Depression and Adherence Counselling Master Trainer’s ... · be provided for the Master Trainer to fulfil their responsibilities in the MhINT programme. About the MhINT cascade

Name

Depression and Adherence Counselling Master Trainer’s Manual for Psychologists

2019edition

MhINT:Psychologists Master Trainer’s Manual

About the MhINT Depression and Adherence Counselling Master

Trainer’s Manual for Psychologists

Welcome to your manual! This manual has been developed to be used by psychologists involved in the implementation of the Mental Health Integration Programme. Please note that this manual is not a stand-alone-manual and is designed to be used in conjunction with the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors and Depression and Adherence Counselling Manual for Lay Counsellors. Where appropriate, the Master Trainer will be referred to the contents of the Registered Psychological Counsellors’ Training Manual and additional or specific information or instructions will be provided for the Master Trainer to fulfil their responsibilities in the MhINT programme.

About the MhINT cascade model of training

The MhINT programme uses a cascade model of training to implement the Depression and Adherence Counselling Sessions at Primary Health Care level. Diagram 1 provides a summary of those involved, where they are located, their activities and the materials used.

The 3 manuals and associated training programmes are developed as a coherent suite of materials that are progressively layered according the need and specific outcome for each level. With this in mind, it is essential for the Master Trainer to know and use all 3 manuals to ensure that the messages remain coherent and are followed through at each level. Likewise, the Registered Psychological Counsellor, or Trainer, needs to have an intimate knowledge of their manual and that of the Lay Counsellors'.

Lay Counsellor or Enrolled Nursing assistant

Registered Psychological Counsellors (Trainer/Supervisor)

Psychologist (Master Trainer)

Where situated

Who

Intervention tasks

Materials

Hospital Community Health Centre

Primary Health Care Clinic

• Lay Counsellor Manual• Adherence leaflets

• Morning Talk/adherence• Individual and group

sessions for depression and adherence counselling

• Training, Supervision & Emotional Support Manual (Trainer Manual)

• Lay Counsellor Manual

Trainer of Master Trainers

• Train, supervise & emotional support of Lay Counsellors

• Individual supervision of Lay Counsellors

• 2x competency evaluations of Lay Counsellors

• 1x Month Lay Counsellor group supervision

• Train & supervise Registered Psychological Counsellors (Trainers)

• Supervision review of Registered Psychological Counsellors (Trainers)

• Train Master Trainers• Mentor Master Trainer

during first training

• Master Trainer Manual• Trainer Manual• Lay Counsellor Manual

External service provider/partner

Patient

Patient Patient

Patient

Patient Patient

Patient

Patient Patient

• Suite of MhINT manuals

» Diagram 1 MhINT cascade model of training

Use of these manuals is strictly restricted to those identified and who have been trained to use it to provide training and supervision in facilities where MhINT is implemented.

MhINT:Psychologists Master Trainer’s Manual

2 MhINT:Psychologists Master Trainer’s Manual

CONTENTS

SECTION 1: MhINT and Me 5

The Mental Health Integration Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6The problem 8The solution 8

MhINT and ME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8What training will I need? 8My role and responsibilities 8

Support and supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Activities of successful Master Trainers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

SECTION 2: Insights for Psychologists with regards to the MhINT Training Approach 13

Starting with the end in mind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modelling 14Anxiety and the disorientating dilemma 14

1 . The Learning Styles Inventory (LSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Learning Styles Graph 15Reflecting on my Learning Style 16What Master Trainers need to know about the Learning Styles Inventory 17

Co-facilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

2 . Training approach based on the work of Lev Vygotsky . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

3 . The application of the principles and practices of Adult Learning and Teaching . . . . . . . . . . 25

Curriculum considerations for MhINT Psychologists to train Registered Psychological Counsellors (RPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

4 . Enabling a safe learning environment through the purposeful use of group structure . . . 27The training environment 27Group size matters 27Seating 27Group phases and facilitator roles and responsibilities 28

Time allocation for group phases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

The use of ice-breakers and energisers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

SECTION 3: Preparing for a training 33

Registered Psychological Counsellors in the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Preparing for training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Recommendations for training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

3MhINT:Psychologists Master Trainer’s Manual

SECTION 4: Master Trainer’s step-by-step 35

Registered Psychological Trainers 4-day training programme at a glance . . . . . . . . . . . . . . . . . . 36

Master Trainer’s Step-by-step Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Day 1 37Day 2 46Day 3 52Day 4 57

SECTION 5: Supervision and emotional support for Registered Psychological Counsellors 59

Exploring supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Activity 1 – What supervision means to ME 60Activity 2 - Self-knowledge 61

Balancing education and psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Diverse professional knowledge and experience channelled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Applying CBT to content and process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Activity 4 – Applying CBT healthy thinking skills to your new role as Master Trainer 66The spiced up sandwich technique 67

Psychologists MhINT Supervision and Support Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

SECTION 6: Monitoring for Improvement 69

The MhINT Process Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Implementation data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Systemic factors 73Lay Counsellor factors 74Supervisor factors 74

Recommended approach to data review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Contribution to CQI Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

In summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

SECTION 7: Resources 77

Pre-training evaluation: Psychologists – Master Trainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Post-training evaluation: Psychologists – Master Trainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79


SECTION 1

MhINT and Me

The contents of this section are tailored for the Psychologist, the Master Trainer, for the MhINT programme.

The more familiar you are with the programme as a whole and the scope of practice of each role player, the more you will be able to help each one to practise safely towards the common good of the whole programme.

A mindset of collaboration, integration and task sharing is key towards the success of MhINT.

SECTION 1: MhINT and Me


The Mental Health Integration Programme

The Mental Health Integration Programme (MhINT) is aimed at integrating mental health care in routine care in Primary Health Care facilities. This integration involves several stakeholders in collaboration with the Department of Health.

As a Psychologist you are in possession of special sets of skills to provide psychological services that are focused on promoting psychosocial health, prevention and primary intervention for psychological difficulties. Part of your expertise also involves providing psycho-education, training and working collaboratively as part of a multi-disciplinary team (HPCSA, Professional Board for Psychology, 2013).

In our context, South Africa, Mental health care is often restricted to hospitals, making the services mostly inaccessible to those who need it most. Additionally, we experience a crisis as we do not have enough mental health professionals like yourselves and this limits the health systems’ ability to provide quality mental health services for all. In an attempt to address these problems the Department of Health has issued guidelines to transform Primary Health Care Clinics as this is the first point of contact for all patients.

MhINT is designed to assist the health system meet its objectives and provides a framework which achieves the following:

• capacitate PHC service providers with the skills to detect common mental health disorders• strengthens the system by providing a referral pathway for patients to receive a psychosocial

intervention provided by lay workers• supports the implementation of a collaborative care package to ensure that mental health

services are aligned from primary health care all the way to the hospitals.

The Infographics on the next page illustrates the collaborative care package showing the various people involved in working together to make a difference for people who come to our clinics. The training that you will receive will equip you to be part of this team.



MhINT INTERVENTION

Training, supervision & emotional support of Lay Counsellors

(REGISTERED PSYCHOLOGICAL COUNSELLORS)

IMPROVE MENTAL & PHYSICAL HEALTH

Initiation of antidepressant

treatment(DOCTORS)

Depression & adherence counselling

(LAY COUNSELLORS)

Mentoring & supportingContinuous quality

improvement activities ofCQI teams in the facilities

(PHC SUPERVISORS)

Training & supervisionof Registered Psychological

Counsellors(DISTRICT PSYCHOLOGIST)

Research

Doctors &Psychologists

workshops

NATIONAL

HEALT

H

INSU

RANCE

RE-ENGINEERING

OF PHC

IDEAL CLINIC

INCLUDING ICSM

Provide Mental Health Screening

(EN/ENA)

Managersmeetings & workshops

Patientself-management

skills

resi

lience

and confidence = wellbeing

Clinicalcommunication

skills

APCtraining

Caring for the caregiver

(Clinical Nurse Practitioner)

CASE MANAGEMENT

OF DEPRESSION

Psychologists

» MhINT Infographic



The problemOne of the main problems in Primary Health Care today is the fact that many people suffer from chronic conditions and they also suffer from depression.

A chronic condition can be defined as a health condition or illness that is lifelong and will require use of chronic medication. Examples of a chronic condition are diabetes, hypertension, asthma, chronic obstructive pulmonary disease (COPD), HIV and arthritis.

Depression can be described as feelings that affect one’s mood negatively. A person who is depressed has strong feelings of sadness, they feel hopeless and they also lose interest in doing what they usually do. An example is if someone usually likes to go to church and then they stop going because they don’t feel like going out of their home. Depression affects how one feels, thinks and behaves which can lead to many different emotional and physical problems.

Many people who come to the clinic for treatment suffer from what is called multimorbidity; they suffer from more than one of the above conditions. Here are some of the facts:

• Having depression and a chronic condition can make both depression and the chronic condition worse.

• People with depression often have poor treatment adherence. People with co-morbid HIV are 55% less likely to adhere to medication.

• People diagnosed with HIV are twice more likely to get depressed than the general population.

The solutionWhen Doctors, Nurses, Registered Psychological Counsellors and District Psychologists work together, to help integrate mental health care in routine care in Primary Health Care facilities, the lives of many people will be changed. You, the Psychologist, play a big role in helping to change these problems through providing psychosocial interventions. Your role in MhINT will be further enhanced as you will be trained to equip and support Registered Psychological Counsellors with skills that they will use to equip Lay Counsellors to offer psychosocial counselling for depressive symptoms and adherence counselling for all chronic condition in Primary Health Care clinics.

MhINT and ME

What training will I need?To become a skilled Master Trainer-Supervisor for integrated mental health services, you need to attend the 4 days of training to learn how to facilitate the 4 day training workshop for Registered Psychological Counsellors and supervise them going forward. You will train the Registered Psychological Counsellors to train, supervise and provide emotional care for Lay Counsellors to manage individual and group sessions for people suffering from depression. The Lay Counsellors will also be trained to understand and know how to provide adherence counselling for people with chronic conditions.

After your 4 days of training you will receive support from external trainers to deliver your slice of the intervention.

My role and responsibilities As you have seen in the Infographics there are many role players. Table 1 describes the team players and explains their role and responsibilities as well as their training requirements. As a key role player, it is imperative that you have insight into all the activities of the role players so that you can assist in the flow and integration of the programme into the health services.



Table 1 MhINT team players, their role and responsibilities and their training requirements

Team Players Roles and responsibilities Training includes

Clinical Nurse Practitioner

• Identify depression using Adult Primary Care (APC) guide

• Provide supportive counselling• Repeat medication • Refer to Lay Counsellor• Refer to Doctor • Review response to treatments

• Orientation to the MhINT Programme.

• Skills for effective preparation for the consultation process.

• Effective history taking and interviewing techniques.

• Skills needed for managing emotions during challenging consultations.

• Strategies for self-care to prevent burnout.

• Techniques for working collaboratively with patients in developing chronic condition management plans.

• Orientation to the 5 additional APC sessions focusing on mental health cases: i.e. ○ Risky alcohol use ○ Depression as a course of non-adherence to chronic medication

○ Assessing intent or risk of suicide

○ Managing depression at PHC level and the role of the lay counsellor

Enrolled Nurse/Staff Nurse

• Screen for mental health symptoms using an approved mental health screening tool.

• Accompany patients that may require emergency care to clinical nurse practitioners (i.e. patients that report suicidal thoughts).


• Training on how to use approved mental health screening tool in their facility.

• Orientation to management of suicidal patients.

Doctor • Diagnose • Review complex/severe cases• Prescribe psychotropic medication


• Orientation to the APC Guide for chronic disease management.

• Guidelines for prescribing and managing patients with mental disorders and severe mental disorders at PHC level.



Lay Counsellors

• Actively interact and be a part of the dynamic team consisting of Nurses, Doctors and Mental Health Specialists to make mental health part of primary health care.

• Attend the required training and give feedback about the training to help improve the training.

• Provide psychoeducation.• Provide psychosocial counselling for depressive

symptoms and adherence counselling for all chronic condition.

• Facilitate the prescribed group or individual sessions to patients that have been referred for counselling.

• Facilitate adherence counselling for all patients with chronic conditions referred to you.

• Work within your scope of practice and refer patients who have problems that you are unable to manage.

• Give feedback about the service you are providing to the clinic team.

• Attend scheduled supervision sessions for skills development.

• Be aware of 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 seek emotional support so that you stay healthy.

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


• Basic helping skills, healthy thinking and problem- management skills and strategies for self-care.

• Adherence counselling for patients with chronic medical conditions.

• Supervision and Emotional support.

• Training on the Psychosocial Counselling Manual with the following sessions: ○ Psychoeducation: Understanding depression

○ Poverty ○ Interpersonal conflict ○ Social isolation and avoidance

○ Grief and loss ○ Experienced stigma ○ Internalised and perceived stigma

Registered Psychological Counsellors

• Train and supervise Lay Counsellors.• Provide emotional support for the Lay

Counsellors. • Manage patients with trauma and complex

cases that cannot be seen by Lay counsellors and are referred by Nurses from the Primary Health Care Facilities or the hospital.

• Orientation to the MhINT Programme.Training on how to train and supervise Lay Counsellors.

Psychologists • Manage more severe psychopathology.• Train and supervise Registered Psychological

Counsellors.• In the absence of a Registered Psychological

Counsellor the Psychologist trains and supervises the Lay Counsellors.


• Training on how to train and supervise Registered Psychological Counsellors and Lay Counsellors.



Facility Managers/ Operational Managers

• Support and promote the collaborative care model.

• Actively engage in integrating services in the facility.

• Ensure that all levels of staff involved in the MhINT collaborative care model receive the appropriate training and ongoing support and supervision.

• Promote training 5 additional APC sessions focusing on mental health cases.

• Include the Lay Counsellors in the staff meetings.

• Give feedback on referrals being passed to Lay Counsellors from Nurses.

• Ensure that the “morning talk” which provides psychoeducation is being done in the clinic.

• Support stress management activities for Nurses and Lay Counsellors so that they are mentally fit to perform their MhINT role and responsibilities.

• Become an active member of the Facility based Quality Improvement committee.

Orientation to the MhINT Programme:• The Collaborative Care

Package• Training and capacity building

activities• Monitoring and Evaluation

(CQI and S-MhINT)

PHC Supervisors

• This role is played by the PHC Supervisor and they support PHC facilities in implementing mental health care integration programme.

• Support the PHC Facility Managers in monitoring and reviewing mental health data alongside with all other clinical programmes data.

• Help the PHC to identify bottlenecks to implementation and support PDSA cycle reviews.


• Orientation to CQI and S-MhINT.

Support and supervision

With anything new that we learn, we need time to digest the information so that we can understand and internalise it so that it becomes meaningful for us. We also need time to practice what we have learnt so that we feel confident in what we say and do.

Your primary role is to train and provide emotional support and supervision for the Registered Psychological Counsellors, the designated group to be MhINT Trainers. Because of your involvement with the Registered Psychological Counsellors, you will have an intimate knowledge and understanding of how the programme is being implemented on the ground. You will also be asked to be the custodian of the programme and at times, the voice during meetings for the Trainers and the Lay Counsellors.

The first time that you train Registered Psychological Counsellors you will be supported by technical partners to ensure that you master the skill and management of the programme. Thereafter, it is your responsibility to actively seek support and supervision from the resources provided for you within your district.

Section 5 in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors details the supervision and support component of the programme that they will provide for the Lay Counsellors.

You in turn, need to provide supervision and support for the Registered Psychological Counsellors.



Activities of successful Master Trainers

Bird’s eye view of what MhINT Master Trainers need to KNOW and DO….

To be a successful MhINT Master Trainer you need to have specific knowledge that results in the successful delivery of the intended outcome. The table below offers a broad overview of what you need to KNOW and what you need to DO for you to be focussed and work with purpose and intent.

Curiosity is a useful attribute to ensure that as a Master Trainer you can take a bird’s eye view of the MhINT programme as a whole. This will assist you to train and supervise the trainers with insight and great understanding about what they too need to KNOW and what they need to DO.

Know Do

Yourself … self-reflect on your personal and professional development

… go for supervision… unpack the influence/impact you have on those

around you (power relationships)

The organisation … find out about the context of the training … explore the impact/influence you will have… identify key role-players and connect with them

The purpose and desired outcome of MhINT

… find ways to actively work towards the common goal of the integrated model of care

… be prepared to task share in a conscious way

The group at hand … understand who you are dealing with at whatever level, and be empathic and supportive to their particular needs and requirements

… train and supervise the groups assigned to you

The roles and responsibilities of all the role players

… gain access and read the suite of manuals that are systematically developed to help all the team players play their part towards successful collaboration

… if everyone does what is intended for them to do, success is guaranteed

… each group to work within the boundary of their scope of practice


SECTION 2

Insights for Psychologists with

regards to the MhINT Training Approach

Section 2 of the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors provides an understanding of the philosophy and the adult education theories that underpin the MhINT training programme.

The step-by step in Section 4 is written to ensure that these theories are made explicit. All that is required for every person who is trained to use the manual, is that they have a basic understanding of why experiential and participatory learning is used. The manual does the rest!

SECTION 2: Insights for Psychologists with regards to the MhINT Training Approach


Starting with the end in mind

There are 3 key concepts that need to be top of mind when you train the Registered Psychological Counsellors. Paramount to the success of these 3 concepts namely; modelling, mirroring and managing your anxiety, is that you find ways to internalise the theories of Adult Learning and Teaching in which the MhINT programme is embedded.

Modelling In the context of the MhINT programme, modelling means that you behave in a way that you want those you train to behave. What you do and how you do it becomes a point of reference for the Registered Psychological Counsellors. In psychological terms this is called observational learning or imitation; they look to you to show them how to train and supervise. In other words, you need to walk your talk.

MirroringThe training programme for each layer of the cascade mimics that of the other. The activities are replicated but made relevant for each layer of the cascade; it is important to note who is being trained and what they need to know and do in order to meaningfully and purposefully fulfil their role in the MhINT programme. For example, the Registered Psychological Counsellors need a basic understanding of the Adult Education Theories that underpin the programme, but, they do not need to educate the Lay Counsellors about these theories. What the Lay Counsellors need to experience is that the training feels great and they can follow the step-by-step for each session with confidence and ease.

Anxiety and the disorientating dilemma Experiential learning is also called transformative learning. To grow and expand ones learning, challenging the usual way things are done is essential. This can often create a sense of turmoil and uncertainty; a grappling with the “what”, “how” and “why” of learning. Jack Mezirow, an adult education theorist calls this a “disorientating dilemma”. What is important for trainers is to allow the learning dilema so that the participant can find their own way of resolving the problem using the tools provided through the training programme. The MhINT training programme steers away from the use of PowerPoint and activities have been created to allow participants to engage with the material and learn how to use it through stimulating their own natural ability to learn.

When participants are struggling to find the answers or solutions it is important for the facilitator to manage their need to rescue and provide answers. What is of greater benefit is to rather sit alongside the person or group and ask appropriate questions, or provide alternate examples taken from the participants own lives or experiences to help them to come to the answer on their own.

Master Trainers, remember you will not be with those you train 24/7! The Registered Psychological Counsellor will not be with the Lay Counsellor 24/7. The greatest gift you can give those you train is autonomy and trust in themselves and the materials provided by the programme.

1. The Learning Styles Inventory (LSI)

• Please use the Learning Styles Inventory provided in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors to find out about your learning style.

• The Theory behind the practice section in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors provides diagrams that detail the essential key activities, features and the questions asked by each of the learning styles. Master Trainers need to be familiar with these concepts so that you can provide concrete feedback and help with meaningful reflection.



Having completed your Learning Style Inventory, plot the outcome and that of your co-facilitators in the graph below. Diagram 1 provides an example of how to complete the graph.

10

9

8

7

6

5

4

3

2

1

0

ACTIVIST PRAGMATIST THEORIST REFLECTOR

Key

Me

You

» Diagram 1 An example of a Learning Styles graph

Learning Styles GraphPlot the group member’s learning styles in the graph provided below.

10

9

8

7

6

5

4

3

2

1

0

ACTIVIST PRAGMATIST THEORIST REFLECTOR

Key



Reflecting on my Learning Style

What I learnt about myself through doing the LSI

What Learning Style/s push my buttons?

Why?

What can I do about it?

In what ways will my preferred Learning Style impact the way in which I facilitate this programme?

In what ways will my preferred Learning Style impact the way in which I supervise the Registered Psychological Counsellors?



What Master Trainers need to know about the Learning Styles InventoryIt is useful to take a step out of your own experience and see how you can facilitate the activity and integrate the outcomes in your facilitation during the Registered Psychological Counsellors 4-day training.

Some thoughts, reflections and actions:• The impact of knowing how one learns is often a profound experience for those who complete

the profile.• There is often an immediate recognition of lifelong patterns which need to be acknowledged. • Once the participants have totalled their scores and they have read through the summary of

the profiles, it is useful for them to see which profile fits best.• Everyone has all four stages of the learning cycle but we have preferences. When we are

challenged we often revert to our preferred style. This is important for Trainers to recognise and understand the impact of this on the group processes.

• The Learning Styles Inventory is not included in the Lay Counsellor training programme. It is useful for MhINT Trainers, to know and understand their learning style and the possible impact on the group learning.

• The 3 training programmes are written to accommodate all learning styles, making this a safe transformative learning environment.

• As a Trainer it is important to become flexible with the styles to match or change the dynamic of the group. For example, if the group (or individual) tends to lean towards reflection, it would not be useful to give experiences that plunge them into action without first providing time to think and prepare for the activity.

• Using the graph provided to plot ones profile, provides a visual of the mix of learning styles. • The Learning Styles Summary provides a quick reference to the likes and dislikes of each

learning style. As a facilitator, it is useful to know this so that you can easily provide feedback or provide the best learning environment for the group or individual at hand.

• The activity on reflecting on my learning style is important to consolidate the experience of doing the Inventory.

• The Learning Styles Inventory provides a common language and reference for growth and development during the Psychologists' and Registered Psychological Counsellors' Training.

• To help you consolidate and integrate this new knowledge into practice, use the table provided to jot down your observations during the 4-day training about the behaviours associated with the 4 learning styles.

Co-facilitation

• Read the section on co-facilitation in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors to gain an in-depth understanding of its essence in the programme.

• Knowing your co-facilitators learning style will help you to work with greater openness to the challenges that this might bring. Use the tables provided to jot down your observations.

• Use the opportunity to become flexible in your learning style so that together you can meet the needs and requirements of the group you are training.



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2. Training approach based on the work of Lev Vygotsky

The MhINT training approach is based on the work of Lev Vygotsky a Russian educational psychologist (1896-1934). His ideas and thinking, which were influenced by Marxist thoughts and writings, were formed during the Revolution in Russia.

Originally, learning was viewed as an individualistic event; there was a stimulus and a response as shown in Diagram 1 below.

BA

» Diagram 1 An individualistic view of learning

Vygotsky recognised that learning is socially constructed and added a third dimension (X) shown in Diagram 2. This approach was seen as holistic - he moved the world from individualistic approaches to learning, towards a more context-related approach or, socio-cultural approach. We do not learn in isolation but with and through one another.

B= OUTCOME

X= TOOL

A= SUBJECT

» Diagram 2 A holistic approach to learning

The X, or the Tools of mediation which essentially takes the form of a question, a manual, a training that the Subject (or person) work towards an Outcome.

For example, a child (A) cannot simply tie their shoe lace (B) without someone (X) showing them or instructing them how to tie it.

In the MhINT Registered Psychological Counsellor training, the Subject (A) is the Registered Psychological Counsellor, the Outcome (B) is the that they can train and supervise Lay Counsellors to facilitate the Depression and Adherence Counselling intervention in a facility and the Tool (X) is you, the Master Trainer equipped to use the training materials and programme to help the Registered Psychological Counsellor to be effective in contributing to their slice of the MhINT pie.



Let us explore what this means for you. Diagram 3 provides details of the Registered Psychological Counsellor and what they need to be trained to do in the health system. Diagram 4 explains the mediating artefacts represented in the Tool. What will be used to get A to achieve B?

B= OBJECT

X= TOOL

A= SUBJECT

= WHAT MUST THEY DO?

Registered Psychological Counsellors have been selected to be trained in a prescribed curriculum to train and supervise the Lay Counsellors to deliver an integrated mental health service in primary health care through: • Task sharing• Becoming an integral MhINT team member• Working within their scope of practice and know

when and how to refer appropriately

What does this mean for MhINT Master Trainers?

= REGISTERED PSYCHOLOGICAL COUNSELLORS

The Registered Psychological Counsellors are: • A group of professionals who work within their

scope of practice• Despite the standardisation that their qualification

offers they all have differing preferences and levels of experience and expertise

• Each person is rooted in a family and community

» Diagram 3 An explanation of the Subject and the Object



B= OBJECT

X= TOOL

A= SUBJECT


The Tool must be relevant for the Subject and must provide a vehicle for the achievement of the Outcome• MhINT Registered Psychological Counsellor and Lay Counsellor Training Manual

○ Written in Plain English ○ No psycho-jargon ○ Clear easy to follow instructional manual trained during the 5-day training to build confidence to provide the Depression and Adherence sessions for individuals and groups

○ Stories of patients used for the teaching during the 8-session intervention ○ Prescribed stories used to teach micro-counselling skills during the training to reinforce recognition and internalisation of the information

• MhINT Training programmes designed using learning styles, experiential learning, reflective practice ○ The theories of Adult Learning and Teaching are embedded in the facilitators' instructional manual to ensure consistency and standardisation of application and scale-up.

» Diagram 4 An explanation of the Tools for mediation

When deepening one’s understanding of Vygotsky’s theory, it is essential to understand the two approaches he uses to understand learning: 1) Mediation (see Diagram 6) and 2) The Zone of Proximal Distance (ZPD) (see Diagram 7). The Tools for this training are written to incorporate these approaches. Those facilitating the training need to simply follow the instructional manual in order to put these approaches into practice. It is useful for the facilitator to understand why they are doing what they do, so that they can find meaning and facilitate with purpose and clear intentions.



X= TOOL


Mediation • Learning takes place between the Registered Psychological Counsellors and the Master

Trainer within the context of MhINT. The interplay between these three entities helps to promote learning. We therefore do not learn in isolation but rather through and from one another.

• Your role as Master Trainer is to ‘mediate’ learning; you need to respond to the contributions that the Registered Psychological Counsellors bring to the training. The examples and the stories they bring will shape the training; it is for you to acknowledge, summarise and make the relevant links to the concepts and skills required for MhINT to be successfully implemented.

• Learning is therefore socially constructed – it is mutually beneficial for all involved in the learning process.

• The Tool is central to this learning process - your guidance in recognising where the Registered Psychological Counsellor is at and bringing them into the learning environment offered through the MhINT training programme you will equip them to successfully internalise the prescribed programme so that they can train and supervise Lay Counsellors autonomously.

Two approaches to understand and to achieve learning are:

1

» Diagram 5 Approach 1, Mediation, summarised to understand and achieve learning



X= TOOL


The Zone of Proximal Distance (ZPD)The ZPD can be defined as the distance between the Registered Psychological Counsellors actual development level made possible by independent learning and the potential development determined by problem solving under your facilitation and guidance of the MhINT training programme.

What does that mean for you in practical terms?• The Tool, and in this case the Registered Psychological Counsellors training programme and

manual is designed to assist you to bridge the gap between the Registered Psychological Counsellors actual knowledge (where they are at right now) to grow and expand into their potential development through helping them to problem solve individually and/or in groups with their peers.

• The ZPD is achieved when the Registered Psychological Counsellors move from dependence to independence.

The processes used to achieve this are:• Scaffolding - move from simple activities to more complex activities • Modelling – showing how to do this

ZPD applied in MhINT• The programme is consciously and systematically scaffolded to move from simple activities

to more complex activities. • The scaffolding of the programme stimulates the interest of the Registered Psychological

Counsellors by first helping them to understand the theories of adult learning and teaching that underpin the methodology of the training approach.

• The sessions are first modelled by the Master Trainer ensuring that depression is unpacked and understood so that Registered Psychological Counsellors can first relate to the content, internalise the concepts and then be able to facilitate the 5-day training themselves with encouragement and constructive feedback from the Master Trainers.

• Master Trainers need to move the Registered Psychological Counsellors through their ZPD, i.e. from dependence to independence.

• The structure of the programme, the manual as well as the activities are designed to assist the Master Trainers to internalise the programme to assist the Registered Psychological Counsellors move from dependence to check spacing independent practice.

Uses the following approaches

2

» Diagram 6 Approach 2, Zone of Proximal Distance, summarised to understand and achieve learning



3. T

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licat

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rinc

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d p

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t Le

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each

ing

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h th

is k

now

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out L

earn

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es a

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e ap

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otsk

y to

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MhI

NT

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ram

me,

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sk w

hat y

ou n

eed

to d

o. D

iagr

am 7

bel

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atio

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for

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. All

leve

ls o

f th

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hIN

T tr

aini

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ed o

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per

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and

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arni

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r wor

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Sum

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Adu

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Curriculum

considerations for M

hINT Psychologists to train Registered

Psychological Counsellors (RPC

)

1What is

the prob

lem?

2H

ow can the

prob

lem b

e fixed?

Intended outcome

3W

ho is being

trained?

4W

hat do they need

to know?

Content

5How

? M

ethods

6Evaluation?W

hat works?

• Non-com

municable

chronic diseases (NCD

) and m

ental disorders each constitute a large portion of the health care burden, and they are often co-m

orbid.• M

ental illness affects adherence to treatm

ent as w

ell as prognosis. • Treatm

ent gap is large – only 1 in four people in SA

with com

mon

mental health disorders

have access to health treatm

ent.• A

n integrated collaborative care package needs to be integrated into Prim

ary Health C

are.• Psychologists becom

e agents in assisting RPC

s to be confident to contribute m

eaningfully to MhIN

T.

• Task-sharing • Psychologists to

train and supervise RPC

s to train Lay Counsellors to offer D

epression and A

dherence Counselling in the facility w

here they w

ork. • Psychologists can

train RPCs to be an

integral component

of a collaborative care m

odel. • M

ental Health C

are w

ill be integrated into routine care in Prim

ary Health C

are facilities.

• Psychologists• D

istrict-based – integral part of the m

ental health services

• In the absence of a Psychologist, supervision m

ay be provided by any other designated trained person.

Psychologists need to know

HO

W to train

and supervise the follow

ing:• O

verview of M

hINT

as a whole.

• Understand the

various roles and responsibilities of the different levels of care in the intervention.

• Structure of supervision, support and em

otional care package.

• Adult education

principles and practices to facilitate the 4-day RPC

training program

me as

intended.

• 4-day training using experiential and participatory learning m

ethods.• Instructional m

anual using plain language w

ith micro counselling

skills and adult education principles em

bedded in the text for use in training and during the onsite supervision.

• CBT made accessible

and integrated in a recognisable step

-by step routine.

• Ongoing support

and supervision through a structured program

me.

• Trained in use of form

s required for the intervention.

• Training to use and provide feedback of self-rating scale.

• Feedback m

echanisms to

evaluate progress of RPC

s during the training to ensure confidence in providing the 5-day training.

• Feedback about the use of the training program

me

and associated m

aterials.• CQ

I feedback to inform

progress. • S-M

hINT evaluation.



4. Enabling a safe learning environment through the purposeful use of

group structure

Master Trainers needs to consciously and purposefully “live” this section to ensure the best learning outcome:

• Model the behaviours you want the group to experience so that in turn they will be able to have a point of reference when they are training.

• If you use your mobile or computer during the training, so will they; if you disengage, so will they; if you don’t use your manual, neither will they; if you don’t move groups around, neither will they. If you are late and don’t adhere to time, neither will they. The list goes on.

• If you break your own rules, turn the experience into a learning event. Identify what has happened, reflect on the impact, course correct and move on. And yes, if you do this, so will they.

The training environment • The training environment impacts on learning. Try to ensure enough natural lighting and a

steady flow of air to keep the energy of the group members focussed. Weather dependent, keep the temperature of the training room at a constant comfortable temperature.

• Keep the training room clean, neat and tidy. • Set the room as you would like to have it ready for the start of the session and preferably before

the participants arrive.

Group size matters The size of small groups affects the way people interact and engage in a group.

Size Purpose

• Beginning phase to allow feelings of safety in the group• Practice new skills• Deepening the sharing when and if required• Calm the group down if there are people who dominate the discussion• Partner 2 very talkative people together

• Expanding the circle of people to share with• Opening to more discussion and opinions to build trust in the group

Good to use for working phase where there is greater trust in the group and people are better able to share freely

Seating It is strongly recommended to have 2 different seating arrangements for this training, both supporting and accommodating different yet complimentary group dynamics. Start the training off in a circle to set the scene and then move into café style seating.

1) Chairs in a circle • No tables and ensure that everyone can see each other • Best used for the beginning and the ending session of the day • It is also used for training Session 1-8 and the session on adherence. • Facilitators are included in the circle and should aim to sit opposite one another so that you can

keep eye contact and support one another as and when needed



2) Café style seating • Arrange tables and chairs to accommodate 4 people• Used for group work in working phase• Rotate participants sitting at the tables to promote team work amongst participants

Changing partner combinations and seating arrangements helps to ensure collaborative practice, shifts the energy in the group when necessary and also gives the message that learning is a joint effort.

Group phases and facilitator roles and responsibilities Even though every group has a life and culture of its own, there are some basic phases that groups follow. A facilitator needs to take these phases into account to promote healthy group functioning. Becoming aware of behaviours, yours and the group’s, helps to prioritise group needs and ultimately group learning.

During any encounter there is always a beginning, a middle and an end. We say hello, we ask how things are going, we chat about something new/old and we say goodbye.

In a group situation these phases are formalised and when done with intent and purpose, can enhance the outcome of any group session. Knowing the group phase, the behaviour you can expect and what the group needs will help you to give attention to your response as a facilitator.

The table below provides a summary of the behaviours one can expect, it identifies what the group needs to be able to and a behaviour of what the facilitator needs to do is identified. The behaviour that the Master Trainer models in terms of how the group phases are managed will set the tone for how the Registered Psychological Counsellors will manage their own training sessions with the Lay Counsellors.

Phase Group behaviour Group needs Facilitator role

Beginning • Trust low• Anxiety high• Dependent on facilitator

• Acceptance• Non-judgement

• Be warm, open and accepting

• Do not judge

Testing • Trust moderate• Anxiety moderate• Dependent on facilitator • Focus on individuals

moving towards groups

• Acceptance • Space to question/

challenge

• Stay focused• Don’t rescue• Don’t defend yourself

Working • Trust high • Anxiety low• Not dependent on

facilitator• Groups formed

• Stimulation to learn and expand

• Freedom to explore test • Independence

• Provide new information • Allow to test and explore• Don’t rescue• Step out of the group

Ending • Anxiety high • Dependent on facilitator • Focus on individuals

• Reassurance• Recognition of own

ability

Next steps

» (Adapted from BHP, Health Science Faculty, UCT)



Lear

ning

to

obse

rve

and

res

pon

dU

se t

he t

able

bel

ow to

obs

erve

and

refle

ct o

n G

roup

Pha

ses

and

appr

opri

ate

resp

onse

s.

Begi

nnin

gTe

stin

gW

orki

ngEn

ding

Tr

usti

ng m

y gu

t re

spon

se to

wha

t I o

bser

ve

Day

1

Day

2

Day

3

Day

4



Time allocation for group phases

When facilitating a group, we need to ensure that there is sufficient time allocated to each phase. Time allocation also needs to be flexible according to the size of the group. The larger the group, the more “small – group” learning needs to be encouraged. It is also important to give breaks/energy shifters.

Every session, every day and every week’s training follows the same group phases. It is useful to pay attention to the phases so that you can anticipate the response that will nurture the group to ensure successful outcomes.

Phase 1 hour activity

1 daytraining

1 weektraining Key activities

Beginning/ testing

5-10 min 15-25 min Day 1 until about mid-morning of Day 2

Introductions, welcome, check in, setting the scene

Working 45 min Rest of day Mid-morning Day 2 until mid-afternoon of Day 4

Engagement and interaction with information, building knowledge and skill

Ending 5-10 min 30-45 min Mid-afternoon Day 4 until closure on Day 5

Summary, closure, way forward



The

use

of ic

e-b

reak

ers

and

ene

rgis

ers

Use

the

tab

le b

elow

to re

cord

use

ful i

ce-b

reak

ers

and

ener

gise

rs y

ou o

bser

ved

duri

ng t

he t

rain

ing

Use

of i

ce-b

reak

ers/

ener

gise

rsW

hat

acti

vity

?W

hen

used

?W

hat

effe

ct?

Intr

oduc

e to

pic

Crea

te a

saf

e w

arm

en

viro

nmen

t

Shif

t en

ergy

/moo

d of

the

gro

up

Hel

p b

reak

dow

n b

arri

ers


Preparing for a training

This section offers some guidance on aspects to consider whilst preparing for training the Registered Psychological Counsellors.

SECTION 3

SECTION 3: Preparing for a training


Registered Psychological Counsellors in the health system

In Section 1 it is highlighted that the lack of psychological human resources constitutes a significant challenge to the health system. The availability of Registered Psychological Counsellors in a health system can provide great relief to the psychologist often inundated with clinical and administrative tasks at the hospital level. The availability of a Registered Psychological Counsellor is vital to the sustainability of the MhINT programme.

As a mid-level worker the Registered Psychological Counsellor occupies a unique space in the health system and is equipped with skills to work effectively with individuals and groups to provide psychological interventions under the supervision of a psychologist. However, as mental health professionals their role also includes provision of training and support to healthcare workers on mental health related content within their scope of practice.

As a Master Trainer, you will play a role in supporting the professional development of the Registered Psychological Counsellor by equipping them with skills to become a trainer and supervisor for Lay Counsellors providing the MhINT intervention. You will provide an initial 4-day training followed by monthly supervision sessions and on an ad-hoc basis as needed.

Preparing for training

The key to a successful training is preparation! Section 3 of the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors provides practical tips and templates to help trainers prepare for a training. Familiarity with this section will help you to support them better. Additionally some of the steps outlined in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors i.e.; submission of a training plan, planning training logistics, preparing training materials and preparing yourself for the training, also apply to you.

Recommendations for training

• It is advisable that you do not train less than 04 or more than 08 Registered Psychological Counsellors at a time. Groups that are either too small or too large can impede on the processes of experiential learning.

• It may be necessary to collaborate with a psychologist from a neighbouring district where the number of trainees is too low in your own district. This would also allow you to have a co-facilitator when you deliver training to the Registered Psychological Counsellors. This can be facilitated through the district mental health coordinator.

• One of the main objectives for the Registered Psychological Counsellor training is to expose them to, and have them experience working with a co-facilitator. Having an uneven number of trainees is therefore not recommended.


Master Trainer’s step-by-step

SECTION 4

In essence, the 4-day training of Registered Psychological Counsellors (RPC) mirrors that of the Lay Counsellors training programme. This method aims to ensure that the key activities, principles and practices embedded in the MhINT programme are recognised, understood and practised. The Registered Psychological Counsellors will be afforded the opportunity to facilitate key activities of the programme, have time to reflect on their new skills and will also be provided with feedback from their peers and MhINT Master Trainers.

The activities of the Lay Counsellor Step-by-Step programme will be allocated amongst the trainee Registered Psychological Counsellors, taking into consideration the 3 key components of the training and intervention:

1. Skills – micro-counselling, CBT (content) and group management (process)2. Systems – training logistics, PHC process mapping and Continuous Quality Improvement3. Support – supervision and emotional care

Please note that the Step-by-Step section of this manual is designed to be used in conjunction with the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors. Where appropriate, you will be referred to the contents of the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors and additional or specific information or instructions will be provided for the Master Trainer to fulfil your training of trainer requirements.

The more you model the use of the Manuals, the higher the likelihood that they too will use their manual as required.

SECTION 4: Master Trainer’s step-by-step


Registered Psychological Trainers 4-d

ay training program

me at a glance

Day 1

Day 2

Day 3

Day 4

Morning

• Introduction to the group• Pre-evaluation • Introduce M

hINT and

collaborative care package • Initiate Process M

ap (CQI)

• Check in and safe spot activation

• From today all the sessions

are trained by the Master

Trainers to practice their training and supervisions skills.

○Q

ualities of a helper

○Listening skills


• 1) Problem m

anagement

• Session 2 Poverty

• Review the rem

aining sessions that use Problem

M

anagement


• Process map w

ith MH

indicators

• Introduction to Adult

Education and structure of the program

me

• Sessions allocation and training m

anuals

• The helping process:

○O

pening

○Exploring

○

Summ

arising • G

roup Skills Activity

• Adherence

• 2) Getting A

ctive• Session 4 Social isolation

• Session 8 Closure • Post-training evaluation• G

roup photograph and lunch

Afternoon

• Model Session 1 -

Psychoeducation • Explore feelings and

terminology

• Personal support • U

npack day’s learnings through trainer’s lens

• Summ

ary and closure + self-

care

• Supervision and emotional

support

○W

hat is it?

○H

ow to m

ake it work

○

How

to train it?• U

npack day’s learnings through trainer’s lens

• Summ

ary and closure + self-

care

• 3) Healthy Thinking Skills

• Session 7 Internalised Stigma

• Unpack day’s learnings

through trainer’s lens• Sum

mary and closure +

self-care



Master Trainer’s Step-by-step Programme

Day 1

Welcome to Day 1!

Day 1 training introduces the Registered Psychological Counsellors to MhINT, the integrated care model and their role in the success of the intervention in their district. The External Master Trainers model the Day 1 programme which mirrors the Lay Counsellor training programme. This method sets the tone and establishes a safe learning environment for experiential learning to take place.

An overview of the 4-day programme is provided and from the get-go you will allocate the sessions that the Registered Psychological Counsellors will be facilitating during their training. The purpose of this is to afford them as many opportunities as possible to practise the new skills so that when there is a group of Lay Counsellors in front of them, they will feel confident.

Remember that today the Registered Psychological Counsellors will generally feel ambivalent about the training and all that it involves. Your role as a Master Trainer is to primarily show respect, be non-judgemental and allow for the group to get to know you and each other as well as all the new information that also has an emotional overlay.

Sit with your co-facilitator and check in with each other to see how you’re feeling about starting the training.

Using the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors, check that you have all the equipment at hand for today.



Abbreviated programme: Day 1

Follow DAY 1 in Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors• External Master Trainers model how to set the tone and train a group using experiential learning • Introduction to MhINT • Introduction to Adult Education • Model Session 1 - Understanding depression• Exploring feelings, personal support and safe spot activation

Time Minutes Section/Topic Facilitator

08:30–09:00 30 min Preparation of self and environment

09:00–09:30 30 min Arrival and registration

09:30–09:45 15 min Welcome and introductions

09:45-10:00 15 min Pre-training evaluation

10:00–10:15 15 min Hopes/fears/expectations

10:15–10:25 10 min Establishing group norms

10:25–11:10 45 min Introduction to Mental Health Integration

11:10–11:30 20 min Human knot activity

11:30–11:50 20 min Tea

11:50-12:35 45 min Learning Styles Inventory

12:35-12:50 15 min An introduction to Adult Education and the structure of the programme

12:50-13:00 10 min Training manuals and sessions allocation

13:00–13:45 45 min Lunch

13:45–14:20 35 min Model Session 1 - Psychoeducation • Waiting Room Talk

14:20–14:50 30 min Explore feelings and terminology

14:50–15:10 20 min Personal support

15:10–15:40 30 min Self-care - daily safe spot activation

15:40–16:00 20 min Unpack the experience of the day and closure



• Preparation of self and environment• Arrival and registration

08:30–09:30(60 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Remember that whatever you do, the Registered Psychological Counsellors will also do!• Your readiness and set up of venue models respect.

Welcome and introductions 09:30–09:45(15 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Adapt the language for the Registered Psychological Counsellors.• Be congruent!

Pre-training evaluation 09:45–10:00(15 min)

Note to MT Use the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Ensure that you have the Depression and Adherence Counselling Trainer’s Manual for Registered

Psychological Counsellors pre-training evaluation form.

Hopes/ Fears/ Expectations 10:00–10:15(15 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• To prevent it from becoming a gripe session, bring the focus into the “here and now” so that the

Registered Psychological Counsellors can express their concerns about being trained into this role.• Focus on what it feels like to be in this training amongst their peers right now.• Be non-judgemental and appreciate the anxiety around expectations – especially that being a

trainer is usually not in their scope of practice or what they are skilled in. • Questions such as “Will I be OK? Will I manage this?” might need to be clearly articulated.

Remember no-one wants to feel vulnerable in front of one’s peers.• Remember there are no answers – allow the questions and concerns to be raised so that they can

be documented and returned to later on during the training.



Establishing group norms 10:15–10:25(10 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Modelling the establishment of group norms is critical in terms of showing how to set meaningful

boundaries. • It is useful to come back to the group norms as and when needed during the training to show that

one is serious about setting limits. This is often needed when there is high anxiety in the group.

Introduction Mental Health integration 10:25–11:10(45 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Focus the discussion by using the Process Map to highlight the various levels of care and specifically

that of the Registered Psychological Counsellors and their role in training, supervising and providing emotional support for the Lay Counsellors.

Human knot activity 11:10–11:30(20 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• It is important to highlight during the debriefing that no matter who we are or our “level” in the

cascade, it is normal to feel anxious when challenged to try something new. When the programme starts working in the clinics it may initially feel entangled and difficult but through collaboration and teamwork, things will slowly begin to untangle and fall into place.

Tea 11:30–11:50 (20 minutes)



Learning Styles Inventory (LSI) 11:50–12:35(45 min)

Note to MT• Please use the Learning Styles Inventory provided in the Registered Psychological Councillor’s

Manual to identify preferred Leaning Styles. • The theory behind the practice section in the Registered Psychological Councillor’s Manual provides

diagrams that detail the essential key activities, features and the questions asked by each of the learning styles.

• Master Trainers need to be familiar with these concepts to provide concrete feedback and help with meaningful reflection and processing with the Registered Psychological Counsellors.

• The Lay Counsellors are not exposed to the LSI but it will be used when applicable by the MT during supervision of the Registered Psychological Counsellors.

Activity Complete the questionnaire and discussion

Aim/purpose • At the end of this activity, the MT will understand that the LSI is a key concept that forms the basis of ensuring a safe learning environment where each person who comes to the training feels understood.

• The MTs will be able to develop a common language to assist the Registered Psychological Counsellors to interpret, reflect and better understand the dynamics of a group and the dynamics between co-facilitators.

Materials • Section 2 of the Registered Psychological Counsellors Manual • Section 2 of the MT Manual

Group All

Time management • Step 1 – Do the LSI = 25 minutes• Step 2 – Understand the LSI = 10 minutes• Step 3 – Apply the LSI = 10 minutes

Instructions Step 1 – Do the LSI• Follow instructions in Section 2 so that each person can identify their

preferred learning style. • Summarise the learning styles using the summary table so that they are

easily recognised.• At this point, they will not understand the detail and implications of each

Style. A broad overview is sufficient. Encourage reading of the materials at a later stage to deepen their understanding and therefore application in practice of the LSI.

Step 2 – Understand the LSI• Explain the theory behind the Learning Style using the diagrams provided

in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors.

Step 3 – Apply the LSI• Complete “Reflecting on my Learning Style” in the MT Manual. • Invite the Registered Psychological Counsellors to think about how the

LSI might influence/impact the training of Lay Counsellors. Refer to “What Master Trainers need to know about the Learning Styles Inventory” as a starting point.



An introduction to Adult Education and the structure of the programme

12:35–12:50(15 min)

Activity Provide information.

Aim/purpose MTs will be introduced to the transformative learning theories so that when applied/reflected on during the training they will be familiar with the basic concepts.

Materials • MT Manual • Depression and Adherence Counselling Trainer’s Manual for Registered

Psychological Counsellors

Group All

Time management 15 minutes

Instructions 1. Using the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors explain the Vygotskian approach to introduce the following:a. The social context of learning b. Scaffoldingc. Mediation and the ZPD

2. Explain the structure of the programme using the “Curriculum Considerations” and the “Lay Counsellor training at a glance” table from the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors and the MT manuals. Use as a demonstration of scaffolding for the layers of the cascade model of training.

Training manuals and sessions allocation 12:50–13:00(10 min)

Activity Provide information and planning.

Aim/purpose The MTs will know the resources available to them to prepare their practice sessions.

Materials • Lay Counsellor Manual• Registered Psychological Counsellors' Manual • Psychologists' Manual

Group All


Instructions 1. Invite the group to page through the 3 manuals and identify what they “see” and how this makes them “feel”.

2. Note the feedback on a flip chart and hang on the wall.3. Use the table provided and the Registered Psychological Counsellors'

Manual and the Psychologists' manual and evenly allocate the activities to the Master Trainers in training.

4. Using the Registered Psychological Counsellors' Manual make sure that there is clarity about co-facilitation, content and process and who is doing what for allocated activity.

5. Explain that they will be facilitating the sessions allocated to them and they will receive feedback from the group.

Lunch 13:00-13:45 (45 minutes)



Model Session 1 - PsychoeducationWaiting Room Talk

13:45–14:20(35 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Invite the Registered Psychological Counsellors to think of themselves as Lay Counsellors hearing

this information for the first time. • Important to highlight in the discussion is that Depression is very often not understood. • Ensure that you highlight the need to develop a language with the Lay Counsellors about

Depression.

Explore feelings and terminology 14:20–14:50(30 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Initiate the activity and once the Registered Psychological Counsellors have an understanding of

the content and process, discuss their role as Trainers. • Manage time to provide an opportunity to discuss the challenges they anticipate when facilitating

this session with Lay Counsellors.• Invite them to think of themselves as Lay Counsellors working through this activity.• De-role the group as Lay Counsellors and discuss the challenges that they as trainers anticipate with

regards to the language associated with depression.• Provide a safe space for the expression of feelings while at the same time remembering that this is

not therapy.

Personal support 14:50–15:10(20 min)


the content and process, discuss their role as Trainers. • Manage time to provide an opportunity to discuss the challenges they anticipate when facilitating

this session with Lay Counsellors.• Personal support is relevant for all levels of trainers and especially when working with the MhINT

emotional content. • Use this opportunity to review their own level of self-care.



Safe spot activation 15:10–15:40(30 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• At the end of the activity discuss when and how to use the safe spot to manage one’s feelings.• Discus the relevance of containment and how to make this culturally acceptable.

Unpack the experience of the day and closure 15:40–16:00(20 min)

Activity Discussion

Aim/purpose • Model how to reflect and integrate the experiences of the day into a learning outcome.

• Allow expression of the experience of the day.

Materials -

Group All


Instructions 1. Ask the MTs to reflect on their experience of the day by checking in with them about how they felt when they walked into the training this morning and how they feel right now.

2. The external facilitators are to reflect on the why the groups feels the way they do through discussing the following:a. Group phasesb. The value of modelling c. Scaffolding of Day 1 programme

3. Start using the tables provided in Section 2 of the MT manual to help the RCPs become aware of the group dynamics.

4. Remind the Registered Psychological Counsellors who will be facilitating Day 2 sessions to prepare with their partner.

5. Close the day with a song or prayer or whatever was decided during the Group Norms session.



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Day 2

Welcome to Day 2!

From today, the Registered Psychological Counsellors facilitate the sessions that have been allocated to them. The more they practice using their manuals, are able to reflect on and receive feedback about their facilitation skills, the greater the chance that they will feel better prepared and more confident when they train and supervise the Lay Counsellors.

• Mirror – today’s programme continues to mirror that of the Lay Counsellors training. The Registered Psychological Counsellors need to practice how they will train the Lay Counsellors. To mimic that training, you will take on the role of the Registered Psychological Counsellor through facilitating the session allocated to you. You will also be the Lay Counsellor receiving the training, or, you will be the Master Trainer providing reflection and feedback using the Sandwich technique. Whatever role is assigned to you today and for the rest of the training, be sure to de-role afterwards so that the discussions that follow will shed light on the purpose, the potential pitfalls and how to facilitate them so that a successful outcome can be achieved.

• Model – reflection-in-action will be modelled so that when you are training and/or supervising the Registered Psychological Counsellors, a level of comfort and trust will be established that can be further developed and strengthened with time.

• How to provide feedback – use the sandwich technique to provide feedback after the Registered Psychological Counsellors have facilitated a session. Remember that this is the first time that they will be using the step-by-step in their manual and it is important to allow for experimentation and possible awkwardness in facilitating the sessions allocated to them. It is your role to be non-judgemental and to supportive as you refer them back to their manual for guidance.

• Time management – is of essence to make sure that the heart of the activity is well understood. It is not going to be possible to complete all the activities/sessions using the time allocated in the step-by-step in the Registered Psychological Counsellors manual. The activity will be initiated by the Registered Psychological Counsellor and once the group is engaged and responding, the Master Trainer can then “fast forward” the activity and ask the Registered Psychological Counsellor to enter into the discussion and summary to ensure that the aim/purpose is discussed.

Sit with your co-facilitator and check in with each other to see how you’re feeling about facilitating the challenges of Day 2.

Using the Registered Psychological Counsellors manual, check that you have all the equipment at hand for today.




Follow DAY 2 in Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors • Trainers facilitate the sessions using the Step-by-step in the Registered Psychological

Counsellors Trainers manual in conjunction with the Master Trainer’s Step-by-step• Understanding the Supervision and Emotional Support programme



08:00–08:15 15 min Check in and safe spot activation for the day Master Trainer

08:15–08:45 30 min Qualities of a helper Master Trainer

08:45–09:15 30 min Listening skills exercise Master Trainer

09:15–09:45 30 min The helping process (1)• Opening

○ Practice appropriate opening and form initiate counselling relationship

Master Trainer

09:45–10:15 30 min The helping process (2)• Exploring

○ Body language - Faces activity

Master Trainer

10:15–10:40 25 min Tea

10:40–11:05 25 min The helping process (2 continued)• Checking information - 2 truths and 1 lie activity

11:05–11:35 30 min The helping process (2 continued) • Clarifying/reflecting - Open and closed questions

11:35–12:05 30 min The helping process (3)• Summarising

○ Situation - (content) ○ Feelings (process)

Master Trainer

12:05–12:50 45 min Group skills activity Master Trainer

12:50–13:00 10 min Summary of morning

13:00–13:45 45 min Lunch

13:45–14:35 50 min Supervision activity

14:35–15:35 60 min Emotional support • Activity: using your manual, devise a strategy

to provide emotional support for Registered Psychological Trainers

Master Trainer

15:35–16:00 25 min • Unpack day’s learnings through trainer’s lens/ Reflection on the day’s “theory in action”

• Summary and closure



Preparation of self and environment 07:30–08:00(30 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors to help you to prepare to set up.• Remember that whatever you do, the Registered Psychological Counsellors will also do!• Your readiness and set up of venue models respect.

Check in and safe spot activation for the day 08:00–08:15(15 min)

Note to MTUse the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• It is important to allow for the safe expression of any uncertainty that might come up especially

that today they will be practising. • Provide reassurance as you allow them to feel anxious to facilitate the session allocated to them. • Use the safe spot as a “come back to myself” tool.• Use the Sandwich Technique to reflect on the facilitation of the activity.

Qualities of a helper 08:15–08:45(30 min)

Note to MT Follow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of the activity.• As the Registered Psychological Counsellors help the Lay Counsellors to identify their qualities, it is

important to also ask the Registered Psychological Counsellors about their own qualities and what they bring to their role in MhINT.

• If time allows, do a round robin and ask the Registered Psychological Counsellors to name 2 of their qualities so that they too get a sense of being recognised and appreciated.

Listening skills exercise 08:45–09:15(30 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of the activity.• Due to time constraints, do 2 of the role plays.• In your discussion, highlight the fact that listening skills is relevant to ALL of us all of the time!



The helping process (1) Opening

09:15–09:45(30 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for the 3 skills that build and form the skills required for the helping process.• Use the Sandwich Technique to reflect on the facilitation of each of the 3 steps of the helping

process.• As a Master Trainer, it is important that you recognise the scaffolding of the helping process and

you see the 3 steps as one leading into the other to ensure a flow in practise. • It is your task to highlight the links where appropriate and applicable when you facilitate this skill.• Manage time well to allow for sufficient experiential learning as well as discussion of the content

and reflection on facilitation skills of the Registered Psychological Counsellor.

The helping process (2)Exploring (body Language)

09:45–10:15(30 min)

Tea 10:15–10:40 (25 minutes)

The helping process (2 continued)Checking information

10:40–11:05(25 min)

The helping process (2 continued)Clarifying/reflecting

11:05–11:35(30 min)

The helping process (3) Summarising

11:35–12:05(30 min)

Group skills activity 12:05–12:50(45 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of the activity.• Using the analogy of animals is a safe and effective way to highlight behaviours that help and

hinder group processes. • If appropriate, ask the group to identify the animal that they have taken on so far and if they have

found it useful or not to help group processes.



Summary of morning 12:50–13:00(10 min)

Activity Sharing

Aim/purpose • Bring closure to the morning’s activities.• Gage where the group is at.• Clarify any outstanding matters where possible.

Materials -

Group All


Instructions 1. Invite the group to take a mental photo of the morning so far. 2. Ask them to describe their photo in 1 sentence.3. Set the start time for after lunch.

Lunch 13:00–13:45 (45 minutes)

Supervision activity 13:45–14:35(50 min)

Activity Experiential learning and discussion.

Aim/purpose • To expose Master Trainers to the process of supervision for every level of the cascade.

• Master Trainers will have an in-depth understanding of the role that supervision plays in building the required skills to implement MhINT.

• Master Trainers will recognise that their mastery of self-reflection and self-care will provide a safe space for those they supervise.

Materials Section 5 in Psychologists Manual

Group Individual and all

Time management • Activity 1 = 5 minutes• Activity 2 = 7 minutes• Activity 3 = 6 minutes • Discussion = 17 minutes

Instructions Activity 1:Invite the Psychologists to share how their personal experience of supervision will assist them to supervise the Registered Psychological Counsellors.

Activity 2:• Share how being comfortable with oneself helps to build authentic

relationships. • Discuss Johari’s window and the value of openness.

Activity 3:Invite everyone to share 1 thing they will do to care for themselves.

Points to highlight for a general discussion:• Supervision is about professional development it is not therapy.• Supervision is about building a trust learning relationship.• Supervision continues until the skill is mastered.



Emotional support 14:35–15:35(60 min)


the content and process,• For clarity of roles, identify the Master Trainer’s role with regards to emotional support for the

Registered Psychological Trainers. • Discuss the difference between emotional support and supervision (see Registered Psychological

Counsellors Manual for detail).

• Unpack the experience of the day, safe spot activation and closure


15:35–16:00(35 min)

Activity Discussion



Materials Psychologists Manual

Group All


Instructions 1. Now that they have had a taste of the programme and how to facilitate it, discuss Balancing Education and Psychology and how to channel their diverse professional experiences into MhINT.

2. Discuss application of CBT model to the training and to themselves: a. Complete Activity 4 in Section 5 of their Master Trainers manual –

Applying CBT healthy thinking skills to their new role as MT.3. The external facilitators are to reflect on the why the groups feels the

way they do through discussing the following:a. Group phasesb. The value of modelling c. Scaffolding of Day 2 programme

4. Briefly add to the tables provided in Section 2 of the MT manual to help the RCPs become aware of the group dynamics.


6. Activate safe spot. 7. Close the day with a song or prayer or whatever was decided during the

Group Norms session.



Day 3

Welcome to Day 3

Today, continue to mirror, model, manage time and provide feedback using the Sandwich Technique. The content for today focusses on the 8 Depression Counselling sessions and on Adherence that the Lay Counsellors will be facilitating in the clinics. A sample of the sessions that highlight the CBT skills that will be taught have been selected to practice. These sessions comprise:

• Session 2 (poverty) introduces Problem Management skills. Session 3 (Interpersonal Conflict), Session 5 (Grief and loss) and Session 6 (Experienced Stigma) use Problem Management Skills and will be reviewed and discussed to highlight any potential problems that might be encountered during the training of Lay Counsellors.

• Session 4 (Social isolation) introduces Getting Active skills and is the only session where this skill is taught.

• Session 7 (Internalised Stigma) introduces Healthy Thinking Skills and is also the only session where this is formally taught. The concept is introduced in Psychoeducation where the symptoms of depression are categorised as Thoughts, Feelings and Behaviours.

On Day 3 you could anticipate that towards the end of the day the group will become restless as they start to move into termination phase. Remember to remain non-judgemental yet firm about keeping to their agreement set during Group Norms on Day 1.

Sit with your co-facilitator and check in with each other to see how you’re feeling about facilitating the challenges of Day 3.

Use the Registered Psychological Counsellors manual to check that you have all the equipment you need for today.




Follow DAY 3 in Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors • The trainers facilitate the sessions• 2 trainers will provide feedback using the supervision feedback form • External Facilitators will facilitate discussion to clarify understanding and build knowledge

and skills



08:00–08:15 15 min Check in and safe spot activation for the day Master Trainer

08:15–08:35 20 min Problem Management (Thandi) Master Trainer

08:35–09:15 40 min Session 2 (Poverty) Master Trainer

09:15–09:45 30 min Review sessions that use problem management: • Session 3 (Interpersonal Conflict)• Session 5 (Grief and Loss)• Session 6 (Experienced Stigma)

09:45–10:05 20 min Tea

10:05–11:30 85 min Adherence Master Trainer

11:30–12:30 60 min Getting Active: Session 4 (Social Isolation) Master Trainer

12:30–12:40 10 min Summary of morning

12:40–13:25 45 min Lunch

13:25–14:25 60 min Healthy Thinking Skills Master Trainer

14:25–15:25 60 min Session 7 (Internalised Stigma) Master Trainer

15:25–16:00 35 min • Unpack the experience of the day, safe spot activation and closure





Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors to help you to prepare to set up.• Remember that whatever you do, the Registered Psychological Counsellors will also do!• Your readiness and set up of venue models respect.

Check in and safe spot activation for the day 08:00–08:15 (15 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• It is important to allow for the safe expression of any uncertainty that might come up especially

that today they will be practising. • Provide reassurance as you allow them to feel anxious to facilitate the session allocated to them. • Use the safe spot as a “come back to myself” tool.• Use the Sandwich Technique to reflect on the facilitation of the activity.

Problem Management (Thandi) 08:15–08:35 (20 min)

Note to MT Follow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of the activity.• The basics of Problem Management are taught during this activity – ensure that it is well

understood so that application in the Sessions that follow will help to internalise the skill.

Session 2 (Poverty) 08:35–09:15 (40 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of the activity.

Review sessions that use Problem Management 09:15–09:45 (30 min)

Note to MTActively page through the sessions in the Lay Counsellor’s Manual so that the Registered Psychological Counsellors will be able to see Problem Management being applied in the following sessions:

○ Session 3 (IP conflict) ○ Session 5 (Grief and loss) ○ Session 6 (Experienced Stigma)

• Discuss any challenged or problems raised by the Registered Psychological Counsellors.• It is interesting to note that intensive research was done to establish the triggers for depression,

hence the topics and the applied CBT model. • The sessions and in particular the Grief and Loss session often triggers the Lay Counsellors (and the

Registered Psychological Counsellors) life stories. • It is in these moments that it is going to be challenging to not get into therapy mode but keep to

the fact that you are teaching a skill.



Tea 09:45–10:05 (20 minutes)

Adherence 10:05–11:30 (85 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of the activity.• Adherence forms a large component of the service offered by the Lay Counsellors and is divided

into 2 sections: ○ A 1-2-1 session with a patient to ensure that the patient understands their condition, their medication and the symptoms that requires them to return to the clinic sooner that their given date.

○ How to use the Chronic Condition Leaflets for the Waiting Room Talk.• Refer to Section 1 and the importance of adherence in the management of chronic illnesses

including depression.

Getting Active: Session 4 (Social Isolation) 11:30–12:30 (60 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of the activity.• Discuss any potential problems that might be encountered while facilitating this session with the

Lay Counsellors.

Summary of morning 12:30–12:40(10 min)

Activity Sharing

Aim/purpose • Bring closure to the morning’s activities.• Gauge where the group is at.• Clarify any outstanding matters where possible.

Materials -

Group All


Instructions 1. Invite the group to take a mental photo of the morning so far. 2. Ask them to describe their photo in 1 sentence.3. Set the start time for after lunch.

Lunch 12:40–13:25 (45 minutes)



Healthy thinking Skills 13:25–14:25 (60 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of this activity.• As a Master Trainer, reflect on where and how Thinking, Feeling and Behaving has been integrated

in the programme so far. • Your role is to highlight and help the Registered Psychological Counsellors to make the links

and find meaning in what they are training the LCs to do. By making the links you will enrich the reflection and help make meaning out of the information provided. In doing so, you will make Content and Process equal; you cannot be successful if only one dimension is applied.

Session 7 (Internalised Stigma) 14:25–15:25(60 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• Use the Sandwich Technique to reflect on the facilitation of this session.• Discuss any potential problems that might be encountered while facilitating this session with the

Lay Counsellors.

• Unpack the experience of the day, safe spot activation and closure


15:25–16:00(35 min)

Activity Discussion



Materials -

Group All


Instructions 1. Check in by allowing free expression of the learnings of the day. 2. Reflect on the why the groups feels the way they do through discussing

the following:a. Group phasesb. The value of modelling c. Scaffolding of Day 2 programme

3. Briefly add to the tables provided in Section 2 of the MT manual to help the RCPs become aware of the group dynamics.


5. Remind the group that tomorrow is the last day and that they will need to vacate their rooms before they come to the training.

6. Activate safe spot. 7. Close the day with a song or prayer or whatever was decided during the

Group Norms session.



Day 4

Welcome to Day 4, your last day of this training!

Today, continue to mirror, model, manage time and provide feedback using the Sandwich Technique. • Today keep firmly to time. • Today expect the return of anxiety. Bonds have been forged and there is often a sense of loss

and will I cope out there without you. • Today keep your energy focussed and goal orientated to ensure that you.

An extra hour is budgeted for during the programme this morning for you to use at your discretion to recap or complete any sessions that have not been done due to time constraints and group processes.

Sit with your co-facilitator and check in with each other to see how you’re feeling about facilitating the challenges of Day 4 and closure.

Use the Registered Psychological Counsellors manual to check that you have all the equipment you need for today.


Follow DAY 4 in Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors • Integration of learning• Ensure that everyone knows what to do on Monday • Review training



08:30–08:45 15 min Check in and safe spot activation Master Trainer

08:45–10:15 90 min PHC process map with Mental Health indicators Master Trainer

10:15–10:35 20 min Tea

10:35–11:35 60 min Session 8 (Closure)

11:35–12:00 25 min Post-training evaluation

Please note: An hour is budgeted for you to use your discretion to recap or complete of any sessions that have not been done due to group processes and time management. This can be slotted in after the check in. Officially the training ends at 13:00.

13:00 Group photograph and lunch


Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors to help you to prepare to set up.• Remember that whatever you do, the Registered Psychological Counsellors will also do!• Today model how to maintain standards and keep up the energy of the training.



Check in and safe spot activation for the day 08:30–08:45 (15 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• It is important to allow for the safe expression of any uncertainty that might come up especially

that the training is coming to an end. • If the group goes into farewells, inform them that there is time allocated for this later on in

the morning.

Process Map with mental health indicators 08:45–10:15 (90 min)

Note to MT Follow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for this activity.• As you process and reflect on this activity make sure that you include the following:

○ Role clarifications ○ Time management of the programme as a whole ○ Referral pathways ○ The significance of the documentation in terms of monitoring and evaluating the programme.

Tea 10:15–10:35 (20 minutes)

Session 8 (Closure) 10:35–11:35 (60 min)

Note to MT• Model Session 8 and use an appropriate closing/ending activity for this training.• Be spontaneous based on the group dynamics but also ensure that there is adequate closure.

Remember that this group will meet again but not in the same way as they have bonded now in this learning environment with you as their Master Trainers.

• Acknowledge the bonds that have been formed during the past few days. • The past few days have been an intense learning curve where memories have been created

as a group. • Remind everyone that they need to rest and recover!

Post-training evaluation 11:35–12:00 (25 min)

Note to MTFollow the steps in the Depression and Adherence Counselling Trainer’s Manual for Registered Psychological Counsellors for to complete the post-training evaluation.

Group photograph and lunch 13:00


SECTION 5

As a Master Trainer you will be training the RPCs to understand and use the structure of the supervision sessions which aims to enable Lay Counsellors to be competent to facilitate the depression and adherence counselling sessions.

The emotional care component of the support programme is directly linked to the possible emotions that could be evoked during the Sessions.

Supervision is therefore skills driven while emotional support is geared towards emotional health for every level of the cascade.

It is recognised and valued that as a trained Psychologist you come in with experience and knowledge of your profession. This section therefore builds on that knowledge and allows for reflection and a deeper understanding of what is required of you in your supervisory and supportive role of the MhINT RPCs and the programme as a whole.

Supervision and emotional support

for Registered Psychological

Counsellors

This section assumes an in-depth knowledge of the structure and process of the MhINT supervision and emotional support model described in Section 5 of the Registered Psychological Counsellors (RPCs) Manual.

SECTION 5: Supervision and emotional support for Registered Psychological Counsellors


Exploring supervision

Activity 1 – What supervision means to METake a moment to reflect and write about the following:

• Are you currently in supervision?• If yes, why?• If not, why not?• What has your experience of supervision been? Think of your journey as a psychologist and the

role that supervision has played in your personal and professional development.• Complete the table below to identify what works and what does not work during supervision.

What works? Why?

What does not work? Why?

The 3 lessons that I will take into the future for those I supervise…

1.

2.

3.



Activity 2 - Self-knowledgeNo matter your experience of supervision, or the model or theory used, self-knowledge is an essential ingredient in building and sustaining the dynamic and authentic relationship between the supervisor and supervisee. To help unpack this relationship, reflect and write about the following:

The IndividualIn what ways will your personal experience of supervision influence the way you supervise, and in this case, how you will supervise the MhINT RPCs?

The groupIn what way will your knowledge of yourself help or hinder group processes and group functioning when you train the RPCs to be MhINT trainers?

The organisation In what way can your self-knowledge influence your functioning within the organisation in relation to your role as trainer and supervisor of the RPCs?



The art of reflection and Johari’s windowThe word “mirror” is used in several ways during this training. In the case of its use during supervision, the mirror is used as a tool for reflection. If we examine Johari’s window, the supervisor reflects with the supervisee to unpack and understand the “Blind Self”; the aspect of ourselves that is seen or experienced by others but is not visible to oneself.

Based on the work of J Luft and H Ingham - a graphic model of Interpersonal Relationships and Self-reflection.

Known to self Unknown to self

Known to others

1. Open and FreeYou know and others know

2. Blind selfYou don't know but others do

Unknown to others

3. Hidden selfYou know but others do not know

4. Unknown to selfYou don't know and others don't know

The principle of Johari’s Widow is that if you open yourself to others and if you allow others to show you aspects of yourself, then you will enlarge the OPEN area resulting in the expansion of all 4 areas.

The portions of each relationship will differ for any individual person. For example:

1 2

3 41 2

3 4

1 2

3 4

As psychologists, it is important to refrain from pathologising the Blind Spot but to rather help make it visible so that the Registered Psychological Counsellor can better understand themselves and the work they do in MhINT.



Self-careMake a commitment to yourself to “Do unto yourself as you advise others to do for themselves”

My self-care plan



Balancing education and psychology

A pragmatic approach to self-reflection is a useful tool towards personal and professional growth. The potential struggle for psychologists is to balance the two fields of Education and Psychology that have blurred boundaries in MhINT. Diagram 1 shows what is central to both disciplines and where the focus is different.

Focus on: • Conscious behaviour

and unconscious behaviour studied and worked with

• Pathology• Psychodynamic • Individual

orientated

Important to both disciplines

Focus on: • Outcomes defined • Information

scaffolded• Knowledge and

information mediated

• Balance between content and process

• Experiential learning in socially situated context specific

Education Psychology

Who am I?

Search for meaning

Understanding

Skills needed

Personal & professional growth

Practical wisdom

» Diagram 1 Balancing education and psychology



Diverse professional knowledge and experience channelled

Whoever you are and no matter your credentials, you are asked to bring your competence to the present moment and apply Cognitive Behavioural Therapy (CBT). This is important as the psychosocial sessions provided by the Lay Counsellors are informed by CBT principles. Therefore, in applying CBT, you model the relationship between facilitators, their use of the content and process as set out in their manual. This builds trust; trust of self, trust between facilitators, trust between the facilitators and their respective manuals, and trust of the intervention between all the stakeholders and parties involved.

CBT

Master Trainers Diverse in: Therapy | Counselling | Coaching

Mentoring | Supervising Training Different models

Different approaches Varying levels of experience

Understanding Schools of thought

Life experience

MhINT requires integration and channelling

into applied CBT

Bring your competence into the

present moment

No blank slate – everyone contributes something of value …

» Diagram 2 Bringing diversity into CBT



Applying CBT to content and process

What and how is Content trained?• 8 depression counselling sessions • Adherence counselling • Theories underpinning the MhINT

programme • Evidence that supports the content of the

intervention

What and how is Process trained?• Apply and reinforce CBT in the MhINT context • Model the methodology of experiential learning and

reflective practice• Boundaries in the training supervising relationship (not

therapy)• Honour the “contract” which determines the focus of the

intervention

CBT

MhINT Master Trainers

apply

» Diagram 3 CBT channelled into the interplay between content and process.

Activity 4 – Applying CBT healthy thinking skills to your new role as Master Trainer Reflect on your new role through the impact of the cycle between your thoughts, feelings and behaviour.

THINK

FEEL

ACT



The spiced up sandwich technique Through their training, the Registered Psychological Counsellors will have a greater understanding of their unconscious behaviour and how it might impact the Lay Counsellors. Similarly, the Lay Counsellors through supervision develop a greater understanding of how the different depression sessions can evoke certain thoughts and feelings that can adversely influence their being able to provide the service. When providing feedback to Registered Psychological Counsellors during their training or during supervision, the questions of the sandwich technique remain the same but the depth and exploration is deepened.

Working with depression and its impact on all stakeholders involved needs to be recognised so that the emotions that surface and need to be dealt with can be taken further into individual therapy when appropriate. Being emotionally healthy will ensure that the work of MhINT is not hampered by the unconscious protective behaviour displayed by the MhINT trainers.

Practice giving feedback that is uncomplicated and that instantly illuminates what needs to change. Always provide practical support of how this can be done.

Deepening the questions

• In your role as a RPC, what thoughts, feelings and actions helped or hampered the relationship with your co-facilitator?

• In what way did the dynamic between the two of you influence the progress of the group as a whole?

• In what way did you allow limiting self-beliefs to block you?

• Apply the 4 quadrants of Johari’s Window

Possible questions to ask to achieve a yummy

sandwich1. What do you think went well

and why?2. What did not go so well for

you? Tell me more…3. When you do this step/

session again what you would do differently? How?

4. What did you learn from this experience?

5. What practical steps can you take to keep on building your confidence when doing this session?

6. In what ways can you use your Lay Counsellor Manual more effectively?

Top slice: What went well?

Filling: What did not go well?

Why? How can it be changed?

Bottom slice:Overall positive

comment

Psychologists MhINT Supervision and Support Form

The form on the next page will be used as follows:• You will be trained to use the MhINT Supervision and Support form for Master Trainers during

the 4-day Registered Psychological Counsellor’s training. • This form will be used by External Trainers to support you, the Master Trainer, build on your own

ability and confidence to supervise and support those you train. • This form can also be used as a self-reflection tool.

The Supervision and Support Form allows for reflection and feedback on 3 key aspects of the programme:1. The application of the spicy sandwich technique2. Use of Thoughts Feelings and Behaviours to reflect on content and process3. Support the administrative component of MhINT

Please rate yourself as follows:1 = you did not manage that aspect 2 = you managed to ask the relevant questions but did not use skills to deepen reflection3 = you did that well



1: Application of Sandwich Technique 1 2 3 Comments

Top slice – “what went well” • First asked the trainer what went well• 1 or 2 good things noted and clearly articulated

Filling – “what did not go so well” • First asked the trainer what did not go so well and

how that can be done differently next time• Choose 1 aspect that can be worked on making sure

that the “how to do it differently” is understood

Bottom slice – “overall positive comment” • Was this slice meaningfully provided?

2: Use of Thoughts Feelings and Behaviours to reflect on content and process 1 2 3 Comments

Opportunity was given for self-reflection before commenting • Were you aware of any limiting self-limiting beliefs

as you were providing feedback?• In what way did you allow limiting self-beliefs to

block you or not?

Reflection on Content • Did the Content knowledge support the application/

internalisation of the CBT skills?• Did knowledge about the adult learning theories

help with facilitation skills?

Reflection on Process • In what ways have you become more “open”; to

yourself and to the feedback from others?• In what ways has your Learning Style influenced the

dynamics of the group/ between you and your co-facilitator? (positive and negative)

Reflection on the relationship between co-facilitators• In what way did the dynamic (positive and negative)

between the two of you influence the progress of the group as a whole?

3: Support Administrative component of MhINT 1 2 3 Comments

Review of implementation data and reporting • Were you able to facilitate the identification of

trends in implementation data?• You facilitate the exploration of systemic, counsellor

and supervisor factors in relation to trends observed in implementation data

• General review of data records and skills development of counsellors as per Lay Counsellor supervision form


SECTION 6

Monitoring for Improvement

SECTION 6: Monitoring for Improvement


Part of your responsibility in your role as a Psychologist is to keep accurate records of activities and services you provide as part of your monthly statistics. Without this data the Department of Health would never get to know the burden of disease and would therefore have no basis to inform planning for mental health services. The role of data in health care services is therefore vital for the following reasons:

1. Data is objective 2. It tells a story better than 1000 words!3. It shows us if things are looking or working as we want them to 4. It helps us to track our performance

Section 6 of the Registered Psychological Counsellor Trainer Manual explains this in detail whilst this section provides further clarity on the specific support you will provide to the M&E activities as a Master Trainer and Registered Psychological Counsellor Supervisor.

The MhINT Process Map

The MhINT Process Map provides a comprehensive overview of MhINT and illustrates the following key components of the intervention:

• MhINT intervention tasks• What materials to use• Record for CQI• Referral pathways• What treatment is being offered and by whom



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Monitoring and Evaluation

At the simplest level, you will be meeting with the Registered Psychological Counsellors on a monthly basis to answer two very broad questions: 1. “How is the MhINT intervention progressing?” 2. “What needs to/can be done to improve?”

During supervision with the Registered Psychological Counsellors, you will have the opportunity to unpack these questions using the routine data that is collected by this group from the Lay Counsellors as the point of departure.

Part of the unpacking will involve exploring how systemic factors, counsellor factors and supervisor factors intertwine and how they impact on the programme’s performance. Ultimately the answers to these questions provide insights into how effective the programme is/is not and also what is required to support successful implementation and sustainability over time.

MhINT implementation

data

systemic factors

counsellor factors

supervisor factors

MhINT implementation data Registered Psychological Counsellors routinely collect MhINT implementation data from Lay Counsellors and collate it in a detailed spreadsheet containing the following details for each of the implementation clinics:

• Demographic details of patients referred • Date of referral • Whether the referral was appropriate or inappropriate • Who referred the patient • Which other healthcare provider the patient was referred to• Date of when the first counselling session was provided • What was the patient’s pressing issue • Date/s when depression or adherence counselling sessions were provided • How many counselling sessions in total the patient received • Total number of depression counselling referrals • Total number of adherence counselling referrals



» The graphic above shows a template of the uptake spreadsheet containing implementation data

Trends in MhINT implementation data should become less erratic as the intervention progresses and start to reflect patterns that are coherent with occurrences in the system in which the intervention is embedded. During supervision, the data guides you on where to deepen questions and facilitates setting “homework” for the Registered Psychological Counsellor to work on following supervision.

Implementation data

Systemic factors The following are telling of a system that is successful in the implementation of the MhINT intervention:

• Variation in referring clinicians: This is indicative of facilities that have embraced task sharing and do not rely on one member of staff to be the “champion” for the intervention. Facilities adopting a “champion” model often struggle to sustain good performance in the absence of the allocated clinician. Encourage Registered Psychological Counsellors to report stats on clinician referring patterns during CQI meetings as this can threaten the intervention.

• A higher number of “appropriate referrals”: This demonstrates that the clinicians have been adequately trained and are competent in assessing for symptoms of depression and are aware of the service provided by Lay Counsellors for patients with depression and those who default on treatment for their chronic conditions.

• Total number of referrals that is consistent with the facilities headcount and prevalence/ adherence statistics: This indicates that patients are receiving the relevant intervention at each stage of care as per mental health treatment cascade; i.e. they are being screened for mental health; they are being adequately assessed and they are referred as needed. This data is also indicative of a trusting relationship between the clinicians and the MhINT trained Lay Counsellors and therefore an acceptance of task sharing. During supervision, you may direct the RPCs attention to Clinics that have a significantly high number of adherence counselling referrals in comparison to depression counselling referrals. This could signal that the clinic may need additional support in integrating the new role of the counsellor following MhINT training.

• Implementation data that reflects consistent provision of counselling sessions can also be indicative of a system that has created space for the MhINT-trained counsellor to be able to provide uninterrupted service to patients thus making it possible for patients to complete the full course of the psychosocial intervention.



Lay Counsellor factors The following are telling of counsellor factors that are conducive for successful provision of the MhINT counselling sessions:

• Patients are receiving their first depression counselling session on the date of referral: When Lay Counsellors do this routinely, the chances of patients returning for subsequent sessions becomes much higher. This also ensures that patients that have been appropriately identified do not leave the clinic without receiving important psychoeducation about depression.

• Consistent increase in provision of counselling sessions: At the beginning of the intervention, counsellors’ with low confidence in their skills may lead them to avoid following up on subsequent sessions with referred patients:

○ When the data reflects consistent increase in patient retention and clear explanations for termination of sessions before the full 8-session course is provided, this could be indicative of both the counsellor and the system adapting well to the intervention. During supervision, you can assist the Registered Psychological Counsellor to notice the trend of this data element for each of the counsellors they supervise as it can highlight counsellors who may still lack confidence in their skills and therefore need additional support and attention.

○ Similarly, when counsellors who previously had consistent data suddenly have a decline in their statistics, you can alert the Registered Psychological Counsellor to the change and explore possible strategies that the Registered Psychological Counsellor can employ to investigate whether the decline is linked to systemic, emotional or other factors that need to be addressed.

• High session completion rate: This indicates that the Lay Counsellor is able to establish a trusting relationship with patients resulting in patients committing to completing the full course of the psychosocial intervention. As indicated earlier, this can also be indicative of a system that is supportive of the intervention.

• Emotional well-being and self-care: Lay Counsellors who are more confident in their counselling skills will tend to also apply the coping techniques embedded in the depression counselling intervention in their own lives. During supervision, direct the Registered Psychological Counsellors attention to discrepancies where a Lay Counsellor is receiving a high number of appropriate referrals from clinicians but they do not initiate the patients on depression counselling or follow up on missed appointments. Also encourage the RPC to reflect on whether there is a noticeable trend on specific sessions (patient’s pressing issue data element) that Lay Counsellor seem to consistently avoid, as those sessions may be too closely related to issues in the Lay Counsellor own life that cause them emotional distress.

Supervisor factors The following are indicative of supervision factors that are facilitative of successful programme implementation:

• Regular reporting to facility-based CQI teams: Section 6 of the Registered Psychological Counsellor Trainer Manual provides clarity on the role of the Registered Psychological Counsellor in CQI activities. When the Registered Psychological Counsellor supports CQI meetings routinely this can result in a decline in systemic factors that hinder successful implementation.

• Up-to-date record keeping: It is difficult to improve that which you do not know. Registered Psychological Counsellors who keep up-to-date records (in terms of referral data and competencies that need to be developed as per supervision form) are likely to also be more responsive to challenges experienced by Lay Counsellors and provide support more efficiently.



• Following the supervision framework: Section 5 of the Registered Psychological Counsellor supervision framework stipulates that counsellors are to receive a minimum of four one-on-one supervision sessions with the supervision form highlighting areas of strength and areas needing improvement. It can be expected that as the Lay Counsellors become more confident in their skills they will have patients returning for subsequent sessions and will have more group sessions than individual sessions.

» Example: Implementation data for the period Sept-Dec 2017

The graph above is an example of representation of MhINT implementation data over a period of 4 months.

The graph shows that that at the beginning of the intervention there are more depression counselling referrals than adherence referrals. By the end of the 4th month; depression referrals have declined significantly and adherence referrals have increased. Additionally there is a noticeable trend where patients referred for adherence counselling typically take up the service in comparison to the discrepancy between the number of patients referred for depression counselling and those who take up the service.

• Based on the number of referrals we explored systemic factors: ○ What possible factors in the system could have contributed to the total number of referrals over this period?

○ What are the possible causes of the shift from more depression referrals to more adherence referrals?

• Counsellor factors: How is it that counsellors have been mostly able to provide adherence sessions on referral but over time, seem to not be initiating patients on depression counselling?

• Supervisor factors: Has the RPC supervisor been keeping to the supervision framework in order to identify the trend in declining uptake in order to facilitate addressing challenges to depression counselling uptake?



Recommended approach to data review

The following approach is recommended to frame your discussion on implementation data and explore data trends. 1. What is the total number of depression referrals for the month? 2. What is the total number of adherence counselling referrals for the month? 3. Discuss any discrepancies between referrals and uptake4. Which clinics are performing well and why? 5. Which clinics are performing poorly and why? 6. What lessons can be learnt from both clinics that are performing well and those that are performing

poorly that can facilitate improvement in mental health services? 7. In line with challenges discussed, which challenges does the RPC want to work with in the course of

the month? What is their plan for addressing the challenges?

(Note: performance is assessed in line with the systemic, lay counsellor and supervisor factors discussed above).

You can use the feedback from this discussion to collate quarterly reports that must be submitted to the district mental health coordinator.

Contribution to CQI Activities

During the 4-day RPC training, you will orientate them to the Process Map in Section 6 and also provide clarity on their role in the continuous quality improvement activities to embed the intervention in the health system. This is outlined in Section 6 of the Registered Psychological Counsellors Trainer manual. As the Master Trainer and Registered Psychological Counsellor supervisor, you need to be familiar with the CQI methodology in order to be able to support the Registered Psychological Counsellors effectively.

In summary

Your role as a Mater Trainer is to have a broad overview of the all the activities pertaining to the MhINT programme. This overview is taken from the stats provided by the Registered Psychological Counsellors. Your responsibility is to:

1. Ensure that you receive and review the stats monthly so that you can look for trends.2. Ask the questions that need to be asked to ensure good governance of the programme and

accountability at every level to perform their allocated tasks. 3. Support and encourage the Registered Psychological Counsellors to build confidence and help

them find fulfilment in their role. 4. Share best practice and celebrate the successes at every opportunity!


SECTION 7

Resources

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SECTION 7: Resources


This material has been funded by CDC (US Government) and UK aid (UK Government), however the views expressed do not necessarily reflect the US and UK Government’s official policies. It has been developed by the Centre for Rural Health of University of Kwa-Zulu Natal (Howard) in collaboration with Gill Faris an Adult Education Specialist for the Mental Health Integration Programme implemented in KwaZulu-Natal, Mpumalanga and North West Province. The information in this publication may be distributed and reproduced unaltered as long as the source is acknowledged and is used for non-commercial purposes only.

DISCLAIMER: The advice and information given in this manual 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.

Contributors • Prof Inge Petersen (UKZN)• Prof Crick Lund (UCT)• Prof Arvin Bhana (UKZN)• Ms One Selohilwe (UKZN)• Ms Gillian Faris (Adult Education Specialist)• Ms Sithabisile Gugu Gigaba (UKZN)• Ms Nozipho Mpontshana (UKZN)• Ms Rethabile Khadikane (UKZN)

Honouring the sources of the training approach:The application of the theories of Adult Learning and Teaching embedded in the design of the MhINT training programme come from many sources. Firstly, from the experienced adult education practitioners who have generously shared their knowledge and abilities with me, and secondly, my own studies and experience working in the field of Adult Education. The concepts and theories that need mention are 1) Knowles for his Principles of Adult Learning and Teaching, 2) Vygotsky for the social context of learning, scaffolding and ZPD, 3) Engeström for his 3rd Generation Activity Theory, 4) Lave and Wenger for Communities of Practice, 4) Kolbe, Honey and Mumford for the Learning Styles Inventory and 5) the Experiential Learning theorists namely, Kolbe, Boud, Mezirow and Schön.

Documents

Depression and Adherence Counselling Master Trainer’s ... · be provided for the Master Trainer to fulfil their responsibilities in the MhINT programme. About the MhINT cascade