Counselling Manual for Depressionwebcms.uct.ac.za/sites/default/files/image_tool... · Counselling Manual for Depression 1 PRIME/COBALT: Welcome » Welcome to your counselling training

Name

2014PRIME/COBALT

edition

21

Counselling Manual for Depression

The behaviour change counsellor’s guide

to depression

MAIN MANUAL

This material has been funded by UK aid from the UK Government, however the views expressed do not necessarily reflect the UK Government’s official policies.

DISCLAIMERThe advice and information given in this booklet is the best we can give based on current evidence based research and clinical experience in a South African context. The advice offered is to aid health providers in working with individuals in primary care settings to provide psychological education and to enable the patient to make an informed choice about their condition and the support they would like to undertake e.g. group counselling, individual counselling and medication.


Welcome to your counselling training manual for depression 1

Introduction to depression 4

Leading groups 12

Individual counselling 60

Getting to know your chronic condition(s) and medication 102

ContentsIn this manual you will find the following sections


1 PRIME/COBALT: Welcome


» Welcome to your counselling training manual for depressionThis training manual is designed to help you, the behaviour change counsellor to lead groups and provide individual counselling that will help people manage their depression. Please write your name on it and make notes in it. This manual is one of two manuals you will receive; Manual 1 and 2.

We will use this manual during the training so that when you facilitate your group you will know how to use the manual and feel confident to lead a group of people who suffer from depression.

We hope that you will enjoy the training and we look forward to growing together with you during this time.

Becoming a behaviour change counsellor for depressed patientsTo become a behaviour change counsellor you need to attend 10 days of training that teach you how to facilitate groups for people with depression. You will also be able to provide individual counselling for depression as well as adherence counselling. You will also be able to provide individual counselling.

Roles and responsibilities of a behaviour change counsellor for depressionYou are already a behaviour change counsellor. Through this training your skills will grow as you learn to facilitate groups for people with depression.

Your role as a counsellor requires you to:• Be part of the dynamic team consisting of nurses, doctors and mental

health specialists to make mental health part of primary healthcare;• Attend the required training and give feedback about the training to help

make it better for further roll out next year;• Facilitate the counselling groups for people referred to you;• Conduct individual counselling for people referred to you• Conduct adherence counselling for all chronic patients referred to you• Give feedback about the service you are providing to the clinic team;• Attend weekly supervision onsite; weekly supervision offsite and peer to

peer supervision to ensure your well-being and the enhancement of your clinical skills;

• Manage your own feelings as you get exposed to group work and people suffering from depression;

• Be professional about respecting patient’s confidentiality and learn how and when to debrief so you stay healthy; and

• Write progress notes in the patient’s clinic record at the end of each session


2PRIME/COBALT: Welcome


Referrals This section is designed to help you recognise when, how and to whom to refer patients who need additional or more specialised help.

Signs of suicide should always be treated as an emergency. The patients should be referred to a consulting Professional Nurse or the Clinic Doctor. Get a clear understanding of the problem before you refer the patient. Use skills learnt in understanding the problem. Use the provided referral form (Behaviour change counsellor Internal Referral Form) to refer the patient and make record of the referral. Preferably escort the patient to see a consulting Professional Nurse or Clinic Doctor and inform the person that you have an emergency. Choose your words carefully when informing the patient of the referral. You could say: ‘It is important that you see a Professional Nurse or Clinic doctor as soon as possible as I am very concerned about you.’

Do not feel guilty if you cannot help the patient. You could say that the specialist person they have been referred to will be able to help them.

When to refer patients you are seeing to other people for further management:

Patients who show the following signs may be referred for further management to the professional nurse or doctor:• Patients talking about traumatic events that they cannot forget the event

or are struggling to live life like they used to (refer to Psychologist). • Patients who have recently tried to commit suicide (refer to PN or Dr).• Patients who talk about wanting to die or wanting to kill themselves

(refer to PN or Dr).• Couples with conflict issues (refer to social worker). You can continue

seeing the individual referred to you.

Defaulter Management As a counsellor you need to keep a register that will help to track the patients’ attending all counselling sessions, like the support group. It is advised that you have a record of patients’ phone numbers and home addresses on their Intake Form. Patients are to be encouraged to attend all sessions. In the event that a patient does not arrive for a session, make a follow up call, find out why and note this in the patient’s clinic file.

Individuals who have defaulted on group sessionsMake an individual catch-up appointment before the next group session with the patient. This session is designed to help the individual catch up with the rest of the group. Encourage the patient to come for the next group session and remind them of the time and place.

If the patient does not turn up for more than one session or is not reachable by phone ask a community health worker who services the area in which the person lives to follow up at the patient’s home.


3 PRIME/COBALT: Welcome

Confidentiality and it limits As a behaviour change counsellor, be clear about the meaning of ‘confidentiality’ and its limits. Confidentiality can be breached when patients pose a danger to themselves and do not want to see a nurse or doctor. In this instance, inform your clinical supervisor. This should be explained upfront when discussing confidentiality and its limits during the first session.

How to use this manual• Introduction to depression: this section is to be used during your first

contact with the patient after they have been referred to you.• Leading groups: this section is to be used when facilitating depression groups• Individual counselling: this section is to be used when conducting

individual counselling• Getting to know your chronic condition(s) and medication: this

section is to be used when conducting adherence counselling for all chronic patients referred to you.

Steps1. First session: On first meeting with patient referred to you go through the

section on “Introduction to depression” with the patient and help patient identify their most pressing need using the counselling skills you have been trained in. Fill in Intake Assessment Form.

2. Second session: Using the individual counselling section, counsel the patient on the issue that they identified as most pressing using the relevant session. Ask the patient to bring their medication for his/ her next session as you will be going through the session on “Getting to know your chronic condition(s) and medication”.

3. Third session: Go through the session on “Getting to know your chronic condition(s) and medication” with the patient. Ask the patient if they would like to join a group.

4. Fourth – ninth sessions: Follow the structure of the sessions as laid out in the manual.

Sessions may be arranged as follows:1. Individual introductory session2. Most pressing session for the individual3. Adherence session4. Remaining individual sessions5. Remaining group sessions

Introduction to depression

Intr

oduc

tion

to

dep

ress

ion


5 PRIME/COBALT: Introduction to depression

Contents

1. The aims of session 1 6

2. Meeting your patient 6

3. Reading a story 7

4. Understanding depression 8

5. Facts about depression 10

6. Managing symptoms of depression 10

7. A way forward 11

8. After the session 11


6PRIME/COBALT: Introduction to depression

1. THE AIMS OF SESSION 1

This is written for healthcare practitioners working in primary care including doctors, nurses, psychologists, behaviour change counsellors and social workers.

This session can be used to teach patients about depression and support them in identifying with any symptoms that they may be experiencing.

It also aims to offer ideas on how to manage symptoms of depression.

This session may be offered as an introduction to depression for those patients presenting with symptoms of the condition.

This is also the first session in the PRIME/COBALT counselling group and individual training manual for depression. The session is to be held with an individual patient.

2. MEETING YOUR PATIENT

Things you need before you meet your patient:• date and time of the next group session 2; and• hand held card for depression.

Introduce yourself to the person you are counselling, invite them to talk about themselves and ask why they think they have come to speak with you.

Explain why you are speaking with them; that you will talk to them about the condition called ‘depression’.

Emphasise confidentiality.

Let the patient know that there is support for depression through counselling, and medication, if prescribed by a specialist.

Say that group counselling sessions will be offered. Mention that group sessions are helpful and you will learn to manage your feelings to feel better in yourself.

Eight group sessions are offered; one held each week. Each session runs for 60 minutes and will ideally be held on the same day and time each week, and in the same venue.

Each week will offer the patient new information on how to manage with the condition and to support them to recover from the symptoms that are keeping them stuck.

In the next section you will find a story to read to your patient.



3. READING A STORY

Read Nontobeko’s story and introduce the story by saying:I am going to read a story that will help us to understand what depression is all about.

Nontobeko, mosadi yo o dingwaga tse 40 o nna le monna wa gagwe mo Kanana. E sale monna wa gagwe a latlhegelwa ke tiro/ mosebetsi o bonwa mo dishebining a dirisa madi a bana a di-grant. Nontobeko

o nna a tshwenyega ka gore o tla jesa bana eng. Ga a kgone go tlogela go tshwenyega mme se se dira gore blood pressure ya gagwe e tsholetsege. O ikutlwa a kgathetse/lapile nako tsotlhe le botshelo bo sa mo natefelele. Ga a kgone go robala bosigo. Fa a tsoga bosigo o palelwa ke go robala gape. Ha a ile kerekeng, o sokola go beya kelelelo mo go rapeleng ebile ga a sa tlhole a natefelelwa ke go opela jaaka pele. Nontobeko o lemogile fa a sa tlhole a rata go kopana le ditsala tsa gagwe morago ga kereke ba tsaya dikgang jaaka pele. O ikutlwa jaaka o kare ga gona se se ba kopanyang. O tswenyegile gore ba tla lemoga gore o ikutlwa o kare botshelo ja gagwe le bokamoso ja gagwe ga se tsa sepe.

Nontobeko is a 40 year old, married woman who lives with her husband in Kanana. Since her husband lost his job, he has been spending more and more time at the shabeen and spending whatever money she gets from her children’s grants. She is constantly thinking about how she is going to feed her children. She can’t stop worrying and this makes her high blood pressure worse. She feels tired all the time and that life is not worth living. At night she has difficulty falling asleep. If she wakes up in the night she can’t get back to sleep. When she goes to church, she battles to concentrate when she is praying and she finds that she doesn’t enjoy singing like she used to. After church, Nontobeko notices

that she doesn’t feel like socializing with her friends like she always did because she feels disconnected from them. She is also worried that they will pick up that she is feeling very negative about her future and about her life.

Check if the patient wants you to read the story again?



4. UNDERSTANDING DEPRESSION

Discuss the story and ask if the patient relates to the story of how Nontobeko is feeling.

Here is a list of symptoms. Show the patient the list and together with your patient, tick the ones you feel are specific to Nontobeko:

Feelings or emotions Maikutlo• Feeling sad, upset, numb

or desperate• O utlwile botlhoko, o se monate,

o sena maikutlo ape

• Guilty or worried • O itshwaya phoso kana o tshwenyegile

• Losing enjoyment or interest in things

• O latlhegelwa ke kgatlhego kana go natefelelwa ke dilo

• Crying a lot, or unable to cry at a sad event

• O lela thata, kana o palelwa ke go lela mo diemong tse di utlwisang botlhoko

• Feeling alone even if you are in company

• O ikutwla o le nosi le o le mo gare ga batho

• Feeling irritable or angry at the smallest thing

• O tenega ka pela kana o tenwa ke diko tse eseng tsa sepe

Physical or bodily signs Matshwao a mo mmeleng• Tiredness • Go lapa kana go kgathala

• Restlessness • O sa kgone go nna o sa dire sepe

• Sleeping more than usual or not being able to sleep

• O robala go feta selekano kana o sa kgone go robala

• Changes in weight, appetite and eating

• O bona diphetogo mo boketeng ja mmele wa gago, mo keletsong/takatso ya dijo le ka fa o jang ka teng

• Decreased sex drive or sexual problems

• O sa tlhole o batla tsa thobalano

• Changes in the menstrual cycle for women

• Mo go bomme go nna le diphetogo fa ba ya malatsing



Thinking or thoughts Dikakanyo kana menagano• Losing confidence in yourself • O sa itshepa

• Expecting the worst and having negative or unhelpful thoughts

• O nna o solofetse sengwe se se maswe go diragala

• Thinking that everything seems hopeless

• O akanya fa go sena sepe se se mosola, go sena tshepo

• Thinking you hate yourself • O akanya fa o ikila kana o sa ithate

• Poor memory and concentration • O lebala thata le o sa kgone go tsipamisa kelelo mo selomg se le sengwe

• Thinking about self-harming or suicide

• O akanya ka go ipolaya kana go ikgobatsa

• Feeling stigmatised by family, friends, colleagues due to the chronic condition

• O ikutlwa fa ba lelwapa, ditsala le babereki mmogo ba go kgetholola ka ntlha ya bolwetsi ja gago.

Behaviour Boitshwaro• Having difficulty in

making decisions• O palelwa ke go tsaya

ditshwetso

• Not worried to do everyday tasks • O sa tshwenyege ka ditiro tsa mo lapeng

• Putting things off • O sa kgone go fetsa dilo tse o di dirang

• Not doing things you used to enjoy

• O sa tlhole o dira dilo tse di neng di go itumedisa pele

• Not bothering to dress properly • O sa tshwenyege ka go apara sentle

Explain that by ticking these boxes you have helped identify symptoms of depression that Nontobeko is experiencing.

Ask: Do any of the items on the list relate to how you have been feeling lately? Then: Talk about the patients symptoms.Now move to Section 5 ‘Facts about depression’.



5. FACTS ABOUT DEPRESSION

Once the patient has thought about Nontobeko and their own symptoms of depression, explain that: • depression is a very common problem;• it can cause you to be limited in your functioning and motivation levels;• it is a condition that leaves people feeling low or very down for a long time;• this is often because of life stresses like bereavement, money and

housing problems or relationship difficulties;• for many people the problem becomes much worse and normal life

becomes difficult to manage;• very many adults will at some time experience symptoms of depression;• depression is an experience that can happen to anyone, young or old,

rich or poor and it is a normal part of life;• also, depression is not a disease so you can’t ‘catch it’ from someone else;• some people might not look sick, but the way they behave changes,

they may not look after themselves as they used to, they may drink more alcohol than usual or they may not want to socialise like they used to;

• some people may be more vulnerable than others, they may have difficult life problems, they may naturally look at the gloomy side of life, they may have just had a baby, and perhaps life circumstances add up to cause a person to feel depressed e.g. experiencing a trauma, losing a loved one, unemployment and managing a single parent family;

• some people, with other health problems like HIV/AIDS or diabetes, may also have depression and the depression makes it difficult for them to feel motivated to take care of themselves, to eat healthily and take their medication; and

• depression becomes a problem when it is more severe, lasts longer and impacts on your relationships, household tasks and it becomes very severe when you have suicidal thoughts.

6. MANAGING SYMPTOMS OF DEPRESSION

Say to the patient:The first thing is to recognise that you have taken a big step forward by coming to the clinic to seek treatment for your depression.

Now that you understand what the symptoms of depression are, please note that there are ways to feel better and to manage your depression.

Reminding ourselves of our support systems is helpful. Give some thought to who you go to when you need support, when you need to talk or get some help or guidance?

At the clinic, we offer you supportive group or individual therapy, and the option of medication, to help you recover from the symptoms of depression.

When you join the depression group, you may meet people with similar stories to yours, and you will develop a new skill each week to manage difficulties with your depression to feel better in yourself.



7. A WAY FORWARD

Ask if the patient has any further questions about depression?

Explain that this talk was the first in a series of talks about depression.

The rest can be attended in individual counselling or the depression support group.

Say: Each session will help you work through your depression and manage your difficulties.

Make sure you have the patient’s contact information.

Offer the patient an appointment for session 2, and complete the details on the patient’s hand held card.

Thank the person for spending time with you and sharing their story.

8. AFTER THE SESSION

Add the information to the patient’s folder.

For yourself as the person who carried out session 1 with a patient, please consider the following:

After this session I feel …… because I ……What I learnt about myself today ……I am worried about ……Anything I need to do differently next time ……Patient referred to or discuss concerns with the sister or doctor ……Next time ……

12

Leading groups

Lead

ing

grou

ps


13 PRIME/COBALT: Leading groups

Contents

Welcome to your counselling training manual for depression 1

About the structure of the group sessions 14

Key to identifying the pictures 15

Tips for running successful groups 16

Steps for running sessions 17

Time guideline for sessions 17

Session 1: Understanding depression 18

Quick guide 18

Group step-by-step guide 19

Session 2: Poverty 25

Quick guide 25


Session 3: Interpersonal conflict 30

Quick guide 30


Session 4: Social isolation and avoidance 35

Quick guide 35


Session 5: Grief and loss 42

Quick guide 42


Session 6: Experienced stigma 47

Quick guide 47



Quick guide 52


Session 8: Closure 58

Quick guide 58



14PRIME/COBALT: Leading groups

About the structure of the group sessions

In this section you will find answers to the questions you might be asking. During the training you will learn more about each session.

How long is a session? Each session should last 1 hour onlyHow many sessions will there be? There will be a maximum of 8 sessions

In total there are 8 sessions.

SESSION 1 understanding depression

SESSION 2 deals with the triggers related to poverty and how to problem solve.

SESSION 3 deals with problems in relationships and how to problem solve and manage them.

SESSION 4 deals with overcoming social isolation and becoming active again.

SESSION 5 deals with grief and loss and how to manage associated problems.

SESSION 6 this session is used when there are people living with HIV/AIDS (PLWHA) in the group and focuses on managing problems associated with externalised stigma.

SESSION 7 this session is used when there are people living with HIV/AIDS (PLWHA) in the group and focuses on healthy thinking to manage internalised stigma.

SESSION 8 the final session facilitates the end of the group sessions.



Key to identifying the pictures

The following pictures will be explained and used during the training and group sessions.

vvA WAY FORWARD

ACHIEVEMENTS

AFTER THE SESSION

CONTACT DETAILS

END OF SESSION

FACTS

FEEDBACK

FLAG

GETTING ACTIVE

GOALS

HEALTHY THINKING

INTRODUCTION

MANAGING SYMPTOMS

MEETING YOUR PATIENT

PEER SUPPORT

PROBLEM MANAGEMENT

READ A STORY

UNDERSTANDING THE CONDITION

UNDERSTANDING THE ISSUE



Tips for running successful groups

SeatingSeating has a strong impact on the groups’ interaction and participation. Find space in the clinic where you will be least disturbed. Also set the scene by arranging the seating before the group arrives to make sure that all participants can see each other.

YELLOW FLAGS

Yellow flags highlight problems with managing the group dynamics that stop the group from interacting. The issues to watch out for are:• if a group member speaks too much and does not give anyone else a

chance to speak;• a group member who does not say a word and does not contribute to the

group or give feedback about themselves when asked; or• a group member cries all the time even after a few sessions.

There are many different ways to manage these challenges. Here are two options:1. speak to the person afterwards to find out what the problem is or2. speak to your supervisor to find out how to best manage the situation

in the group.

RED FLAGS

Read flags are serious warning signs. They indicate that immediate action must be taken. Signs of suicide to look out for in the support group are the following: • talking and having thoughts about killing or harming oneself;• saying things like “I wish the earth would open up and swallow me” or

“everything would be better if I am dead”; and• expressing strong feelings of hopelessness or giving up on life.



Steps for running sessions

Every session follows the same 5 steps. During the training you will become familiar with these steps and how to apply them during a group session. A key to the pictures used in the counselling sessions is also provided. The section you will use the most of in this manual is the following:• quick guide to a session; and• step-by-step to facilitating a session.

These pictures will remind you of the steps you need to follow. The quick guide for each session will show the picture and will remind you of the goal, the story and the helping skill you will need to use during the session.

STEP 1 Feedback from last week

STEP 2 Read the story

STEP 3 Identify with the story

Problem

management

Healthy

thinking

Getting

active

STEP 4 Explore ways of managing the problem

STEP 5 Select issues for feedback in the next session

Time guideline for sessions

• Step 1 - 10 minutes• Step 2 - 10 minutes• Step 3 - 15 minutes• Step 4 - 15 minutes• Step 5 - 10 minutes

= 1 hour per session



» Session 1: Understanding depressionQuick guide

Use your quick guide to remind yourself about the goals of the session, the way to introduce the members to each other and the group sessions and the story that highlights the issue of depression.

GOALS FOR SESSION 1

• Introduce the group members to each other and the group sessions.• Reflect on the individual session ‘understanding depression’ .• Help group members to identify their symptoms of depression.• Help group members express in what way depression has affected them.

» My notes

STEP 1 INTRODUCTIONS Introduce yourself and the sessions and get the group

members to introduce themselves to each other

STEP 2 READ THE STORY Nontobeko is worried about money, struggles to fall asleep at

night and feels that life is not worth living

STEP 3 IDENTIFY WITH THE STORY Identify with Nontobeko’s story. Go through the symptoms

and facts of depression

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Think about support systems and the support the

group may offer

STEP 5 SELECT ISSUES FOR FEEDBACK IN THE NEXT SESSION Group members choose suggestions to act upon and give

feedback on in the next session the following week



Group step-by-step guide

Before you start your group, ensure that you have confidentiality agreements for each member to sign.

STEP 1 Introductions

IntroductionsWelcome the group members and ask them to introduce themselves by saying their name and tell the group the animal that best describes them.

For example: My name is ……… I am like a …….. because ……...

PurposeThe purpose of this session is meeting the group members and recapping on what depression is.

Say: “The purpose of this first session is to get to know each other and to learn about depression. Everyone in the group has identified with what depression is during your individual session on ‘Understanding Depression’.

By understanding this condition and through sharing your experiences you will be able to help yourselves and each other. “

How the group sessions will workNow that everyone has introduced themselves and they know the purpose of the group explain how the group will work.

It is really helpful to set a framework for the group by letting the members know the following information:Time• Let them know: ‘we usually meet each week for the next 7 weeks at the same time

and day of the week and in the same venue. The group runs for one hour.’ • “Each week you will learn new information on how to manage with the condition

and to support you to recover from the symptoms that are keeping you stuck. This is a group to support you feel better so it’s important that you attend all the sessions.”

Confidentiality• Say: “Part of sharing your story of depression is that the information is often

sensitive and private. We therefore emphasise confidentiality.

Confidentiality means that you as a behaviour change counsellor will not go and speak about what you hear and see in the group unless you are worried about someone and you need to get help from the clinical supervisor.

• Say that: “Confidentiality means that the group members are requested to not talk about what they see and hear in the group to others outside of the group. They can talk about their own story outside the group if they need to. So what we talk about here in the group stays in the group.



If they are worried about someone in the group, they can talk to the counsellor before or after the group.

Get everyone in the group to sign the confidentiality form here as a sign of their agreement to maintain group confidentiality.

• There is no medication or remuneration offer from the group but what they will get out of the group is knowledge about depression and how to manage it.

By going through these points, you are demonstrating your commitment to the group and enhance the development of trust between the group members.

In the next section you will find a story to read to your patient.


Read Nontobeko’s story and introduce the story by saying:I am going to read a story that will help us to understand what depression is all about.

Nontobeko is a 40 year old, married woman who lives with her husband in Kanana. Since her husband lost his job, he has been spending more and more time at the shabeen and spending whatever money she gets from her children’s grants. She is constantly thinking about how she is going to feed her children. She can’t stop worrying and this makes her high blood pressure worse. She feels tired all the time and that life is not worth living. At night she has difficulty falling asleep. If she wakes up in the night she can’t get back to sleep. When she goes to church, she battles to concentrate when she is praying and she finds that she doesn’t enjoy singing like she used to. After church, Nontobeko notices that she doesn’t feel like socializing with her friends like she always did because she feels disconnected from them. She is also worried that they will pick up that she is feeling very negative about her future and about her life.



Nontobeko, mosadi yo o dingwaga tse 40 o nna le monna wa gagwe mo Kanana. E sale monna wa gagwe a latlhegelwa ke tiro/ mosebetsi o bonwa mo dishebining a dirisa madi a bana a di-grant. Nontobeko o nna a tshwenyega ka gore o tla jesa bana eng. Ga a kgone go tlogela go tshwenyega mme se se dira gore blood pressure ya gagwe e tsholetsege. O ikutlwa a kgathetse/lapile nako tsotlhe le botshelo bo sa mo natefelele. Ga a kgone go robala bosigo. Fa a tsoga bosigo o palelwa ke go robala gape. Ha a ile kerekeng, o sokola go beya kelelelo mo go rapeleng ebile ga a sa tlhole a natefelelwa ke go opela jaaka pele. Nontobeko o lemogile fa a sa tlhole a rata go kopana le ditsala tsa gagwe morago ga kereke ba tsaya dikgang jaaka pele. O ikutlwa jaaka o kare ga gona se se ba kopanyang. O tshwenyegile gore ba tla lemoga gore o ikutlwa o kare botshelo ja gagwe le bokamoso ja gagwe ga se tsa sepe.

Check with the group wants you to read the story again?


Discuss the story and ask if anyone in the group relates to the story of how Nontobeko is feeling.

Encourage the group to say what they think is happening to Nontobeko. Acknowledge each contribution.

Here is a list of symptoms of depression on this page. It may be helpful to use the list as a guide as some of the group members will begin to identify with Nontobeko’s story.

At the end of Step 3 these symptoms will become clear. If the group has not mentioned these, then add them to the discussion.

Feelings or emotions• Feeling sad, upset, numb or desperate • Guilty or worried • Losing enjoyment or interest in things • Crying a lot, or unable to cry at a sad event • Feeling alone even if you are in company • Feeling irritable or angry at the smallest thing • Multiple bereavements



Physical or bodily signs• Tiredness • Restlessness • Sleep problems • Feeling worse at a particular time of day – usually morning • Changes in weight, appetite and eating • Decreased sex drive or sexual problems • Changes in the menstrual cycle for women • Living with HIV/AIDS, diabetes, high blood pressure, TB

Thinking or thoughts• Losing confidence in yourself • Expecting the worst and having negative or unhelpful thoughts • Thinking that everything seems hopeless • Thinking you hate yourself • Poor memory and concentration • Thinking about self-harming or suicide • Feeling stigmatised by family, friends, colleagues due to the

chronic condition

Behaviour• Having difficulty in making decisions • Not worried to do everyday tasks • Putting things off • Not doing things you used to enjoy • Not bothering to dress properly

Explain to the group members that by identifying their own symptoms of depression, they will become more aware of them and become better able to manage them.

Say: Now that we know more about symptoms of depression lets learn some interesting facts about depression

Interesting Facts• Depression is a very common problem. • It can cause you to become limited in your functioning and motivation levels.• It is a condition that leaves people feeling low or very down for a long time. • This is often because of life stresses like bereavement, money and

housing problems or relationship difficulties. • For many people the problem becomes much worse and normal life

becomes difficult to manage. • Very many adults will at some time experience symptoms of depression. • Depression is an experience that can happen to anyone, young or old,

rich or poor and it is a normal part of life. • Also, depression is not a disease so you can’t ‘catch it’ from someone else. • Some people might not look sick, but the way they behave changes,

they may not look after themselves as they used to, they may drink more alcohol than usual or they may not want to socialise like they used to.

• Some people may be more vulnerable than others, they may have difficult life problems, they may naturally look at the gloomy side of life, they may have just had a baby, and perhaps life circumstances may add up to cause a person to feel depressed e.g. experiencing a trauma, losing



a loved one, unemployment and managing a single parent family. • Some people, who have other health problems like HIV/AIDS or diabetes,

may also have depression and the depression makes it difficult for them to feel motivated to take care of themselves, to eat healthily and take their medication.

• Depression becomes a problem when it is more severe, lasts longer and impacts on your relationships, household tasks and it becomes very severe when you have suicidal thoughts.

Ask the group: Does anyone in the group have any more interesting facts about depression they would like to add to the list?


Now that the group is familiar with the symptoms of depression they will be able to recognise their own symptoms.

Ask the group if anyone relates to Nontobeko’s story? (The group may well have already shared some of their own experiences of their depression).

Thank the person for sharing their story.

Say to the group:You have all taken a big step forward by attending this depression group at the clinic today.

Now that you understand what the symptoms of depression are, please note that there are ways to feel better and to manage your depression.

Reminding ourselves of our support systems is helpful. Give some thought to who you go to when you need support, when you need to talk or get some help or guidance?

Over the next 7 weeks, this group will meet and each week we will work and support each other on different areas that are possibly impacting on how you are feeling.

You will hear similar stories to your own and you will learn a new skill each week to manage difficulties with your depression to feel better in yourself.



STEP 5 Select issues for feedback in next session

Ask if the group if there are any further questions about the session?

Ask the group if there is anything they feel they would like to do this week and to bring it back to the group for the following session.

Give the theme of the next session e.g. Poverty. Remind the group of the date, time and place of the next session.

Closure for todayThank the group for spending time with you and sharing their stories.

After the group sessionAdd the information of attendance to the depression group to the patient’s folders.

For yourself as the person who carried out this session with the group, please consider the following:

After this session I feel …… because I ……What I learnt about myself today……I am worried about ……Anything we need to do differently next time ……Anyone we need to refer to or discuss with the sister or doctor ……Thank you for supporting me when ……Next time ……



» Session 2: PovertyQuick guide

GOALS FOR MODULE ON POVERTY

To explore what aspects of poverty are most distressing in a person’s life.• To help group members generate realistic solutions that they will be able

to implement.• Help group members to utilize untapped existing resources, for example,

people they know who could help them.• Increase group members’ beliefs that they have the power to change

their situations.

» My notes

STEP 1 FEEDBACK FROM LAST WEEK Feedback from session 1 on starting the group and learning

about the symptoms of depression

STEP 2 READ THE STORY Thandi is worried about money and does not know how she

will provide for her son

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of poverty (draw on the

skills learned for understanding a problem)

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Think about how to deal with poverty problems using

problem management


feedback on in the next session




Welcome the group members! Make sure everyone is comfortable before you start the session.


To get feedback from the group members you can ask the following questions one at a time:• What does it feel like to be part of a group like this?• Did learning about depression help to make you feel better?

When a group member shares, remember to thank them for their contribution. Ask if other group members had the same feeling or thoughts.

Once everyone has had a chance to talk about their experience of the first session, tell them that today the group will focus on how to deal with the problems that come from poverty.


The next step is to read or tell the following story so that the groups will be able to identify the issues associated with poverty.

Read the following story out loud to allow group members to think about what they are experiencing in their lives that is similar to the issues in the story associated with poverty.



Introduce the story by saying:I am going to read a story that will help us to understand poverty.

Thandi is 22 years old and has been married for 3 years. She has been taking diabetes medication for two years. She has a five year old son, Thulani, with her husband. Thandi’s husband Sifiso works far away from home, so she is often alone with their five year old son. Her husband does not send home enough money to buy all the things she needs for the family. Thulani will be starting school the following year. She cannot help but constantly worry about how she will meet her son’s school needs. There are some days when Thandi herself does not have enough to eat, she would rather give her food to her son and this worries her as she has to be careful with her a diet as a diabetic patient.

Thandi doesn’t know what she can do to try and get more money. A social worker has helped Thandi get a child care grant, but it is not enough because that is sometimes the money she gets for the month. She is also worried about what will happen to her son if she gets sick and her husband does not come home. Thandi feels helpless

and often cries because she does not know what to do about her situation. She can’t see any way this situation can get better, and sometimes thinks it would be better to give up on her life and die.

Thandi yo o ngwaga tse 22, o na le dingwaga tse 3 a nyetswe. O na le dingwaga tse pedi a tsaya ditlhare tsa sukiri (diabetes). Ene le monna wa gagwe ba na le ngwana wa mosimane yo o dingwaga tse 5 e leng Thulani. Monna waga Thandi, Sifiso o bereka kgakala

le legae, mme se se dira gore Thandi a ba setse le ngwana wa gagwe ba le nosi ka nako tse dintsi. Monna wa gagwe ga a romele madi/chelete e lekaneng gore Thandi a kgone go reka dilo tshotlhe tse di tlhokegang. Thulani o simolola sekole ngwaga e tlang. Thandi o nna a tshwenyega gore o tla kgona jang go reka tsotlhe tse Thulani a tla di tlhokang ko sekoleng. Go na le malatsi a dijo di seyong mo ntlong mme Thandi a itime dijo gore ngwana wa gagwe a kgone go ja. Se se se tshwenya Thandi ka gore o tshwanetse go ja sentle ka e le molwetsi wa sukiri.

Thandi ga a itse gore o ka dira eng go bona madi/ chelete. Social worker e mo thusitse go re a kgone go amogela di-grant tsa bana mme se ga se a lekana ka gore nako tse dingwe ke one madi fela a bonang mo kgweding. Thandi o nale go tshwenyega gore ngwana wa gagwe o tla bonwakje mang fa a ka lwala mmonna wa gagwe a bo a sa tle gae. Ga itse gore a direng ka nako tse dintsi e bile o nna ka go lela ka gore ga itse gore a fetole seemo sa gagwe jaang. Ga a bone botshelo ja gagwe bo tokafala mme nako tse dingwe o ipolelela gore go botoka a ineele mo botshelong a tlhokafale.




When we understand a problem we are better able to learn how to manage the problem. To do this we need to find out from the group about their experience of poverty by asking if they can identify with this story. You can expect group members to nod their heads in agreement.

Here are some questions to help you ask the group to participate:• Does anyone have an experience similar to Thandi’s?• How has not having enough money or food affected your life?• How does it make you feel?• How have you tried to cope with the situation?

Once group members have had a chance to share their experience of poverty, move to Step 4 where you can help the members find ways to manage their own problems.


» Remember to draw on your skills on problem management that you learnt during the first part of your training.

STEP 1 Understanding the problem

STEP 2 Finding different ways to manage the problem

STEP 3 Deciding on the best way to manage the problem

STEP 4 The patient carries out the plan to manage the problem

STEP 5 Feedback at the next session

One often finds that when a group member has had the opportunity to share a problem, or can identify with the stories of other group members, they seem to be able to find ways to manage their own problems. As a facilitator it is very tempting to offer solutions. Your role is to rather let the group members offer suggestions which you can support.



Here are some questions to help you ask the group to support each other:Has anyone been in a similar situation to one of the stories we have just heard?

Then ask the following: Does anyone have any suggestions to help with this problem?

Acknowledge the suggestions and then ask the person whose problem it is if any of these suggestions are helpful in the situation.


Ask this same person to choose a strategy to act on the problem.

Ask the group the following:From listening to the stories and suggestions to help manage your problem, can you share with the group which one of these suggestions you want to work on?

What you would like to aim for is that everyone in the group has an idea of how they want to manage their problem. It is useful to encourage each one to find one thing to work on until the next session.

Continue the same process with other group members. Ask: Does anyone else want to share their experience with poverty?

Your role as a facilitator of the group is to do the following:• help the group members to choose realistic ways of managing problems

that will be achievable; and• support and encourage group members to believe that they have the

power to change their situations.

Closure for todayThank the group for their participation. End the group session with a song or a prayer. Remind the group members about the details of the next meeting. Give them the date and time and venue.

After the group sessionOnce everyone has gone, sit with your co-facilitator and debrief together. Here are some sentences that you can use to help you debrief.




» Session 3: Interpersonal conflictQuick guide

GOALS FOR SESSION ON INTERPERSONAL CONFLICT

• Help group members explore what has happened with a person they have had a disagreement with.

• Help explore whether they should try to reconcile this relationship• Help think of ways that this could be done.• Help the group members to think of the problem from the other person’s

point of view to understand it from another perspective.• Help the group members identify and develop ways of connecting with

other people in their lives for emotional support.• Help the group members to see that they do not have to allow this

disagreement to overwhelm them and that there are ways of dealing with it and moving on.

» My notes

STEP 1 FEEDBACK FROM LAST WEEK Get feedback on how acting on the problem with suggestions

drawn from the Poverty session went

STEP 2 READ THE STORY Masa is worried about her relationship with her partner. He abuses

her physically, is misusing alcohol & often stays away from home

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of interpersonal conflict

with Masa’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Getting support and ideas from the group on dealing with

interpersonal conflict through problem management








To get feedback from the group members you can ask the following questions one at a time:• Last week we spoke about poverty and we ended the session with

everyone choosing what they were going to work on. Let us hear how you managed to act on your problem.

• How do you feel now that you managed to act on a problem?

If there are group members who did not manage to act on their problem, ask them if they have picked up an ideas from what they heard other group members do.


The next step is to read or tell the following story so that the groups will be able to identify interpersonal conflict.

Read the following story out loud to allow group members to think about what they are experiencing in their lives that is similar to the issues in the story associated with interpersonal conflict.



Introduce the story by saying:I am going to read a story that will help us to understand interpersonal conflict.

Masa yo o dingwaga tse 27 o nale mathata le mokapelo wa gagwe yo a dulang le ene. Ba lelwapa la ga Masa ga bana madi/ chelete mme se ke sone se direleng gore Masa a fuduge a nne le mokapelo wa gagwe a santse a la monnye. O itsisitswe fa a nale blood pressure mme o tshwanetse go tsaya dipilisi malatsi otlhe. Mokapelo wa gagwe o bereka ko lefelong la dijo (restauran)t mme o bereka dinako tse di sa tshwaneng (shifts). O nwa thata mme a tle lapeng a tagilwe ka nako tse di ntsi. Masa o tswhenyegile ka gore o mo tsietsa ka basadi ba bangwe. Se ke ka gore nako tse dingwe ga a tle gae gotlhelele mme se se dire gore ba lwe nako tsotlhe. Fa Masa a leka go bua le ene ka go nwa ga gagwe le go tlhoka go tla gae o a tenega/kwata a bo a mmetsa. Masa o utlwisiwa botlhoko ke se a iphitlhele o kare o nosi mo botshelong. Seemo sa ko lapeng se mo tshwentse ka se sa siamela high blood ya gagwe. Masa o tshaba go buwa le mokapelo wa gagwe ka gore ba feleletsa ba lwana ka nako dile dintsi.

Masa is 27 years old and is having problems with her partner whom she lives with. Masa’s family does not have much money and because of this she moved in with boyfriend when she was very young. She has been diagnosed with high blood pressure and has to take medication every day. Her boyfriend has a job at a restaurant and often works very different times shifts. He also drinks at work and often comes home drunk. Masa is also worried that he is unfaithful to her. This is because sometimes he does not come home at all. They constantly fight about this and when Masa tries to speak to him about his drinking and not coming home he gets very angry and hits her. This makes her sad and angry which leads to her feeling very alone. She is worried about her home environment as it is not good for her high blood pressure. Masa is scared to talk to her partner because they end up fighting almost every time.




It is useful to unpack Masa’s story as some of the group members may be nodding their heads because they recognise the conflict in the story. You could ask for a volunteer and ask them the following questions to help understand the interpersonal conflict in the story:• What happened?• How do you understand the problem?• How do you think Masa’s boyfriend understands the problem?• How did Masa try to resolve the disagreement• How did Masa feel then?

When the interpersonal problem is one of interpersonal conflicts or disagreement, the counsellor helps the group members to identify the problem by asking:• What is the problem between the two people?• Do you think this disagreement can be sorted out or do you think you

have reached a point where you cannot go any further?

Ask if any of the group members would like to share their experience of interpersonal conflict and how it makes them feel. Ask: Is there anyone with experience similar to Masa’s?

Once interpersonal conflict is more clearly understood and there is greater clarity about the associated feelings, it is easier to use problem management skills to work out a resolution.


To achieve your goal of assisting group members to help one another deal with interpersonal conflict, by using their own experiences of what has helped them in similar situations, the following questions can be asked:Is there anyone who would like to share their problem so that we can all help to problem solve?

Then ask the following: Does anyone have any suggestions to help with this problem?

Acknowledge the suggestions and then ask the person whose story it is if any of these suggestions are helpful in the given situation.




Ask this person to choose a strategy for acting on the problem.

Ask the group the following:From listening to the stories and suggestions to help manage problems, can you share with the group which one of these suggestions you want to work on?

What you would like to aim for is that everyone in the group has an idea of how they want to manage their problem. It is useful to encourage each one to find one thing to work on until the next session.

Continue the same process with other group members. Ask: Does anyone else want to share their experience with interpersonal conflict?

Your role as a facilitator of the group is to do the following:• help the group members to choose practical problems to manage that

they can act on during the week; and• support and encourage group members to believe that they have the

power to change their situations through managing their problems.


After the group sessionOnce everyone has gone, sit with your co-facilitator and debrief together. Here are some sentences that you can use to help you leave you both debrief.




» Session 4: Social isolation and avoidanceQuick guide

GOALS FOR MODULE ON SOCIAL ISOLATION

• To explore how social isolation impacts on group members lives.• To help group members get active and engage in activities they stopped

doing because of their depression.

» My notes


drawn from the Interpersonal Conflict session went

STEP 2 READ THE STORY Meiki avoids spending time with other people and has stopped

doing things she used to enjoy

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of social isolation with

Meiki’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Strategies for dealing with social isolation by getting active







To get feedback from the group members you can ask the following questions one at a time:• Last week we spoke about how to manage interpersonal conflict and we

ended the session with everyone choosing how they were going to use their problem management skills. Let us hear how you managed to do this.

• Was this helpful in dealing with disagreements?

If there are group members who did not manage to apply their problem management skills, ask them if they have developed ideas from what they heard other group members do.


The next step is to read or tell the following story so that the groups will be able to identify the issues associated with social isolation/avoidance.

Read the following story out loud to allow group members to think about what they are experiencing in their lives that is similar to the issues in the story associated with social isolation and avoidance.



Introduce the story by saying:I am going to read a story that will help us to understand social isolation/avoidance.

Meiki ke mosadi yo dingwaga tse 43 yo o nang le bana ba le babedi mme a ba godisa a le nosi. O nale asthma gotswa bonyaneng le ngwaga tse tharo a tsaya di ARV. Mo nakonyaneng ya go feta o itsisitswe fa a na le high blood. O ile a tsaya tshwetso ya go fuduga ko ntlong ya batsadi ba gagwe ka a sa utlwane le kgaitsadie. O leka

ka thata gore a seke a nna teng fa go nang le dikopano tsa lesika selo se se neng se mo itumedisa pele . O tlogetse go dira ditiro tsa kereke ko e neng e le moeteledi pele. Ga a sa tlhole a taboga le ditsala tsa gagwe ka a utlwa o kare ba modumo mme ebile a bona o kare mmele was gagwe ga o a nonofela go taboga. O ile a tsenya bana ko boarding school ka gore o ikutlwa e kare o ka se kgone go ba tlhokomela. O tshaba le go ba bolelela gore o na le bolwetsi ja HIV.

Sa gagwe ke go ya tirong/ mosebetsing a bo a dirisa nako e setseng ya gagwe mo kamoreng ya gagwe. O fa mabaka a seng a sepe fa distala tsa gagwe di mo etetse. O dirisa nako yotlhe ya gagwe a robetse mme o lela nako tsotlhe. O simoletse go ja thata mo go dirileng gore a oketse mmele. Ga gona ope yo a mmoleletseng ka seemo sa gagwe sa HIV ka a tlhabiwa ke dilthong gore batho ba tla mo leba jang e le mokeresete. O tshwentse gape ke gore o tshwanetse go tsaya dipilisi tsa high blood.

Meiki is a 34 year old single parent with two children. She has had asthma since she was a child and has been on ARVs for three years. She has recently been diagnosed with high blood pressure. She decided to move out of her parents’ home because she does not get along with her brother and she tries her best not to be around when there are family gatherings, which she previously enjoyed.

She also withdrew from participating in church activities which she had been leading. She has now stopped jogging with her friends as she feels they are too loud and that her body can no longer deal with exercise. She has since put her children in boarding school as she feels she cannot care for them and is afraid of telling them that she has the virus.

She now goes to work and comes back to spend her free time inside her room and she always makes excuses if friends want to visit her. She spends all her free time sleeping and cries herself to sleep. She has also gained weight as she finds comfort in food. She has not disclosed her

status to anyone as she is ashamed of how people will look at her as she is a saved Christian. She is also worried that she now has to take high blood pressure medication.




When we understand what happens to us when we isolate ourselves from others because of depression, we learn to understand why we behave in this way.

An example of this from the story of Meiki is illustrated in the diagram below. Meiki feels sad and lonely because of her illness, she does not feel like going out and visiting and then this makes her feel even more sad and lonely.

I feel sad and lonely because of my illness

I do not feel like visiting my friends

I feel more sad and lonely

The next step is to first find out if everyone understands what is meant by social isolation. After that it will be easy for them identify with the story of Meiki and then tell their own story.

Here are some questions to help you ask the group to participate:• What do you think social isolation means?• Why do you think people do this?• Can anyone identify with the story of Meiki?• Would anyone like to share their experience of social isolation?• How does avoiding people make you feel?

Once group members have had a chance to share their experience of social isolation and avoidance, move to Step 4 where you can help the group members find ways of getting active as a way of managing their own problems.


In Step 4 remember to draw on your skills on how to get active that you learnt during the first part of your training.

When people are depressed they often avoid social situations, stop exercising, withdraw from friends and family, and avoid activities that they would normally enjoy. All of this makes people feel even more depressed.

Getting active can encourage depressed people to do activities that they have stopped doing. Getting active can make them feel better.



» Steps for encouraging people to do get active and do things.

STEP 1 Helping people recognise how negative feelings about oneself can make them stop doing things that they used to enjoy

STEP 2 Helping people recognise and identify enjoyable activities that they have stopped doing

STEP 3 Identifying positive enjoyable activities

STEP 4 Taking action

As the facilitator of this group, you want to help group members recognise social isolation in their own lives and encourage them to become more active.

The table below offers some ideas of what to do to get active.

First you need to ask the group members what they think they can do in their lives to get active by asking the following:

• Now that we understand what social isolation is about and have identified with the story of Meiki and recognised our own behaviour, think about what you used to do that made you feel happy.

• Let us brainstorm some ideas…



» Here are some positive examples that you can add to the contribution of the group members.

Do some gardening Go home to visit family

Dress up and look nice Enjoy a cup of tea

Visit the farm Talk to a friend on the phone

Chat to a friend Do community work

Style your hair Cook a meal

Join a social group Clean your house

Spend some quiet time to think and be calm / meditate

Tell a story to the children or play a game

Meet new people Do some volunteering

Mend clothes / sew Send an SMS to friend

Attend a church group gathering Listen to music

Go Shopping Attend choir practice

Watch TV Look at photos

Play with the children Go for a walk

Go for soccer or netball Sing to yourself

Make music Dance

Read a newspaper Help someone in need

Sew / knit Play a game

Paint your nails Put on your favourite hat

Visit an old or lonely person Make love

Walk children to school Make home look nice

Whistle a tune Tell a joke

Bake something nice Say ‘I Love You’ to someone special

Focus on happy memories Wash dishes

Do laundry, washing and ironing Hug your children




After the discussion on getting active ask the following:• What activities could you do in the next week that would make

you feel happy?• From our discussions on getting active to move out of social isolation,

can you share with the group one thing that you can do in the next week that would make you feel happy?

Continue the same process with other group members. Ask: Does anyone else want to share their experience with social isolation?

Your role as a facilitator of the group is to do the following:• help the group members to choose realistic activities they can do that

will be achievable; and• support and encourage group members to believe that they have the

power to change their situations.


After the group sessionOnce everyone has gone, sit with your co-facilitator and debrief together. Here are some sentences that you can use to help you debrief.




» Session 5: Grief and lossQuick guide

GOALS FOR SESSION ON GRIEF AND LOSS

• Help group members who have lost someone close to them mourn the loss of their loved one.

• Allow group members to express feelings of sadness.• Find ways to normalise these feelings of sadness.• Help group members come to terms and accept their loss by finding ways

to reorientation their lives through finding support or activities to help connect with other people.

» My notes

STEP 1 FEEDBACK FROM LAST WEEK Get feedback on how acting on the problem with solutions

drawn from the Social isolation and avoidance session went

STEP 2 READ THE STORY Thabo recently loss his wife and sister and is having problems

in coming to terms with the loss

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of grief and loss with

Thabo’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Getting support and ideas from the group on mourning the

loss of loved ones through problem management








To get feedback from the group members you can ask the following questions one at a time:• Last week we spoke about social isolation and we ended the session with

everyone choosing what they were going to do to get active. Let us hear how you managed to do this.

• How do you feel now that you have done something that makes you feel more connected?

If there are group members who did not manage to get active, ask them if they have picked up ideas from what they heard other group members do.


The next step is to read or tell the following story so that the groups will be able to identify with loss and grief.

Read the following story out loud to allow group members to connect with the story of loss and grief.



Introduce the story by saying:I am going to read a story that will help us to understand loss and grief.

Thuso ke monna yo o dingwaga tse 40 yo e leng moagi wa lekeishane lengwe gaufi le toropo nngwe. O na le bana ba le bane- Thabo yo a leng dinwaga tse 18, Tshepang yo a leng 16, Jabu yo a leng 12 le Palesa yo a leng 7. Thuso o ne a itsisiwe fa a nale tshwaetso (HIV) ngwaga e fitileng mme a simolola di ARV morago ga gore Sophie mosadi wa gagwe a tlhatlhobiwe mme ga fitlhelwa a nale HIV. Morago ga dikgwedi tse thataro (6) mosadi wa gagwe a lwala TB o ne a tlhokofala. Kgaitsadia Thuso, Tlamelo, le ene o ne a tlhokafala nako e khutshwane morago ga mosadi wa gagwe. Thuso le Tlamelo ba ne ba utlwana thata e bile a kgona go bua le ene sengwe le segwe. Tlamelo o tlogetse bana bale babedi, Dika le Rose. Bana ba botlhe ka borataro ba bone ba lebagane le Thuso. Ke ene a ba direlang sengwe le sengwe. Mo nakong e thata e, Thuso o ile a simolola go akanya ka leso. O ne a ipotsa gore ke mang yo o tla tlhokomelang bana ba fa a ka tlhokofala. Tota o ne a sa bone fa bagwagwadi ba gagwe ba ka tlhokomela bana ba ka ba ne ba re ke ene a bolaileng ngwana wa bone Sophie. Thuso o tshela ka go lela e sale Sphie le Tlamelo ba tlhokofala. Ga a kgone go robala bosigo a touta ka Sophie. O ipolelela fa e le ene a mmolaileng ka go mo tshwaetsa le fa a sena bosupi ja gore ke mang yo o swaeditseng yo mongwe. O tenega ka pela mme ebile o felela batho ba bangwe pelo. Ditsala tsa gagwe di emesiste go mo etela ka gore ga a ba buise fa ba tlile go go ene. O utlwa botlhoko thata fa akanya ka Sophie le Tlamelo. Thuso ke motho yo o neng a sa nwe bojalwa mme jaanong o simolotse go bo nwa gore a leke go lebala kutlobotlhoko e kanakana e.

Thuso is a 40 year old man who lives in an informal settlement near a small town. He has four children- Thabo who is 18 years old, Tshepang who is 16 years old, Jabu who is 12 and Palesa who is 7 years old. Thuso was diagnosed with HIV a year ago and started ARV treatment immediately after his wife, Sophie, tested positive. Six months ago after suffering a long and excruciating fight against TB his wife died. While grieving the loss of his wife, Thuso lost his sister Tlamelo. Tlamelo and Thuso were very close and he used to share everything with her. She left behind 2 children; Dika and Rose. Thuso is now the sole provider for 6 children. During this difficult time Thuso started thinking about his own death. He started worrying about who would look after the children were he to die. His in-laws would most certainly not assist in being guardians as they blamed him for the death of their daughter. Since Sophie and his sister Tlamelo died he cries every day. He lies awake at night finding it difficult to fall asleep and thinks about Sophie. He feels guilty; he does not know if he infected her with HIV/AIDS or if she infected him. He gets angry and impatient with other people. His friends no longer visit him because he does not talk to them when they do. He finds it very difficult not to feel pain when thinking about Tlamelo and Sophie. He does not normally drink but recently started in an attempt to dull the pain.




Loss and grief are part of everyday life. Grief is a normal but often very painful response to loss. Grief can be experienced with the loss of different things and not only loved ones. Different people react differently to loss. For example, one person may want to talk about their feelings and another would prefer not to talk about what they are experiencing. How you respond to loss will depend on a lot of factors which include the kind of relationship you had with the person who has passed away. There is no right or wrong way of grieving. No matter what the reaction, a grieving person needs support from other people.

The focus of this session is on the loss of a loved one as we have seen with the story of Thuso. • Did hearing about the losses that Thuso is grieving, make you think of

your own loss?• Would anyone like to share their experience of grief and loss

with the group?• What have you tried to do to help yourself overcome the loss?


Using problem management skills in a session is familiar to you and the group. Dealing with loss and grief can often leave one feeling very vulnerable and having something practical to do can be helpful. To get group members to help one another deal with grief by using their own experiences of what has helped them in similar situations you can ask a volunteer to share their experience.

Once someone has shared their story you can ask the group for assistance in the following way: Does anyone have a suggestion for the volunteer to help with managing the problem?




Once there have been suggestions from the group, check with the volunteer whether any of these suggestions are helpful in their situation. If yes, ask the volunteer to choose a suggestion and act on it during the week.

There might be more volunteers who would like to share their story and get support from the group members. This technique is familiar to you and allows you to facilitate support for the group to deal with issues around loss and grief.

Encourage the group member to try some of these suggestions out in their lives in the next week by asking the following:From our discussions on loss and grief, can you share with the group how you plan to use your problem management skills during the next week that will help you to feel better about the losses in your life?

Your role as a facilitator of the group is to do the following:Support and encourage group members to believe that they have the power to change their situations through managing their problems.

Closure for todayThank the group for their participation. End the group session with a song or a prayer. Give them the date and time and venue.

After the group sessionOnce everyone has gone, sit with your co-facilitator and debrief together. Here are some sentences that you can use to help you both debrief.




» Session 6: Experienced stigmaQuick guide

GOALS FOR SESSION ON EXPERIENCED STIGMA/DISCRIMINATION AND REJECTION

• Help group members define what experienced stigma, discrimination and rejection means for them.

• Help group members who have experienced actual stigma, discrimination and rejection express their feelings around these issues.

• Explore with group members why others may react in this way.• Share suggestions on how to approach those who have attitudes

of discrimination.• Explore ways of responding to experiences of stigma, discrimination

and rejection.• Encourage individuals to find new support systems.

» My notes:


drawn from the Grief and Loss session went

STEP 2 READ THE STORY Lerato’s in-laws blame her for their son’s death; people are

treating her differently since her husband died from AIDS

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of external stigma with

Lerato’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Getting support & ideas from the group on dealing with

experienced stigma through problem management








To get feedback from the group members you can ask the following questions one at a time:• Last week we spoke about Grief and loss and we ended the session with

everyone choosing how they were going to manage the loss of a loved.• Was this helpful in making you feel better?

If there are group members who did not manage to implement suggestions, ask them if they have develop ideas from what they heard other group members do.


The next step is to read or tell the following story so that the groups will be able to identify experienced stigma.

Read the following story out loud to allow group members to think about what they are experiencing in their lives that is similar to the issues in the story associated with experienced stigma.

Introduce the story by saying:I am going to read a story that will help us to understand experienced stigma.

Lerato is a 32 year old woman married with 3 kids. She currently lives with her in-laws in a rural community near Durban. Her husband passed away a year ago. She does not have a good relationship with her in-laws as they blame her for their son’s death. People from her village found out that her husband died from AIDS. Since then they have been treating her differently. Her in-laws no longer want her to cook for the family and have requested her to move out of their compound. The neighbours do not want her kids to play with their kids anymore. They have even kicked her out of their stokvel group with an excuse that she will not afford to pay since her husband who was their sole provider passed away. They have been calling her names behind her back and saying that it is her fault that she has HIV because she is a sinner.



Lerato ke mosadi yo o dingwaga tse 32. O nyetswe mme o na le bana ba le 3. O nna le bomatsalaagwe ko magayeng gaufi le Durban. Monna wa gagwe o na le ngwaga a tlhokafeste. E sale monna wa gagwe a tlhokafala ga a utlwane le bomatsalaagwe ka gore ba re ke ene a mmolaileng. Batho mo motseng ba a mo kgetholola sale ba utlwa fa monna wa gagwe a bolailwe ke HIV. Bomatsalaagwe ga ba batle go tlhakanna pitsa le ene mme ba mo laetse gore a fuduge mo lelwapeng la bone. Baagisane ga ba bate bana ba gagwe ba tshameka le ba bone. Gotswa ka nako eo ba mo tshwara ka mofuta o mong. Bo mogadibo ga ba so tlhole ba batla a apela ba lelapa e bile bamo kopile gore a tswe ka

motse wa bone. Baagisane ga ba batle bana ba gagwe ba tshameka le bana ba bone. Ba mo kobile/lelekile ko stokvel ba dirisa lebaka la gore o kase kgone go patala ka gore monna wa gagwe e ne e le ena fela yo o nang le letseno. Bantse ba mo bitsa ka maina mo morago ga gagwe ba re ke molato wa gagwe a bo a nale tswaetso (HIV) le gore ke modira dibe.


Now that we have heard the story of Lerato you can ask the following questions to get the group members to understand and discuss experienced stigma that they identified in the story. Once they have identified experienced stigma in Lerato’s story it will be easier to identify how it affects their own lives.

Ask these questions one at a time. • What do you think experienced stigma is and where does it comes from?• Can you identify with this story?• What did you identify with the story about experienced stigma?• Would anyone like to share their experience of experienced stigma?

Once it is clear to the group members what is meant by experienced stigma, it is useful to use problem management skills to manage the issues.




» Remember to draw on your skills on problem management.






To achieve your goal of assisting group members to help one another deal with experienced stigma, by using their own experiences of what has helped them in similar situations, the following questions can be asked:Is there anyone who would like to share their problem so that we can all help to manage it better?

Then ask the following:Does anyone have any suggestions to help with this problem?

Acknowledge the suggestions and then ask the person whose story it is if any of these suggestions are helpful in their situation.




Once the person has shared and there have been suggestions, ask the volunteer if any of these suggestions are helpful in the situation. The conversation can continue in the following way:Can you choose a strategy for acting on your problem?

Your role as a facilitator of the group is to do the following:• help the group members to choose practical problems that they can

manage during the week; and• support and encourage group members to believe that they have the

power to change their situations through managing their problems.


After the group sessionOnce everyone has gone, sit with your co-facilitator and debrief together. Here are some sentences that you can use to help you leave the group behind.




» Session 7: Internalised and perceived stigmaQuick guide

GOALS FOR MODULE ON INTERNALISED AND PERCEIVED STIGMA

• Help group members define what internalised stigma means for them.• Help group members and individuals who have experienced internalised

stigma express their thoughts and feelings around this issue.• Explore ways of responding to experiences of internalised stigma.• Assist with ways of how to deal with experiences of internalised stigma.

» My notes


drawn from the Experienced Stigma session went

STEP 2 READ THE STORY Katlego thinks people see her as dirty and worthless due to her

disease, and sees herself as a disgrace to her family

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of internalized stigma

with Katlego’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Work on identifying negative thoughts and replacing them with

Healthy Thinking








To get feedback from the group members you can ask the following questions one at a time:• Last week we spoke about experienced stigma and we ended the session

with everyone choosing how they were going to use their problem management skills to feel better. Let us hear how you managed to do this.

• Was this helpful in reducing your negative feelings?

If there are group members who did not manage to apply their problem management skills, ask them if they have developed ideas from what they heard other group members do.


The next step is to read or tell the following story so that the groups will be able to identify internalised stigma.

Read the following story out loud to allow group members to think about what they are experiencing in their lives that is similar to the issues in the story associated with internalised stigma.



Introduce the story by saying:I am going to read a story that will help us to understand internalised stigma/perceived stigma.

Katlego ke mosadi yo dingwaga tse 30 mme ga a nyalwa. O nna ke ba lelwapa la gagwe mme o na le barwadi ba babedi; yo o dingwaga tse 5 le yo dingwaga tse 2. O ile a itse fa a nale tshwaetso (HIV) fa a le mo mmeleng wa ngwana wa bobedi. O ipona e le motho yo o leswe ka a na le tshwaetso. O tlhabiwa ke ditlhong go bolelela ba kelwapa la gagwe ka tshwaetso ya gagwe ka a akanya gore ba tlare ke ditiro tsa gagwe tse di dirileng gore go nne jaana. Gape o akanya gore ba ka tlogela go tlhokomela bana ba gagwe ka gore o na le tshwaetso. O tshaba le gore ba kase mo amogele le gore ba tla moleleka ko ntlong. Fa Katlego a le mo gare ga batho ka nako tse dintsi o akanya gore ba bona fa e se motho wa sepe le fa ba sa itse seemo sa gagwe. O ipona molato ka se se mo diragetseng gape o akanya fa a tlontlolotse ba lelwapa.

Katlego is a 30 year old single woman. She currently lives with her family and has 2 daughters, a 5 year old and a 2 year old. She found out that she was HIV positive when she became pregnant with her second child. She now thinks of herself as dirty and contaminated because of her status. She feels ashamed of telling her family and fears that they will blame her for having HIV and they will not support her or her kids if they find out. She is also afraid that they will reject her and kick her out of the house. When Katlego is around others she often thinks that they see her as worthless even though they do not know her status. She also blames herself and feels guilty for what has happened to her and sees herself as a disgrace to her family.




Now that we have heard the story of Katlego you can ask the following questions to get the group members to understand and discuss internalised stigma that they identified in the story. Once they have identified internalised stigma in Katlego’s story, it will be easier to identify how it affects their own lives.

Ask these questions one at a time. • What was Katlego’s unhealthy thinking doing to her relationship

with her family?• Did her family say anything about her being a disgrace to them?• What did you learn from the story?• What do you think internalised stigma is?• Where do you think it comes from?

Once the discussion is going well, ask the group members to think of any negative stigmatising thoughts they may have about themselves.

The “box” below provides some examples of unhealthy thinking that you can use during the discussion.

» Common examples of unhealthy thinking.

• You exaggerate what is happening in a situation.• You see a general comment as meaning something about

you personally.• You see something someone said about a specific situation or

person as applying to all situations or groups of people.• You reject any positive events and only focus on the negative.• You jump to a negative conclusion most of the time.• You think that making a small mistake will lead to a big punishment.• You feel bad about yourself, so you think that others must see you

as a bad person.• You tell yourself that you ‘should do this’ or that you ‘shouldn’t do that’.• You focus on the negative aspects of a situation until they become

the only thing that you can see.• You think that your life is now over because you have HIV.• You worry about negative things even though they are beyond your

control and you can’t change them.




Once group members understand and identify internalised stigma and the effect it has in their lives, it will be useful to get the group to help one another deal with internalised stigma. Use group members own experiences of what has helped them in similar situations. The steps to promote healthy thinking are shown in the diagram below.

» Steps in promoting healthy thinking that will be followed in Step 4.

STEP 1 Gaining awareness of unhealthy thoughts

STEP 2 Analyse the accuracy of the thoughts

STEP 3 Replacing unhealthy thoughts with more accurate ones

To put healthy thinking into practice you can ask the individual being helped the following questions: • How do these negative thoughts make you feel? • What do these negative thoughts make you do?• Do you have proof that these thoughts are actually the truth? • What are other explanations for the situation to help replace these

negative thoughts with healthy ones?• How does this new thinking make you feel now?




After the discussion on internalised stigma ask the following:• What practical things can you do to change your thinking from negative

to healthy during the next week until we meet again?• From our discussions on moving from unhealthy to healthy thinking, can

you share with the group one thing that you can do in the next week that will help you to remember to think in a healthy way?

Continue the same process with other group members. Ask: Does anyone else want to share their experience with internalised stigma?

Your role as a facilitator of the group is to do the following:• help the group members to choose situations that they can practice

using healthy thinking; and• support and encourage group members to believe that they have the

power to change their situations through healthy thinking.


After the group sessionOnce everyone has gone, sit with your co-facilitator and debrief together. Here are some sentences that you can use to help you leave the group behind.




» Session 8: ClosureQuick guide

GOALS FOR SESSION ON CLOSURE

• Help group members to express what they have learnt though participating in the group.

• Allow group members to express their feelings about ending the group sessions.

• Encourage group members to elect a song they like and sing together even after the group sessions as a reminder of their learnt skills and knowledge gained from the sessions.

» My notes

STEP 1 FEEDBACK FROM LAST WEEK Get feedback on how acting on the problem drawn from the

Internalised and perceived stigma session went

Raise issues and feelings associated with ending the sessions

Recognise the successes that individuals have had during the group sessions

Explain the importance of group members’ continual support for each other

Provide Contact details of relevant NGO’s or professionals for cases in which additional help is required if the depression reoccurs




Welcome the group members for the last time! Make sure everyone is comfortable before you start the session. Recognise that this is the last session and group members might be feeling a bit “lost” because group is now ending and they have grown used to this safe space.


To get feedback from the group members about their week you can ask the following questions:• Last week we spoke about internalised stigma and we ended the session

with everyone choosing how they were going to use their problem management skills to feel better. Let us hear how you managed to do this.

• Today is the last group, let us see how group members feel about the group ending today. We have been together for many weeks now and have got used to being together. Not coming to group sessions might leave a gap in your week… How do you feel about this being the last session?

• In what ways do you think group can continue to help you even if we are not together in group sessions?

Once the group has had the opportunity to share, then ask the following:• Ask each group member to give brief summary of what they have learned.• Commend the successes of each group member.• Ask group members how they can continue to put their new skills into practice.• Ask the group how they feel about ending the group and normalize any

fearful feelings.• Ask the group members for practical suggestions of how they can

continue to provide one another with support.• The group may want to choose a song that they like that they could sing

together, even after the workshop, as a reminder of what they learnt about dealing with their depression.

After the group sessionOnce everyone has gone, sit with your co-facilitator and debrief together. Here are some sentences that you can use to help you both debrief.

After this session I feel …… because I ……What I learnt about myself today……I am worried about ……Anything we need to do differently next time ……Anyone we need to refer to or discuss with the sister or doctor ……Thank you for supporting me when ……

60

Individual counselling

Ind

ivid

ual c

ouns

ellin

g


61 PRIME/COBALT: Individual counselling

Contents

About the structure of individual sessions 62

Key to identifying the pictures 63

Tips for running successful session 64

Steps for running sessions 64

Time guideline for sessions 65

Session 1: Understanding depression 66

Session 2: Poverty 67

Quick guide 67

Individual step-by-step guide 68

Session 3: Interpersonal conflict 72

Quick guide 72


Session 4: Social isolation and avoidance 77

Quick guide 77


Session 5: Grief and loss 84

Quick guide 84



Quick guide 89


Session 7: Internalised and perceived stigma 94

Quick guide 94


Session 8: Closure 100

Quick guide 100


62PRIME/COBALT: Individual counselling

About the structure of individual sessions

In this section you will find answers to the questions you might be asking. During the training you will learn more about each session.

How long is a session? Each session should last 45 minutes.How many sessions will there be? There will be a maximum of 8 sessions

SESSION 1 Understanding Depression

SESSION 2 TO 7 The middle sessions are a place to learn and practice skills to manage the problems that caused, maintain or make the depressive symptoms worse.

The sessions cover the following topics:

SESSION 2 deals with the triggers related to poverty and how to better manage problems.

SESSION 3 deals with problems in relationships and how to manage them.

SESSION 4 deals with social isolation and how to become active to overcome that.

SESSION 5 deals with grief and loss and how to manage the problems associated with that.

SESSION 6 this session focuses on managing problems associated with experienced stigma.

SESSION 7 this session focuses on healthy thinking to manage internalised stigma.

SESSION 8 The final session to facilitate the end of the individual sessions.



Key to identifying the pictures

The following pictures will be explained and used during the training and group sessions.

A WAY FORWARD

ACHIEVEMENTS

AFTER THE SESSION

CONTACT DETAILS

END OF SESSION

FACTS

FEEDBACK

FLAG

GETTING ACTIVE

GOALS

HEALTHY THINKING

INTRODUCTION

MANAGING SYMPTOMS

MEETING YOUR PATIENT

PEER SUPPORT

PROBLEM MANAGEMENT

READ A STORY

UNDERSTANDING THE CONDITION

UNDERSTANDING THE ISSUE



Tips for running successful session

RED FLAGS

Read flags are serious warning signs. They indicate that immediate action must be taken. Signs of suicide to look out for are the following: • talking and having thoughts about killing or self-harming;• saying things like “I wish the earth would open up and swallow me” or

“everything would be better if I am dead”; and• expressing strong feelings of hopelessness or giving up on life.

Steps for running sessions

Every session follows the same 5 steps. During the training you will become familiar with these steps and how to apply them during a session. A key to the pictures used in the counselling sessions is also provided. The section you will use the most of in this manual is the following:• quick guide to a session;• step-by-step to facilitating a session;• resource for sessions with individual patients; and• a guide to a session with an individual patient.

These pictures will remind you of the steps you need to follow. The quick guide for each session will show the picture and will remind you of the goal, the story and the helping skill you will need to use during the session.




Problem

management

Healthy

thinking

Getting

active





Time guideline for sessions

• Step 1 - 5 minutes• Step 2 - 5 minutes• Step 3 - 15 minutes• Step 4 - 15 minutes• Step 5 - 15 minutes

= 45 minutes per session



» Session 1: Understanding depression

REFER TO THE BOOKLET ‘UNDERSTANDING DEPRESSION’

This session must be completed with the patient as the introduction session, before you proceed to Session 2: Poverty.



» Session 2: PovertyQuick guide

GOALS FOR MODULE ON POVERTY

• To explore what aspects of poverty are most distressing in a person’s life.• To support individuals to generate realistic ways of managing problems

that they will be able to implement.• Help patient to utilize untapped existing resources, for example, people

they know who could help them.• Increase patient’s beliefs of their power to change their situations.

» My notes

STEP 1 FEEDBACK FROM LAST WEEK Feedback from Session 1 on learning about the symptoms

of depression

STEP 2 READ THE STORY Thandi is worried about money and does not know how she

will provide for her son

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of poverty (draw on the

skills learned for understanding a problem)

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Think about how to deal with poverty problems using

problem management

STEP 5 SELECT ISSUES FOR FEEDBACK IN THE NEXT SESSION Choose suggestions to act upon and give feedback on in the

next session the following week



Individual step-by-step guide


Welcome your patient to the session and ask how they are doing today.

Reflect on Session 1: Understanding Depression, and what the patient has learnt from this session.

Ask the patient if learning about the symptoms of depression was helpful in improving their mood.

Let the patient know that the session will focus on how to deal with problems associated with poverty.


Read the following story out loud to allow your client to think about an experience in their lives that is similar to the issues in the story associated with poverty.

Introduce the story by saying:I am going to read a story that will help us to understand poverty and depression.

Thandi is 22 years old and has been married for 3 years. She has been taking diabetes medication for two years. She has a five year old son, Thulani, with her husband. Thandi’s husband Sifiso works far away from home, so she is often alone with their son. Her husband does not send home enough money to buy all the things she needs for the family. Thulani will be starting school the following year. She cannot help but constantly worry about how she will meet her son’s school needs. There are some days when Thandi herself does not have enough to eat, she would rather give her food to her son and this worries her as she has to be careful with her diet as a diabetic patient.

Thandi doesn’t know what she can do to try and get more money. A social worker has helped Thandi get a child care grant, but it is not enough because that is sometimes the money she gets for the month. She is also worried about what will happen to her son if she gets sick and her husband does not come home. Thandi feels helpless and often cries because she does not know what to do about her situation. She can’t see any way this situation can get better, and sometimes thinks it would be better to give up on her life and die.



Thandi yo o ngwaga tse 22, o na le dingwaga tse 3 a nyetswe. O na le dingwaga tse pedi a tsaya ditlhare tsa sukiri (diabetes). Ene le monna wa gagwe ba na le ngwana wa mosimane yo o dingwaga tse 5 e leng Thulani. Monna waga Thandi, Sifiso o bereka kgakala le legae, mme se se dira gore Thandi a ba a setse le ngwana wa gagwe ba le nosi ka nako tse dintsi. Monna wa gagwe ga a romele madi/chelete e lekaneng gore Thandi a kgone go reka dilo tshotlhe tse di tlhokegang. Thulani o simolola sekole ngwaga e tlang. Thandi o nna a tshwenyega gore o tla kgona jang go reka tsotlhe tse Thulani a tla di tlhokang ko sekoleng. Go na le malatsi a dijo di seyong mo ntlong mme Thandi a itime dijo gore ngwana wa gagwe a kgone go ja. Se se se tshwenya Thandi ka gore o tshwanetse go ja sentle ka e le molwetsi wa sukiri.

Thandi ga a itse gore o ka dira eng go bona madi/ chelete. Social worker e mo thusitse go re a kgone go amogela di-grant tsa bana mme se ga se a lekana ka gore nako tse dingwe ke one madi fela a bonang mo

kgweding. Thandi o nale go tshwenyega gore ngwana wa gagwe o tla bonwake mang fa a ka lwala monna wa gagwe a bo a sa tle gae. Ga itse gore a direng ka nako tse dintsi e bile o nna ka go lela ka gore ga itse gore a fetole seemo sa gagwe jang. Ga a bone botshelo ja gagwe bo tokafala mme nako tse dingwe o ipolelela gore go botoka a ineele mo botshelong a tlhokafale.


Ask if the patient can identify with this story.

Ask the person to share a problem in relation to not having enough food or money. Ask how this impacts on them and how they feel?




GoalTo get the patient to deal with poverty by exploring solutions and using examples of other people known to the patient who have gone through similar situations.

• Both the counsellor and individual can think of different ways to manage the problem.

• Ask the patient which of the suggestions would be helpful in their situation.

» Remember to draw on your skills on problem management that you learnt during the first part of your training.









• Ask the patient to choose a strategy to act on regarding the problem.• Encourage the patient to try some of these solutions out during

the next week.

Select the focus of the session by identifying the trigger of the patient’s depression. For example the trigger might be grief, illness or poverty.

Closure for todayThank the patient for their participation. Remind the person about the details of the next meeting. Give them the date and time and venue.

After the session, consider the following points.




» Session 3: Interpersonal conflictQuick guide

GOALS FOR SESSION ON INTERPERSONAL CONFLICT

• Help individual client explore what has happened with a person they have had a disagreement with.

• Help explore whether they should try to reconcile this relationship.• Help think of ways that this could be done.• Help to think of the problem from the other person’s point of view to

understand it from another perspective.• Help person to identify and develop ways of connecting with other

people in their lives for emotional support.• Help the person to see that they do not have to allow this disagreement to

overwhelm them and that there are ways of dealing with it and moving on.

» My notes


drawn from the Poverty session went

STEP 2 READ THE STORY Masa is worried about her relationship with her partner. He

abuses her, misuses alcohol and often stays away from home

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of interpersonal conflict

with Masa’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Getting support and ideas on dealing with interpersonal

conflict through problem management

STEP 5 SELECT ISSUES FOR FEEDBACK IN THE NEXT SESSION Choose suggestions to act upon and give feedback on in the






Ask the individual if suggestions from the previous weeks session used to work on a problem.

Ask the individual if it was helpful in reducing any negative feelings

Say: I met with you to go through your medication. How are you coping with taking your medication regularly? What challenges have you faced?

Use problem solving steps if patient is having problems with taking medication regularly.


Read Masa’s story.

The next step is to read or tell the following story so that your client will be able to identify interpersonal conflict.

Read the following story out loud to allow the person to think about what they are experiencing in their lives that is similar to the issues in the story associated with interpersonal conflict.



Introduce the story by saying:I am going to read a story that will help us to understand interpersonal conflict.

Masa is 27 years old and is having problems with her partner whom she lives with. Masa’s family does not have much money and because of this she moved in with boyfriend when she was very young. She has been diagnosed with high blood pressure and has to take medication every day. Her boyfriend has a job at a restaurant and often works very different times shifts. He also drinks at work and often comes home drunk. Masa is also worried that he is unfaithful to her. This is because sometimes he does not come home at all. They constantly fight about this and when Masa tries to speak to him about his drinking and not coming home he gets very angry and hits her. This makes her sad and angry which leads to her feeling very alone. She is worried about her home environment as it is not good for her high blood pressure. Masa is scared to talk to her partner because they end up fighting almost every time.

Masa yo o dingwaga tse 27 o nale mathata le mokapelo wa gagwe yo a dulang le ene. Ba lelwapa la ga Masa ga bana madi/ chelete mme se ke sone se dirileng gore Masa a fuduge a nne le mokapelo wa gagwe a santse a la monnye. O itsisitswe fa a nale blood pressure mme o tshwanetse go tsaya dipilisi malatsi otlhe. Mokapelo wa gagwe o bereka ko ko lefelong la dijo (restaurant) mme o bereka dinako tse di sa tshwaneng (shifts). O nwa thata mme a tle lapeng a tagilwe ka nako tse di ntsi. Masa o tshwenyegile ka gore o mo tsietsa ka basadi ba bangwe. Se ke ka gore nako tse dingwe ga a tle gae gotlhelele mme se se dire gore ba lwe nako tsotlhe. Fa Masa a leka go bua le ene ka go nwa ga gagwe le go tlhoka go tla gae o a tenega/kwata a bo a mmetsa. Masa o utlwisiwa botlhoko ke se a iphitlhele o kare o nosi mo botshelong. Seemo sa ko lapeng se mo tshwentse ka se sa siamela high blood ya gagwe. Masa o tshaba go buwa le mokapelo wa gagwe ka gore ba feleletsa ba lwana ka nako dile dintsi.




It is useful to unpack Masa’s story if your client is nodding their head because they recognise the conflict in the story. You could ask the following questions to help understand the interpersonal conflict in the story:• What happened?• How do you understand the problem?• How do you think Masa’s boyfriend understands the problem?• How did Masa try to resolve the disagreement• How did Masa feel then?

When the interpersonal problem is one of interpersonal conflicts or disagreement, the counsellor helps the person to identify the problem by asking:• What is the problem between the two people?• Do you think this disagreement can be sorted out or do you think you

have reached a point where you cannot go any further?

Explore options about a plan of action for solving the problem.Ask if the patient would like to share their experience of interpersonal conflict and how it makes them feel. Ask “Have you had a similar experience to Masa’s?”

Once interpersonal conflict is more clearly understood and there is greater clarity about the associated feelings, it is easier to use problem management skills to work out a resolution.




Goal• To get the patient to deal with interpersonal conflict by exploring

possible solutions to the identified problem. • Think of examples of other people the patient knows who have gone

through similar situations and have managed.

Both the counsellor and individual can think of different ways to manage the problem.


• Ask the individual which suggestions would be helpful in this situation.• Ask the individual to choose a strategy for acting on the problem.

Closure for todayThank the patient for their participation. Encourage the person to try some of these solutions out during the next week.

After the session, consider the following points about the session.




» Session 4: Social isolation and avoidance Quick guide

GOALS FOR MODULE ON SOCIAL ISOLATION

• To explore how social isolation impacts on the patient’s life.• To help the patient to get active and engage in activities they stopped

doing because of their depression.

» My notes


drawn from the Interpersonal Conflict session went

STEP 2 READ THE STORY Meiki avoids spending time with other people and has stopped

doing things she used to enjoy

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of social isolation with

Meiki’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Strategies for dealing with social isolation by getting active

STEP 5 SELECT ISSUES FOR FEEDBACK IN THE NEXT SESSION The patient considers suggestions to act upon and gives

feedback in the next session the following week





Last week we spoke about how to manage interpersonal conflict and we ended the session with you choosing a strategy to act on your problem.

Ask: How did you manage to do this?Ask: Was it helpful in making you feel better in yourself?

Get feedback on medication by asking:How are you coping with taking your medication regularly?

Remember to use problem management steps if individual is experiencing challenges with taking his/her medication.




Read Meiki’s story.

Introduce the story by saying:I am going to read a story that will help us to understand social isolation and avoidance.

Meiki is a 34 year old single parent with two children. She has had asthma since she was a child and has been on ARVs for three years. She has recently been diagnosed with high blood pressure. She decided to move out of her parents’ home because she does not get along with her brother and she tries her best not to be around when there are family gatherings, which she previously enjoyed.

She also withdrew from participating in church activities which she had been leading. She has now stopped jogging with her friends as she feels they are too loud and that her body can no longer deal with exercise. She has since put her children in boarding school as she feels she cannot care for them and is afraid of telling them that she has the virus.

She now goes to work and comes back to spend her free time inside her room and she always makes excuses if friends want to visit her. She spends all her free time sleeping and cries herself to sleep. She has also gained weight as she finds comfort in food. She has not disclosed her status to anyone as she is ashamed of how people will look at her as she is a saved Christian. She is also worried that she now has to take high blood pressure medication.



Meiki ke mosadi yo dingwaga tse 43 yo o nang le bana ba le babedi mme a ba godisa a le nosi. O nale asthma gotswa bonyaneng le ngwaga tse tharo a tsaya di ARV. Mo nakonyaneng ya go feta o itsisitswe fa a na le high blood. O ile a tsaya tshwetso ya go fuduga ko ntlong ya batsadi ba gagwe ka a sa utlwane le kgaitsadie. O leka ka thata gore a seke a nna teng fa go nang le dikopano tsa lesika selo se se neng se mo itumedisa pele . O tlogetse go dira ditiro tsa kereke ko e neng e le moeteledi pele. Ga a sa tlhole a taboga le ditsala tsa gagwe ka a utlwa o kare ba modumo mme ebile a bona o kare mmele was gagwe ga o a nonofela go taboga. O ile a tsenya bana ko boarding school ka gore o ikutlwa e kare o ka se kgone go ba tlhokomela. O tshaba le go ba bolelela gore o na le bolwetsi ja HIV.

Sa gagwe ke go ya tirong/ mosebetsing a bo a dirisa nako e setseng ya gagwe mo kamoreng ya gagwe. O fa mabaka a seng a sepe fa distala tsa gagwe di mo etetse. O dirisa nako yotlhe ya gagwe a robetse mme o lela nako tsotlhe. O simoletse go ja thata mo go dirileng gore a oketse mmele. Ga gona ope yo a mmoleletseng ka seemo sa gagwe sa HIV ka a tlhabiwa ke dilthong gore batho ba tla mo leba jang e le mokeresete. O tshwentswe gape ke gore o tshwanetse go tsaya dipilisi tsa high blood.


Ask what the individual thinks about social isolation and why people do this. An example of this from the story of Meiki is illustrated in the diagram below. Meiki feels sad and lonely because of her illness; she does not feel like going out and visiting and then this results in her feeling even more sad and lonely.

I feel more sad and lonely

I do not feel like visiting my friends

I feel sad and lonely because of my illness

• Ask the individual to identify with this story.• Ask the individual to share an experience of social isolation.




GoalsTo help people recognise social isolation in their own lives and encourage them to become more active.

In Step 4, remember to draw on your skills on how to get active that you learnt during the first part of your training.

When people are depressed they often avoid social situations, stop exercising, withdraw from friends and family, and avoid activities that they would normally enjoy. All of this makes people feel even more depressed.

Getting active can encourage depressed people to do activities again that they previously enjoyed but have stopped doing. Getting active can make them feel better.

» Steps for encouraging people to do get active and do things.

STEP 4 Taking action

STEP 3 Identifying positive enjoyable activities

STEP 2 Helping people recognise and identify enjoyable activities that they have stopped doing

STEP 1 Helping people recognise how negative feelings about oneself can make them stop doing things that they used to enjoy

As the counsellor, you want to help the patient recognise social isolation in their own lives and encourage them to become more active.

The table on the next page offers some ideas of what to do to get active.

First you need to ask the patient what he/she thinks they can do in their lives to get active by asking the following:

• Now that we understand what social isolation is about and have identified with the story of Meiki and recognised our own behaviour, think about what you used to do that made you feel happy.

• Let us brainstorm some ideas…



» Here are some positive examples that you can add to the contribution of the group members.

Do some gardening Go home to visit family

Dress up and look nice Enjoy a cup of tea

Visit the farm Talk to a friend on the phone

Chat to a friend Do community work

Style your hair Cook a meal

Join a social group Clean your house

Spend some quiet time to think and be calm / meditate

Tell a story to the children or play a game

Meet new people Do some volunteering

Mend clothes / sew Send an SMS to friend

Attend a church group gathering Listen to music

Go Shopping Attend choir practice

Watch TV Look at photos

Play with the children Go for a walk

Go for soccer or netball Sing to yourself

Make music Dance

Read a newspaper Help someone in need

Sew / knit Play a game

Paint your nails Put on your favourite hat

Visit an old or lonely person Make love

Walk children to school Make home look nice

Whistle a tune Tell a joke

Bake something nice Say ‘I Love You’ to someone special

Focus on happy memories Wash dishes

Do laundry, washing and ironing Hug your children




Reflect on the activity list.

Ask the patient if there is an activity they would like to do during the next week? If the person is stuck and can’t think of an activity to do, ask him to choose one from the list of examples.

Closure for today Thank the patient for his participation. Remind the person about the details of the next meeting. Give them the date and time and venue.

After the session, consider the following points about the session.




» Session 5: Grief and lossQuick guide

GOALS FOR SESSION ON GRIEF AND LOSS

• If your patient has lost someone close to them, help them to mourn the loss of their loved one.

• Allow the person to express feelings of sadness.• Find ways to normalise these feelings of sadness.• Help the person to come to terms and accept their loss by finding ways

to reorientation their lives through finding support or activities to help connect with other people.

» My notes


drawn from the Social isolation and avoidance session went

STEP 2 READ THE STORY Thabo recently lost his wife and sister and is having problems

in coming to terms with the losses

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of grief and loss with

Thabo’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Getting support and ideas on mourning the loss of loved ones

through problem management

STEP 5 SELECT ISSUES FOR FEEDBACK IN THE NEXT SESSION Support patient to choose suggestions to act upon and give






Ask if the individual was able to do one thing that made them feel happier in the previous week.

Ask: Was it helpful in making you feel better?


Use problem management steps if individual is experiencing challenges with taking his/her medication.


Read the story of Thuso.

Introduce the story by saying:I am going to read a story that will help us to understand loss and grief.

Thuso is a 40 year old man who lives in an informal settlement near a small town. He has four children- Thabo who is 18 years old, Tshepang who is 16 years old, Jabu who is 12 and Palesa who is 7 years old. Thuso was diagnosed with HIV a year ago and started ARV treatment immediately after his wife, Sophie, tested positive. Six months ago after suffering a long and excruciating fight against TB his wife died. While grieving the loss of his wife, Thuso lost his sister Tlamelo. Tlamelo and Thuso were very close and he used to share everything with her. She left behind 2 children; Dika and Rose. Thuso is now the sole provider for 6 children. During this difficult time Thuso started thinking about his own death. He started worrying about who would look after the children were he to die. His in-laws would most certainly not assist in being guardians as they blamed him for the death of their daughter. Since Sophie and his sister Tlamelo died he cries every day. He lies awake at night finding it difficult to fall asleep and thinks about Sophie. He feels guilty; he does not know if he infected her with HIV/AIDS or if she infected him. He gets angry and impatient with other people. His friends no longer visit him because he does not talk to them when they do. He finds it very difficult not to feel pain when thinking about Tlamelo and Sophie. He does not normally drink but recently started in an attempt to dull the pain.



Thuso ke monna yo o dingwaga tse 40 yo e leng moagi wa lekeishane lengwe gaufi le toropo nngwe. O na le bana ba le bane- Thabo yo a leng dinwaga tse 18, Tshepang yo a leng 16, Jabu yo a leng 12 le Palesa yo a leng 7. Thuso o ne a itsisiwe fa a nale tshwaetso (HIV) ngwaga e fitileng mme a simolola di ARV morago ga gore Sophie mosadi wa gagwe a tlhatlhobiwe mme ga fitlhelwa a nale HIV. Morago ga dikgwedi tse thataro (6) mosadi wa gagwe a lwala TB o ne a tlhokofala. Kgaitsadia Thuso, Tlamelo, le ene o ne a tlhokafala nako e khutshwane morago ga mosadi wa gagwe. Thuso le Tlamelo ba ne ba utlwana thata e bile a kgona go bua le ene sengwe le segwe. Tlamelo o tlogetse bana bale babedi, Dika le Rose. Bana ba botlhe ka borataro ba bone ba lebagane le Thuso. Ke ene a ba direlang sengwe le sengwe. Mo nakong e thata e, Thuso o ile a simolola go akanya ka leso. O ne a ipotsa gore ke mang yo o tla tlhokomelang bana ba fa a ka tlhokofala. Tota o ne a sa bone fa bagwagwadi ba gagwe ba ka tlhokomela bana ba ka ba ne ba re ke ene a bolaileng ngwana wa bone Sophie. Thuso o tshela ka go lela e sale Sophie le Tlamelo ba tlhokofala. Ga a kgone go robala bosigo a touta ka Sophie. O ipolelela fa e le ene a mmolaileng ka go mo tshwaetsa le fa a sena bosupi ja gore ke mang yo o swaeditseng yo mongwe. O tenega ka pela mme ebile o felela batho ba bangwe pelo. Ditsala tsa gagwe di emesiste go mo etela ka gore ga a ba buise fa ba tlile go go ene. O utlwa botlhoko thata fa akanya ka Sophie le Tlamelo. Thuso ke motho yo o neng a sa nwe bojalwa mme jaanong o simolotse go bo nwa gore a leke go lebala kutlobotlhoko e kanakana e.




Loss and grief are part of everyday life. Grief is a normal but often very painful response to loss. Grief can be experienced with the loss of different things and not only loved ones. Different people react differently to loss.

For example, one person may want to talk about their feelings and another would prefer not to talk about what they are experiencing. How you respond to loss will depend on a lot of factors which include the kind of relationship you had with the person who has passed away.

There is no right or wrong way of grieving. No matter what the reaction, a grieving person needs support from other people.

The focus of this session is on the loss of a loved one as we have seen with the story of Thuso.

Ask the individual to share his/her experience of grief and loss.


Goal• To get the patient to deal with grief and loss by exploring possible

solutions; to even use examples of other people known to the patient who have gone through similar situations.

• Both the counsellor and patient can think of different ways to manage the problem.

• Ask the patient which of suggestions would be helpful in the situation.




Support the person to identify and choose a strategy to act on in relation to the theme of grief and loss.

Encourage the patient to try the solution out during the week.

Closure for todayThank the patient for their participation and give them the date and time and venue.

After the session consider the following.




» Session 6: Experienced stigmaQuick guide

GOALS FOR SESSION ON EXPERIENCED STIGMA / DISCRIMINATION AND REJECTION

• Help the patient to define what experienced stigma, discrimination and rejection means.

• If the patient has experienced actual stigma, discrimination and rejection, help the person to express feelings around these issues.

• Explore with the person why others may react in this way.• Share suggestions on how to approach those who have attitudes

of discrimination.• Explore ways of responding to experiences of stigma,

discrimination and rejection.• Encourage individuals to find new support systems.

» My notes


drawn from the Grief and Loss session went

STEP 2 READ THE STORY Lerato’s in-laws blame her for their son’s death; people are

treating her differently since her husband died from AIDS

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of external stigma

with Lerato’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Getting support and ideas on dealing with experienced stigma

through problem management

STEP 5 SELECT ISSUES FOR FEEDBACK IN THE NEXT SESSION With the patient, choose suggestions to act upon and give






Ask the individual if he/she was able to use the suggestions from the previous week on the loss of a loved one.

Ask the individual if was helpful in making him/her feel better.


Use problem management steps if individual is experiencing challenges with taking his/her medication.




Read Lerato’s story.

I am going to read a story that will help us to understand experienced stigma.

Lerato is a 32 year old woman married with 3 kids. She currently lives with her in-laws in a rural community near Durban. Her husband passed away a year ago. She does not have a good relationship with her in-laws as they blame her for their son’s death. People from her village found out that her husband died from AIDS. Since then they have been treating her differently. Her in-laws no longer want her to cook for the family and have requested her to move out of their compound. The neighbours do not want her kids to play with their kids anymore. They have even kicked her out of their stokvel group with an excuse that she will not afford to pay since her husband who

was their sole provider passed away. They have been calling her names behind her back and saying that it is her fault that she has HIV because she is a sinner.

Lerato ke mosadi yo o dingwaga tse 32. O nyetswe mme o na le bana ba le 3. O nna le bomatsalaagwe ko magayeng gaufi le Durban. Monna wa gagwe o na le ngwaga a tlhokafetse. E sale monna wa gagwe a tlhokafala ga a utlwane le bomatsalaagwe ka gore ba re ke ene a mmolaileng. Batho mo motseng ba a

mo kgetholola sale ba utlwa fa monna wa gagwe a bolailwe ke AIDS. Bomatsalaagwe ga ba batle go tlhakanna pitsa le ene mme ba mo laetse gore a fuduge mo lelwapeng la bone. Baagisane ga ba bate bana ba gagwe ba tshameka le ba bone. Gotswa ka nako eo ba mo tshwara ka mofuta o mong. Bo mogadibo ga ba so tlhole ba batla a apela ba lelapa e bile bamo kopile gore a tswe ka motse wa bone. Baagisane ba mo kobile/lelekile ko stokvel ba dirisa lebaka la gore o kase kgone go patala ka gore monna wa gagwe e ne e le ena fela yo o nang le letseno. Bantse ba mo bitsa ka maina mo morago ga gagwe ba re ke molato wa gagwe a bo a nale tshwaetso (HIV) le gore ke modira dibe.




Ask the individual what they think experienced stigma is and where it comes from.

Ask the individual to share an experience of experienced stigma.


Goal• To get the individual to deal with externalised stigma by exploring solutions.

The person could think of other people known who have gone through similar situations and how they managed to cope with their experience.

• Share suggestions as to how one could approach those who have attitudes of discrimination.

• Explore ways of responding to experiences of stigma, discrimination and rejection.

• Encourage individual to find new support systems.

Both the counsellor and individual can think of different ways to manage the problem.

» Remember to draw on your skills on problem management.









• Ask the individual which of the suggestions would be helpful in this situation.

• Ask the individual to choose a strategy for acting on the problem.• Encourage the individual to try a solution out during the next week.

Closure for today Thank the patient for his participation. Remind the person about the details of the next meeting. Give him the date and time and venue.

After the session:




» Session 7: Internalised and perceived stigmaQuick guide

GOALS FOR MODULE ON INTERNALISED STIGMA AND PERCEIVED STIGMA

• Help the patient to define what internalised stigma means for them.• Help individuals who have experienced internalised stigma express their

thoughts and feelings around this issue.• Explore ways of responding to experiences of internalised stigma.• Assist with ways of how to deal with experiences of internalised stigma.

» My notes


drawn from the Experienced Stigma session went

STEP 2 READ THE STORY Katlego thinks people see her as dirty and worthless due to her

disease, and sees herself as a disgrace to her family

STEP 3 IDENTIFY WITH THE STORY Identify own problems or experience of internalized stigma

with Katlego’s story

STEP 4 EXPLORE WAYS OF MANAGING THE PROBLEM Work on identifying negative thoughts and replacing them with

Healthy Thinking

STEP 5 SELECT ISSUES FOR FEEDBACK IN THE NEXT SESSION Think of suggestions to act upon and give feedback on in the






Last week we spoke about experienced stigma and we ended the session with you choosing how you were going to use your problem management skills to feel better.

• Was the patient able to use the suggestions from the previous week to act on the problem?

• Ask the individual if it was helpful in reducing any negative feelings.


Remember to use problem management steps if individual is experiencing challenges with taking his/her medication.




Read Katlego’s story.

I am going to read a story that will help us to understand internalised stigma/perceived stigma

Katlego ke mosadi yo dingwaga tse 30 mme ga a nyalwa. O nna le ba lelwapa la gagwe mme o na le barwadi ba le babedi; yo o dingwaga tse 5 le yo dingwaga tse 2. O ile a itse fa a nale tshwaetso (HIV) fa a le mo mmeleng wa ngwana wa bobedi. O ipona e le motho yo o leswe ka a na le tshwaetso. O tlhabiwa ke ditlhong go bolelela ba kelwapa la gagwe ka tshwaetso ya gagwe ka a akanya gore ba tlare ke ditiro tsa gagwe tse di dirileng gore go nne jaana. Gape o akanya gore ba ka tlogela go tlhokomela bana ba gagwe ka gore o na le tshwaetso. O tshaba le gore ba kase mo amogele le gore ba tla moleleka ko ntlong. Fa Katlego a le mo gare ga batho ka nako tse dintsi o akanya gore ba bona fa e se motho wa sepe le fa ba sa itse seemo sa gagwe. O ipona molato ka se se mo diragetseng gape o akanya fa a tlontlolotse ba lelwapa.

Katlego is a 30 year old single woman. She currently lives with her family and has 2 daughters, a 5 year old and a 2 year old. She found out that she was HIV positive when she became pregnant with her second child. She now thinks of herself as dirty and contaminated because of her status. She feels ashamed of telling her family and fears that they will blame her for having HIV and they will not support her or her kids if they find out. She is also afraid that they will reject her and kick her out of the house. When Katlego is around others she often thinks that they see her as worthless even though they do not know her status. She also blames herself and feels guilty for what has happened to her and sees herself as a disgrace to her family.




• After hearing the story of Katlego, ask what the individual thinks internalised stigma is and where it comes from.

• Ask individuals to think of any negative stigmatising thoughts they may have about themselves.

• Ask the person to share these thoughts.

The “box” below provides some examples of unhealthy thinking that you can use during the discussion.

» Common examples of unhealthy thinking.

• You exaggerate what is happening in a situation.• You see a general comment as meaning something about

you personally.• You see something someone said about a specific situation or

person as applying to all situations or groups of people.• You reject any positive events and only focus on the negative.• You jump to a negative conclusion most of the time.• You think that making a small mistake will lead to a big punishment.• You feel bad about yourself, so you think that others must see you

as a bad person.• You tell yourself that you ‘should do this’ or that you ‘shouldn’t do that’.• You focus on the negative aspects of a situation until they become

the only thing that you can see.• You think that your life is now over because you have HIV.• You worry about negative things even though they are beyond your

control and you can’t change them.




Goals• To help individuals replace unhealthy thinking with healthy thoughts.• Getting support to identify negative thoughts and replace them with

healthy ones through Healthy Thinking.• To get individuals to deal with internalised stigma. Consider people they

knows who have gone through similar situations and how they managed to cope with their experiences.

» Steps in promoting healthy thinking.

STEP 3 Replacing unhealthy thoughts with more accurate ones

STEP 2 Analyse the accuracy of the thoughts

STEP 1 Gaining awareness of unhealthy thoughts

To put healthy thinking into practice you can ask the individual being helped the following questions: • How do these negative thoughts make you feel? • What do these negative thoughts make you do?• Do you have proof that these thoughts are true? • What are other explanations for the situation to help replace these

negative thoughts with healthy ones?• How does this new thinking make you feel now?




Ask the individual to choose a strategy for acting on the identified problem.

Encourage the individual to try some of these solutions out during the next week.

Closure for todayThank the patient for their participation. Remind the person about the details of the next meeting. Give them the date and time and venue. Remind the individual that nest week’s session will be the closing session.

After the session:




» Session 8: ClosureQuick guide

GOALS FOR SESSION ON CLOSURE

• Help your patient to express what they have learnt though participating in the sessions.

• Allow your patient to express their feelings about ending the sessions.

» My notes

STEP 1 FEEDBACK FROM LAST WEEK Get feedback on how acting on the problem drawn from the

Internalised and perceived stigma session went

Raise issues and feelings associated with ending the sessions

Recognise the successes that individual had during the sessions

Provide Contact details of relevant NGO’s or professionals for cases in which additional help is required if the depression reoccurs




To get feedback from the patient about their week, you can ask the following questions:• Did you manage to resolve the issues we spoke about last time?• What worked for you?• How do you feel about this being the last session?• In what way do you think these sessions can continue to help you even if

we do not continue to meet for weekly sessions?

The following points are useful to bring closure to the sessions: • invite the patient to give an outline of what they have learned;• ask how they can continue to put their new skills into practice;• reflect on how difficult it can be to end sessions and to say goodbye;• ask about the feelings of ending the sessions and normalize any

fearful feelings; • ask for practical ideas about how they can get support from their

community or family;• offer additional contact details of professionals and NGO’s that may be

helpful should the patient need to speak to someone about their difficulties;

• acknowledge the patient’s commitment to the sessions and how much you have learnt about their capacity to learn about depression and their difficulties; and

• thank the person for sharing their story with you.

Closure for todayReflect on these sentences to help you to debrief.

After this session I feel …… because I ……What I learnt about myself today ……I am worried about ……Anything I need to do differently next time ……Patient referred to or discuss concerns with the sister or doctor ……

102

Getting to know your chronic condition(s)

and medication

Get

ting

to

know

you

r ch

roni

c co

ndit

ion(

s) a

nd

med

icat

ion


103 PRIME/COBALT: Getting to know your chronic condition(s) and medication

Contents

Aim of the session 104

Read Musa’s story and introduce the story by saying: 105

Understanding our chronic condition 106

Understanding medication 107

Managing problems with taking medication regularly 110

Closure 111


104PRIME/COBALT: Getting to know your chronic condition(s) and medication

» Aim of the sessionThis session can be used to provide patients with information about their chronic illness and how they can help themselves

It can also be used to provide information on how their chronic medications work to help the different chronic conditions and why it is important to take their chronic medication regularly

It also aims to help patients who are not taking their medications regularly to take them more regularly.

It is offered on an individual basis to patients after the counselling session of poverty.

Counsellors need to make individual appointments for patients and ask them to bring their medications to the session so that you can go through them with the patient.

Example of what to say:As part of your depression treatment, we are offering this one-on-one session to help you understand the condition(s) you have and the chronic medication that has been recommended for you. During the session you will get information about your chronic condition(s), why medication is needed for them, and a chance to go through your specific medications learning what they are, how they help you, and why it is important to take them regularly at the set times.

Often people have medication started for a chronic condition, yet never have a chance to learn about that condition, and how medication might help them. During this session we will go through your conditions, and share some information about them, and what actions you can take to help remain healthy.”



» Read Musa’s story and introduce the story by saying:I am going to read a story about someone who has to take chronic medication to help us understand some of the issues with adherence

Musa is a 55 year old man. He is HIV-positive and has also been told that he suffers from hypertension. He used to work on the mines but was retrenched recently. He has recently been put on anti-retroviral treatment (ART) and also receives medication for hypertension. He complains that he doesn’t know what is wrong with him and why he has to take so many pills. Besides, not being able to remember when he is supposed to take which pills because there are just too many, he is not sure how this “white” medicine is supposed to help him. He also

likes to drink and has been told he can’t take alcohol with the medicine. Consequently he only takes the medication when he remembers and when he hasn’t been drinking.

Musa ke rre yo o dingwaga tse masome a matlhano le botlhano. O na le tshwaetso (HIV) mme gape o itsesitswe fa a nale madi a kwa godimo kana high-blood. O ne a direla moepong kwa a neng a kgaolwa mo tirong bosheng. O sa tswa go bewa mo lenaneong

la go tsaya ditlhare tsa ART mme gape o tsaya le tsa high-blood. O ngongorega ka gore ga itse gore o lwala eng le gore ke eng a tshwanetse go tsaya dipilisi tse di bontsi bo kana. Kontle ga gore o lebala gore o di nwa leng, ga a na nnete ya gore melemo e ya makgowa e tlile go mo thusa. Ene tota ke motho yo a ithatelang go nwa mme o boleletswe gore a seka a tlhakanya bojalwa le melemo kana ditlhare. Ka jalo o nwa melemo fa a gakologelwa gape a sa nwa bojalwa.



» Understanding our chronic condition Discuss the story and ask if the patient relates to the aspect of the story of how Musa doesn’t understand his conditions and why he has to take so many pills.

Say: Do you have any experiences similar to Musa’s with regard to not understanding your condition?

Ask the patient to list their chronic conditions.

Then take each one in turn, and using the patient information leaflets explain to the patient what each condition is about.

Example of what to say:I see you have hypertension or high blood. Let’s use this leaflet to learn what hypertension is about, and what you can do to remain healthy. At the end of today’s session I will give you copies of the leaflets to take home with you, so that you can read further about them at home. So please don’t worry if you can’t remember every little detail we discuss today.”

Take each leaflet in turn (see example below). Read through the leaflet with the patient. Use your listening skills and observation skills (verbal and non-verbals) to find out how much a person knows about their conditions. People may know a fair amount about some conditions (like HIV and ART) but less about others. Spend time on the conditions they know less about, and praise their knowledge about conditions they do know something about.

If there are many conditions, consider doing this session over two visits. Remember people can only absorb so much information at a time.

» Example of a leaflet

© 2015, University of Cape Town Lung Institute (Pty) Ltd - all rights of copyright vesting in all the original works and material used by the University of Cape Town Lung Institute (Pty) Ltd in the preparation and development of the Information Leaflet, in and during 2015.

What is hypertension?• Hypertension is high blood pressure (BP) that puts strain on the heart, blood vessels and kidneys.

• Hypertension does not usually cause you to feel sick, stressed or have a headache.

• Hypertension increases the risk of heart attack, stroke (brain attack) and kidney failure.• A TIA is a brain attack that gets better within 24 hours. Seek help urgently to avoid a bigger stroke.

• The goal of hypertension treatment is a BP under 140/90 or if you have diabetes a BP between 120/70 and 140/80.

What can help you reach your goal for hypertension?

Take medication as instructed

Hypertension treatment is lifelong to prevent heart attack, stroke and

kidney failure.

Most people need more than 1 medication to control their BP. Be sure you know what your medication is for and how much and how often to take it. Take pills as instructed on the packet/box every day. They should never run out.

Take action!

If you have any of:• Sudden chest pain – may be a heart attack• If you take enalapril and have swelling of tongue, lips, face or difficulty breathing

• Sudden weakness of arm, leg, side of face – maybe a stroke or brain attack

• Sudden loss of speech or vision – maybe a stroke or brain attack

A stroke can be reversed if treated within 4 hours. Visit the health facility urgently today.

If you are unsure how to take your medication, ask your CCW for help.

Hypertension

How will you fit this into your day?

Choose 1 at a time:

Eat less

Get active

Stop smoking

Cut out or cut down

alcohol

If the patient has a chronic condition for which you do not have a leaflet, ask them to ask their nurse or doctor to explain their condition at their next consultation:

Say: “I don’t have any information about that particular condition available. Please would you ask the nurse or doctor to explain your condition to you at your next consultation”



» Understanding medicationAsk if the patient relates to the aspect of the story of how Musa doesn’t understand which medication is for what condition and how the medications can help his conditions. Say: Do you have any experiences similar to Musa’s with regard to not understanding how your medications can help your condition/s?

Probe a bit about what they don’t understand about their medications

Say: “Chronic conditions like yours often require several chronic medications. It can be difficult to take them all if you haven’t learned exactly what they all are, how they work and why you need to take them regularly.

That’s great that you bought all your medications today. Let’s go through them one by one shall we?”

Patient should bring along their pack of medication to the session. Go through their medication with them by using the drug list. 1. Look for your patients’ medication on the drug list.2. Be sure the patient understands what condition the medication is for3. Explain how the medication works4. Make sure they know the dosage and when to take the medication (Check

on the packet/bottle for when and how often to take it).5. Explain possible side effects. Ask if there are problems that s/he thinks

might be caused by the medication. If the problem is a side effect below, the patient should discuss it at the next health facility appointment or if in red, seek help urgently.

Drug Condition How it works Side effects

Amitriptyline Depression Relieves pain at low dose and treats depression at higher dose.

Sleepiness, dry mouth, constipation, sexual problems

Amlodipine(step 3 treatment for hypertension)

Hypertension Relaxes blood vessels, decreases BP, placing less strain on heart.

Swelling of feet, tiredness, dizziness, stomach ache

Amoxicillin COPD Treats lung infections Nausea, diarrhoea, itchy skin rash

Aspirin Hypertension, diabetes

Thins the blood to prevent a stroke or heart attack.

Stomach pain or bleeding, avoid in asthma

Atenolol(step 4 treatment for hypertension)

Hypertension Slows down the heart rate which puts less strain on the heart and decreases the BP.

Heartburn, dizziness, impotence, depression, tiredness, problems sleeping

Beclomethasone nasal spray

Asthma Prevents hayfever – itchy, runny nose

Uncommon

Budesonide inhaler(preventer)

Asthma, COPD

Helps prevent a tight chest. Use even if chest is not tight.

Sore mouth – rinse mouth after use to avoid it.

Carbamazepine Epilepsy Prevents fits. Sleepiness, headache



Co-trimoxazole HIV Helps protect from some infections when the immune system is weak.

Skin rash (seek help urgently if also rash in mouth)

Doxycycline COPD Treats lung infections. Take with lots of water to avoid heartburn.

Efavirenz HIV Antiretroviral drug used together with 2 others to lower HIV level in the body.

Problems sleeping, nightmares, dizziness – should pass in 6 weeks

Enalapril(step 2 treatment for hypertension)

Hypertension, diabetes

Prevents tightening of blood vessels, which decreases the BP and protects the kidneys.

Swelling of tongue, lips, face, difficulty breathing, dizziness on standing up, dry cough

Fluconazole HIV Kills and protects from germs that occur in AIDS.

Yellow skin and eyes

Fluoxetine Depression Treats depression Headache, nausea, diarrhoea, sexual problems

Glibenclamide(Take with food or 30 minutes before food)

Diabetes Lowers the sugar in the blood.

Irritable, tired, sweaty, shaky and/or confused – eat sugary food/drink, if no better, seek help.

Gliclazide(Take with food)



Hydrochlorothiazide(HCTZ)(step 1 treatment for hypertension)

Hypertension Helps the kidneys get rid of excess water, thus decreasing the BP.

Headache, nausea, swollen painful joint/s

Insulin(Take 30 minutes before food)



Ipratropium inhaler reliever

Asthma, COPD

Helps to open the chest. Use when chest is tight.

Uncommon

Isoniazid HIV Helps prevent TB Painful feet and legs

Lamivudine/3TC HIV Antiretroviral drug used together with 2 others to lower HIV level in the body.

Uncommon

Metformin Diabetes Lowers the sugar in the blood.

Nausea, diarrhoea, abdominal cramps

Phenytoin Epilepsy Prevents fits. Gum thickening, unsteady on feet, sleepiness

Prednisone Asthma, COPD

Helps to open the chest. Disturbed sleep, depression

Pyridoxine – vitamin B6

TB Protects from nerve damage in the legs caused by isoniazid.

Uncommon

Rifafour e-275® (rifampicin, isoniazid, pyrazinamide, ethambutol)

TB Combination of 4 drugs that work in different ways to kill TB germs.

Painful feet and legs, yellow eyes and skin, orange urine, skin rash

Rifinah®(rifampicin, isoniazid)

TB Combination of 2 drugs that work in different ways to kill TB germs.

Painful feet and legs, orange urine, skin rash

Salbutamol inhaler reliever

Asthma, COPD

Helps to open the chest. Use when chest is tight.

Tremor, dry mouth, anxiety, headache



Simvastatin Diabetes, hypertension

Lowers cholesterol in the blood to prevent heart attack, stroke.

Stomach pain, muscle weakness

Sodium valproate Epilepsy Prevents fits. Yellow skin/eyes, indigestion, weight gain, tiredness.

Tenofovir HIV Antiretroviral drug used together with 2 others to lower HIV level in the body.

Kidney problems – routine blood tests will identify this.

Tenofovir/emtricitabine/efavirenz

HIV 3 drugs in one tablet work together to lower HIV level in the body.

Problems sleeping, nightmares, dizziness – should pass in 6 weeks. Kidney problems – routine blood tests will identify this.

Theophylline Asthma, COPD

May help to open the chest if taken regularly.

Nausea, diarrhoea, headache, irritability, dizziness, fits



» Managing problems with taking medication regularlyAsk if the patient relates to the aspect of the story of Musa not talking his medication regularly.

Say: Do you have any experiences similar to Musa’s with regard to not taking your medication regularly?

Ask: What challenges are you facing in taking your medication?”

Allow for the patient to answer drawing on skills learned for understanding a problem.

Probe: Say: Some of the challenges you mentioned in taking your medication regularly were….[PAUSE – to allow for patient to lead here by coming up with a possible solution to some of the challenges]

Acknowledge what the patient has been doing well in managing her medicationExplore what has helped the patient during the times that taking the medication was easier for him/her.

Say: What has been helping you in remembering to take your medication?”Draw on your skills on problem management to help the patient explore possible ways of helping them to take their medication regularly and decide on a strategy/strategies

Develop action plan with patient for taking their medication or review action plan that they have developed with nurse

Steps for Problem Management








» ClosureThank the patient for coming for the session. Remind the person about the details of the next counselling session. Give them the date and time and venue.

Say: “In our next group/individual counselling session I will ask how well you are doing with taking your medication regularly”.

Documents

Counselling Manual for Depressionwebcms.uct.ac.za/sites/default/files/image_tool... · Counselling Manual for Depression 1 PRIME/COBALT: Welcome » Welcome to your counselling training