4 How to help people with mental health conditions

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Contents

• Objectives
• Introduction to helping people with a mental health condition
• Helping mothers
• Helping infants
• Helping adolescents
• Helping ourselves as care workers
• Helping people who are suicidal
• Other simple ways to help people with mental health conditions
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Understand the principles of helping people with mental health conditions.
2. Help mothers and pregnant women with a mental health condition.
3. Help prevent infants and young babies from developing a mental health condition.
4. Help adolescents who are experiencing mental health conditions.
5. Help protect ourselves as care workers from developing mental health conditions.
6. Help people who are feeling suicidal.
7. Understand simple ways of helping people with mental health conditions.

Introduction to helping people with a mental health condition

4-1 Why is it important to help people with a mental health condition early?

It is important that mental health conditions are noticed early so the person can be helped quickly. The longer people suffer from a mental health condition, the more difficult it will be to treat. Many people with mental health conditions can be helped within the community, using very simple treatments.

4-2 Do all people with mental health conditions need specialist care?

No. Many people with mental health conditions can be helped within the community. Sometimes people simply need another person to notice their struggle and listen to their story.

Many people who have a mental health condition can be helped within the community.

4-3 Which people with a mental health condition need referral for treatment?

There are some people who will not be able to be helped in the community, and they need to be referred to a clinic or taken to the hospital for special care. If the person doesn’t feel better, or if you are worried, it is important to contact your supervisor for guidance. People who are psychotic and those who are suicidal need to be referred to the closest hospital immediately.

4-4 Why are infancy and adolescence so important for mental health?

During infancy and adolescence, the brain develops and changes very quickly. When a person reaches adulthood, brain development slows down. The brain is able to change and grow throughout life, but this takes more effort in older people. In adults, patterns of thinking and attitudes become more and more rigid and harder to change. This is why it is so important for infants to develop stress-free brains, and to encourage adolescents to develop healthy habits and ways of thinking, so these patterns are helpful throughout life.

Reducing stress in infants and encouraging good habits in adolescents promotes healthy brain development.

4-5 How can we help people with common mental health conditions?

Every situation, every age group and each person will have slightly different needs. The principles for helping anyone with a mental health condition are:

1. We first need to notice the person and see their struggle.
2. Then we help them feel relaxed, safe and calm.
3. We encourage and help them to build healthy relationships, so the person can feel connected to others.
4. Finally, we use reason to help the person understand their situation, and support them to find their own solutions.

This whole process can be quick, but mostly it will take a number of meetings to help someone who has a common mental health condition.

4-6 Why is it helpful to listen well to someone with a mental health condition?

When we listen actively without judgement and show we are curious and interested, the person will start to feel understood and connected. When people feel heard, they feel less alone and are able to relax.

Listening well to people with a mental health condition is very helpful.

Helping mothers

4-7 Why is it important to help mothers with a common mental health condition?

It is very important to notice and try to help mothers who are experiencing a mental health condition as soon as possible. Mental health conditions that go unnoticed in mothers can cause problems for the baby.

4-8 Is it only new mothers who need help?

No. People often don’t notice common mental health conditions in pregnant women. This is because we sometimes expect pregnant women to behave differently. Pregnant women often don’t ask for help as they think what they are experiencing is normal, or they may feel ashamed if they don’t feel happy about expecting the new baby. Women must get help as soon as possible because anxiety can be harmful to the brain of the unborn baby. Depression will make it difficult for the mother to bond with and breastfeed her new baby. Fathers can also experience common mental health conditions, but unfortunately they seldom seek help.

4-9 How can we help mothers with a common mental health condition?

When working with pregnant women and new mothers, we need to make sure we are calm, so we can help the mother to feel safe and calm:

• Greet the woman, be curious and show you are interested.
• Listen well, speak kindly and without judgement.
• Ask her the three Whooley questions.
• Refer her to a social worker or the clinic if she asks for help.
• Reassure her that you are not making a diagnosis, and that mental health conditions are common during pregnancy.
• Encourage her to meet and talk to friends or family she trusts.
• Ask if you can help with problem management.
• Make a follow-up appointment.

4-10 What are the three Whooley questions?

The three questions to screen a person for a common mental health condition are:

1. In the past two weeks, have you been troubled by feeling down, depressed or hopeless?
2. In the past two weeks, have you had little interest in doing things?
3. In the past two weeks, have you been unable to stop worrying or thinking too much?

If the person answers yes to any of these questions, we should ask if they would like help with their feelings.

Helping infants

4-11 When do we need to start making infants feel safe?

Babies start to learn about the world while they are still in the womb (uterus). They feel warm, held and protected. Babies in the womb are comforted by the sound of the mother’s regular heartbeat and by the rocking movement of her breathing. They hear sounds and voices from very early in life and start to recognise those they hear often. Babies feel stressed when the mother is stressed, and are relaxed by a slow rhythmic heartbeat and gentle breath movements, as well as the joyful sound of her singing.

4-12 How can we help infants feel attached?

Babies are helpless at birth. They need close contact with a warm, kind, responsive and reliable adult. They need to be able to relax, knowing someone will feed them and keep them safe. Relaxed babies grow and develop well and trust the world is a kind, safe place.

To grow and develop well, babies need to feel safe and protected.

4-13 What makes infants feel safe?

Feeling close to a stable, loving and kind adult makes babies feel safe. Anything that reminds them of the safety of the womb is also useful. For example:

• Skin-to-skin contact and being close to their mother
• Slow, gentle rhythmic movements and rocking
• Being swaddled (tightly wrapped)
• Music, singing and kind voices
• The smell of their mother’s breast milk.

Babies should experience as little stress as possible. If stress happens they should be calmed quickly. Stressed babies will grow into adults who struggle to relax. Calm, caring adults are the best people to help babies feel safe and able to learn more about the world through their senses. Foster babies, and those who have been separated from the birth mother, as well as those with depressed mothers, need another stable adult to help them feel connected and safe.

4-14 How can you help a depressed mother improve her connection with her infant?

There are many ways the mother can make her baby feel secure even when she is feeling depressed or anxious. These include:

• Skin-to-skin contact will help both the mother and baby to relax.
• Keep the baby close by strapping the baby on the back or using a front baby carrier.
• The mother can try to keep the baby’s attention when the baby is awake. This can be done by talking, singing or humming to the baby. Babies must hear sounds, so they are able to talk later. Many mothers find it helps to talk out loud about the things they see and do throughout the day.
• Young mothers who are still at school could, for example, explain their schoolwork and read to their baby while studying.
• Rocking, singing or humming is very useful to lower stress and make the baby relax.
• Baby massage helps with bonding, and helps to relax both the baby and the mother. Massage the baby’s whole body using slow, gentle strokes.

In the same ways, fathers should also be encouraged to improve contact with their babies.

Depressed mothers should be helped to make better contact with their baby.

4-15 Why do infants cry?

Babies can’t say how they are feeling or let adults know when something is wrong. The only thing tiny babies can do to get attention is to cry. Hearing their baby cry can feel very frightening for new mothers, if they do not understand what is wrong. Mothers quickly learn to understand their baby’s different cries. They can soon tell if the baby is tired or hungry, needs a clean nappy, is too hot or cold, or is uncomfortable because of wind or feeling sick. Babies also cry when they feel over-stimulated.

It’s not important if the mother doesn’t understand exactly what the cry means. The most important thing is that she tries to help the baby, and keeps herself calm. Some older people say that crying babies are naughty. This is not true, as tiny infants cannot be naughty. Babies cry when something is wrong, and it is never okay to just leave them alone to cry. Not getting help makes babies very stressed and can affect brain development.

Babies cry when they need attention.

Helping adolescents

4-16 Why can it be difficult to help adolescents?

It is often difficult to notice when adolescents have a mental health condition. This is because there is so much normal change happening at this age that it can be difficult to work out what is normal and what is a problem. What is important is that adults try to understand what is happening with their adolescent. It can often be very difficult to communicate with adolescents in ways that help them feel connected and understood. Adolescents don’t understand their own emotions. They need to be able to talk about what is happening to them with a calm and caring adult. Adolescents who are not heard will often show they are having emotional problems by behaving badly.

4-17 What can be done to communicate better with adolescents?

Adolescents need adults they trust to give them attention and to listen to them. They need adults to notice when they do well, and to support and encourage them when they don’t succeed. They need adults to listen to their ideas with respect and without judgement. Adolescents want support while they try to manage their own problems, they don’t usually want adults to fix life for them.

To improve communication with adolescents, we as adults can:

• Make time available, so it is easy for adolescents to find and talk to us.
• Listen first and try to understand their world and perspective. We don’t have to change our ideas and beliefs when we try to understand their ideas.
• Always try to be open, respectful and non-judgemental.
• Adolescents need adults to tell them about the different ways we see the world without trying to force them to change their ideas and way of thinking.
• After listening we can try to explain why certain behaviour is concerning, and try to link concerns with values, instead of just saying it’s not allowed, don’t think like that or that way of thinking is bad.
• Tell adolescents openly, honestly and in a balanced way about friendship, sex, love, relationships and the things they find interesting.
• Speak in a non-judgmental way about mental health and mental health conditions. This will help stop stigma. If adolescents know they won’t be judged, they can feel free to ask for help when they or their friends are struggling with a mental health condition.

It is important that adolescents feel they are being listened to with respect and without judgement.

4-18 How can adults help adolescents who are struggling?

Adults can help adolescents by showing they care and by trying to understand:

• Show adolescents they are important and do not judge them.
• Never make an adolescent who asks for help feel ashamed about asking.
• Try to prevent situations that look dangerous before they get out of control.
• Be positive, notice effort, and support and encourage adolescents when they do well.
• Praise, affirmation and reward works very well in this age group.
• Help adolescents to plan ahead.
• Give clear instructions so they are more likely to succeed and feel encouraged.
• Explain that emotions like anger are normal, but bad behaviour and hurting other people are not acceptable.

4-19 Why do adolescents behave badly?

Adolescents are impulsive and have feelings that change very quickly. It is normal for adolescents to find it difficult to manage their emotions and feelings. It’s the task of adults to help guide and show adolescents how to manage their emotions and feelings. We need to remember that:

• Strong emotions like anger and fear can cause adolescents to behave badly.
• Bad behaviour sometimes only happens at home or in places where the adolescent feels safe. This is understandable. However, they must be guided towards healthy ways of expressing emotion that do not hurt or harm others.
• Sometimes bad behaviour leads to bullying and hurting other children.
• Bad behaviour and bullying are signs that the adolescent is struggling. This does not mean they have a mental health condition.
• Once the adolescent is calm, an adult needs to help them understand what happened and work out ways to manage emotions more effectively in future.

Feeling angry or frightened may cause an adolescent to behave badly.

4-20 How should adults respond when an adolescent is behaving badly?

The adult must first stay calm and not make the situation worse:

• Ignore the bad behaviour until everyone has calmed down.
• Stay close to the adolescent while making sure everyone is safe.
• When everyone is calm, try to find out what caused the strong feelings.
• Try to name the emotion by looking for non-verbal signs, and check whether you are correct. For example: ‘You look very angry’ or ‘I imagine you had a difficult day at school’ or ‘Do you want to tell me what happened?’.
• Remind the adolescent that emotions and feelings are normal. Adolescents have bigger emotions than adults. They need to learn to manage, not suppress emotions.
• Make sure the adolescent understands that all feelings are normal. Everyone feels angry at times, but it is never okay to hurt or harm people or animals or to break things, however justified our anger.
• Teach them to use their emotional energy in a positive way, for example, exercise, working, chopping wood, drumming, dance, music or art.
• Always check if they are tired or hungry. Help them understand that physical needs make emotions more difficult to manage.

Being calm when an adolescent is out of control does not mean ignoring bad behaviour. Bad behaviour must always have consequences. We need to allow the adolescent to calm down first, so they are able to reason, understand consequences and work out better ways of managing their strong emotions.

Stay calm when an adolescent behaves badly and try to find out what caused the strong feelings. It is never acceptable to hurt people or animals or to damage property.

4-21 What should adults do if they think an adolescent has a common mental health condition?

It is important that the adult shows they are interested and care about the adolescent. This can be done in the following ways:

• Stay calm when with an adolescent.
• Ask them about how they are feeling and try to understand how they think.
• Listen carefully without judgement.
• Ask the three Whooley questions.
• If worried, be honest and tell the adolescent about your concern, taking care not to frighten them. The sooner mental health conditions are managed in this age group, the easier they are to treat.
• Adolescents want to be treated as adults, but at the same time they need adult support and guidance. Always ask permission before taking action on their behalf.
• If we are worried, we should always ask our supervisor, clinic or school staff for advice.

Helping ourselves as care workers

4-22 Why are care workers at risk for mental health conditions?

Working in your community can be very rewarding as you can help others and see the change you can make in other people’s lives. However, it can also be very stressful and challenging to know about all the problems happening in your community. We often forget that care workers need as much kindness, care and support as anyone else in the community.

4-23 How should care workers take care of themselves?

Care workers need to make sure they live healthy lives. This means making sure our physical needs for sleep, healthy food, water and exercise are met. We don’t have to be very energetic to enjoy walking in nature, dancing or making music. Care workers should make sure we have people we trust to talk to. We also need to have time to think about life and find healthy ways to reduce stress, which can happen while doing housework, cooking or while exercising or fishing.

Care workers should take time to look after their own mental health.

4-24 What do we need to remember with social connections?

One of the biggest challenges with care work is having to keep confidence. Confidentiality is a very important part of working with people and making sure others trust us. Confidentiality means we cannot share information about the people we visit and the things we learn about them with anyone, except our supervisors. This can be difficult to do, especially when we learn interesting or shameful things about people in our community. Knowing secrets can make us feel important and powerful. Some people like to show off by talking and gossiping about secrets. The community will quickly learn if a care worker cannot be trusted, and in the end this person will not be able to work effectively.

We are allowed to break confidentiality is someone tells us about plans to harm themselves or others. We need to warn the person about this rule. But if we share stories at peer meetings, we must not break confidence. This means we can share information with colleagues about what happened, but we need to tell the story in a way that doesn’t give away who the people in our story are.

This is discussed in detail in the forthcoming book Compassionate Care on empathic communication and care in the Bettercare series.

Confidentiality is important if we are to win the trust of the people we care for.

Helping people who are suicidal

4-25 What is suicide?

Suicide means the person ends their life on purpose. This is a tragedy that can affect the family and the whole community very badly, for a very long time.

4-26 Will asking people if they have thought about suicide make them more likely to do this?

Talking about suicide does not make people kill themselves. Studies show that telling someone about suicidal thoughts can make the person feel better:

• Always take suicide threats seriously
• Stay calm and try to understand why the person wants to die
• Listen empathically without judgement.

Many people have suicidal thoughts without going on to kill themselves. It is important to ask if the person has started to think about a plan to commit suicide.

4-27 What should you do if someone tells you they have a plan and want to commit suicide?

If someone talks about wanting to hurt themselves or if they say they don’t want to live any more, we must not ignore them:

• We must always take threats of suicide seriously.
• People who have a plan for suicide must be referred to hospital at once.
• Remember that suicide is a threat to harm someone and is therefore a reason to break confidentiality.
• Stay calm. Tell them you want to help, but this is too big to manage alone, so you need to let the supervisor know.
• Stay with the person while you contact your supervisor.
• The person should be sent to hospital as soon as possible. They should not go alone.

Always take a threat of suicide very seriously, especially if the person has a plan to kill themselves.

Other simple ways to help people with mental health conditions

4-28 What are the simple things that can be done in the community to help people who are struggling with poor mental health?

Everyone has basic physical needs for food, water and safe housing. Those who are vulnerable and who struggle to meet these needs depend on being noticed or ‘seen’ by others before they can feel safe. Having a sense of connection and belonging allows people to relax, feel better about themselves, be more positive and able to show kindness to themselves and others.

There are many simple things we can do to help people who are struggling. For example:

• Active listening
• Affirmation
• Behavioural activation (discussed further on)
• Problem management.

4-29 What is active listening?

Active listening means we listen to try and understand not just what the person is saying, but also the non-verbal emotions and body language.

Active listening is explained in detail in Empathetic Care, a book on empathic communication and care in the Bettercare series.

Active listening not only assesses what someone says, but takes note of their non-verbal emotions and body language.

4-30 What is affirmation and why does this help?

Affirmation means using words to encourage, reward and lift the spirit of others. Everyone loves to be affirmed because this means someone else has seen them. This is an especially useful way to encourage and reward adolescents or anyone with a mental health condition who is feeling very bad about themselves:

• We can affirm positive choices and behaviours.
• We should affirm effort rather than the outcome.
• Affirmation empowers people to keep going.
• Affirmation helps us develop better relationships and connection.
• Affirmation makes the person feel valued and gives them a sense of belonging.

Affirmation encourages others and makes them feel valued and connected.

4-31 Is affirmation the same as praise?

No, praise and affirmation are different. Praise is based on our judgement and tells the person we approve of something. Affirmation is about noticing and highlighting positive behaviour, choices or ways of thinking we want to encourage. Affirmation does not depend on the result. We can affirm people even when they fail at something. Affirmations need to be genuine and the person needs to understand exactly what is being affirmed, for example:

• ‘Well done for deciding to ask …’
• ‘You did a great job when …’
• ‘I like the way you …’
• ‘I can see you tried hard because …’
• ‘You’ve tried your best in very difficult circumstances.’
• ‘You made a good choice when …’

4-32 What is behavioural activation?

Behavioural activation means helping and encouraging people to do activities they enjoy. Doing things we enjoy helps us feel better about ourselves, and feel more connected to others. When people are depressed, it is common for them to stop doing things they enjoy because it just takes too much effort and seems too hard. This can make them feel even more isolated and useless. Promoting positive behaviour can change these feelings and is a very useful technique for adolescents.

Behavioural activation helps and encourages people to do activities they enjoy.

4-33 How do we do behavioural activation?

We usually start by asking the person to think about and make a list of the things they used to enjoy doing, and get them to think about the parts they enjoyed:

1. We help them plan how they can start doing one of these activities again.
2. Get the person to commit to try doing the activity.
3. Work out exactly what steps they need to get started again.
4. Follow up to find out if the person did the activity.
5. Affirm what went well and help with re-planning if there were challenges.

4-34 What is problem management and why is this important?

People with mental health conditions usually struggle to think clearly. They can often feel overwhelmed by their problems. Sometimes they need someone to help them think more clearly, so they feel empowered to manage their own problems. It can also be helpful for adolescents to have a framework they can use for managing problems, so they do not make important choices based on habitual or automatic ways of thinking.

Problem management helps people understand and address their problems.

4-35 What are the steps in problem management?

People don’t always understand what the problem is. To help them understand, we need to use empathic communication, which means listening carefully and trying to see things from their viewpoint. These are useful steps:

1. What exactly is the problem?
2. Is the problem in our area of control?
3. Together think of ideas to manage the problem.
4. Check which idea the person thinks will be easiest and will work for them.
5. Help work out a detailed plan.
6. Meet again to see if the plan has worked.

4-36 Why do we need to help people understand what their problem is?

When people experience big challenges, they may feel too fearful or ashamed to even think about it, and so worry about a smaller, less frightening problem instead. When people ask for help, they may sometimes change their mind at the last minute if they think we will judge them. We need to show we are calm and interested in helping.

4-37 How do we find out exactly what their problem is?

We should:

• Be interested in and curious about the other person.
• Listen actively, ask open questions, reflect on their non-verbal emotions and body language until we understand the problem.
• Remain calm and non-judgmental no matter what is shared.
• Later we can summarise what we have heard. Try to describe the problem in as much detail as possible. Mention all the hard facts as well as any understanding of how the person is feeling.

4-38 Can the problem be managed?

Many people feel disempowered and helpless because they try to manage situations where they have no control. We can’t change what has already happened, or know what will happen in the future. We can only do the best we know how right now.

4-39 How do we help brainstorm for a solution?

Brainstorming means thinking of lots of ideas without judging if they will work or not. Brainstorming helps people to be creative and also allows them to voice anger. For example, one idea may be to hunt down a rapist and stab him. While this obviously is not a solution, it would be helpful for someone to say this and have others acknowledge their anger and write it down. Later you can talk about why this would be a bad choice. To brainstorm:

1. The first step is to find out how the person usually manages problems.
2. Write down all the ideas without judging any as good or bad.
3. Get ideas from the person and also add our own ideas.
4. When adding our ideas check what the person thinks, before adding to the list. We can ask ‘Do you think you could do …’ or ‘What about doing …’.

4-40 How do we help find a realistic solution?

At the end of the brainstorming there is usually a long list of possible ways to manage the problem. The next step is to talk about each suggestion and decide if it is good or bad, and if the person has the necessary resources. So go through everything on the list and judge its value. Try to think about all the positive and negative parts of each idea:

• Keep going until you find an idea that could work, mark this as a possibility and go to the next idea.
• You may find two or more ideas that can be joined together to create a solution.
• Find out if the person has the necessary resources to try the idea.
• Think about all the possibilities.

4-41 What needs to happen after the client has decided on a realistic solution?

Even easy solutions can be overwhelming if one has a mental health condition, so it is very important to:

• Help the person break down the solution into small, easy steps.
• Work out when, how and what is needed to complete these steps.
• The person must have a clear idea of exactly what needs to be done.
• Ask them to repeat the plan back to you and get them to promise to try and do their best.

4-42 What are the best ways to follow up?

Those with mental health conditions need to be supported to carry out their plan. It might feel easy when you are discussing it, but much harder when the person is alone. Agree to make contact so you can follow up and also motivate the person:

• Agree on a day when you can phone.
• Make some time to meet again so you can see if the plan worked.
• If the plan did not work, affirm the parts that did and repeat the steps of problem management.

Case study 1

Merafe is a care worker. You have both worked in a local clinic for a long time and sometimes walk home together. You notice Merafe has been walking more and more slowly, complaining a lot and is unusually impatient and even rude to some clients. You feel worried about her mental health.

1. What can you do to help?

It is important to be kind to and supportive of other care workers. Merafe is a care worker and so at high risk for mental health problems. Without making Merafe feel guilty, tell her you are worried and ask how she is feeling inside. You can even ask her the same Whooley questions you would ask a client.

Merafe thanks you for your care. She tells you she has been feeling sad most of the time for a few months and work feels too much for her. She has stopped going to church, which is something she never used to miss.

2. What could you do to help Merafe?

Thank Merafe for trusting you with this information and reassure her that you will keep what she has told you confidential. Tell her that it is common for care workers to develop mental health conditions and these are easy to treat. Suggest that she talks to the supervisor. Ask if Merafe has a close friend or relative she trusts who she can talk to about her feelings.

A few days later you see Merafe and ask how she is. She says she spoke to her cousin and was surprised by how much better she felt. She still feels sad but seems to have more energy.

3. Is there anything else you can suggest that may be helpful for Merafe?

Yes, you can guide her through behavioural activation. Ask Merafe how she would feel about going back to church, as this is something she really enjoyed. Suggest that she gets her cousin to go with her, if she feels awkward about going back after so long. Tell her you will ask about this next time you meet.

Case study 2

You go outside and find Zimasa sitting at the gate. She stands up when she sees you and starts to walk away. You call, and when she looks around, you can see she has been crying. Zimasa tells you she is 19 years old and a second year student at Fort Hare University. She says she can’t stop crying and feels sad all the time. You invite her to sit and talk. You ask the three Whooley questions. She tells you she has been feeling depressed and hopeless for about a month, she doesn’t even want to go to class anymore and can’t stop worrying.

1. Would you tell Zimasa that she is wasting money by not going to class, that she needs to stop feeling sorry for herself and be more grateful?

No, Zimasa is struggling with some difficult problem. She is in a high risk group for a common mental health problem and has been suffering for a short time. You need to be calm and be curious about why Zimasa feels this way.

You ask Zimasa if she would like help with these difficult feelings. She says she would, and starts to cry again.

2. What would you do now?

You can tell Zimasa that she looks very upset. You can try to help her now or you can refer her to the clinic tomorrow.

3. What should you do if Zimasa wants help now?

Ask her to tell you what has made her so upset. Explain you will not share what she tells you with anyone except your supervisor, unless she tells you that she plans to hurt someone. Then listen well, so you can understand the problem.

In between her tears, Zimasa tells you how she came home late from class last month and was raped by one of the men in the community. The man said he would kill her if she told anyone. Zimasa has not told her mother as she knows she will be angry with her for walking alone after dark. She is too scared to go to class in case she meets the man. Zimasa is also worried about HIV and pregnancy. You feel shocked and very angry when you hear her story.

4. How best can you help?

It is important to stay calm even though you are angry. Try to summarise the problems as clearly as possible, for example:

1. Zimasa was raped a month ago and she has not reported the rape.
2. Zimasa is too scared to go to class and will not succeed in her studies if she does not return to class.
3. Zimasa is worried about HIV and pregnancy.
4. Zimasa has not told her mother and is not getting emotional support.

Zimasa has a lot of challenges. There are some she cannot solve, and there are others that you cannot help her manage.

5. What is your next step?

Ask Zimasa how she normally manages problems and suggest you sit together and brainstorm possible solutions. Get a piece of paper and write down all the things you can think of. For example, Zimasa could report the rape to the police, get a restraining order against the rapist, she could get friends to beat the man, she can tell her mother, she can apply for time off from Fort Hare, she can go to a clinic for testing. Write down everything. If you have suggestions, ask Zimasa what she thinks and if you can add your ideas.

You have a long list of ideas. Zimasa already looks better and smiles at some of the silly suggestions. She says she feels less helpless now she sees how many options she has.

6. What is the next step after that?

The next step is to go through all the suggestions and decide which she would like to do right away, and which are not really possible. Help her work out which you can help her with.

Zimasa says she is too scared to do anything about her rapist, but would like her mother to know what happened. She says that having spoken to you, she realises this is not that scary and so will do this by herself.

7. Is there anything else you can say to Zimasa before she goes home?

You can help Zimasa plan how she will tell her mother. She can think about when will be the best time and where should they talk. What will she say? Then make a plan to meet her at the clinic the next day to find out how she managed. Suggest that she has a pregnancy and HIV test at the same time. You can end by affirming her courage in speaking to you.