Flexible protocols and paused audio recorders: The limitations and possibilities for technologies of care in two global mental health interventions

Lay-counselors have become a key human resource in the field of global mental health, aiming to address the estimated one-million-person shortage of mental healthcare providers. However, the role of lay-counselors is ambiguous and in tension: their role is quasi-professional, with specific training and skills that set them apart within communities, yet their role is also defined in contrast to professional mental healthcare providers. We explore how these tensions manifest through the material technologies for protocolizing and evaluating lay-counselor roles. We draw on our ethnographic fieldwork within two global mental health interventions that represent different ends of the spectrum of lay-counselor involvement, in order to explore the possibilities and limitations of such material technologies. Thinking Healthy Program-Peer delivered is a cognitive behavioral therapy-based intervention for women with perinatal depression delivered in Goa, India, and Tuko Pamoja (Swahili: “We are Together”) is a family therapy intervention to improve mental health and family functioning in Eldoret, Kenya. First, we explore how intervention manuals – the step-by-step protocols that guide therapy delivery – can both constrain counselors to a script and enable their novel contributions to therapeutic encounters. Then, we examine assessment tools used to evaluate interventions writ large and lay-counselors specifically. We describe how, even where lay-counselors are encouraged to bring their own expertise into therapy delivery, this expertise is not often reflected in evaluation tools. Instead, the focus tends toward fidelity checklists, which require adherence to the manualized intervention and can penalize counselors for “going off book.” Even though lay-counselors are often recruited specifically because of their existing roles and “local expertise,” we argue that the material technologies of interventions can at times limit how their expertise is enabled and valued. We offer recommendations for global mental health programs to facilitate greater recognition and valuing of lay-counselor expertise.