Chapter 8: Discussion, recommendations, and conclusion
8.4 Models of implementation processes and outcomes
Two models have been developed to understand what has been discovered through this process evaluation of the AFFIRM-SA RCT counselling sessions. These models enable reflection on the contrasts that have been highlighted in this thesis and that are demonstrated in the contrasting findings of the HDRS and EPDS: that there were many visible deviations from protocol and therapeutic breakdowns in the counselling, but that there were also obvious elements that were therapeutically effective within the sessions.
8.4.1 Model 1: The intervention did not disrupt the mechanisms that perpetuate perinatal depression
Guided by the work of Murdoch (2016), the first model unpacks the various aspects of the intervention, from theory, to conceptualisation of the intervention, to implementation, bordered by contextual need. The model, based on the data around deviations from protocol, is that in general, the intervention as it was, did not meet or fit the contextual needs of either the counsellors or the participants, and subsequently did not disrupt the
‘mechanisms’ that create or perpetuate perinatal depression (Hawe, 2015; Moore and Evans, 2017). It posits that in the formative work, the need that was (rightly) identified was depression, and that the theory and manual to address this need was based on evidence from the time (2011), which relied heavily on psychological techniques to address depressive symptoms.
In addition, due to inadequate training and supervision, the intended manual and protocol was not administered as intended, and psychological skills were not taught or learnt adequately by counsellors and participants alike, thus not encouraging a permanent ability to use these skills in the inevitably repeated instances of trauma in the participants’ lives.
The counselling sessions did provide certain benefits for participants, such as a sense of relief, support, advice, and a sense of connection. However, due to the above factors, 1) the ‘contextual need’ of the participants was not met by the intervention, and 2) the intended psychological skills were not learnt or internalised to be able to effectively address context. This resulted in a feedback loop where neither the intended protocol nor the actual implementation were able to address the continued trauma and context that the women faced in their daily lives, which were core factors that lead to the development of depression in the first place.
In the AFFIRM-SA trial, the intention of the theory, protocol and manual was to teach participants psychological skills to improve their life circumstance and feelings of depression. Yet these would not have been able to
160 address the mechanisms that perpetuate or sustain perinatal depression (Hawe, 2015; Moore and Evans, 2017), which are mostly poverty related. Therefore, going forward with task-shared interventions for mental health, there needs to be an inclusion of contextually relevant responses that potentially include an economic skill building component, and strategies to deal with IPV to realistically address the context that women living in Khayelitsha (and many other low resource settings) face.
Figure 4: Model 1. The intervention did not disrupt the mechanisms that perpetuate perinatal depression
8.4.2 Model 2: The intervention provided connection and short-term resilience
A second way of looking at the data, guided by the reports of session outcomes, is through the lens of connection and resilience. This model posits that against the highly stressed and traumatic contextual background in which the participants live, the act of talking to a counsellor and having the commitment from a counsellor of six sessions together, may have provided a sense of connection, support, and ease of isolation that was able to act as a buffer to keep distress at bay, and provide a reprieve – albeit brief – of their everyday stress.
This sense of connection could have assisted in relieving immediate symptoms of distress, stress and trauma, created a sense of hope that problems could be solved, built some form of psychological resilience, improved the ability to communicate, and increased feelings of support. This would have encouraged a desire to foster
161 further social connections, which is an essential element in the reduction of feelings of isolation, and led to a subsequent improvement in mood and symptoms of depression.
Unfortunately, although the counselling sessions were obviously helpful to the participants for the duration of the sessions, these changes were probably of a temporary nature that existed because of and within the therapeutic time frame where the women felt that they had some form of support through the connection with the counsellors. Unfortunately, this sense of connection and support was short-term, and therefore could not reduce clinical symptoms of depression or provide longer-term resilience against the context of extreme poverty.
Model Two (see Figure 5) is a graphic representation of this theory, whereby the sense of connection felt through the sessions created a small buffer of resilience that helped to reduce distress and deal with everyday stress (which is possibly what the EPDS picked up), but that this buffer was temporary in nature, and was not robust enough to reduce clinical symptoms of severe depression (on the HDRS) or to ward off the impacts of poverty such as unemployment, abuse, food insecurity and trauma.
Figure 5: Model 2. The intervention provided connection and short-term resilience
162