|Year : 2021 | Volume
| Issue : 1 | Page : 101-106
A Field Report on the Pilot Implementation of Problem Management Plus with Lay Providers in an Eritrean Refugee Setting in Ethiopia
Frezgi Gebrekristos1, Liyam Eloul2, Shannon Golden3
1 EQUIP Focal Person, The Center for Victims of Torture, Ethiopia
2 Clinical Advisor, The Center for Victims of Torture, St. Paul, Minnesota, USA
3 Research Associate, The Center for Victims of Torture, St. Paul, Minnesota, USA
|Date of Submission||30-Sep-2020|
|Date of Decision||08-Jan-2021|
|Date of Acceptance||02-Feb-2021|
|Date of Web Publication||31-Mar-2021|
Research Associate, The Center for Victims of Torture, 2356 University Avenue West, Suite 430, St. Paul, Minnesota 55114
Source of Support: None, Conflict of Interest: None
We conducted a pilot to train paraprofessional helpers to deliver Problem Management Plus (PM+) in refugee camps with Eritrean refugees in Ethiopia. This field report presents reflections from trainers, supervisors and participants. We offer lessons learned from material translation and adaptation, including strategies for training on PM+ with low-literacy populations. The training covered foundational helping skills and the PM+ intervention. We share lessons from the training process, highlighting the importance of role plays and considerations for trainee selection. We discuss the importance of supervision for this intervention, particularly in contexts where paraprofessionals have experienced violence and displacement. We present challenges encountered, as well as adaptations for a low-resource, camp-based context. Overall we found it was possible to train nonspecialist helpers in PM+ within 2 weeks; however, intensive supervision was required for the first course of clients. We found PM+ to be useful, but our field experience suggests that PM+ may be more appropriately applied with the local population facing adversity, as we found it did not meet some of the primary needs, constraints and symptom severity encountered in the refugee camp context. Further field experience and research is needed to understand in which contexts PM+ is suitable for widespread roll-out.
Keywords: camp setting, Eritrea, Ethiopia, humanitarian emergencies, nonspecialists OR paraprofessionals, Problem Management Plus (PM+), psychological treatments, refugees, supervision, training
|How to cite this article:|
Gebrekristos F, Eloul L, Golden S. A Field Report on the Pilot Implementation of Problem Management Plus with Lay Providers in an Eritrean Refugee Setting in Ethiopia. Intervention 2021;19:101-6
|How to cite this URL:|
Gebrekristos F, Eloul L, Golden S. A Field Report on the Pilot Implementation of Problem Management Plus with Lay Providers in an Eritrean Refugee Setting in Ethiopia. Intervention [serial online] 2021 [cited 2021 Oct 20];19:101-6. Available from: https://www.interventionjournal.org/text.asp?2021/19/1/101/312724
| Introduction|| |
Individual Problem Management Plus (PM+) is a brief transdiagnostic psychological intervention for people facing adversity, designed to be safely administered by trained paraprofessionals (WHO, 2018). It has been used effectively in an urban setting in Kenya with women survivors of violence (Rahman et al., 2016), in post-conflict Pakistan in a healthcare setting (Bryant et al., 2017), and with Syrian refugees in The Netherlands (de Graaff et al., 2020). However, at the time of writing, we are not aware of any published studies in which Individual PM+ has been evaluated in a low-resource camp setting with a refugee population facing adversity due to protracted displacement. A randomised control trial has been conducted with Syrian refugees in Azraq camp in Jordan; results will be an important step in understanding the intervention’s efficacy for populations dealing with specific challenges of a refugee camp (Akhtar et al., 2020; Bryant et al., 2020).
Ethiopia is a low-income economy (World Bank, 2020) hosting approximately 900,000 refugees, including 183,383 Eritreans (ARRA, 2020). At the time of our training, four camps in the northern Tigray region hosted 125,556 Eritrean refugees (ARRA, 2020); this article describes implementation of PM+ in two camps. The majority of residents are under 30 years old, and until 2018 the vast majority were men and boys (UNHCR, 2018a, UNHCR, 2018b). This is a rural camp setting with minimal services, low resource access and high reliance on humanitarian aid. The restrictions of the setting preclude sustainable livelihood options, which limit self-reliance and often result in negative coping mechanisms (Samuel Hall Consulting, 2014). The inability to work and frequent social isolation increase risk-taking behaviour in youth in particular, with high rates of secondary migration (Mallett et al., 2018) and suicidality (Hayden, 2015).
Operating since 2013, The Center for Victims of Torture (CVT) has been the only dedicated mental health and psychosocial support (MHPSS) provider in two of the camps. Its interventions focus on individuals with acute needs, primarily survivors of torture or severe trauma experiences in Eritrea or during migration. This focus was designed to meet the needs of the predominantly young men escaping abusive treatment due to political opinion or religious belief or escaping enforced military conscription. However, following the peace agreement between Ethiopia and Eritrea in 2018, the border was opened after 20 years. The normalisation of border crossings led to a surge in asylum seekers entering Ethiopia and drastically changed the camp profiles (Jeffery, 2018). Women and children arrived (UNHCR, 2019), hoping to reunite with spouses or sons. Many faced disappointment; often their loved ones were no longer there and the economic conditions were as difficult, or worse, than in Eritrea. This indicated the need for new services, targeting the challenges and symptoms that arise from chronic stress. CVT determined that PM+ may be a good match for these needs (Dawson et al., 2015) and embarked on a pilot. Through adapting PM+ materials, training refugee lay helpers and piloting service delivery, we gained important lessons on the implementation of PM+ in this setting which may be applicable to similar refugee contexts. This field report highlights key clinical observations of CVT staff implementing the PM+ pilot, as well as reflections about when and where PM+ is an efficient intervention to prioritise.
| Material Adaptation and Training|| |
CVT sent two local staff with extensive counselling experience with CVT’s programme and the refugee setting to a masters PM+ training of trainers. This reduced the gap between trainer contextual awareness and helper and client lived experiences found with expatriate trainers (van’t Hof et al., 2018). The master trainers led our local teams in translating and adapting PM+ materials into Tigrinya for the Eritrean refugee context. The interpreters on the team had MHPSS experience and had a tailored technical vocabulary. The team found the PM+ manual language generally simple and clear to translate. However, some terms were challenging to adapt and translate both concisely and accurately. These included: “paraphrasing”, translated as “after the counsellor hears the client story, he/she repeats the major concerns to the client;” “reflecting;” “summarising;” “adversity”, as distinct from “problems;” “empathy”, as distinct from “pity” and “Get Going Keep Doing”, translated as “beginning and continuing”. The terms “problem management” and “stress management” were also problematic and required significant explanation for clients. The direct translation of “management” means something is completely controlled or disappears, setting unrealistic expectations for clients. Ultimately it was decided to use the Tigrinya term for “reduction”.
The trainers first provided PM+ training to 27 CVT counselling staff, all of whom who had at least 1 year (average: 3.7) of supervised, trauma-focused, clinical work in the context. The second stage was to train two cohorts of partner organisation staff − refugee community mobilisers without previous MHPSS experience − to assess the feasibility of a broader application of PM+. Cohort one was a small group (n = 8) in Addis Ababa. These helpers lived and worked in an urban refugee setting, all had completed secondary school; several had vocational training or bachelor’s degrees. Training days were 7 hours, and helpers did not have additional work duties during the two-week training. Cohort two was in the Tigray camps. This training was larger (n = 35), including six CVT paraprofessional staff and 29 partner organisation staff: education levels varied from elementary to undergraduate degrees. Training days were restricted to 5 hours and helpers had additional duties during the two-week training period. Consequently, the opportunity to discuss, practise and reflect on content was more limited. The camp-based helpers also received intensive individual, competency-based live supervision while delivering PM+ with their first client, reinforcing competencies learned and providing ongoing guidance.
Both cohorts of helpers were Eritrean refugees, living in the same communities and having experienced similar forms of adversity as the clients they were being trained to help. As indicated by van der Veer and Francis (2011), it is a benefit and a challenge when helpers have the same problems as client populations. This was addressed carefully in the training, with attention to creating a safe space for the helpers, and allowing them to relate the material to their personal as well as professional experiences. Some helpers shared their problems and psychological symptoms, as well as their experiences managing their own stress or solving problems. Facilitating opportunities for helpers to support each other resulted in concrete experiences of providing therapeutic support and set the foundation for future peer supervision. A full training day focused on self-care and supervision to underscore their importance in psychosocial practice and to help helpers learn new strategies and build their self-care plans.
The training was conducted in Tigrinya, the helpers’ native language, which increased understanding and eliminated the need for interpretation. Five days were devoted to foundational counselling skills, particularly listening and empathy. Similarly to the experience of other trainers working with paraprofessionals (van der Veer & Francis, 2011), trainers observed that helpers had a strong penchant for advice-giving and judgement, seeing this as the primary way to help. To develop core therapeutic skills, experiential role plays were necessary for helpers to believe in “helping through talking” and not rely on advice-giving and material services. During the first week, helpers expressed impatience to learn concrete techniques, for example stating, “We are learning about understanding the client’s problems but not how to support the client. When are we going to learn how to solve the client’s problems?” The trainers emphasised the importance of understanding a client’s problem to effectively support the client, as well as the therapeutic benefit from allowing clients to feel heard.
Role plays were a key training strategy and the core of pre- and post-training competency assessments (see Pedersen et al., 2021). Through training role plays, helpers practised what they learned and trainers offered feedback. Trainers gave instructions on how to present clients’ problems and case examples were realistic within culture and context. Each PM+ session was role played repeatedly, both by helpers and demonstrated by trainers. In groups of three, helpers rotated between playing the client, helper and observer. Trainers moved around the training hall to observe the helpers. Demonstration role plays were conducted in pairs with the rest of the helpers observing; the helpers were more vigilant in applying the appropriate skills in front of an audience. Feedback, discussions and reflections were conducted after every activity to build clinical analysis and reflection skills. In post-training assessments, helpers cited role plays as the most impactful technique in the training. They reported that practising strategies and receiving feedback helped integrate theoretical lessons learned and increase confidence to use the techniques.
Helper competency was assessed using the ENhancing Assessment of Common Therapeutic Factors (ENACT) framework (Kohrt et al., 2015) and PM+-specific role plays and rating scales, post-tests of knowledge gain and trainer observations. Helpers demonstrated notable improvement between the pre- and post-training role play assessments, particularly in their capacity to maintain a therapeutic presence. Most helpers were able to understand and adopt nonverbal skills such as facial expression, posture and vocal tone. However, verbal communication competency varied, and required more coaching to implement normalisation (helpers often used phrases such as “all of us are facing similar problems”), as well as encouraging, praising and appreciating client strengths, particularly when only minor gains were made between sessions. While these skills are important in PM+, praising is not common in Eritrean culture and helpers struggled to implement this component. Demonstrating empathy also required coaching; trainers emphasised that providing positive regard and space for the client to share was in itself healing. Helpers often felt this was insufficient, desiring to provide advice and direction to clients in role plays. In some cases, advice could be perceived as judgemental (“you should not feel like this, be strong”) and undermined the therapeutic interaction. These areas were noted and supervisors used this feedback to guide supervision with individual helpers.
Through the training, helpers gained familiarity with PM+ strategies, but struggled with the Managing Problems strategy and explaining the inactivity cycle (consistent with van’t Hof et al., 2018). This required additional coaching and role playing during and after the training. Helpers struggled to remember steps of the managing problems strategy and relate these clearly to clients. It takes significant practice to assist a client to select a solvable problem and break it into manageable pieces; this was difficult for helpers. They often did not help clients brainstorm and list all of their problems, instead choosing one of the first problems mentioned. Helpers expressed feeling anxious and overwhelmed by the client listing multiple problems, perceiving it would be too difficult or take too much time to help the client select one problem. Similarly, helpers struggled to help clients brainstorm creative solutions for their selected problem, and instead referenced common strategies and chose one of the first healthy options mentioned by the client. The PM+ manual suggests the helper could use humour or offer “silly” solutions to aid in the client’s brainstorming (WHO, 2018, p. 49). However, this was not comfortable for helpers, as they worried about the perception of the client who would expect them to act professionally.
Live Supervision and Support
Live supervision was provided for all five sessions with the helpers’ first clients. Despite the practice role plays in the training, many helpers were shy to take the lead in sessions. For some helpers, anxiety decreased their motivation and resulted in avoidance of preparing for the sessions. In sessions, even helpers who had prepared well missed specific elements of the intervention. When they missed a point, some lost confidence in facilitating the rest of the session, and supervisors had to play a greater role. This underscores the importance of live supervision and debriefing. Pre-session discussion between supervisor and helper was useful to review the session content and goals, building helper confidence. Live supervision reduced anxiety and allowed the supervisor to model foundational counselling skills and PM+ techniques when the helper needed guidance. Live supervision facilitated clear, tailored, practical debriefing feedback, resulting in improved performance in subsequent sessions.
While there was concern that helpers would be self-conscious having a supervisor present in a session, this pilot showed that the helpers were often relieved and viewed the supervisor’s presence as supportive. Clients also did not seem to view the supervisor’s presence as problematic, once confidentiality was explained. However, in debriefing, helpers often struggled to view feedback as constructive rather than intimidating. Ethiopian and Eritrean cultures often use indirect communication, and leadership styles commonly rely on strong judgements and punitive structures. This creates challenges building reflective capacity among helpers. Building relationships of safety with helpers was essential to elicit more open sharing of the helper’s experiences and struggles. When supervisors relied on self-reports rather than observation, helpers often were not aware of what they should note for the supervisor, and had a tendency to generalise that the session went well, making it difficult to provide concrete feedback.
One of the primary challenges of intensive supervision was that it required significant time investment, with 90–120 minutes per session and 20–30 minutes for preparation and debriefing. This tight schedule for supervisors was particularly challenging when clients or helpers were late, which is frequent in this context. Supervisors also had to balance when to interject in a session to model a technique and when to wait and give debriefing feedback. Often when the supervisor stepped in, the client would shift focus to the supervisor and it could be challenging to hand the lead back to the helper; asking permission from the helper when interjecting in the session helped balance the power dynamic. However, despite these challenges, we feel strongly that live supervision is vital for the first round of implementation, at a minimum.
Challenges and Adaptations
One challenge was the lack of a clinically driven selection process for helpers. The partner organisation assigned incentive workers to the training, none with MHPSS experience, resulting in varied educational backgrounds, literacy, therapeutic presence and interest in MHPSS services. This was an obstacle to a consistent training style, as well as helper motivation, skills competency and potential sustainability of the work. This reinforces the recommendations of van’t Hof et al. (2018), and suggests that a key action when training lay MHPSS workers is clinically driven selection of helpers. In addition, in many contexts existing staff are being trained as PM+ helpers and often have to negotiate other, contemporaneous responsibilities, thus PM+ training and service may not get prioritised.
Low literacy levels in the camp population, especially among women, made some PM+ activities challenging for clients. Additionally, some PM+ activities rely on Western concepts of time organisation, such as the calendar, and required significant explanation. Several adaptations were developed. Tying activities to daily practices that clients were already engaging in was helpful, such as practising stress management directly after cooking lunch or before evening prayers. When using the calendar with nonliterate clients, helpers used coloured stickers for homework tasks. For example, if a client is given three tasks, they used three stickers with different colours to represent activities, sticking them on the respective dates and times. Another adaptation was to have the client bring a trusted person to a portion of the session who could write and read the calendar; however, this relies on regular follow-up by the other person.
A third challenge was that helpers struggled to maintain consistent session length. Session 1 required an average of 90 minutes, session 2 about 100 minutes and session 4 about 120 minutes. Notably, revising the managing problems strategy often took more than 30 minutes, depending on the client’s problem. We anticipate session time will reduce with increased helper practice. However, in this context, the cognitive behavioural concepts are not culturally congruent and require significant time in session to explain well. In future implementation, supervisors may provide coaching about how to efficiently explain concepts, or provide prepared handouts for helpers with outlined topics and brief scripts for more complex concepts.
Clients were drawn from a treatment-seeking population who had received basic psychoeducation about symptoms and available services. Individuals were screened and those who did not meet criteria for our Level 4 intervention, but met criteria for PM+ were referred for the pilot. There were challenges recruiting sufficient clients for the pilot, since most individuals approaching for services had experienced an acute trauma event. We conducted additional recruitment through sensitisation. Another challenge observed by our clinicians was that it is common to underreport symptom severity because to express distress is seen as “complaining against God”. Thus it was challenging to screen clients at the correct level of distress into the intervention; a number of clients screened into PM+, but disclosed more severe distress after several sessions, requiring referral and more intensive support. To reduce the likelihood of this, clear psychoeducation on the purpose of the screening questions should be given during the prescreening process.
A significant challenge was that several common problems in the population were not able to be effectively addressed with PM+. These included ambiguous loss, lack of access to safe shelter, abandonment by family members, trauma experiences and cases of community discrimination. Although helpers coached clients to practise PM+ coping strategies, there were circumstances for which these were ineffective. For example, PM+ helped clients facing ambiguous loss to lower negative symptom escalation, which could temporarily improve functioning, but this did not address the core problem of complex grief. Ultimately, these common forms of adversity were not possible to address within the PM+ framework or within the capacity of paraprofessional helpers. Clinical staff with more training and experience were required to follow-up with these clients effectively. This is notable because in our context higher levels of therapeutic support are uncommon and can be difficult to access.
This pilot was interrupted by COVID-19 and the suspension of in-person services for 4 months. During this period, remote support was provided, constrained by limited phone access and internet unavailability. Supervisors called helpers weekly to follow up on client contacts, as well as helper self-care, modelling support and helping helpers utilise PM+ strategies to manage their own heightened stress. Helpers then called clients, providing similar support and guidance, reframing the PM+ techniques to address adversity caused by the pandemic. The stress management strategy was useful in managing COVID-related worries. Problem management was useful in problem-solving changes to daily life activities caused by the lockdown. Ultimately, the experience seemed supportive and built rapport throughout the pilot. Helpers felt cared about and experienced the benefit of PM+ strategies personally. This aided their motivation to work with clients, strengthening the therapeutic relationship when they returned to in-person services.
| Discussion|| |
In general, PM+ met several core intervention needs of many of clients. In our context much of the population struggles with practical problems such as unemployment and housing. There are also common emotional problems which result in moderate symptoms, such as grief, worry and hopelessness (Golden, 2017). Most clients responded positively to the intervention, sharing their problems and symptoms without indicating discomfort with the helpers or the modality. We observed emotional, physical and behavioural improvements with the majority of clients since the initiation of PM+.
However, in a refugee context, the practical problems that may be causing or worsening symptoms are often both severe and have no realistic solutions, for example problems like separation from family, legal restrictions on work or other activities or lack of legal pathways for durable solutions (Silove et al., 2017). The PM+ framework means these problems are often prioritised by clients, but are not well-suited to PM+ techniques. Similar problems have been encountered elsewhere and required greater adaptation of the intervention (Perera et al., 2020). We also encountered a large number of help-seeking individuals whose symptoms were too severe or not a good fit for PM+. This elevated baseline of distress is common in refugee settings, compounded by a dearth of available MHPSS services and the need to prioritise individuals receiving care. This leads to an ethical conundrum for programming: In cases where PM+ (or another Interagency Standing Committee (IASC) level 3 intervention) is the only MHPSS intervention available, do service providers expand inclusion criteria to serve those who are technically too high-needs to be appropriate for the intervention, or serve only those in the correct range of severity, leaving those with higher needs unserved? The first option puts helpers and therefore clients at risk, as helpers’ competencies are overwhelmed. However, not providing care to the highest need population goes against tentets of humanitarian service. It is useful to have low-intensity interventions designed to scale easily, but when the service population has common needs that are more severe than the intervention can address, what is the ethical move forward with the available resources?
Supervision is a vital component of any level 3 intervention, particularly when implemented by paraprofessionals (Silove et al., 2017). Our pilot suggests that the detailed and contextually nonintuitive steps in PM+ make supervision essential for the first course of clients. Two weeks of training, while sufficient to present the material, is not enough for lay practitioners to master basic helping skills or PM+ techniques. Training on a particular intervention and having a manual to follow can be a double-edged sword. As has been found previously (van der Veer & Francis, 2011), when concrete instruction is given to paraprofessional workers who do not have confidence in their own skills, they can become over-reliant on specific manualised instructions, rather than developing their proficiencies as helpers. Helpers lose trust in their instincts and experience anxiety about following guidelines precisely. This often results in helpers losing touch with the client in front of them, too focused on what they are “supposed” to say to the client. Based on field reflections from our pilot, live supervision of each session is recommended for the first client. If this is not possible, a longer training period and role playing each session prior to the session is strongly recommended.
Further, when helpers are drawn from the same population as clients, supervision is fundamental to staff support. Based on this pilot, we do not think it necessary for all trainees to go through the intervention themselves before becoming a helper, as long as sufficient supervision is provided. However, debriefing must include the helper’s emotional experience, not only technical points of the session. Concrete strategies for self-care should be identified after each session.
| Conclusion|| |
PM+ has been shown to be effective at an individual level and is well suited for contexts in which the symptom constellation is primarily mild to moderate anxiety and depression. It alleviates pressure on mental healthcare systems by utilising trained paraprofessionals. However, in contexts where the common symptoms causing distress in the treatment-seeking population are more severe or related to other clusters, it may not be the most appropriate intervention for large-scale implementation. These are complex context-specific issues; further attention from clinicians and researchers is needed. For example, Group PM+ may provide added benefit in a refugee setting due to the reconstruction of social networks. In our context, clinical observations from our pilot suggest that Individual PM+ may be more appropriately implemented in the host community. The PM+ intervention may be appropriate for the Ethiopian communities who live in adversity, or who are returnees from working on the Arabian Peninsula. In the host community there is greater availability of alternative services and institutions, allowing referrals to higher levels of professional support. Having a cohort of trained paraprofessionals operating in the community could increase the identification of high-need or at-risk individuals and could channel clients to the appropriate referral centre. This could increase awareness and overall access to MHPSS services across the country. The widespread roll-out of PM+ lessens some burden on the few MHPSS professionals available in most global settings. However, the compromise for being a “do no harm” intervention administered by lay practitioners is that it is not designed to provide in-depth therapeutic services often needed in humanitarian settings. While PM+ and the Mental Health Gap Action Programme (mhGAP) are important components of the solution to making MHPSS care accessible, we should also advocate for the national development of mid-level therapeutic services.
Authors thank the CVT-Ethiopia team, in particular Samson Issak, Afewerki Abrahaley, Eshete Teshager, Dejen Yewhalaw, Fisseha Micheale, Mulalem Fisseha, Esayas Kiflom, Maki Katoh and other CVT staff, particularly those who participated in the EQUIP programme as actors and raters. The EQUIP project received support and guidance from Brandon Kohrt, Alison Schafer and Gloria Pedersen, as well as other members of the EQUIP team and collaboration partners.
Financial support and sponsorship
The EQUIP project is supported by the World Health Organization through a grant from USAID. CVT’s work in Ethiopia is supported by the Bureau of Population, Refugees and Migration from the U.S. Department of State, by the United Nations Voluntary Fund for Victims of Torture, and by private donors. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
Conflicts of interest
There are no conflicts of interest.
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