Table 2 Intervention design, training, and supervision

Tuko Pamoja (Kiswahili: “We are together”) is a family therapy intervention developed based on exploratory qualitative research with Kenyan families, mental health providers, and informal counselors identified by communities [43]. The exploratory research indicated primary areas of focus for an intervention, including conflict related to roles and responsibilities and avoidant or negative communication during problem-solving and decision-making. Based on these findings, elements of multiple evidence-based practices (EBPs) were incorporated based on their alignment with the identified needs and existing local counseling practices: (1) solution-focused family therapy, (2) systems-focused approaches, (3) parenting skills training, including behavior management and positive relationship-building, and (4) cognitive behavioral therapy.

Tuko Pamoja is modular, with families receiving only those modules relevant to them (marital, parent-child, whole family). Each module is completed over the course of 2 to 5 counseling sessions, with treatment lasting approximately 12 to 15 sessions [44]. Strategies drawn from the above EBPs were combined and streamlined for delivery by lay counselors, allowing them to be distilled into concrete “steps” with succinct manualized instructions. Though the manual is structured, with specific steps and goals within a module, activities are not time-limited, and lay counselors are provided flexibility in delivery [34], with a key goal being active participation of family members, in-session communication, and generation of solutions by families.

To best fit existing practices in communities, Tuko Pamoja draws on “natural counselors” – people who already provide informal counseling within their communities (e.g., pastors, community leaders; [43]). The goal was to provide new skills to people who are already sought out by families for advice and conflict mediation, without significantly expanding their workload. This study draws on data from a pilot of Tuko Pamoja that included 8 counselors, with 2 being a husband-wife team who counseled together (see Table 3). These natural counselors were nominated by community leaders then interviewed by the research and implementation team to assess interest, availability, and the extent to which delivering Tuko Pamoja would fit into their existing informal counseling routines. Each counselor typically only had one to two case families during this study, and counselors recruited families themselves, whom they knew and believed would benefit.

Counselors received a 10-day training that included training in non-specific clinical skills (e.g., reflection, validation) and process skills central to family treatment and then training on manualized content. Training included didactic instruction and demonstrations of intervention steps, followed by extensive role play, coaching, and feedback. Counselors were also trained on how to identify safety concerns, including concerns related to suicide and violence, and the process for consulting with supervisors to address them with safety planning and referrals.

A total of 14 families were included in the study, with 10 completing therapy. With the exception of one counselor who worked with 3 families and another counselor who worked with only one family, all other counselors worked with two families who completed part or all of the intervention.

We used a tiered supervision process with local supervisors who were students in medical psychology at a local university and expert consultation by US and Kenyan psychologists. Local supervisors completed a 4-day training on basics of the intervention, as well as participating in the 10-day counselor training [43]. Supervision occurred after each therapy session, either by phone or in person. Supervisors listened to recordings of therapy sessions and elicited counselors’ impression of sessions, practiced collaborative decision-making to address challenges, and used role play to support development of clinical skills. The uniquely intensive practice of listening to each session allowed supervisors to flag any instance of a counselor using practices that were not aligned with TP content and principles. These were then addressed directly by (a) guiding the counselor to understand the disconnect and, when relevant, potential for harm and (b) developing and role playing a plan to course correct during the next session.