REPUBLIC OF KENYA
MINISTRY OF HEALTH
Mental Health
Training Manual
For Community
Health Volunteers
REPUBLIC OF KENYA
MINISTRY OF HEALTH
DIVISION OF MENTAL HEALTH
MENTAL HEALTH TRAINING MANUAL FOR
COMMUNITY HEALTH VOLUNTEERS
Transforming Mental Health for Universal Health Coverage 2021
i
Copyright statement for CHV Manual
Nairobi, February 2021
Any part of this document may be freely reviewed, quoted,
Reproduced or translated in full or in part. Provided the source is acknowledged.
It may not be sold or used for commercial purposes.
Community Health Volunteer (CHV) Mental Health Manual
Published by: Ministry of Health
Afya House, Cathedral Road PO Box 30016 Nairobi 00100
http://www.health.go.ke
ii
TABLE OF CONTENT
ACKNOWLEDGMENT
.....................................................................................................................................
1
FOREWORD
....................................................................................................................................................
2
PREAMBLE
.....................................................................................................................................................
3
LIST OF ABBREVIATIONS AND ACRONYMS ................................................................................................
4
CHAPTER 1 .........................................................................................................................................
5
INTRODUCTION
..............................................................................................................................................
6
Objectives of this manual ..............................................................................................................................
6
Aims of this manual ........................................................................................................................................
6
What is mental health? ..................................................................................................................................
6
What is mental illness? ..................................................................................................................................
7
Myths and misconceptions ...........................................................................................................................
7
Benefits of mental health ..............................................................................................................................
8
Factors influencing mental health (Protective and risk factors) ...................................................................
8
Roles of community health volunteers in mental health service .................................................................
8
CHAPTER 2 ..................................................................................................................................................
9
UNIT 1 - MENTAL HEALTH PROMOTION .......................................................................................................
9
Mental Health Promotion ..............................................................................................................................
10
Objectives
.......................................................................................................................................................
10
Specific ways to promote mental health .......................................................................................................
10
Reduction of stigma and discrimination ........................................................................................................
10
CHAPTER 3 ..................................................................................................................................................
11
UNIT 2 - COMMON MENTAL HEALTH DISORDERS .....................................................................................
11
Common mental health disorders .................................................................................................................
12
Depression
......................................................................................................................................................
12
.............................................................................................................................................................
12
Bipolar disorder ..............................................................................................................................................
13
Schizophrenia/psychotic disorders ...............................................................................................................
13
Substance use disorders (alcohol and drug use) ........................................................................................
14
Suicidal behavior ............................................................................................................................................
14
Self
.........................................................................................................................................................
15
........................................................................................................................................................
16
Anxiety
harm
Dementia
Common emotional, behavioral and Neuro-Developmental conditions in children and adolescents .....
16
Autism spectrum disorder ...............................................................................................................................
16
Epilepsy
..........................................................................................................................................................
18
Post traumatic stress disorder ......................................................................................................................
18
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CHAPTER
4
...................................................................................................................................................
20
UNIT 3 - THE PRINCIPLES OF BASIC COUNSELING ....................................................................................
20
Basic counseling skills ...................................................................................................................................
21
Active
................................................................................................................................................
21
Processing
......................................................................................................................................................
23
Responding
.....................................................................................................................................................
23
..........................................................................................................................................................
24
CHAPTER 5 ..................................................................................................................................................
26
UNIT 4 - MENTAL HEALTH FIRST AID ............................................................................................................
26
Definition of mental health first aid ................................................................................................................
27
Mental health first aid in the community .......................................................................................................
27
Mental health first aid in action ......................................................................................................................
27
How to help a person who is threatening to attempt suicide ........................................................................
28
How to help a person who is hearing voices, suspicious of others, or expressing unusual beliefs .........
28
Violence
...........................................................................................................................................................
29
Annexes
...........................................................................................................................................................
31
Common mental disorders ..............................................................................................................................
31
Resource page information .............................................................................................................................
35
Case
....................................................................................................................................................
35
Contributors and technical advisory panel ......................................................................................................
37
References
38
listening
Teaching
studies
.......................................................................................................................................................
vi
ACKNOWLEDGMENT
The development of the Community Mental Health Manual for CHVs has been made possible by the support
of the Ministry of Health under the leadership of Dr. Simon Njuguna, Head, Division of Mental Health
and other technical officers drawn from the Division of Mental Health, Kenya Red Cross (KRC), KMTC
Mathare Campus, Basic Needs, and other relevant developmental partners. Most gratitude goes to the
Mental Health technical Group members and the Kenya Red Cross (KRC) for logistical/financial support
professional editorial and ensuring the completion of this Manual. Special appreciation is accorded to Dr.
Matilda Mghoi for the untiring coordination of the technical working team and to Dorothy Anjuri and
Christine Nzilani for their unwavering technical support whenever need arose.
1
FOREWORD
Mental Health is an integral part of overall Health and is defined as the state of wellbeing that allows an
individual to achieve their full potential and contributes to their community. Mental ill health in the absence
of proper interventions and support mechanisms for recovery, negatively impacts individual, families and the
community.
Effective interventions for prevention and treatment for mental health conditions do exist and can be delivered
at different levels of the healthcare systems, including the primary health care and the community, with the
complementary support of trained community-based workers. Generally, there is a scarcity of mental health
professionals globally, and Kenya is no exemption. However, the rising burden of mental illness calls for a
paradigm shift including task shifting and empowerment of various level of healthcare and complementary
workers in the provision of this service.
Mental health literacy, which refers to knowledge and believes about recognition, management and prevention
of mental health disorders has been found to be poor in most communities. Additionally, mental disorders and
poverty tend to go hand in hand, limiting access to specialized mental health services due to the prohibitive
cost. Empowering the Communities in matters related to Mental well-being is a core concept of the Ministry
of Health as it has envisioned to have a nation where mental health is valued and promoted in order to attain
the highest standards of Health. This can only be achievable through strengthening of leadership and
governance; promotion and prevention; curative and rehabilitative of mental health services and systems.
The Ministry of Health and its partners, in line with its goal on attainment of Universal Health Coverage,
and in achieving the set objectives in the Kenya Mental Health Action Plan, has developed this Mental Health
Training Manual for Community Health Volunteers with the aim of building their skills and knowledge on
mental health to enable them provide complementary mental health services at the community level.
Evidence has shown that CHVs have the potential to supplement and/ complement formal health systems in
the journey to achieve UHC especially in low- and middle-income countries.
This Manual will enable CHVs participate in the promotion of mental health as well as prevention, identification
and appropriate referral of persons with mental disorders in the community. Their empowerment will also
trigger a social process through which individuals and groups will gain a better understanding and control
over their Mental Health, establish and mobilize social support networks ultimately leading to better mental
health for our community.
I am persuaded that the implementation of this manual will help reduce stigma and discrimination among
Persons with Mental Disorders and in the long run increase, availability, accessibility and acceptability of
Mental Health Services.
Dr. Patrick Amoth, EBS
Ag. Director General for Health
2
PREAMBLE
The National mental health policy addresses mental health disorders and broader issues that promote mental
health. The knowledge of what to do about the escalating burden of mental disorders has improved
substantially over the past decade. There is a growing body of evidence demonstrating both the efficacy and
cost-effectiveness of key interventions for priority mental disorders at different levels of economic development.
Mental health promotion therefore, should be mainstreamed into the public, private and nongovernmental
policies and programs.
Training of the CHVs on Mental Health is one of effective measures of promoting Mental Health and preventing
mental disorders. The mental health Gap Action Programme (MhGAP) has shown that training non-specialist
on Mental Health, will enable them to better understand and identify a range of priority mental health disorders
Furthermore, through this Mental Health manual, the CHVs will be empowered to be able to recognize
the early signs and symptoms of Common Mental Disorders and thereafter do the necessary referrals to
MentalHealth professional for further management. This is in line with the Universal Health Care, Sustainable
Development Goals (SDGs) and Vision 2030, where the Government of Kenya is committed to supporting
primary health care initiatives.
3
LIST OF ABBREVIATIONS AND ACRONYMS
CHVs -A community health volunteer is an individual chosen by the community and trained to address health
issues of individuals and communities in their respective localities, working in close relationship with health
facilities.
CHVs
Community Health Volunteers
KRC
Kenya Red Cross
MHFA
Mental Health First Aid
MHL
Mental Health Literacy
MhGAP
Mental Health Gap Action Programme
WHO
World Health Organization
WHA
World Health Assembly
SUD
Substance Use Disorders
ADHD
Attention deficit hyperactivity disorders
PTSD
Post-Traumatic Stress Disorder
ASD
Autism Spectrum Disorders
ODD
Opposition Defiant Disorder
CD
Conduct Disorder
PLWPICD
Person living with Psychological Intellectual Chronic Disability
CRPD
Conventional on the Rights of Persons with Disability
4
CHAPTER 1
5
5
INTRODUCTION
The Kenya Mental Health Policy 2015-2030 provides for a framework on interventions for securing mental
health systems reforms in Kenya. This is in line with the Constitution of Kenya 2010, Vision 2030, the Kenya
Health Policy (2014-2030) and the global commitments. The Constitution of Kenya 2010, in article 43. (1)(a)
provides that “every person has the right to the highest attainable standard of health, which includes the right
to healthcare services” which includes mental health. The 65th World Health Assembly adopted Resolution
WHA 65.4 on the global burden of mental disorders and the need for a comprehensive coordinated response
from the health and social sectors at country level. Subsequently, during the 66th World Health Assembly,
Resolution WHA 66.8 was adopted. It called on member states to develop comprehensive mental health
action plans in line with the Global Comprehensive Mental Health Action Plan 2013-2020.
The World Health Organization (WHO) in its constitution of 1948 defines health as “a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity”. Mental health is
defined as “a state of well-being whereby individuals recognize and realize their abilities, are able to cope
with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities”
(WHO: 2003). Mental health is a key determinant of overall health and socio-economic development. It
influences a variety of outcomes for individuals and communities such as: healthier lifestyles, better physical
health, improved recovery from illness, fewer limitations in daily living, greater productivity, employment and
earnings, better relationships with adults and with children, improved social cohesion and engagement and
improved quality of life (WHO: 2009). This can be achieved through the implementation of the Mental Health
Policy whose vision is to ensure efficient and high-quality health care system that is accessible and affordable
for every Kenyan and its mission that is aimed at the provision of integrated and high quality promotive,
preventive, curative and rehabilitative services to all Kenyans.
OBJECTIVES OF THIS MANUAL
The overall Objective of this training manual is to build the capacity of CHVs in the field of mental health so
that they are able to effectively respond to the mental health needs of their communities.
Aims of this Manual
1. To promote mental health within their communities.
2. To understand symptoms of mental disorders.
3. To support people with mental disorders and their families.
4. To respond appropriately to people experiencing symptoms of mental disorders.
5. To refer people experiencing possible mental disorders to appropriate services
NOTE: The manual is NOT designed to prepare CHVs as independent mental health practitioners.
What is mental health?
Mental health is defined as “a state of well-being whereby individuals recognize and realize their abilities, are
able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their
communities” (WHO: 2003)
6
What is mental illness?
Mental illnesses are health conditions involving changes in emotion, thinking or behaviour (or a combination
of these). Mental illnesses are associated with distress and/or dysfunction in social, occupational, or family
set ups.
MYTHS AND MISCONCEPTIONS
Some of the myths commonly associated with mental health include:
MYTHS
FACTS
Only people without friends need
therapists
There is a large difference between structured talking therapies and speaking
with friends. Both can help people with mental illness in different ways, but a
trained therapist can address issues constructively and in ways that even the
best of friends cannot match.
People with mental health conditions Most people with mental health conditions are no more likely to be violent than
are violent and unpredictable.
anyone else.
Data by WHO suggests that currently, 450 million people are experiencing
such conditions.
Mental health conditions are
uncommon
In Kenya, it is estimated that 1 in every 10 people suffer from a common
mental disorder. The number increases to 1 in every 4 people among
patients attending routine outpatient services. Depression and anxiety
disorders are the leading mental illnesses diagnosed in Kenya, followed by
sub- stance use disorders
Mental illness is a sign of weakness
Mental health disorders are illnesses, not signs of poor character. Fighting a
mental health condition takes a great deal of strength.
Mental health conditions are
permanent
A mental health diagnosis is not necessarily a “life sen- tence.” With
professional help some people are able to return to their ‘normal’ self
Addiction is a lack of willpower
Addiction is a brain disease and some experts consider substance use
disorders to be chronic diseases.
People with schizophrenia have a
split personality
According to the WHO, schizophrenia “is characterized by distortions in
thinking, perception, emotions, language, sense of self, and behavior.” These
distortions can include hallucinations and delusions.
It is true that someone living with a particularly severe mental health condition
People with mental health conditions might be unable to carry out regular work. However, the majority of people
with mental health condition can be as productive as individuals without
cannot work
mental health disorders.
Mental illnesses are as a result of
witchcraft and demon possession.
There are various factors that cause mental illnesses or predispose someone
to them. These can include biological factors such as genetic predisposition,
psychological, social and environmental factors.
Mental Illness is a Western Disease
Mental Health is universal.
7
Benefits of mental health
Mental health is important in every stage of our lives, which entails emotional, psychological, physical and
social wellbeing which includes:
• Increased self esteem
• Improved social interactions and relationships
• A greater sense of calm and inner peace
• Improved moods, clearer thinking
• Coping with the stresses of life
Factors influencing mental health (Protective and Risk factors)
Many factors (social, psychological, and biological factors) are known to affect mental health. Early life
development can have huge impacts, both positive and negative, on a person’s mental health later in life.
Factors known to increase the risk of developing mental health conditions include:
• Limited social supports or connections
• Substance use
• Violence (Physical, emotional and sexual violence)
• Persistent socio-economic pressures
• Exposure to adverse events, especially in childhood or on a large scale like natural calamities such
• as floods
• Stressful work conditions
• Stigma and discrimination – e.g., gender discrimination, social exclusion
• Unhealthy lifestyle – poor nutrition
• Physical ill-health and some infections e.g., chronic ailments
• Human rights violations.
• Specific psychological and personality factors that make people vulnerable to mental health problems
• Genetic factors (runs in the family)
Roles of Community Health Volunteers in mental health service
• Understand and identify the common mental health conditions in the community.
• Understand the causes of the mental illnesses.
• Recognize the signs and symptoms of the mental illnesses and refer appropriately.
• Identify factors influencing the progression of the illness.
• Creating Mental health awareness
• Addressing the myths and misconceptions.
• Support vulnerable persons e.g., bereaved, caregivers, orphans
• Monitoring adherence to mental health treatment
• Offering of Mental health first aid
8
CHAPTER 2
UNIT 1 - MENTAL HEALTH PROMOTION
9
9
MENTAL HEALTH PROMOTION
Mental health promotion are activities offered to individuals, groups, or large populations to enhance
competence, self-esteem, and a sense of well-being.
OBJECTIVES
• Ensuring people are free from stigma and discrimination.
• Promoting community networks and harmony so that all people feel included.
SPECIFIC WAYS TO PROMOTE MENTAL HEALTH
Mental health promotion includes services that operate on a population level which aims to raise awareness
of mental health issues, improve mental health knowledge, reduce stigma and discrimination and maximize
the population’s mental health and wellbeing.
There are a number of ways to promote mental health, these include:
• Good nutrition
• Staying positive
• Helping others
• Getting enough sleep
• Getting physically active
• Connecting with others
• Developing coping skills
• Getting professional help if you need itAvoiding substance use (alcohol and other drugs)
• Maintaining maternal mental health by offering psychosocial support during pregnancy and coping skills.
• Supporting safe environments
REDUCTION OF STIGMA AND DISCRIMINATION
• Talk openly about mental health, such as sharing on the media platforms and through social media.
• Educate yourself and others – Dispel myths and misconceptions or negative comments by sharing facts
and experiences.
• Be conscious of language – remind people that words matter.
• Show compassion for those with mental illness.
• Be honest about treatment – normalize mental health treatment, just like other health care treatment.
• Let the media know when they are using stigmatizing language when presenting stories related to mental
illness.
• Choose empowerment over shame - “I fight stigma by choosing to live an empowered life. To me, that
means owning my life and my story and refusing to allow others to dictate how I view myself or how I feel
about myself.” – Val Fletcher, responding on Facebook to the question, how do you fight stigma?
10
CHAPTER 3
UNIT 2 - COMMON MENTAL HEALTH
DISORDERS
11
11
COMMON MENTAL HEALTH DISORDERS
1. Depression
6. Suicidal Behavior
2. Anxiety
7. Self-Harm
3. Bipolar disorder
8. Dementia
4. Schizophrenia and Psychotic disorder
9. Epilepsy
5. Substance use disorders (Alcohol and Drugs
Use)
10. Post-Traumatic Stress|Disorder (PTSD)
DEPRESSION
Definition
Depression is a mental health condition characterized by persistently depressed mood or loss of interest in
activities, causing significant impairment in daily life.
Common Signs and Symptoms
• Feeling of low or sad mood
• Loss of interest or pleasure.
• Feeling of hopelessness about the future, guilt or low self-worth.
• Loss of self confidence
• Suicidal thoughts or acts
• Fatigue or loss of energy
• Agitation or slowing of movement or speech
• Disturbed sleep, appetite or decreased libido
Refer to Resource page case Study A
ANXIETY
Anxiety is a mental health condition marked by repeated feelings of worry, nervousness, or discomfort about
something with an uncertain outcome.
Signs and Symptoms:
• Feeling nervous, restless or tense
• Having a sense of impending danger, panic or helplessness.
• Having an increased heart rate, breathing rapidly
• Sweating and trembling
• Feeling weak or tired
• Trouble concentrating or thinking about anything other than the present worry.
• Having trouble sleeping
• Experiencing gastrointestinal (GI) problems
Refer to Resource page case Study B
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BIPOLAR DISORDER
Bipolar disorder is a mental health condition that causes changes in a person’s mood, energy, and ability to
function. It can present as either very high moods or very low moods.
Signs and Symptoms of bipolar disorder with very high moods (MANIA)
• Excessive irritability, aggressive behavior
• Racing speech, racing thoughts, flight of ideas
• Poor judgment easily distracted.
• Grandiose thoughts, inflated sense of self-importance
• Decreased need for sleep without experiencing fatigue
• Increased activity, energy, or agitation
• Irresponsible and careless behavior
• Heightened mood, exaggerated optimism, and self-confidence
• In the most severe cases, delusions, and hallucinations
Symptoms of bipolar disorder with very low moods (depressive phase)
• Feeling of low or sad mood
• Loss of interest or pleasure.
• Feeling of hopelessness about the future, guilt or low self-worth.
• Loss of self confidence
• Suicidal thoughts or acts
• Fatigue or loss of energy
• Agitation or slowing of movement or speech
• Disturbed sleep, appetite or decreased libido
Refer to Resource page case Study C
SCHIZOPHRENIA/PSYCHOTIC DISORDERS.
Schizophrenia/Psychotic disorders is a chronic and severe mental disorder marked by distortions in thinking,
perception, emotions, language, sense of self and behavior.
Common experiences include hallucinations (hearing voices or seeing things that are not there) and delusions
(False, strongly fixed beliefs).
Signs and symptoms of Schizophrenia/Psychotic disorders
• Hallucinations (Hearing of voice of people talking in one’s head, False perceptions)
• Delusions (false, strongly fixed beliefs)
• Confused or unconnected speech.
• Confused thinking.
• Lack of emotion (doesn’t make eye contact, doesn’t change facial expressions or speaks in a monotone).
• Increased energy levels
• Strange, possibly dangerous behavior.
• Slowed or unusual movements.
• Loss of interest in personal hygiene.
• Loss of interest in activities.
• Problems at school or work and with relationships.
13
• Social withdrawal or lack the ability to experience pleasure.
• Trouble sleeping
Refer to Resource page case Study D
SUBSTANCE USE DISORDERS (ALCOHOL AND DRUG USE)
Substance use disorder (SUD) is a chronic and relapsing mental health condition resulting from the use of a
substance that one continues to take, despite experiencing problems as a result.
Signs and Symptoms
• Feeling that you have to use the drug regularly — daily or even several times a day
• Having intense urges for the drug that block out any other thoughts
• Over time, needing more of the drug to get the same effect
• Taking larger amounts of the drug over a longer period of time than you intended
• Making certain that you maintain a supply of the drug
• Spending money on the drug, even though you can’t afford it
• Not meeting obligations and work responsibilities or cutting back on social or recreational activities
because of drug use
• Problems with law enforcement authorities
• Continuing to use the drug, even though you know it’s causing problems in your life or causing you
physical or psychological harm.
• Doing things to get the drug that you normally wouldn’t do, such as stealing
• Driving or doing other risky activities when you’re under the influence of the drug
• Spending a good deal of time getting the drug, using the drug or recovering from the effects of the drug
• Failing in your attempts to stop using the drug
• Experiencing withdrawal symptoms when you attempt to stop taking the drug
Recognizing the signs and symptoms of substance and drug use in family members
Sometimes it is difficult to distinguish normal teenage moodiness or angst from signs of drug use. Possible
indications that your teenager or other family member is using drugs include:
1. Problems at school or work — frequently missing school or work, a sudden disinterest in school activities
or work, or a drop in grades or work performance
2. Physical health issues — lack of energy and motivation, weight loss or gain, or red eyes
3. Neglected appearance — lack of interest in clothing, grooming or looks
4. Changes in behavior — exaggerated efforts to bar family members from entering his or her room or being
secretive about where he or she goes with friends; or drastic changes in behavior and in relationships with
family and friends.
Refer to Resource page case Study E
SUICIDAL BEHAVIOR
Suicidal behavior is any action that could cause a person to die, such as taking a drug overdose or crashing
a car on purpose.
Risk Factors for Suicidal behavior
• Previous suicide attempt(s)
14
• A history of suicide in the family.
• Substance use.
• Other mental illnesses.
• Easy access to lethal means (e.g., keeping firearms in the home)
• Loss and grief (for example, the breakup of a relationship or a death, academic failures, legal difficulties,
financial difficulties, bullying)
• History of trauma or abuse.
• Chronic physical illness, including chronic pain.
• Exposure to the suicidal behavior of others.
Warning Signs of Suicide
• Often talking or writing about death, dying or suicide
• Making comments about being hopeless, helpless or worthless
• Expressions of having no reason for living; no sense of purpose in life; saying things like “It would be
better if I wasn’t here” or “I want out.”
• Increased alcohol and/or drug use
• Withdrawal from friends, family and community
• Reckless behavior or more risky activities, seemingly without thinking
• Dramatic mood changes
• Talking about feeling trapped or being a burden to others
NB: One of the biggest barriers to preventing suicidal behavior is stigma, which prevents many people
from seeking help.
SELF HARM
Non suicidal self-injury is the act of deliberately harming your own body, such as cutting or burning yourself.
It’s not meant as a suicide attempt, but this type of self-injury is a harmful way to cope with emotional pain,
intense anger and frustration.
Signs and symptoms of self-harm
• Scars, often in patterns
• Fresh cuts, scratches, bruises, bite marks or other wounds
• Excessive rubbing of an area to create a burn
• Keeping sharp objects on hand
• Wearing long sleeves or long pants, even in hot weather
• Frequent reports of accidental injury
• Difficulties in interpersonal relationships
• Behavioral and emotional instability, impulsivity, and unpredictability
• Statements of helplessness, hopelessness, or worthlessness
NB: Self-injury usually occurs in private and is done in a controlled or ritualistic manner that often
leaves a pattern on the skin
15
DEMENTIA
Dementia describes a group of symptoms affecting memory, thinking and social abilities severely enough to
interfere with your daily life. It isn’t a specific disease, but several different diseases may cause dementia.
Signs and symptoms
• Memory loss, which is usually noticed by a spouse or someone else
• Difficulty communicating or finding words
• Difficulty with visual and spatial abilities, such as getting lost while driving
• Difficulty reasoning or problem-solving
• Difficulty handling complex tasks
• Difficulty with planning and organizing
• Difficulty with coordination and motor functions
• Confusion and disorientation
Refer to Resource page case Study F
COMMON EMOTIONAL, BEHAVIORAL AND NEURO-DEVELOPMENTAL CONDITIONS IN
CHILDREN AND ADOLESCENTS
These are developmental (growth related) conditions that mostly involve children and present with persistent
challenges in social interaction, speech and nonverbal communication, hyperactivity, restricted/repetitive
behaviors and difficulty in sustaining attention.
Signs and Symptoms
• Being unable to sit still, especially in calm or quiet surroundings.
• Constantly playing.
• Impulsivity
• Being unable to concentrate on tasks.
• Excessive physical movement and talking.
• Poor eye contact
• Learning difficulties.
• Being rebellious and unruly
• General Low moods or unhappiness.
• Poor (social & interactive) interpersonal relationships
• Being unable to wait for their turn.
• Acting without thinking.
• Interrupting conversations.
AUTISM SPECTRUM DISORDER
Definition
Autism spectrum disorder (ASD) is a condition related to brain development that impacts how a person
perceives and socializes with others, causing problems in social interaction and communication.
16
Signs and Symptoms
Social communication and interaction
A child or adult with autism spectrum disorder may have problems with social interaction and communication
skills, including any of these signs:
• Fails to respond to his or her name or appears not to hear you at times
• Resists cuddling and holding, and seems to prefer playing alone, retreating into his or her own world
• Has poor eye contact and lacks facial expression
• Doesn’t speak or has delayed speech, or loses previous ability to say words or sentences
• Can’t start a conversation or keep one going, or only starts one to make requests or label items
• Speaks with an abnormal tone or rhythm and may use a singsong voice or robot-like speech
• Repeats words or phrases verbatim, but doesn’t understand how to use them
• Doesn’t appear to understand simple questions or directions
• Doesn’t express emotions or feelings and appears unaware of others’ feelings
• Doesn’t point at or bring objects to share interest
• Inappropriately approaches a social interaction by being passive, aggressive or disruptive
• Has difficulty recognizing nonverbal cues, such as interpreting other people’s facial expressions,
• body postures or tone of voice
Patterns of behavior
A child or adult with autism spectrum disorder may have limited, repetitive patterns of behavior, interests or
activities, including any of these signs:
A child or adult with autism spectrum disorder may have limited, repetitive patterns of behavior, interests or
activities, including any of these signs:
• Performs repetitive movements, such as rocking, spinning or hand flapping
• Performs activities that could cause self-harm, such as biting or head-banging
• Develops specific routines or rituals and becomes disturbed at the slightest change
• Has problems with coordination or has odd movement patterns, such as clumsiness or walking on toes,
and has odd, stiff or exaggerated body language
• Is fascinated by details of an object, such as the spinning wheels of a toy car, but doesn’t understand the
overall purpose or function of the object
• Is unusually sensitive to light, sound or touch, yet may be indifferent to pain or temperature
• Doesn’t engage in imitative or make-believe play
• Fixates on an object or activity with abnormal intensity or focus
• Has specific food preferences, such as eating only a few foods, or refusing foods with a certain texture
• Signs of autism spectrum disorder often appear early in development when there are obvious delays in
language skills and social interactions.
Doesn’t respond with a smile or happy expression by 6 months
• Doesn’t mimic sounds or facial expressions by 9 months
• Doesn’t babble or coo by 12 months
• Doesn’t gesture — such as point or wave — by 14 months
• Doesn’t say single words by 16 months
• Doesn’t play “make-believe” or pretend by 18 months
• Doesn’t say two-word phrases by 24 months
• Loses language skills or social skills at any age
17
EPILEPSY
Epilepsy is a central nervous system (neurological) disorder in which brain activity becomes abnormal,
causing seizures or periods of unusual behavior, sensations, and sometimes loss of awareness.
Symptoms
Because epilepsy is caused by abnormal activity in the brain, seizures can affect any process your brain
coordinates. Seizure signs and symptoms may include:
• Temporary confusion
• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Psychic symptoms such as fear, anxiety or a feeling of having already experienced the present situation.
Examples of seizures
• Seizure without loss of consciousness, known as simple partial seizures, these seizures don’t cause
a loss of consciousness. They may alter emotions or change the way things look, smell, feel, taste or
sound. They may also result in involuntary jerking of a body part, such as an arm or leg, and spontaneous
sensory symptoms such as tingling, dizziness and flashing lights.
• Seizures with impaired awareness, also known as complex partial seizures, these seizures involve
a change or loss of consciousness or awareness. During a complex partial seizure, you may stare into
space and not respond normally to your environment or perform repetitive movements, such as hand
rubbing, chewing, swallowing or walking in circles.
• Seizures that appear to involve all areas of the brain are called generalized seizures. Six types of
generalized seizures exist.
• Absence seizures often occur in children and are characterized by staring into space or subtle body
movements such as eye blinking or lip smacking. These seizures may occur in clusters and cause a
brief loss of awareness.
• Stiffening of the muscles seizures These seizures usually affect muscles in your back, arms and legs
and may cause you to fall to the ground.
• Loss of muscle control seizures. They cause a loss of muscle control, which may cause you to
suddenly collapse or fall down.
• Seizures associated with repeated or rhythmic, jerking muscle movements. These seizures usually
affect the neck, face and arms.
• Seizures involving sudden brief jerks or twitches of your arms and legs.
• Seizures that cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss
of bladder control or biting of the tongue. This is the most dramatic type of epileptic seizure.
Refer to case Study G
POST TRAUMATIC STRESS DISORDER
Post-traumatic stress disorder (PTSD) is a mental health condition that is triggered by a terrifying event —
either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as
well as uncontrollable thoughts about the event.
18
Intrusive thoughts/memories
Symptoms may include: Symptoms of intrusive thoughts/memories may include:
• Recurrent, unwanted distressing thoughts/memories of the traumatic event.
• Reliving the traumatic event as if it were happening again (flashbacks)
• Upsetting dreams or nightmares about the traumatic event
• Severe emotional distress or physical reactions to something that reminds you of the traumatic event
Avoidance
Symptoms of avoidance may include:
• Trying to avoid thinking or talking about the traumatic event
• Avoiding places, activities or people that remind you of the traumatic event
Negative changes in thinking and mood
Symptoms of negative changes in thinking and mood may include:
• Negative thoughts about yourself, other people or the world
• Hopelessness about the future
• Memory problems, including not remembering important aspects of the traumatic event
• Difficulty maintaining close relationships
• Feeling detached from family and friends
• Lack of interest in activities you once enjoyed
• Difficulty experiencing positive emotions
• Feeling emotionally numb
Refer to Resource page case Study H
19
CHAPTER 4
UNIT 3 - THE PRINCIPLES OF BASIC
COUNSELLING
20
20
Counselling is a process between a client and the therapist to explore difficulties, learn to see things clearly and facilitate
positive change (Sextone 1996).
Counselling aims to help people cope better with situations they are facing. This involves helping the individual
to cope with their emotions and feelings and to help them make positive choices and decisions.
Counselling involves:
1. Establishing a trusting relationship,
2. Helping the client tell their story,
3. Listening carefully and respecting the client,
4. Being non-judgmental,
5. Providing confidentiality
6. Providing correct information,
7. Helping the individual make informed decisions
8. Helping the client to recognize and build on their strengths
9. Helping the client develop a positive attitude
10.Maintaining a professional relationship.
It does not involve:
• Making decisions for the client
• Judging, interrogating, blaming, preaching, lecturing, or arguing
• Making promises that you cannot keep
• Allowing clients to become dependent on you
BASIC COUNSELING SKILLS
The following are some of the basic counseling skills a CHV should have;
• Active listening
• Processing
• Responding
• Teaching
ACTIVE LISTENING
Active listening encourages the client to share information by providing verbal information and nonverbal
expressions of interest
It includes the following skills:
1. Attending
Attending is expressing awareness and interest in what the client is communicating both verbally and
nonverbally. It helps the CHV better understand the client through careful observation, makes the client relax,
feel comfortable to express their ideas and feelings freely in their own way and trust the CHV and takea more
active role in their own sessions.
Proper attending involves the following:
• Appropriate eye contact, facial expressions.
• Maintaining a relaxed posture and leaning forward appropriately.
• Using natural hand and arm movements.
21
• Verbally “following” the client, using a variety of brief encouragements such as “Um-hm” or “Yes,” or by
repeating key words.
• Observing the client’s body language
Client: I feel tired and lately so overwhelmed.
CHV: Yes , mmmh mmmh
2. Paraphrasing
Paraphrasing involves restating the content of the client’s previous statement using words that are similar
to the clients, but fewer. Its purpose is to communicate to the client that you understand what he or she is
saying.
Paraphrasing helps the CHV
• Verify their perceptions of the client’s statements
• Spotlight an issue
Paraphrasing helps the client
• Realise that the CHV understands what they are saying.
• Clarify their remarks and focus on what is important and relevant
Client: My mom irritates me. She picks on me for no reason at all. We do not like
each other.
Therapist: So…you are having problems getting along with your mother. You are
concerned about your relationship with her.
3. Reflection of feelings
Reflection of feelings involves the expression of the client’s feelings, either stated or implied. The CHV tries
to perceive the emotional state of the client and respond in a way that demonstrates an understanding of the
client’s emotional state.
Reflection of feelings helps the CHV;
• Check whether or not they accurately understand what the client is saying.
• Bring out problem areas without the client being pushed or forced.
Reflection of feelings helps the client
• Realize that the CHV understands what they feel
• Increase awareness of their feelings
• Learn that feelings and behavior are connected.
Client: When I get home in the evening, my house is a mess. The kids are dirty…
My husband does not care about dinner...I do not feel like going home at all.
Therapist: You are not satisfied with the way the house chores are organized. That
irritates you.
22
4. Summarizing
Summarizing is an important way for the CHV to gather together what has already been said, make sure that
the client has been understood correctly, and prepare the client to move on. It is putting together a series of
reflections.
Summarizing helps the CHV
• Provide focus for the session
• Confirm the client’s perceptions
Focus on one issue while acknowledging the existence of others. Terminate a session in a logical way
Summarizing helps the client
Clarify what they mean
Realize that the CHV understands
Have a sense of movement and progress.
Therapist: We discussed your relationship with your husband. You said there
were conflicts right from the start related to the way money was handled, and
that he often felt you gave more importance to your friends. Yet on the whole,
things went well and you were quite happy until 3 years ago. Then the conflicts
became more frequent and more intense, so much so that he left you twice
and talked of divorce, too. This was also the time when your drinking was at its
peak. Have I understood the situation properly?
Client: Yes, that is it.
PROCESSING
Processing is the act of the CHV thinking about his or her observations about the client and what the client
has communicated includes providing feedback and emotional support, addressing issues of concern, and
teaching skills
Processing allows the CHV to mentally catalogue the following data:
1. Client’s beliefs, knowledge, attitudes, and expectations
2. Information given by his or her family
3. CHV’s observations
RESPONDING
• Responding is the act of communicating information to the client that includes providing feedback and
emotional support.
• Addressing issues of concern, and teaching skills.
Expressing empathy
Empathy is the action of understanding, being aware of being sensitive to, and vicariously experiencing the
feelings, thoughts, of another.
Probing
Probing is the CHV’s use of a question to direct the client’s attention, to explore his or her situation in greater
depth.
23
Probing;
• A probing question should be open-ended
• Probing helps to focus the client’s attention on a feeling, situation, or behavior feeling,
• Probing may encourage the client to elaborate, clarify, or illustrate what he or she has been saying
• Probing may enhance the client’s awareness and understanding of his or her situation and feelings
• Probing directs the client to areas that need attention
Interpreting
Interpreting is the CHV’s explanation of the client issues after observing the client’s behavior, listening to the
client, and considering other sources of information.
Silence
Silence is making no noise or not talking
Silence can encourage the client to reflect and continue sharing.
It can also allow the client to experience the power of his or her own words
TEACHING
Teaching is the CHV’s transfer of skills to the client through a series of techniques and counseling strategies.
Repetition
Repetition entails CHVs restating information and clients practicing skills as needed for clients to master the
necessary knowledge and skills to control or deal with their problems.
Encourage practice
Mastering a new skill requires time and practice. The learning process often requires making mistakes and
being able to learn from them.
It is critical that clients have the opportunity to try new approaches.
NOTE
CHVs should not expect a client to practice a skill or do a homework assignment without understanding
why it might be helpful.
CHVs should constantly stress how important it is for clients to practice skills outside of the counseling
session and explain the reasons for it.
Explore resistance
Failure to implement skills outside of sessions may be the result of a variety of factors (e.g., feeling hopeless).
By exploring the specific nature of a client ’s difficulty, CHVs can help them work through it.
Praise approximations
CHVs should try to shape the patients’ behavior by praising even small attempts at working on assignments,
highlighting anything they reveal as helpful or interesting.
24
Common side effects of anti-psychotic medication
• Spasm of muscles in the face and neck, or difficulty controlling eye movements (if this
• Occurs the person should be taken to a doctor as soon as possible)
• Restlessness that causes the person to rock back and forth or pace up and down
• Limited emotion with no facial expression showing
• Muscle stiffness and shakiness particularly in the hands
• Sexual problems in both men and women
• Sensitivity to sunlight
• Itchy skin rashes, rash, dizziness, drowsiness, dry mouth or hyper-salivation, amenorrhea, weight gain,
Constipation, Nausea, Vomiting, Sexual dysfunction, Blurred vision, Memory problems, Unsteadiness,
Slowed movements and speech
How to support a person on drug treatment for a mental disorder
• Side effects usually happen early in treatment and are often helped by the doctor adjusting the type or
dose of medication.
• Some side effects get better with time - it is important not to stop taking medication abruptly.
• Make sure the person has understood the dosage and reason for the drug therapy ordered by the doctor,
and that he/she is following the instructions correctly.
• Explain that many drug treatments take time to act effectively and should be taken even when the
person starts to feel better to prevent them from becoming ill again.
• Try to see the person who has just started drug treatment for a mental disorder more frequently to check
for medication adherence and side effects.
• If you have any concerns about the effects of the drug treatment then encourage the person and their
family to return to the doctor.
• The side effects of the treatments can sometimes be more troubling for the person than the symptoms
of the mental disorder
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CHAPTER 5
UNIT 4 - MENTAL HEALTH FIRST AID
26
26
PURPOSE
To introduce participants to the concept of MHFA and provide them with five steps that can be taken to help
people experiencing a mental health crisis.
OBJECTIVES
• Define Mental Health First Aid
• Recognize clients requiring Mental Health First Aid
• To be able to outline the steps of mental health first aid
DEFINITION OF MENTAL HEALTH FIRST AID
Mental health First aid is the help you give to someone developing a mental health problem, experiencing a
worsening of a mental health problem or in a mental health crisis. You can give this help until the person has
received appropriate professional treatment through effective referral or until the crisis is resolved.
MENTAL HEALTH FIRST AID IN THE COMMUNITY
There are many effective ways of responding to people with a mental disorder, and CHV’s have an important
role to play in providing assistance and helping the person and his/her family seek appropriate help.
Not all people with a mental disorder need specialist psychiatric care but many need to be guided towards
appropriate professional help
MENTAL HEALTH FIRST AID IN ACTION
How to respond to someone experiencing a mental disorder in the community. Mental Health First Aid Actions
Five basic steps that can be taken to help people suffering from a mental disorder:
1. Assess the risk of suicide or harm to self or others
People with mental disorders sometimes feel so overwhelmed and helpless about their life, the future appears
hopeless.
Engage the person in a conversation and encourage them to describe their feelings.
Ask the person if they are having thoughts of suicide. If they are, find out if they have a plan for suicide. This
is not a bad question to ask someone who is mentally unwell. It is important to find out if he/she is having
these thoughts in order to refer him/her for help.
If you believe the person is at risk of harming him/herself then:
• Don’t leave the person alone
• Seek immediate help from someone from a mental health professional.
• Try to remove the person from access to the means of taking their own life
• Try to stop the person continuing to use alcohol or drugs.
2. Listen without judgment
Listen to what the person describes without being critical or thinking they are weak. Don’t give advice such
as ‘just cheer up’ or ‘pull yourself together’.
Avoid getting into an argument with the person.
27
3. Give reassurance and accurate information
Provide hope for the person and their family and talk about a good outcome for that person.
Tell the person that he/she has an illness that can be treated, and it doesn’t mean that he/she is a bad person.
Let them know that you want to help.
4. Encourage the person to get appropriate professional help
As a CHV you can encourage the person to consult a mental health professional who knows about mental
disorders, and who is able to prescribe medication if necessary. Then you can follow-up by giving ongoing
support to the person and their family.
If the person is very unwell i.e., you think they are suicidal or psychotic, and he/she is refusing to get any help
from a doctor, encourage the family to consult with the mental health professional so that they can explain
the situation and get professional support.
5. Encourage Self care
Suggest actions that the person can perform him/herself that can help relieve the symptoms of mental
disorder such as:
• Getting enough sleep
• Eating a healthy diet
• Regular exercise
• Relaxation and breathing exercises e.g., taking a walk, meditation
• Avoiding alcohol
• Joining support groups for women, men or youth, Chama groups, etc.
How to help a person who is threatening to attempt suicide
• Remove access to all dangerous items such as knives and poison.
• Ensure the person is not left alone – enlist help from family and friends to keep the person company if
necessary.
• Seek professional help as soon as possible.
• If the person is consuming alcohol, try to stop him/her from consuming any more.
• Listen non-judgmentally, do not give advice according to your own personal values or contradict the
person.
• Let the person know that you and others care about him/her.
• Let the person know that even though the situation seems hopeless at present, things are likely to
improve – feeling bad is only temporary.
• If the person has already harmed him/herself e.g., swallowed poison, emergency medical treatment is
required.
• Assess risk of suicide or self-harm
How to help a person who is hearing voices, suspicious of others, or expressing
unusual beliefs:
1. Assess the risk of harm to self or others
• Try to determine if there is any risk of self-harm or any threat of harm to others.
• A person who is hearing voices may be frightened and suspicious and needs to be approached in a very
nonthreatening way.
• If the person threatens violence to others try to restore calm and safety.
28
2. Listen without judgment
• Speak calmly, clearly and in short sentences.
• Introduce yourself and let him/her know that you want to help.
• Don’t be critical of the person.
• Avoid confrontation and arguments.
• Don’t tell him/her that there are no voices or that his/her beliefs are wrong.
• Don’t pretend that you can hear the voices or agree with false beliefs.
3. Give reassurance and accurate information
• Try to talk to the person when he/she is calm and thinking clearly.
• Be honest and try to win the person’s trust.
• Do not make promises you cannot keep and do not lie to the person.
• Explain to the person and his/her family that hearing voices is a symptom of a mental disorder (or a
problem in the brain) and treatment is available.
4. Encourage the person to get appropriate help
• Encourage the person to see a professional mental health worker to be assessed and put on antipsychotic
medication, which is usually the best treatment for this disorder.
5. Encourage self-care
• Visit the person regularly once he/she has started to recover.
• Assist the person to reintegrate into the social life in the community and into employment or other family
duties
VIOLENCE
• Violence involves threatened or real physical aggression by one person against another.
• Only a small percentage of people with mental disorders will threaten violence.
• Violence and aggressive behavior can occur in all people, but in those with a mental disorder, violence
is more often linked to people with a psychosis or harmful use of alcohol.
Factors contributing to violence
• Frustration and anger can lead to aggression and violence.
• People may act aggressively on the basis of delusions (false beliefs) if they believe that you or someone
else is trying to hurt them.
• A person may act on the basis of hallucinations if they are hearing voices that are compelling them to
do something violent.
• Use of, or withdrawal from, alcohol or other drugs may lead to violent behavior.
How to help - Restoring calm and safety
• Do not get involved physically to stop violence.
• Never put yourself at risk; if you are frightened, seek outside assistance immediately.
• Remove any items which could be used as weapons, from the immediate environment.
• Stay calm and keep the atmosphere as non-threatening as possible; talk quietly, firmly, and simply,
• avoid making any abrupt movements.
• Do not raise your voice or talk too quickly.
• Do not threaten the person, as this will increase their fear and may trigger an aggressive reaction.
• Give the person enough space so that they don’t feel trapped.
29
• Try to get the person to sit down; it is best if you are both seated side by side rather than facing each
other.
• Do not ask a lot of questions as these can cause the person to become defensive, agitated or angry.
• If the person’s behavior appears to be getting out of control, you must remove yourself from the situation
and immediately call for other people to help.
WHAT NOT TO DO FOR A PERSON WITH A MENTAL DISORDER
Common treatments or responses that do NOT help a person with a mental disorder:
• Ignoring/ avoiding the person
• Believing the symptoms will just go away
• Locking the person away
• Being angry with him/her
• Relying exclusively on faith healing
• Relying on traditional healers
• Arranging a marriage if they are unmarried.
• Giving sleeping tablets or appetite stimulants
• Believing that you can cure the person or that you have all the solutions to their problems.
• Restraining them
• Calling names and using derogatory terms
• Do not minimize the issue.
30
ANNEXES
COMMON MENTAL DISORDERS
MENTAL
HEALTH
CONDITION
HELP THAT CAN
REFERRAL
BE PROVIDED
SIGNS AND SYMPTOMS
Feeling of low or sad mood
Loss of interest or pleasure.
Depression
Feeling of hopelessness about the future, guilt or low self-worth.
Apply mental
health first aid
Loss of self confidence
Suicidal thoughts or acts
Refer to the nearest
health facility/
Dispensary/Sub
County hospital.
Fatigue or loss of energy
Feeling nervous, restless or tense
Having a sense of impending danger, panic or helplessness.
Anxiety
Having an increased heart rate, breathing rapidly
Sweating and trembling Feeling weak or tired
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Trouble concentrating or thinking about anything other than the
present worry
Excessive irritability, aggressive behavior
Racing speech, racing thoughts, flight of ideas
Poor judgment, easily distracted
Bipolar disorder
Grandiose thoughts, inflated sense of self-importance
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Feeling of low or sad mood
Loss of interest or pleasure.
Feeling of hopelessness about the future, guilt or low self-worth.
Loss of self confidence
3rd person auditory Hallucinations (False perceptions)
Delusions (false, fixed beliefs)
Confused or unconnected speech.
Schizophrenia
and Psychotic
disorder
Confused thinking.
Lack emotion (doesn’t make eye contact, doesn’t change facial
expressions or speaks in a monotone).
Increased energy levels
Strange, possibly dangerous behavior.
Feeling that you have to use the drug regularly daily or even several
times a day
Having intense urges for the drug that block out any other thoughts
Over time, needing more of the drug to get the same effect
Substance use
Taking larger amounts of the drug over a longer period of time than
disorders (Alcohol
you intended
and Drugs Use)
Making certain that you maintain a supply of the drug
Spending money on the drug, even though you can’t afford it
Not meeting obligations and work responsibilities, or cutting back on
social or recreational activities because of drug use.
31
Being unable to sit still, especially in calm or quiet surroundings.
Developmental,
Emotional, and
Behavioral
conditions in
Children and
Adolescent
Constantly playing. Impassivity
Being unable to concentrate on tasks.
Excessive physical movement and talking.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Poor eye contact
Learning difficulties.
Being rebellious and unruly
Previous suicide attempt(s)
A history of suicide in the family. Substance use.
Other mental illnesses.
Easy access to lethal means (e.g., keeping firearms in the home)
Loss and grief (for example, the breakup of a relationship or a death,
academic failures, legal difficulties, financial difficulties, bullying)
Suicidal Behavior
History of trauma or abuse.
Often talking or writing about death, dying or suicide
Making comments about being hopeless, helpless or worthless
Expressions of having no reason for living; no sense of purpose in
life; saying things like “It would be better if I wasn’t here” or “I want
out.”
Scars, often in patterns
Fresh cuts, scratches, bruises, bite marks or other wounds
Self-Harm
Excessive rubbing of an area to create a burn
Keeping sharp objects on hand
Wearing long sleeves or long pants, even in hot weather
Frequent reports of accidental injury
Memory loss, which is usually noticed by a spouse or someone else
Dementia
Intellectual
developmental
Disorder /
disability
Communication
disorders
(Language
disorder, speech
sound disorder,
stuttering)
Difficulty communicating or finding words Difficulty with visual and
spatial abilities, such as getting lost while driving Difficulty reasoning
or problem-solving Difficulty handling complex tasks Difficulty with
planning and organizing
Troubles in problem solving, thinking, judgment and academic
learning.
Troubles with communication, social interactions and independent
living across different environments e.g., home, school and
community.
Reduced vocabulary and limited sentence structure
Difficulty with speech sound production that interferes with speech
and prevents verbal -communication of messages.
Repetition of syllables and sounds, broken words, one syllable word
repetition e.g. E-e-e-e-e
Difficulty with communication, both verbal and non-verbal
communication
Autism Spectrum
Disorder
Deficits in social emotional reciprocity e.g., reduced sharing of
interests and emotions.
Troubles forming relationships
Certain repetitive patterns or activities and behaviors e.g., squirming.
32
Difficulty in sustaining attention in tasks or play activities. Not
following instructions
Difficulty organizing tasks and activities.
Attention Deficit
Hyperactivity
disorder
Often fidgets with or taps hands or feet or moving back and forth on
seat (squirming)
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Apply mental
health first aid
Refer to the nearest
health facility/
Dispensary/Sub county
hospital.
Running up and about all the time, leaves the seat when expected to
be sitting
Talks excessively, interrupts others and has a difficulty waiting for
their turn.
Impulsive
Often angry, loses temper, gets easily annoyed.
Argues with the authority figure e.g. parent/teacher.
Oppositional
Defiant Disorders
(ODD)
Doesn’t follow rules and deliberately annoys people and blames
others for their mistakes.
Decline in performance always in trouble.
Rule out substance use.
Often bullies and threatens others.
Initiates physical fights.
Conduct Disorder
Physically cruel to people and animals.
Forcing someone into a sexual activity.
Destruction of property deliberately. Lying and stealing.
Not following rules or instructions.
33
THE QUALITYRIGHTS ARTICLES AS STATED IN THE CRPD
(CONVENTION ON THE RIGHTS OF PERSONS WITH DISABILITY)
Article
The right to:
28
An adequate standard
of living and social
protection
Human rights are what no one can take away from you
Human rights and living a good life.
Humane Living conditions & access to social protection
Persons living With Psychosocial, Intellectual Chronic Dis- ability are denied the rights to housing,
basic needs, food, social protection.
PLWPICD face discrimination in most areas of their life, education, work, family life, housing &
leisure.
25
Enjoyment of the
highest attainable
standard of physical
and mental health
Promoting mental health and well-being.
Access to mental and physical health services on an equal basis with the same standard of
service as others.
Ensuring there is adequate and timely provision of medication, and promoting service
user(patient) led treatment programs & respect for their decisions.
Improving standards of care in mental health facilities/services in line with the CRPD.
12 & 14
Exercise legal capacity
and the right to
personal liberty and the
security of person
The CRPD supported decision-making approach instead of substitute decision making - client
is able to choose someone who they are comfortable with assisting them in making decision
needed in their recovery journey they are made aware of their rights informed consent before any
procedure is carried out service user is explained to clearly what treatment their options are, and
their pros and cons.
Individualized Treatment and recovery plans – Each service user should have a personalized
recovery plan. Involvement of caregivers in the treatment plan. Service user should have a say in
their treatment plan.
Advanced planning – allow clients to have advanced / pre- planned treatment plans to use in
case of crisis or mental breakdown. Promote family inclusion and support during treatment and
care.
15 & 16
Freedom from torture
or cruel, inhuman or
degrading treatment or
punishment and from
exploitation, violence
and abuse
Types of violence, coercion and abuse
• Seclusion such as isolating some in a room or confined space and preventing them from
leaving.
• Restraint, including hands-on physical restraint, mechanical restraint or using medication to
control someone’s behavior (chemical restraint).
• Forced admission to, and treatment in, mental health and social services.
• Forced treatment in the community.
• Economic violence and coercion (i.e. controlling a person’s resources to compel the person to
do things he or she does not want to do)
Involuntary sterilization, contraception or abortion. Sedation (injection of tranquilizer when the
clients are aggressive)
Physical, sexual & verbal abuse of service users
Strategies/ways to avoid coercion, violence and abuse:
• Learn effective Communication techniques
• Have a Supportive environment
• Creating a saying yes” and “can do” culture
• Individualized plans to explore sensitivities and signs of dis- tress
• Response teams - have effective means of responding that are not violent
19
Live independently
and be included in the
community
Access to a wide range of support and services to enable them to live, be included & participate
in their chosen community.
Availability of Community based mental health services that cater for the client in the best way
possible
34
RESOURCE PAGE INFORMATION
CASE STUDIES
Depression Case Study A
Rita is a 58-year-old woman whose husband died last year. Her children are all grown up and have left the
village for better employment opportunities in a big city. She started experiencing poor sleep and loss of
appetite soon after her husband died. The symptoms worsened when her children left the village. She feels
low and sad most of the day and does not visit her close friends like she used to and prefers to be alone. She
experiences other physical discomforts, which have led her to consult the local clinic many times.
There she was told she was well but was prescribed sleeping tablets and vitamins. She felt better immediately,
particularly because her sleep improved. However, within two weeks her sleep has got worse again. She
went back to the clinic and was given more sleeping pills and injections. This has been going on for months,
and now she can no longer sleep without the sleeping pills.
Anxiety Case Study B
Aisha seems generally happy when at home but when asked to go out (of the house, to the market) starts to
shake and gives several reasons why she cannot go out and must stay at home e.g., her heart is not working
properly, and she cannot breathe so need to lie down. It is now weeks since she has left the house. About
half an hour later she will get up and once again seem okay until her mother asks her to go out again and the
same thing happens.
Bipolar disorder Case Study C
Kate is a 31-year-old woman whose husband is worried because she has started behaving in an unusual
manner. She is sleeping much less than usual and is constantly on the move. Kate has stopped looking after
the house and children as efficiently as before. She is talking much more than normal and often says things
that are unreal and grand e.g., that she can heal other people and that she comes from a very wealthy family
(even though her husband is a farmer). She has also been spending all their money on things they cannot
afford. When Kate’s husband tries to bring her to the clinic she becomes angry and irritable. Sometimes she
experiences symptoms described in case study A
Schizophrenia and Psychotic disorder Case Study D
Juma is a 25-year-old student who started locking himself in his room and refused to bathe. Amal used
to be a good student but failed his last exams. His mother says that he often spends hours staring into space.
Sometimes he mutters to himself as if he were talking to an imaginary person. During the burial of his
grandfather, he was laughing while others were mourning. He was forced to come to the clinic by his parents.
At first, he refused to talk to the nurse. After a while he admitted that he believed that his parents andneighbors
were plotting to kill him and that the devil was interfering with his mind. He said he could hear his neighbors
talk about him and say nasty things outside his door. He said he felt as if he had been possessed but did not
see why he should come to the clinic since he was not ill.
Substance use disorders (Alcohol and Drugs Use) Case Study E
Mutisya is a 44-year-old man who has been ill with a number of physical complains over the past several
months. His main complaints were that his sleep was not good, that he often felt like vomiting in the morning
and that he was generally not feeling well. Amar has recently been to see the doctor for severe burning pain
in the stomach area; he was prescribed more medication for stomach ulcer. Today he is sweating profusely,
and his hands are shaking, when you ask him how he is feeling he sits down and starts to cry.
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He admits that he is sick because he has been drinking increasing amounts of alcohol in the previous few
months as a way of coping with stress in the family. However now the drinking itself has become a problem
and he cannot pass even a few hours without having a drink.
Dementia Case Study F
Kivunyu is a 65-year-old woman who lives with her 2 children in the city. One day she went to the local
butchery with her son. As the son was talking with the butcher man, he turned and could not see his mother.
He raised an alarm and they searched for her. She was later found 2 km away at the local market asking a
stranger for directions to her home. She looked confused and could not remember where she had come from
nor identify her son. On further probing the son explained that for the last 2 years his mother has been unable
to carry out her normal tasks as before, she forgets easily and cannot remember the names of her own child,
close family, and friends.
Epilepsy Case Study G
Mwakazo is a 9-year-old boy, his mother was called to school because he had fallen and lost consciousness
and he had wet himself. By the time his mother reached the school, the child was awake, and nothing seemed
wrong with him. After two weeks, as he was playing, he fell and started twitching and shaking. On being
called, his mother found that he had wet himself and had bitten his tongue. This happened seven moretimes
over a period of one month, so his mother decided to take him to the hospital. When he was taken to hospital,
the doctor prescribed some medication for him and that seem to help him. Mwakazo only experienced this
once a month after being put on the medication.
Post-Traumatic Stress Disorder (PTSD) Case Study H
Three months ago, robbers broke into the residence of Mr.Onyango. His family was held hostage at gunpoint,
and they witnessed the shooting of the watchman. They called for help and the police were responded. Since
then, Mr.Onyango experiences nightmares. Sometimes while busy at work, he suddenly has flashbacks of
the event. He has been afraid to employ the services of a watchman and sometimes fears going to his home
at night. To make him forget about this event and sleep, he began taking alcohol.
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CONTRIBUTORS AND TECHNICAL ADVISORY PANEL
I am obliged to the following committee members for their effort and contribution to the finalization of this Manual
1. Dr. Simon Njuguna – Director Mental Health, Ministry of Health
2. Dr. Mercy Karanja – Ministry of Health
3. Dr. Matilda Mghoi –Ministry of Health
4. Florence Maina – KMTC Mathari
5. Rebecca Mbuti– BasicNeeds, BasicRights Kenya
6. Christine Nzilani – Kenya Red Cross
7. Samuel Kiogora –Ministry of Health
8. Jane Gichuru –- Ministry of Health
9. Margaret Ongera–Ministry of Health
10.Joseph Otin – KMTC , Mathari
11. Robert Ogola - KMTC , Mathari
12.Mercy Wanjala – KMTC , Mathari
13.Martin Wathika – Kamili Organization
14.Catherine Kaleli- KMTC , Mathari
15.Mary Wahome – Schizophrenia Foundation
16.Anne Muhinja – Kenya Red Cross
17.Naomi Anyango – Mathari NationalTeaching and Referral Hospital
18.Jacqueline Aloo –Ministry of Health
19.Dorothy Anjuri –Kenya Redcross
20.Josephine Emukule – NACADA
21.Aphlyne Turfy –Mathari National Teaching and Referral Hospital
22.Jane Njoroge - KMTC , Mathari
23. Evans Bett – Ministry of Health
24. Rev. Dr. William Sifuna –Kenya Police Service
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