Chapter 5. Review of the AFFIRM-SA counselling manual
5.1 Manual structure and topics
The development of the counselling intervention and manual was described briefly in Chapter One and is reported in detail by Munodawafa (2018). As mentioned, the intervention comprised six sessions, structured to be approximately 45-60 minutes in length, and ideally occurring every week or two weeks over two-to-four months before birth. In reality, due to the practicalities of participants’ lives, not all participants completed all sessions before birth, leading to 51/184 participants receiving some or all sessions after birth.
5.1.1 Manual structure
All six sessions followed a basic structure that involved a welcome and introduction, administering a standardised 14-item checklist, discussion of the purpose of the session, introducing and practicing activities, explanation of homework, agreeing on the next session date, and termination of the session. In addition to the basic structure, each session had a topic that was based on a specific therapeutic modality. This was explained to the participants, and then was demonstrated through participatory activities that the counsellor led the participant through.
5.1.2 Session topics
Each session followed one of the following topics: 1) psychoeducation, 2) problem solving, 3) behavioural activation, 4) healthy thinking, 5) birth preparation, and 6) termination and evaluation. Table 6 provides a summary of these sessions.
78 Table 6: Counselling intervention topic description
Session topic Description
1. Psychoeducation Providing information on the symptoms and causes of depression specific to the local context; provision of a relaxation CD
2. Problem solving Work according to a step-by-step method to identify, prioritise, make plans, and manage problems
3. Behaviour activation Identify activities mothers were no longer doing due to their symptoms of depression and encourage re-activation of these
4. Healthy thinking Identify ‘unhealthy’ thoughts, find positive and more realistic thoughts to replace the unhealthy ones, and then practice this
5. Preparation for birth Provide information on nutrition, birth, and preparing for life with a baby 6. Termination and
evaluation
Summarise all past sessions, elicit feedback on the sessions, and assess whether the participant requires further mental health assistance The following section describes the sessions in more detail:
1) Session 1, “Psychoeducation”, involved provision of information on the symptoms and causes of depression specific to the local context, exploring the participants own depression, and building rapport with the counsellor. Participants were also given a CD which had a relaxation exercise recorded in isiXhosa.
2) Session 2, “Problem solving”, used a step-by-step method to: identify problems that participants were facing, prioritise the most important one(s), discuss ways of managing the problem, choose the best possible solution, make a plan for action, and check in on whether the solution worked in the next session.
3) Session 3, “Behaviour activation”, required mothers to use the previous week’s homework to list activities that she used to enjoy doing but doesn’t do any more. In the session the counsellor was then to discuss when and why the mother stopped doing these activities, identify what activities they would like to do again that might make them feel better, and then make a plan for the best time to take action on these activities.
4) Session 4, “Healthy thinking”, focused on the link between ‘unhealthy thinking’ and ‘unhealthy behaviour’.
It described steps for changing unhealthy thinking into healthy thoughts, through learning to identify unhealthy thoughts, find positive and more realistic thoughts to replace the unhealthy ones, and then practice this. The session used a locally contextualised vignette to practice identifying unhealthy thoughts and replacing them with healthy thoughts (based on the ‘Thinking Healthy’ manual that Rahman et al. created (2008)).
5) Session 5, “Preparation for birth”, used the session to provide information on nutrition, birth, and preparing for life with a baby, to assist in decreasing anxiety and fear about birth and a new baby. The mother was provided with an opportunity to ask questions she was unsure about.
6) Session 6, “Termination and evaluation”, was a shorter session, that summarised the past five weeks and asked for feedback from the mother about what she enjoyed or did not enjoy in each session, what she thought
79 could have been done better, and whether she felt she needed further help, in which case she was referred to a local counselling organisation.
The manual also included a section on suicidal ideation management. When participants expressed suicidal ideation, the manual instructed counsellors to acknowledge and reflect feelings, normalise, educate, and refer participants to the mental health nurse at the clinic (this was described in more depth in the manual itself).
Therapeutic relationship and basic counselling skills
The counsellors were required to follow the instructions and activities in the manual, while also maintaining an empathic and open attitude to participants, using basic counselling skills. These were based on the principles of client-centred counselling (Rogers, 2012), and included: Confidentiality, trust, respect, empathy, non-judgemental attitude, warmth, genuineness, open-ended questioning, active listening, normalising thoughts and feelings, clarification, confrontation, reflection and summarising. These basic counselling skills were described in the first two sections of the manual that provided information and training activities for the counsellors, and were included in the initial five-day training course. Counsellors were initially trained, and later reminded in supervision, not to give advice to participants or provide their own opinions on their problems. They were instead asked to encourage solutions and perspectives from participants themselves.
The three above capacities (following the manual, using the therapeutic topics, and establishing a genuine therapeutic relationship and basic counselling skills) were all taught to the CHWs in the initial five-day training course.
In addition to the counselling, in every session the counsellors asked the participants 14 standard questions on a checklist about their physical and mental health, and about intimate partner abuse. This was included to allow for a systematic, regular, and comparable assessment of basic emotional state and level of threat that participants were experiencing in every session, and with every phone call that the control participants received as well, which allowed for measurement across sessions if necessary. See Appendix I for the questions.
The aim of the intervention was for the counsellors to use the six sessions to teach participants certain psychological skills such as problem solving, behaviour activation and cognitive restructuring, as well as to educate them about depression, pregnancy, birth and baby health. It was intended that the participants would practice the skills through homework activities and then provide feedback on the use of the skills in the following session. It was theorised that this would assist participants in applying these skills and improved
80 knowledge in their everyday lives, thereby reducing depressive symptoms and increasing resilience, going forward.