Removing Obstacles to Mental Health Care — Over the Phone

LUSAKA, ZAMBIA — In May of last year, after learning of her teenage son’s battle with illicit drugs, Dainess Mulumbi tumbled into depression. Her secondhand clothes business failed. She attempted suicide.

The normally jovial Mulumbi, 37, considered a psychiatric hospital but feared people “would say I was mad.”

Instead, she committed to a five-week program through StrongMinds Zambia, a nonprofit that treats depression and anxiety among women through group talk therapy. Two weeks in, the coronavirus pandemic heightened, and the program ended.

Mulumbi spiraled again. But she bounced back after StrongMinds Zambia tried something new: teletherapy.

The practice, in which patients talk with a counselor on the phone, is still in its infancy in Zambia. But if it takes hold, it could transform mental health treatment in this south-central African country by vastly broadening access to counseling and by allowing patients to get help without suffering stigma.

A 2017 World Health Organization report found that Zambia has only .06 psychiatrists, .03 psychologists and 1.43 mental health nurses per 100,000 people. The worldwide median, according to the organization, is nine mental health workers per 100,000 people.

Prudence Phiri, GPJ Zambia

Dainess Mulumbi, with her son Bright, says teletherapy helped pull her out of depression.

Stigma poses another major problem. A small, Zambia-focused study published last year in the International Journal of Mental Health Systems found that even supportive families “could not protect [patients] from the ridicule and judgment from their neighbours and friends.”

Such stigma means that Zambians rarely seek medical attention before a serious mental breakdown, says George Tafuna, spokesperson for Chainama Hills College Hospital, Zambia’s largest psychiatric facility.

The coronavirus has begun to change that situation.

Tafuna says Chainama Hills has seen three times as many cases since last March. Most new cases involve stress, anxiety and depression related to substance abuse brought on by the pandemic, he says. Chainama Hills saw seven to 10 substance abuse cases a week, before the coronavirus outbreak. Now, it sees a half-dozen cases daily.

The spike in cases and the shortage of mental health professionals forced Chainama Hills to partner with organizations such as StrongMinds Zambia, among the relatively few mental health providers that offer teletherapy services. Those organizations use teletherapy for anxiety disorders, stress and mild depression.

Patricia Habasimbi, a senior counselor at StrongMinds Zambia, says it embraced teletherapy last June after the pandemic created a peculiar problem: Many people wanted in-person help but couldn’t get it because of the government’s stay-at-home orders.

She says teletherapy was immediately popular.

“Before introducing teletherapy, it was difficult to reach out to a lot of people who are out of Lusaka,” the capital, Habasimbi says. “But now we have people from all over the country talking to us.”

Prudence Phiri, GPJ Zambia

Patricia Mapani, right, says teletherapy helped her open up about her depression because she didn’t worry about people identifying her.

Habasimbi says a counselor works with a cluster of five people who agree on times for twice-weekly group calls over five weeks. Clients pay nothing, as the organization bears the calling costs.

Teletherapy does bring its own hurdles, Habasimbi says.

“One of the challenges is not having to see and experience the emotions of this person,” she says. “Although you can [read emotions] from the voice, sometimes facial interaction is another form of therapy.”

Precious Posta, manager of the Lusaka-based Great North Road Academy Rehab Centre, adds that would-be clients are sometimes hard to reach.

“We had a number of people call in for help,” Posta says. But when the organization responded, “they weren’t picking [up] our call, or their phones were off.”

The Great North Road Academy started offering teletherapy in mid-January after the staff became overwhelmed with mental health cases, Posta says. Clients pay for the first session, but then the counseling is free. So far, the organization is treating three patients via teletherapy.

Frank Harle, country director of StrongMinds Zambia, says that since June his organization has treated more than 1,500 women via teletherapy. It has used the method to counsel about 100 men, too.

Harle and Tafuna say the overwhelming response suggests that people are desperate to access mental health services without stigma.

“We are imagining how these people that are receiving therapy would have reacted without the therapy,” Tafuna says. “It would be a disaster.”

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In January 2020, Patricia Mapani lost her brother, a businessman who supported her and her three children. Mapani, 34, says his death pushed her into depression. Teletherapy frees her to open up more because no one can identify her, she says.

“I first started with group therapy and later teletherapy,” says Mapani, a roadside food vendor. “In group therapy I could not freely talk because I was scared that some of my friends would start talking about my issues. But on phone, we don’t even know each other, and we talk freely.”

Teletherapy doesn’t work for everyone. Charles Daka, 40, says it didn’t help him at all after he lost his job last June as a chef in Livingstone, Zambia’s tourist capital. He thought the counseling would suggest ways to make money.

He lasted only three weeks in teletherapy with a local counseling service, which he wouldn’t name.

“Money was my problem,” says Daka, a Lusaka resident who is married with four school-age children. “I just needed money, not talking. I found the program a waste of time.”

Mulumbi, meanwhile, has emerged from her depression after finishing StrongMinds Zambia’s teletherapy program. The mother of three says she concentrates on tasks more easily now and sleeps well. She no longer has suicidal thoughts.

“My life is back to normal,” she says.

As further evidence, she points out that she plans to revive her business. And, she says, she has introduced more than 10 people to teletherapy.