Friendship Bench

1. Introduction

Version followed: the adult Friendship Bench (FB) as specified in the cluster-RCT protocol (Chibanda, Bowers, Verhey et al., 2015, Int J Ment Health Syst 9:21) that underpinned the 2016 JAMA trial, with session-by-session content from the Harare pilot (Chibanda, Mesu, Kajawu et al., 2011, BMC Public Health 11:828) and the add-on Circle Kubatana Tose (CKT) groups as Friendship Bench now describes them. The official FB manual is obtained only through the organisation [uncertain on any manual detail not reported in the papers].

The Friendship Bench is a programme, not a psychotherapy school: a task-shifted, culturally adapted, six-session problem-solving therapy (PST) with a behavioural-activation component, delivered one-to-one on a wooden bench in a discreet spot in primary-care clinic grounds by trained, supervised lay health workers (LHWs). In Harare the LHWs were City Health community workers, all female, mean age about 58, with roughly 8 years of schooling and prior experience of HIV home-based care and TB follow-up; locally they are called "grandmothers" [source: Chibanda et al. 2015 protocol; REF 2021 impact case study]. It was developed by psychiatrist Dixon Chibanda with Melanie Abas and colleagues in Zimbabwe, and the PST core is described as based on Abas's seven-point PST for common mental disorders [source: REF 2021] [uncertain: the seven points themselves].

Core idea of change: distress is framed in the Shona idiom kufungisisa ("thinking too much"). The LHW "opens up the mind": she helps the person name and order their problems, then pick and carry out their own concrete solution. Done in steps, with rewarding activity and peer connection added, this reduces rumination, restores a sense of control and rebuilds social support. Lay workers from the person's own community make the help acceptable [source: Boehringer Ingelheim Connecting Psychiatry 2024; Happier Lives Institute 2026; MHPSS.net profile; REF 2021]. The listed therapeutic strategies are problem solving, behavioural activation and social connectedness [source: MHPSS.net].

For a psychotherapist, the realistic roles are: (a) training, supervising and backing up LHWs (the role psychologists and psychiatrists play in Harare); (b) running or adapting the model in a service; (c) using its structure directly in brief low-intensity work [synthesis]. Delivery under the Friendship Bench name goes through the organisation, which supplies the manual and training on request (contacts on MHPSS.net). No public certification or licensing scheme was found [uncertain]. Fidelity in the trial relied on audio-recording every session and rating it against a PST checklist [source: 2015 protocol].

2. Framework

Entry and triage. Clinic attenders are screened with the Shona Symptom Questionnaire (SSQ-14), a locally developed 14-item screen for common mental disorders. The trial cut-off was raised from 8 to 9 (out of 14) after revalidation in an HIV setting. People scoring above 11 also complete the PHQ-9 to confirm red flags and gauge depression severity. Suicidality and very high scores trigger contact with the supervisor and referral [source: 2015 protocol]. Today FB describes three pathways after screening: (1) one talk with the LHW, advice, then discharge; (2) up to six free, confidential PST sessions; (3) referral to a supervisor for specialist care [source: Boehringer 2024].

Exclusions and referral at entry (trial version): suicidal intent, current psychosis (referred to one of two tertiary psychiatric units), intoxication, dementia, end-stage AIDS, current psychiatric care, and third-trimester pregnancy or the 3 months after delivery. In the intervention arm, a PHQ-9 of 20 or more meant referral to a clinical psychologist while PST continued [source: 2015 protocol]. A later study reported that trained LHWs also reduced symptoms in adults with suicidal ideation (Munetsi et al. 2018) [uncertain on how suicidal ideation is now handled on the bench].

Format: individual, face to face on the bench, 30–45 minutes per session (the first up to 60 minutes). Six sessions, weekly in the trial table (the protocol text says over 4–6 weeks). Home visits are added when needed, and up to six weekly SMS messages or calls go to people who attend fewer than 3 sessions or are flagged [source: 2015 protocol]. In-person and messaging-app delivery now both exist [source: Boehringer 2024].

Phases. Two published versions name the steps differently [uncertain]. Both are given below.

Trial protocol (2015) structure

Part 1, problem identification (kuvhura pfungwa, "opening of the mind"): share the SSQ result, listen, list and define the problems.
Part 1 continued, problem exploration (kusimudzira, "uplifting"): prioritise, brainstorm the client's own solutions, agree one specific plan.
Part 2 (kusimbisa, "strengthening", labelled "reassure"): review progress, problem-solve obstacles, set homework.
Part 3 (kusimbisisa, further strengthening): summarise, reassure, and go back to Part 1 if the plan is not working.
Referral to the peer support group after session 4.

[source: 2015 protocol Table 1; English glosses from Boehringer 2024]

Pilot (2011) session plan

Session	Goal	Content
1	Problem identification and exploration	Explain SSQ result through kufungisisa; hear the story; identify, define, prioritise problems; brainstorm feasible solutions
2	Home visit	Visit before next session; meet family where possible
3	Action planning	Summarise session 1; choose a feasible solution; plan how, when, with whose help; refer (e.g. income-generation scheme); identify and encourage rewarding activities
4	Implementation	Review; plan carrying out the solution; motivate; set homework; refer to agency or support group if appropriate
5	Home visit and follow-up	Review achievements and obstacles; revisit sessions 3–4 as needed
6	Reinforcement and review	Consolidate; review achievements; repeat SSQ; if no improvement refer to nurse counsellor

[source: Chibanda et al. 2011, Table 1]

Current FB describes the first session as moving through all three movements at once: feeling safe and naming the main problem (opening the mind), emotional support and encouragement (uplifting), and simple practical steps (strengthening) [source: Happier Lives Institute 2026].

Criteria for moving on (partly explicit, partly inferred):

Move from identification to action planning when the problem list is defined, one problem is prioritised and the client has generated options [source: 2015 protocol].
Move from planning to review when one specific, measurable, achievable, realistic plan has been chosen by the client [source: 2015 protocol].
If the plan fails, cycle back to Part 1 [source: 2015 protocol].
Offer CKT after at least four sessions [source: 2015 protocol].
At session 6, repeat the SSQ. No improvement means referral to the nurse counsellor or supervisor [source: 2011 pilot; 2015 protocol].
Red flags at any point mean immediate supervisor contact [source: 2015 protocol].

After the bench: optional CKT peer groups (six sessions per MHPSS.net) giving continued psychoeducation, social support and economic strengthening [source: MHPSS.net; Verhey et al. 2024 BMJ Open protocol abstract via DOAJ].

3. Guiding principles

Use the local idiom of distress. Explain symptoms as kufungisisa, not psychiatric labels. Practical meaning: frame the screening result in the client's own words for distress [source: 2011 pilot; Boehringer 2024]. Outside Zimbabwe, find the local equivalent with the community before you start [synthesis].
Open the mind, don't give advice. The grandmothers described the work as "opening up the mind" rather than advising [source: REF 2021]. Practical meaning: ask, reflect and summarise until the client sees their problems more clearly; hold back your own solutions.
The client generates and chooses solutions. Practical meaning: brainstorm with the client and let them pick; the LHW never assigns the plan [source: 2015 protocol].
One concrete plan at a time. Plans should be specific, measurable, achievable and realistic. Practical meaning: shrink every plan until the client can say what, when, how and with whom [source: 2015 protocol].
Listening skills are the vehicle. Active listening, empathy, reflection and summarising are named active ingredients. Practical meaning: every session starts by hearing the story before any structure [source: Happier Lives Institute 2026].
Add rewarding activity. Activity scheduling and behavioural activation are part of the core. Practical meaning: each plan pairs problem work with at least one meaningful, enjoyable activity [source: 2015 protocol; 2011 pilot].
Community insiders, not outsiders. LHWs live in the community, which clients said made them feel comfortable [source: Chibanda et al. 2016 ToC paper]. Practical meaning: recruit and match counsellors from the served community, and build in confidentiality safeguards because they share a neighbourhood with clients [synthesis].
Discreet but ordinary setting. A bench in a discreet area of the clinic grounds. Practical meaning: low-stigma access without a consulting room, but out of earshot [source: 2015 protocol].
Reach out actively. Missed sessions are followed by call or SMS, then a home visit. Practical meaning: non-attendance is the team's problem to solve, not the client's failure [source: 2015 protocol].
Involve family and link to resources. Home visits meet family, and referrals go to income-generation schemes, agencies and support groups. Practical meaning: treat poverty and social problems as legitimate targets, not distractions [source: 2011 pilot].
Measure, then step up. The SSQ is repeated at session 6, with referral if there is no improvement. Practical meaning: decide on escalation by score and red flags, not impression alone [source: 2011 pilot; 2015 protocol].
Lay workers are never alone. Weekly group supervision, a clinician on call and clear referral routes. Practical meaning: no LHW holds risk without a named clinician backing her up [source: 2015 protocol; Happier Lives Institute 2026].
Fit technology to workers. LHWs refused tablets for fear of theft and of being suspected of witchcraft, so basic phones were used instead. Practical meaning: co-design tools with the workers who will use them [source: 2016 ToC paper].

4. Intervention inventory

The items below are the components named in the sources. Step detail beyond what the sources state is marked [synthesis]. The FB manual's exact scripts and worksheets are not reproduced or known [uncertain].

4.1 Screening with the SSQ-14 and red-flag check

Purpose / when: at first contact, to identify common mental disorder, set the pathway (advice and discharge, six sessions, or specialist referral) and catch risk [source: 2015 protocol; Boehringer 2024].
Steps: (1) Administer the SSQ-14 orally in the client's language. Do not reproduce the items outside licensed or trained use. (2) Score: at or above cut-off (9 of 14 in the trial version) means eligible for PST. (3) If the score is above 11, add the PHQ-9 to confirm severity and red flags. (4) Ask directly about suicidal thoughts and intent, psychosis, intoxication and other exclusions. (5) Red flag means phone the supervisor that day and refer, using the trial thresholds: PHQ-9 of 20 or more goes to a clinical psychologist while PST continues; psychosis goes to tertiary psychiatric care [source: 2015 protocol]. (6) Record the score, because it is repeated at session 6 [source: 2011 pilot].
Example language (illustrative): "I'm going to ask you some questions about how you have been feeling this past week. There are no right or wrong answers." / "Some people who feel this way have thoughts of ending their life. Have you had thoughts like that?"
Watch for: scores driven by physical illness such as HIV or TB; disclosures of violence; anyone who cannot be safely kept on the bench. If in doubt, escalate [synthesis]. Use standard suicide-risk assessment by the supervising clinician, not by the LHW alone [synthesis].

4.2 Psychoeducation through kufungisisa

Purpose / when: session 1, right after screening, to make the score meaningful and destigmatise distress [source: 2011 pilot; 2015 protocol].
Steps: (1) Share the SSQ result in plain words. (2) Link the symptoms to kufungisisa: thinking too much about problems, which then causes poor sleep, worry, tiredness and body aches [source: Boehringer 2024 for the gloss; the symptom linkage is synthesis]. (3) Explain that working on problems one at a time, and doing things that bring some good feeling, reduces thinking too much. (4) Check what the client makes of this.
Example language (illustrative): "Your answers show you have been carrying a lot of kufungisisa, thinking too much. That is common when life presses hard, and it can ease when we work on the problems together, one at a time."
Watch for: relief and recognition (good sign); a client hearing "thinking too much" as blame. Reframe it as a burden, not a fault [synthesis].

4.3 Listening to the story ("opening up the mind")

Purpose / when: every session opening, and most of session 1. The aim is safety and for the client to see their situation more clearly [source: Happier Lives Institute 2026; REF 2021].
Steps: (1) Invite the story with an open question. (2) Listen without interrupting or advising. (3) Reflect feelings and key facts. (4) Express empathy. (5) Summarise periodically and check the summary is accurate. These are the named micro-skills [source: Happier Lives Institute 2026]; the sequencing is [synthesis].
Example language (illustrative): "Tell me what has been happening." / "So since your husband lost his job, the rent and school fees fall on you, and at night your mind will not rest. Have I got that right?"
Watch for: the client talking more freely and correcting your summaries (engagement). Rising distress you cannot contain means slowing down, grounding, and asking the supervisor if needed [synthesis].

4.4 Problem identification: listing and defining

Purpose / when: Part 1, session 1, to turn a flood of worries into a list of discrete problems [source: 2015 protocol; 2011 pilot].
Steps: (1) From the story, name each separate problem with the client. (2) Write or say them back as a list. (3) Define each one concretely: what exactly, who is involved, since when. (4) Separate problems the client can act on from those they cannot change [synthesis].
Example language (illustrative): "Let's put each worry on its own. I hear money for rent, the fights with your son, and your own health. Is there anything else?"
Watch for: vague global problems ("my life"). Break them down further [synthesis].

4.5 Problem exploration and prioritisation (kusimudzira, "uplifting")

Purpose / when: end of session 1, to choose the problem to work on first and to encourage [source: 2015 protocol; Boehringer 2024; Happier Lives Institute 2026].
Steps: (1) Ask which problem weighs most, or which is most solvable soon. (2) Explore the chosen problem: what has been tried, and who could help. (3) Give genuine encouragement and name the client's strengths and past coping. The uplifting stance is sourced; its specific content is [synthesis].
Example language (illustrative): "Of these, which one would make the biggest difference if it moved even a little?" / "You have kept your children in school through all this. That tells me you know how to find a way."
Watch for: the client picking a problem outside their control. Gently steer to the part they can influence [synthesis].

4.6 Brainstorming client-generated solutions

Purpose / when: sessions 1 and 3, to widen options and build agency [source: 2015 protocol; 2011 pilot].
Steps: (1) Ask for every possible way to tackle the problem, without judging. (2) Keep prompting, for example "What else?" or "What would a friend do?" [synthesis]. (3) Only then, weigh each option for feasibility with the client. (4) The client chooses [source: 2015 protocol].
Example language (illustrative): "Let's think of all the ways, even ones that sound silly. What could you do about the rent?"
Watch for: the LHW slipping into advice-giving, which the source stance discourages. If the client produces nothing, offer a prompt about resources rather than an answer [synthesis].

4.7 Action planning (SMART plan)

Purpose / when: session 3, or end of session 1 in the protocol version, to convert the chosen solution into a doable step [source: 2011 pilot; 2015 protocol].
Steps: (1) Summarise the earlier session. (2) Confirm the chosen solution. (3) Specify what, how, when, where and with whose help. (4) Check the plan is specific, measurable, achievable and realistic [source: 2015 protocol]. (5) Anticipate obstacles and plan around them [synthesis]. (6) Refer where the plan needs outside help, for example an income-generating programme [source: 2011 pilot].
Example language (illustrative): "So on Thursday morning you will go to the ward office with your ID and ask about the school-fee assistance, and your sister will mind the baby. What could get in the way?"
Watch for: plans that depend on others' behaviour, or are too big. Shrink them to the first step [synthesis].

4.8 Activity scheduling (behavioural activation)

Purpose / when: from session 3 onward, alongside the problem plan, to counter withdrawal and low mood [source: 2011 pilot; 2015 protocol; Happier Lives Institute 2026].
Steps: (1) Ask what the client used to enjoy or found meaningful. (2) Choose one or two rewarding, personally meaningful activities [source: 2015 protocol]. (3) Schedule them for specific days and times [synthesis]. (4) Review at the next contact how it went and how mood was afterwards [synthesis].
Example language (illustrative): "Before all this, what did you enjoy? Singing at church, visiting your friend? Which day this week could you do one of those?"
Watch for: activities chosen to please the counsellor rather than the client; anhedonia ("nothing helps"). In that case start with very small activities, and remember that the activity counts even if the pleasure is small [synthesis].

4.9 Homework

Purpose / when: end of sessions 3 and 4 (pilot), Part 2 (protocol), to carry the plan into daily life [source: 2011 pilot; 2015 protocol].
Steps: (1) Agree one plan step and any scheduled activity as the week's task. (2) Have the client say it back [synthesis]. (3) Agree how you will check on it: next session, SMS or home visit [source: 2015 protocol for contact routes].
Example language (illustrative): "So this week your task is the ward office on Thursday and visiting your friend on Sunday. Tell me in your own words what you will do."
Watch for: the task not done. Explore the obstacle without blame (see 4.10) [synthesis].

4.10 Review, troubleshooting and reassurance (kusimbisa, "strengthening")

Purpose / when: start of sessions 4 to 6, to consolidate gains and fix what failed [source: 2015 protocol; 2011 pilot].
Steps: (1) Ask what was done and what happened. (2) Praise any step, however partial. (3) Problem-solve the obstacles: adjust the plan, pick a different option from the brainstorm, or break it down further [source: 2015 protocol]. (4) Motivate and set the next homework [source: 2011 pilot]. (5) If the plan is clearly not working, return to Part 1 and redefine the problem [source: 2015 protocol].
Example language (illustrative): "You went, even though they sent you away the first time. That took courage. What did you learn there that helps us plan the next step?"
Watch for: progress on one problem allows moving to the next on the list [synthesis]. Repeated failure on the same problem means reconsidering whether it is solvable, or referring [synthesis].

4.11 Home visits and family involvement

Purpose / when: in the pilot, as session 2 and session 5; in the trial, "if needed" and to trace people who miss sessions [source: 2011 pilot; 2015 protocol].
Steps: (1) Arrange the visit with consent. (2) See the client's situation first-hand. (3) Meet family where possible [source: 2011 pilot]. (4) At the follow-up visit, review achievements and obstacles, and revisit planning if needed [source: 2011 pilot]. In the trial, missed-session tracing visits were made by the LHW together with the project coordinator [source: 2015 protocol].
Example language (illustrative): "I've come as we agreed to see how things are at home. Would it be all right if your mother joins us for a little while?"
Watch for: confidentiality inside the household, and the client's choice about what family hear. Domestic violence means not involving the perpetrator, and assessing safety [synthesis].

4.12 SMS, phone follow-up and tracing

Purpose / when: to keep engagement between sessions and recover dropouts [source: 2015 protocol].
Steps: (1) Collect the mobile number at intake, or an alternative contact if the client has no phone. (2) Send up to six weekly SMS messages or calls for clients attending fewer than 3 sessions, or those flagged by the LHW or supervisor. (3) After a missed session, call or text; if that fails, make a home visit [source: 2015 protocol]. The content of the messages is not specified in the sources [uncertain].
Example language (illustrative): "Hello Mai Tendai, this is Gogo Ruth from the bench. I missed you today. Shall we meet Thursday at 10?"
Watch for: shared phones. Keep message content neutral and non-revealing [synthesis].

4.13 Referral and linkage to resources

Purpose / when: whenever the plan needs outside help, or the client needs more than the bench [source: 2011 pilot; 2015 protocol].
Steps: (1) Social and economic needs: refer to income-generating programmes, agencies or support groups [source: 2011 pilot]. (2) Clinical needs: refer to the nurse counsellor, clinical psychologist or tertiary psychiatry using the red-flag thresholds in 4.1 [source: 2015 protocol]. In the trial, clinic nurses later prescribed antidepressants for severely depressed participants before onward referral [source: 2016 ToC paper]. (3) Follow up whether the referral was taken up [synthesis].
Watch for: referrals that go nowhere. Keep the bench contact going until the client is connected [synthesis].

4.14 Session 6: reinforcement, review and repeat screening

Purpose / when: final session, to consolidate and decide what happens next [source: 2011 pilot; 2015 protocol].
Steps: (1) Summarise the journey: problems, plans, what worked. (2) Reinforce the problem-solving steps as a skill the client can reuse [synthesis on the "reuse" framing]. (3) Repeat the SSQ-14. (4) Improved: offer the CKT group if not already joined. Not improved: refer to the nurse counsellor or supervisor [source: 2011 pilot; 2015 protocol].
Example language (illustrative): "When a new problem comes, you now know the way: put the worries side by side, choose one, think of all the options, pick one small step."
Watch for: fear of ending. Point to CKT as continued contact [synthesis].

4.15 Circle Kubatana Tose (CKT) peer support group

Purpose / when: optional, after at least four PST sessions (trial version) or after PST (current description). It offers peer sharing, continued psychoeducation, self-care, behavioural activation, social support and economic strengthening [source: 2015 protocol; MHPSS.net; Happier Lives Institute 2026; Verhey et al. 2024 abstract]. The name means "holding hands together" [source: MHPSS.net].
Format: six sessions (MHPSS.net). In the trial era, members shared experiences while crocheting shopping bags from recycled plastic, a skill intended to generate income [source: 2015 protocol]. Who facilitates, how long sessions last and the session-by-session content were not found [uncertain]. A former-client or peer-led format is implied by "peer-led" (MHPSS.net), but the details are unverified.
Steps for a clinician setting one up (synthesis): (1) Invite clients who have done at least four sessions. (2) Agree group ground rules on confidentiality and respect. (3) Open each meeting with a round of sharing while the group does a shared practical or income activity. (4) Include a short psychoeducation or self-care topic. (5) Let members problem-solve for each other using the bench steps. (6) Have a named LHW or supervisor available for red flags.
Example language (illustrative): "While we work on the bags, who would like to share how their week went, and one thing they tried?"
Watch for: members disclosing others' stories in the community; financial disputes around income activity. Set clear rules on money from the start [synthesis].

4.16 Supervision, fidelity and LHW support (clinician's role)

Purpose / when: throughout, because this is where a psychotherapist most often fits [source: 2015 protocol; Boehringer 2024].
Steps: (1) Hold weekly group supervision run by a psychologist or a senior team member trained in PST. (2) Be reachable by phone at any time for red flags. (3) Audio-record every session, with consent. (4) Rate a sample against a fidelity checklist of critical PST components; in the trial, psychiatrists or clinical psychologists did the rating [source: 2015 protocol]. (5) Clinic nurses proved too busy to supervise counselling, so plan for dedicated supervisors; WhatsApp-based support for supervisors was discussed [source: 2016 ToC paper]. Training is available in English and Shona [source: REF 2021]. Its length and curriculum are not given in the sources [uncertain].
Example language (illustrative, supervisor): "Let's listen to the part where she chose her plan. Whose idea was it, hers or yours?"
Watch for: advice-giving drift; LHWs carrying risk alone; vicarious distress from hearing community trauma [synthesis].

5. Handling problems

The sources give explicit procedures only for non-attendance, non-improvement, red flags and supervision gaps. Everything else is marked [synthesis].

Missed sessions or dropout. Call or SMS after any missed session, then make a home visit (LHW plus coordinator) if that fails. Send up to six weekly messages to people attending fewer than 3 sessions [source: 2015 protocol]. Also ask at intake what might stop them coming, such as transport, work or caring duties, and agree times around it [synthesis].
No improvement by session 6. Repeat the SSQ. Unchanged or worse means referral to the nurse counsellor or supervisor [source: 2011 pilot; 2015 protocol]. Before that, check whether the chosen problem was actually solvable, whether depression severity needs the PHQ-9 and medical review, and whether an untreated physical illness (HIV, TB) is driving symptoms [synthesis].
Stuck client: plan not working. Go back to Part 1, redefine the problem, pick a different option, or shrink the step [source: 2015 protocol].
Stuck client: no options generated. Offer resource prompts ("Who in the community has faced this?"), then use the client's past successes [synthesis].
Problems outside the client's control (unemployment, bereavement, HIV diagnosis). Split them into what can and cannot be influenced. Work on the influenceable part, such as support, income links or adherence routines, and pair it with activity scheduling [synthesis; income-scheme referral from 2011 pilot].
Client wants advice, or the LHW starts advising. Return the question to the client and generate options together. The source stance is "opening up the mind" rather than advising [source: REF 2021]. In supervision, use the recordings to spot advice-giving [synthesis, building on recordings in the 2015 protocol].
Resistance or doubt about a lay counsellor. Some people question the credibility of non-professional counsellors [source: Happier Lives Institute 2026]. Respond with transparency about training and supervision, offer one trial session, and emphasise the counsellor's community knowledge [synthesis].
Overwhelm or high distress on the bench. Slow down, reflect, summarise. Do one problem only and leave the list for later. Check for red flags, and phone the supervisor if risk is present [red-flag route sourced, 2015 protocol; rest synthesis].
Suicidal ideation or intent. Trial exclusion was suicidal intent; red flags trigger supervisor contact and referral [source: 2015 protocol]. A clinician should complete a standard risk assessment and safety plan, including lethal-means counselling (secure storage or removal of means, involving family), and arrange a same-day or next-day review [synthesis]. Whether LHWs keep working with people who have ideation but no intent varies by version [uncertain; Munetsi et al. 2018].
Psychosis, intoxication, dementia, severe medical illness, perinatal period. These are outside bench scope in the trial version. Refer to the appropriate clinical service [source: 2015 protocol]. Many services now add perinatal adaptations; check current FB guidance [uncertain].
Domestic violence or abuse disclosed. Assess immediate safety and avoid involving the perpetrator in home visits. Refer to protection and legal services and follow local reporting duties, especially for child abuse [synthesis].
Ruptures (client feels judged, gossiped about, or pushed). Name it openly, apologise, and re-agree confidentiality. Offer a different LHW if the client knows her socially [synthesis]. Confidentiality matters because LHWs live in the same community. A client valued this closeness [source: 2016 ToC paper], but it can also cut the other way [synthesis].
Non-adherence to homework. Explore the obstacle without blame, cut the task to its first step, and link it to something the client already does [synthesis].
Stigma about being seen on the bench. Place the bench in a discreet area of clinic grounds [source: 2015 protocol]. Offer messaging-app or phone sessions where available [source: Boehringer 2024].
LHW strain, safety and tools. LHWs rejected tablets for fear of theft and of being suspected of witchcraft. Use tools the workers accept [source: 2016 ToC paper]. Build in debriefs, caseload limits and recognition, and watch for burnout [synthesis; burnout was not addressed in the sources].
Supervision capacity. Overstretched clinic nurses could not supervise counselling. Budget for dedicated psychologist or senior supervisors and remote support [source: 2016 ToC paper; 2015 protocol].
CKT group problems (disclosure outside the group, money disputes, dominant members). Set rules at the start, use a facilitator, keep transparent accounts, and use an exit route back to individual sessions [synthesis].
Adapting outside Zimbabwe. Identify the local idiom of distress, revalidate the screen and its cut-off, recruit trusted community members, and keep the six-session PST core with supervision. Adaptations exist for youth (16–19), university students, people living with HIV, and settings in Kenya, Malawi, Zanzibar and New York [source: REF 2021; MHPSS.net]. Their specific changes are [uncertain].

Sources

Sources: