back towork. What will happen thefollowing Friday? 74

the Friendship Bench substance use disorderAlcohol has the following effects: »» Happy mood »» Sedation »» Loss of inhibition »» Talkativeness »» Confusion »» Drowsinessidentifying a problem drinker:We often think of the long term heavy drinker who is passed out on the ground, unable to get up and not able tokeep a job and look after his family.Longterm abuse can make a person depressed, anxious, even paranoid, and dysfunctional.Abuse of alcohol cancause psychosis, dementia and physical symptoms such as liver damage.Chronic alcoholics tend to also lose the ability to look after themselves, they neglect body care, proper foodintake and all other responsibilities towards themselves and others. What about those who drink too much at times or drink more than recomended regularly? They put their lives and health and that of their families at risk. They disregard the danger of alcohol (and other drugs). And often the family members believe that there is nothing they can do to stop this behavior. So they suffer silently. We can ask a few simple questions when we suspect that someone might drink too much and too often. We should also ask about the use of other substances. 75

the Friendship Bench substance use disorder FirstLY, Secondly, we want to we want to find find out about out whether they their alcohol have developed a consumption. dependence. ALCOHOL QUESTIONING:1. Alcohol consumption: YES NOHave you had 5 or more standard drinks on any given occasion in the last 12 months?Do you drink more than 2 drinks per day?Do you drink every day of the week?If the person says yes to any of the first questions about consumption, we proceed with thenext set of questions to find out about a possible dependence.2. Dependence YES NODo you have a strong desire or does it feel like you have to have alcohol?Do you find it difficult to control the amount of alcohol, the timing of drinking or to stopthe drinking?Have you found that you need to take more alcohol than before to feel the same?Have you found that you neglect activities that you used to like and that you spend moreand more time on getting and consuming alcohol?Have you found that you ignore harmful consequences such as liver damage, depression,problems with thinking and remembering and continue to drink?If a person says ‘yes’to at least 3 of these questions, he or she has an alcohol use disorder.Less than three ‘yes’answers indicate that a person practices harmful alcohol use. 76

the Friendship Bench substance use disorderMost of our efforts when talking to a person with substance abuse issues will be centered around making theperson see that the substance abuse is actually making life worse. We can explore with substance users what theythink others think about them. Do people even know that they abuse substances? In the case of alcohol does itmaybe even seem acceptable and no one has ever said anything to the users about their drinking?When a person starts to see that the substances are affecting his or her life negatively, we can offer our help tofind ways to either reduce or even stop the drinking.Another common substance that is used in our communities is:Broncleer/ BronchoDRUG CASET. is 21y old. He dropped out of school in form 2 ashis relatives were not able to afford the school feesanymore. Both his parents had died when T. wasquite young. He tried to find a job, helped out at ashop for a while, worked on the field, and helped hisaunt chopping fire wood and sell it by the road side.One of the guys on the street showed him once how tofeel better by drinking cough syrup. T. did not wantto believe it. He found the taste of it rather horrible.His friend reassured him that it was just coughingsyrup and that it was quite affordable as well.He did feel his head get lighter, buzzing somehow.Funny things happened to his vision and he felt likehe was not in his body anymore, he felt like he had tolean into something not to fall over. Also, his friendlaughed at him as his voice became really slurred.Over the weeks, T. carried on…He also constantly needed money, so agreed to sell coughsyrup to others. He had to be careful not to be caught by thepolice. Sometimes he was his own best customer.Today he has 5 bottles of Broncho a day just to keep functioning. He cannotsupport the withdrawal symptoms. His aunt is really angry with him. 77

the Friendship Bench substance use disorderBroncho has the following effects: »» Slurred speech »» Blurred vision »» Euphoria »» Sedation »» Lethargy »» Drowsiness »» Impaired motor skills »» Out of body experiencesDependence and withdrawal:Chronic use of a substance makes a person need to take more of the substance to have the same effect. Also,when intake is suddenly stopped the body will develop withdrawal symptoms.Withdrawal symptoms are very uncomfortable and the addicted person will try everything to avoid havingthem. Medication given by the health care provider can help a person to go through the physical withdrawal.Withdrawal symptoms have the power to make a person relapse and forget everything about the plan of changinghis or her behavior. They might steal and lie if they think that it will help them to obtain more of the substancethey are addicted to. The addiction becomes the only focus in their lives.Clinically, we can observe these symptoms of withdrawal in the table below:substance examples withdrawal symptoms»» depressants alcohol, agitation, hyperactivity, high BP and mbanje, palpitations, anxiety, hallucinations, sedatives confusion, seizures, shakiness»» stimulants amphetamines, fatigue, depression, social withdrawal crystal meth, cocaine anxiety and agitation and others might present with depression and loss of»» opioids pethidine, motivation broncho, heroine 78

the Friendship Bench substance use disorderPregnancy and alcoholWomen have slightly different patterns of drinking comparedto men. Women’s bodies also react differently to alcohol thanmen’s bodies. This means that women might suffer fromalcohol-related problems when they have taken much lessalcohol than men. Even if a woman weighs the same as a man,when they both drink the same amount of alcohol, the womanhas a much higher blood alcohol level than the man. Thus, sheis exposed to a much bigger health threat through the alcohol’stoxicity compared to the man.Alcohol affects the liver and can lead to alcohol hepatitis.Chronic heavy drinking leads to heart disease. Again, evenif women drink less overall compared to men, they are morevulnerable to developing heart disease due to chronic drinking.Women who drink regularly, even if only one drink a day,have a higher risk of developing breast cancer. There is no safe amount of alcohol, no safe type of alcohol and no safe time for a pregnant woman to drink alcohol. The baby will be harmed!Fetal alcohol syndromeAlcohol is a very strong poison. Pregnant women and those wanting to fall pregnant should never have alcohol.When a pregnant woman drinks alcohol the baby’s normal development will be disturbed.Children born to women who had alcohol during the pregnancy are prone to suffer from developmental delayas well as behavioral and learning difficulties. The face of a baby with fetal alcohol syndrome is also oftenabnormal. Alcohol and drug use can make a person take risks such as not use protection when engaging in sexual activities.79

the Friendship Bench substance use disorderWho do we talk to? Families of usersA worried family member might address us and speak about the person who drinks too much or takes drugs.The family looks at us to reach out to that person, and we need the family to work with us.How do we support the family?1. Listen2. Acknowledge3. Explain why some people use substances.4. Find out what the family thinks maintains the problem and what makes it worse. (Who finds it most difficult to say NO to the addict? Who gives money to the addict? Who fights with the addict and what happens then? Who is most affected by the addict’s behavior?)5. Explain to the family that the addict needs support and first has to stop being in denial before he or she can accept help.6. Explain that bringing about change will take time and patience.The user/drinkerHow do we support the person the family complains about?Can we just approach a person because we have heard that they drink too much?Of course we can… but what is the best way of getting this person to listen to us?Our most important job is to reach out to the person in a caring, understanding and very patient way.What we want is to get the person to be interested in changing his or her behavior which is one of the mostdifficult tasks.A person who is addicted to whatever substance is not able to just stop. Addiction is a DISEASE.They would have stopped already if they could.They might have tried and failed.They also have a lot of good explanations why they keep drinking and they might say that they do not have aproblem.This is called DENIAL.Our first goal must therefore be to make the person want to stop. How do we do this? This is a very difficult question. Maybe we can start with what will not help to make the person want to stop. 80

the Friendship Bench substance use disorder Not helpful:»» Get angry with him or her»» Expect him or her to stop»» Show no understanding»» Blame the addict Helpful:»» Persist and visit him or her again and again.»» Understand that the person might react negatively to our questions.»» Try to see him or her when they are not under the influence of any substance.»» Ask them about their life and invite them to come to the Friendship Bench to talk. It helps people to speak about their lives and have someone listen without judging them. We try to find out together with the client what keeps him or her turning to alcohol or drugs.»» Involve him or her in finding out how alcohol or drugs have stopped him or her from doing what they wanted to do or achieve.»» Invite the person to come to meetings like our CKT where they can talk about what is going on in a safe environment. 81

the Friendship Bench for your use…Notes … 82

the Friendship BenchChapter 8Psychosiswhat is it?Aperson who suffers from psychosis experiences symptoms that a mentally healthy person can hardly understand.The person seems like he or she has lost touch with reality and, indeed, he or she has. People who do not knowmuch about mental health issues might be scared of the person or make fun of him or her. The psychotic personis very vulnerable and cannot look after himself or herself properly. Thinking, perceiving, feeling and interpreting of what is going on around a person with psychosis are not like ours. 83

the Friendship Bench psychosissymptomsThe main symptoms of psychosis are hallucinations and delusionsHaving hallucinations means the person is seeing, hearing (“voices”) or feeling things that other people will notsee, hear or feel.Delusions are beliefs that are false but feel true to the psychotic person. Delusions can be about the personhimself or herself or about others. (Awoman might believe that the neighbors want to harm her, a man might beconvinced that he is an important person and should be treated.) Main symptoms of psychosis are hallucinations and delusions.Some of our cultural beliefs need to be carefully looked at whether they are not said by a person who is actuallysuffering from psychosis. 84

the Friendship Bench psychosisThese symptoms are so compelling that the psychotic person will react to them, she or he might speakor act out and be very agitated, sometimes even aggressive.Psychotic hallucinations and delusions are very scary to the person who is experiencing them so heor she might be terrified, feeling paranoia (big fear) and is probably highly stressed.There is medication that can help stop the psychotic symptoms. This medication is administered bya doctor or nurse. The ants are getting in my head! Make them stop!Often people feel tired of taking medication, also because they might experience side effects, theystop taking it and will eventually relapse. In order to avoid that we have to work with the client onmedication adherence and solve all issues around it using PST. Nothing works as good as the right medication for psychosis. So we have to work with our client so that they agree to take their medication as prescribed! 85

the Friendship Bench psychosisWhat causes psychosis?»» Schizophrenia»» Very stressful life events»» Substance abuse Schizophrenia This is a psychiatric disorder that causes a person to have hallucinations and delusions. A person who suffers from schizophrenia needs regular medication (anti-psychotic medication) and support. Patients who suffer from schizophrenia will be needing to take their medication for the rest of their lives. They will need a lot of support to keep taking their medication. They also face stigma in the community. They are being seen as weird and crazy, they might talk to themselves and if they are not looked after they are the often the ones who wander the streets, looking lost and forlorn. This puts them at risk of malnutrition, lack of getting medical care for diseases and becoming victims of violence. They also suffer from social neglect as no one will speak to them. This will make their condition worse. This is why we need to prevent our patients with schizophrenia from relapsing and we need to watch out for those who show first signs of psychosis. Very stressful life events Very stressful life events can cause a person to experience psychotic symptoms like death of a close family member, trauma such as being exposed to violence, accidents, fire, man made or natural disaster. Awoman can also develop post partum psychosis after having given birth, usually within 2 weeks with very sudden onset of a wide range of disorganized symptoms. This illness needs immediate medical attention in order to protect mother and baby from harm. The risk for maternal suicide or infanticide is real! Substance abuse Many substances can cause the above described psychotic symptoms and also lead to symptoms of anxiety and depression, depending on what substances a person has taken. It is especially dangerous when a lot of different substances are being taken together. Psychosis can be caused by long-term abuse or due to overdosing and is an acute condition that needs medical care. These substances can particularly cause psychosis: »» Alcohol »» Amphetamines (cocaine, extasy, crystal meth) »» Opioids (Broncho, Stopayne) »» Hallucinogens »» Sedatives (benzodiazepines, sleeping pills) »» Cannabis 86

the Friendship Bench psychosisWhat happens to a person whodevelops a psychosis?Usually, we notice really fast that someone is being different or acting very strangely.We have lots of words for it in our language… kupenga, kuvhunduka, kurwara nepfungwa- (being crazy,weird, a person has lost his or her marbles). All the words we use to describe psychotic disorders have a negative taste to them! That is also stigma and discrimination.Often the police are called as people are afraid of the psychotic person and the person is then taken to the hospitalunder the mental health act.As the person does not understand due to the thinking problems, he or she often doesnot want to be taken to the hospital.This can be very scary for the person, he or she might not cooperate as he or she is so overwhelmed by thenoise in his or her head. He or she needs to be talked to very calmly and gently. It is of no use to argue about thedelusional beliefs. We should also not laugh about what the client tells us although it might sound very strangeto us. 87

the Friendship Bench psychosisOnce at the psychiatric hospital, the person is sedated with the help of medication and will most likely sleepa lot. Clients feel quite disorientated when coming out of a psychotic episode. Then they need support andunderstanding when they slowly calm down. People who do not understand what is going on might get very annoyed by the sick person and use abusive behavior which is not helpful. We want to educate people about mental illness.If the psychosis was caused by substance abuse, the psychotic symptoms will become weaker whenthe person stops to use the substance.This can take from hours to days as the body recovers from substance poisoning (withdrawal), unlessthe person has had a history of long abuse of the substances. They might not recover well when theyhave had long term abuse which makes it so important to help people to stop using substances.The hospital is the best place for the person to be observed and safe while withdrawing from thesubstance.How can we help a person whoexperienced psychosis?We will mostly deal with people after their psychotic episode. When they come back from the hospital they needour support.All these clients need to take their medicationas prescribed.People who are regularly using asubstance need to learn how to controltheir behavior.This can be very difficult for them. Sothey are always at risk of relapsing.Throughout the world, it was found thatgroup support can be very helpful forpeople to realize that using substances is destroying their lives.We can offer support through the Circle Kubatana Tose. We can invite those clients that have substance issuesto come regularly and meet others who face the same problems.We might even regularly meet with the family members in a special family members of substance usersCKT so that they can talk about what it is like for them. 88

the Friendship Bench psychosis The family needs a lot of support so that they can support our client! Caring for a special group As Friendship Bench we serve the community and we want to make a difference. Many mentally ill people who ended up in prison will be released back into the community. They need us to get their feet back on the ground. During their imprisonment, they are assessed and stabilized with medication. When they come back to the community, we need to help them to stay stable. We have to make sure they are taking their medication, go regularly to the clinic and always have enough medication at home. The best way to do all this is to see them very often and be very involved in their lives.We also have to encourage them to be active, to exercise, and to be helpful around the house and go back to workif possible.And we have to support the families, neighbors and communities to support our clients.How to speak with a person whosuffers from psychosis?We have to understand that the strange behavior is part of a mental disorder.It has nothing to do with being bewitched or cursed.As psychosis means a person loses touch with reality, the people around the ill person need to look out for them.They also need to be educated on how to interact with an ill person.»» Talk to the ill person calmly and with respect.»» Avoid arguing the strange beliefs (they might continue with their beliefs although all other symptoms have disappeared).»» Encourage them to engage in activities (household chores and any other tasks). 89

the Friendship Bench psychosisfirst signs of developing psychosis or relapsing intoa psychotic episode These are the first signs of developing psychosis or relapsing into a psychotic episode... »» Sense of restlessness »» Agitation »» Less need to sleep »» Sense of being stressedWe teach the family and community members, when someone shows the first symptoms of acting strangely:»» Avoid too much stress and chaos around the person.»» Make sure they have enough food, water and sleep.»» Reduce stress and chaos around them.»» Take them to the clinic or alert the lay health worker who is looking after the ill person so she or he can call for adequate help.Part of our work as lay health worker is to bring awareness to our communities. We understand better now thatpsychosis is an illness of the brain that causes the ill person to lose touch with reality.We will encourage our communities to stop mistreating mentally ill people.We shall not allow them to be threatened, locked up, chained, beaten, neglected, or suffer any other form ofabuse.We will tell everybody in our community that these ill people must have the proper medical care and that thiscare is available at the local Polyclinic.It is best to not let these ill pople take any other treatment (i.e. herbal remedies) as it can interfere with theprescribed medication. Mentally ill people have rights too. We need to treat them with respect. Even if they are difficult to deal with and annoy us sometimes. 90

the Friendship BenchChapter 9Problem SolvingTherapy (PST)In this chapter we will learn about a powerful counselling technique and how to use it appropriately. The techniques we use are based on Cognitive-Behavioural Therapy.Cognitive behavioral therapy is a therapy approach that is problem-oriented, focuses on the ‘here andnow’, is very structured and aims to teach the client how to use the techniques herself in order for heror gis to be independent of the therapist.On the Friendship Bench, we mostly focus on problem solving.After explaining Problem Solving Therapy theory in detail for every step, we will go through aclient’s example to show how Problem Solving Therapy is done.We also watch videos that show examples of how Problem Solving Therapy is used. Learn how Problem Solving Therapy is done! 91

the Friendship Bench problem solving therapy Problem solving should be done in several steps: 1. How does the client deal with problems? 2. How to recognize a problem? 3. How to select a problem, find the goal and define the problem? 4. How to brainstorm for solutions? 5. How to select a solution? 6. How to make a SMART action plan? 7. Did it work?1. How does the client deal with problems? We ask how the client sees problems in general and what she or he believes about her or his ability to address a problem. When someone has an impulsive or careless way of going about problems or is generally avoidant of problems, we need to explain how it is much more beneficial to take a rational stance to solve a problem efficiently and how she or he will benefit from learning the Problem Solving Technique.HOW TO DO IT? We ask our client: 1. “How have you tried to solve problems in the past?” 2. “What do you do when you have problems?” 3. “How do you feel when you have problems?”An example:S. had unprotected sex times with a much older man. He had promised her to giveher some money and help her out with food from time to time.She felt quite sick lately. She had heard on the radio once that people actually canhave flu-like symptoms when they contract HIV. She is not sure what is going on andignores how she is feeling. She goes to church more often and prays every night thatshe is not HIV positive. She can not imagine talking to the man she is involved withto ask him about his status.What could be a rational way for S. to approach the subject?The counselor asks S.:1. What do you do when you have problems?S. says: “I don’t know, I try to avoid thinking about it. I can’t solve my problems.”2. How do you feel when you have problems?S. says: “I feel terrible and hopeless. I often can’t sleep and keep thinking.”3. What problems have you managed to solve in the past?S. says: “Actually, once my aunt was angry with me, she thought I had taken someof her money, I spoke to my mom about it and my mom and I went to speak to myaunt and we figured out that it could not have been me who took the money.” 92

the Friendship Bench problem solving therapy Problem solving should be done in several steps: 1. How does the client deal with problems? 2. How to recognize a problem? 3. How to select a problem, find the goal and define the problem? 4. How to brainstorm for solutions? 5. How to select a solution? 6. How to make a SMART action plan? 7. Did it work?2. How to recognize problems? Sometimes people feel they are not able to tackle problems because they lack the skill to break down a problem into simpler components. Instead of searching for solutions, they might avoid (withdrawal, distraction, playing it down…) or show impulsive reactions and behave in a non-helpful way (start a fight with someone, blame oneself, harm oneself, get drunk, quit a job, leave the partner…). Negative feelings such as fear, anger, sadness and thoughts that they are worthless or that nobody likes them contribute to this non-helpful behaviour. They might also have body experiences like feeling very run down, headaches, tight chest, feeling like crying. While these symptoms appear like stemming from a medical condition, they are actually caused by kufungisisa. All these, the feelings, the thoughts, the body experiences and the behavior are indicators that are captured by the SSQ 14. It is our job to help the client to open up about what is happening in her or his life. Remember to listen, summarize and compile a list of problems! 93

the Friendship Bench problem solving therapy Saka tingabatsirane sei muzuva ranhasi? How can we help each other? 94

the Friendship Bench problem solving therapy HOW TO DO IT? We encourage our client to freely speak about what is going on in her or his life. Saka tingabatsirane sei muzuva ranhasi? While we listen, we summarize ever so often and pick out all those things that are problematic for our client. This way, we will compile a problem list. We can use the problem category table to help categorize the problems.Nature of main Shona terms Tick what problem applies to client relationship ukama marital nyaya dzemagariro mumba work related nyaya dzekubasa bereavement kuchema mufi school zvechikoro family nyaya dzemumhuri zveutanointeirnpteerrspoenraslodneafilcits (kudzevfictairtissi(rsaeplfa-si/eksutnezewma, sleonuerilwineegsas)) health related money problem nyaya dzemari nyaya dzepekugara accommodation problem mhosva legal problem sexual problem nyaya dzepabonde alcohol/drugs nyayadzekudhakwa other, what?? zvimwe 95

the Friendship Bench problem solving therapyAn Example: Afraid to go for testing, doesn’t want to knowS.’s problem list: Wants to avoid thinking about itHad unprotected sex Not enough food at the houseNo money Afraid that she has contracted an STINature of main Shona terms Tick what problem applies to clientrelationship ukama marital nyaya dzemagarirowork related mumba nyaya dzekubasabereavement kuchema mufi school zvechikoro family nyaya dzemumhuri  zveutanointeirnpteerrspoenraslodneafilcits  (kduzevfiictaitrsisi(rsaeplfa-si/ eksutnezewma, sloenuerilwineegsas)) health relatedmoney problem nyaya dzemari nyaya dzepekugaraaccommodation problem mhosva legal problemsexual problem nyaya dzepabondealcohol/drugs nyayadzekudhakwaother, what?? zvimwe 96

the Friendship Bench problem solving therapy Problem solving should be done in several steps: 1. How does the client deal with problems? 2. How to recognize a problem? 3. How to SELECT a problem, FIND THE GOAL and DEFINE a problem? 4. How to brainstorm for solutions? 5. How to select a solution? 6. How to make a SMART action plan? 7. Did it work?3. How to select and define a problem? SELECT The next step is to help our client to select one problem of the list to focus on. This problem should be manageable and meaningful and maybe even practical. The client must feel that she or he has some control over the problem. FIND GOAL Once the client selected a problem, we briefly discuss and formulate the goal and note it down on the FB card. DEFINE We use the following questions to explore more details. Our aim is to define the problem. When we have defined the problem really well, we write it down on the FB card. Remember to ask what, who, where, when, how and summarize! 97

the Friendship Bench problem solving therapy HOW TO DO IT? SELECT We tell the client: “At first, we must choose one problem of the problem list! Let us go through it together and select the one that is most meaningful and manageable for you, if it is also practical, even better!”FIND GOALWe ask the client: “How would you like the situation to be when the problem is solved?” Weformulate the goal together with the client and we write it down on the FB card.DEFINEWe tell our client how important it is to know exactly what problem she or he deals with. Wesay:“Tell me all about this problem. It is good and helpful for you to speak about it and the betterwe know your problem, the easier it will be to find a solution.”We can use the following questions:• What happened? (Chii chakitika kana chinoitika?)• Who is involved?• When and where (situation/environment) does it happen? (Zvinowanzoitika rinhi/kupi?)• What happens right before and right after?• Why does it happen? (Uye chikonzero chiri chii?) What triggers it?• How often does it happen?• When it happens, how do you feel and what do you think of?• How do you react? (Unonzwasei? Unofungei? Unoitasei?)• Do you have control over this? The better a problem is defined, the easier it is to find a solution for it.Example:SELECTThe counsellor and S. looked at her list of problems together and S. chose the issuerevolving around her fear about her HIV status as the problem she wants to workon. This is a meaningful problem for her, it is practical as one can get tested, andmanageable as she also knows other people who have gotten tested.The counsellor helps S. to formulate the problem: “I am avoiding to know my aboutstatus.” 98

the Friendship Bench problem solving therapyFIND GOALThe counsellor asked: “How would you like the situation to be when the problem issolved?” Her goal is to not feel all this fear anymore and not to put herself at riskany longer. Her counsellor helps her to rephrase this into “to know my status”.Together with her counsellor, she puts down the following on the FB card.DEFINEThe counsellor asks S.: “What happened?”She fears she has gotten infected.“Who is involved?” She is involved and maybe her partner.“How does she feel when it happens?” She feels a lot of fear every time she feels a bitsick.“How do you react? (Unonzwasei?, Unofungei? Unoitasei?)”She can see how she avoids thinking about the topic and how she keeps on ignoringher health. Especially, ignoring it does not really work, she can lie in bed for hoursthinking about all the terrible things that would happen if she were to find out thatshe were positive.“Do you have control over this problem?”She also says that she has some control over the problem, after all she couldtheoretically go to the clinic to get tested..Image II: S.’ FB cardSee what the counsellor has written on the FB card after this step. Date PID number Counsellor Clinic ZitaZuva Nhamba yemupangwi Nzvimbo wezano rachipangamazanoProblem that is worked on: Goals:avoid to know about need to know my statusH I V status.Smart action plan: Next appointment: 99

the Friendship Bench problem solving therapy Problem solving should be done in several steps: 1. How does the client deal with problems? 2. How to recognize a problem? 3. How to select a problem, find the goal and define the problem? 4. How to brainstorm for solutions? 5. How to select a solution? 6. How to make a SMART action plan? 7. Did it work?4. How to brainstorm for solutions? In the next step, we encourage the client to come up with as many ideas for potential solutions as possible. It is important to explain to the client that she or he should not judge any of her or his ideas at this moment. The more ideas she or he has, the higher the chance that one or two will work. We will write all ideas down on our notepad. HOW TO DO IT? We tell our client that she should come up with any solution idea she can think of: “Please tell me anything that comes up in your mind which could somehow help with your problem. We can discuss later whether the ideas are feasible. We just want to collect as many ideas as possible.” We can help the client by asking more questions such as: • Who could help? • Do you know someone with a similar problem? What have they done? • What would your best friend/mother/ sister/brother/important person…. do? 100