Trigger warning: this piece includes references to sexual violence
Community-based organisations have innovative methodologies to support varying mental health needs but often don’t have the resources to evaluate their impact. This poses two key challenges: on the one hand, it can be difficult to secure funding without an evidence base; on the other, it can mean that fewer people and organisations learn about these methods and draw on the insights they provide. What’s more, understanding the impact of mental health interventions can be particularly complicated of how interconnected mental health is to other dimensions of life.
PHOLA is s South Africa-based NGO that provides targeted culturally sensitive psychosocial therapies to address the effects of trauma, violence and abuse in the lives of those affected. We brokered a partnership between PHOLA’s Ncazelo and Dr Rochelle Burgess, a leading community health psychologist, researcher and lecturer at UCL, to conduct an evaluation of one of PHOLA’s key methodologies. This piece, written in collaboration with PHOLA and Dr Burgess, captures the impact of the COURRAGE Plus methodology.
Women face higher burdens of depressive disorders given their increased exposure to compounded risk factors including violence, marginalisation and poverty, particularly in the Global South. This intersects with a scarcity of mental health services, with poor individuals, especially women, less likely to be able to access care due to stigma, lack of financial resources, among numerous other factors. Despite gains achieved by the movement for global mental health, significant gaps remain in the provision of mental health support that addresses structural drivers of distress. Interventions addressing symptoms and structural drivers of depression are gravely needed but largely absent in South Africa.
In the face of this need, narrative therapist, Ncazelo Ncube Mlilo designed a collective storytelling intervention called COURRAGE. This methodology aims to provide women experiencing complex trauma and hardships with opportunities to reimagine their place in the world. The COURRAGE Plus Methodology includes an additional three sessions, developed in collaboration with University College London researcher Dr Rochelle Burgess, creating opportunities for women to engage with social determinants of mental health, such as poverty, alongside addressing psychological distress.
The COURRAGE Plus intervention ran for 13 weeks, starting in September 2019, with 47 women participating, all of whom have a child with a disability. The research intervention was delivered through a partnership between PHOLA, Institute for Global Health, UCL, SHM Foundation-UK, the University of Johannesburg and Afrika Tikkun a South African NGO specialising in community support and development for women and children. Participants were women over 18 years of age, service users at Afrika Tikkun, largely mothers of children living with disability, recruited via targeted sampling (via onsite referrals from social workers) and self-referral. Sessions were delivered at four Afrika Tikkun locations, a South African NGO specialising in community support and development of children.
At the beginning of the intervention, PHQ-9 forms were administered to women in order to get baseline evidence of their clinical symptoms of depression. 39 women met the criteria for depression. In the last session, the PHQ-9 questionnaires were administered again, and many women had scores of zero! This means that they showed no clinical symptoms of depression.
Lead researcher Dr Rochelle Burgess of UCL presented preliminary research findings which showed that the COURRAGE methodology had proven to be very effective in reducing the symptoms of clinical depression amongst women who have experienced complex trauma and hardships. The evaluation demonstrated that 65% of women had scores of zero at the end of the intervention pointing to a reduction in depression symptoms in women. At the end of the programme, the team held a graduation ceremony attended by over 160 delegates, including the participants. The graduates took centre-stage during the event, sharing their stories and experiences of the COURRAGE intervention. They sang and danced to celebrate the steps that they had taken to separate from a painful past and their hopes to live new powerful lives.
The women who took part in this intervention felt its impact in more than symptom reduction. Towards the end of the intervention a few of the women found employment. They felt that they learned many lessons, but the most important one was that, while they are mothers who love their children, they themselves are just as important, and they deserve to be happy and taken care of.