By Susan Gallagher
In small communities on the outskirts of Eldoret, Kenya, when families are struggling with intimate partner violence, parenting issues or other problems related to family functioning, they often turn to a trusted person or couple in the community for help. This custom gave Eve Puffer, an assistant professor of psychology and neuroscience and global health at Duke, an idea: could these informal counselors be trained to deliver evidence-based family therapy to their peers?
Puffer and her team have been testing this approach, and so far, the results are promising.
Structured family therapy programs in low- and middle-income countries are few and far between. Most interventions that aim to develop positive family relationships are preventive; they don’t target families that are already experiencing serious conflict or violence.
Puffer, a clinical psychologist who began working with families in Kenya about ten years ago, has led the development and implementation of preventive programs in Kenya. The goals of these programs were to strengthen family relationships and improve parent-child communication as a way to prevent future mental health disorders.
But while these programs have yielded positive outcomes, Puffer and colleagues learned both anecdotally and through research that that level of support isn’t always enough. “For some families, the prevention programs just scratch the surface of much more complex problems,” she says. “We developed this [family therapy] program to help families who needed more intensive support, including those with children who were already experiencing some mental health symptoms.”
Family violence, chronic negative interaction patterns in families, and mental health disorders go hand in hand. For example, survivors of intimate partner violence often suffer from depression, anxiety and loss of functioning, and it’s common for children who witness this violence or experience it themselves to sustain long-term consequences.
Addressing these issues is at the heart of family therapy theory and practice. However, many low-resource settings, including Eldoret, lack the specialists and mental health care systems to offer this type of treatment.
As they began to conceptualize a family therapy intervention, Puffer and her team, co-led by Moi University professor David Ayuku, considered the possibility of tapping into community health workers. However, their mental health care experience is typically limited, and they’re often overburdened with a host of other responsibilities. And beyond these considerations, given the sensitive nature of the topics the program would address, the researchers thought it would be ideal to build on the support that people in the community were already providing for their friends and acquaintances.
“We were looking for people who already had relationships with the families in need of therapy, including the fathers, mothers and children,” she says. “And we wanted to see if we could develop a truly community-based model that mirrored what was already in place.”
These informal or “natural” counselors—typically church leaders and people who work closely with community elders—talk with families to figure out the nature of the problems and share advice. Often, they’re called upon in times of crisis, so they’re working to resolve a focused problem quickly.
Puffer, Ayuku and their team hoped that family therapy training would give them more structure and tools to better assist the families. To develop the program and training manual, the team drew from a range of evidence-based family therapy models, including solution-focused family therapy and cognitive behavioral approaches. They also sought input from local adolescents, parents, natural counselors and health providers.
Named “Tuko Pamoja,” or “We Are Together” in Kiswahili, the program addresses relationship problems between partners and between parents and children, as well as issues related to overall family cohesion. It also guides counselors in helping families learn communication and coping skills. Tuko Pamoja counselors visit their assigned families regularly to help them learn a process for solving current and future problems.
Puffer and her team have taken care to ensure that the counselors and their supervisors feel supported. During the study, the counselors received extensive training and were then supervised by medical psychology students from Moi University in Eldoret as they implemented the program with families. They also had access to a smartphone that provides reminders of the therapy steps and role play videos that demonstrate skills taught in the program. And Elsa Friis-Healy, a PhD student in clinical psychology and global health doctoral scholar, is leading the development of a mobile app to streamline the supervision process.
The Tuko Pamoja counselors pose for a group photo with Eve Puffer (third from right).
Although the study was small, Puffer is encouraged by the results: improved family functioning and mental health of both adolescents and caregivers, including changes in harsh or violent behaviors and improvements in alcohol-related problems.
“We have a promising indication now that family therapy can be done by lay providers and can be done in a way that’s flexible enough to address a lot of different family problems,” she says. “I think our results show that we can take a broader lens on family well-being and tackle multiple outcomes at once without diluting the process.” The study findings will be published soon in the journal Global Social Welfare.
And as it turns out, the families weren’t the only ones who benefited from being a part of the program. Taylor Wall, a second-year master’s student at the Duke Global Health Institute, researched how the counselors felt about their experiences. He found that although they encountered various challenges throughout the process and their motivation dipped at times as a result, they embraced the new elements of their counseling role.
“They were very motivated, and they felt that they had a better toolbox for working with these families, whereas before they had felt limited in what they could do to help,” says Puffer, Wall’s advisor. “And some of them wanted to work with even more families and get further training.” Puffer and her team are exploring ways to support these goals.
They’re also looking to build on the success of Tuko Pamoja by combining prevention and treatment programs to improve family functioning and decrease family violence and mental health disorders. The team plans to implement a prevention program with members of a church congregation, and those with more significant family problems will be referred to the more intensive family therapy program. Puffer believes that partnering with churches and other social structures that work with families is a promising model for sustainability.
We have a promising indication now that family therapy can be done by lay providers and can be done in a way that’s flexible enough to address a lot of different family problems.Eve Puffer, assistant professor of psychology and neuroscience and global health