Organization-Level Determinants for Low Secondary Traumatic Stress in Lay Counselors Delivering Trauma-Focused Cognitive Behavioral Therapy in Kenya

Abstract

Eighty percent of the world’s youth live in low- and middle-income countries (LMICs), yet access to trauma-focused mental health care in these settings remains limited despite a high burden of mental health disorders and trauma exposure among youth. Task-shifting models that train lay counselors to deliver evidence-based treatments can expand access to care, yet delivering trauma-focused treatment may increase counselors’ vulnerability to secondary traumatic stress (STS). Organization-level support may play an important role in sustaining counselor well-being, yet little is known about which organizational factors are protective (i.e., contribute to low STS) in resource-limited settings. Data came from an implementation-effectiveness trial for an adapted trauma-focused cognitive behavioral therapy in western Kenya, to examine organizational factors linked to low STS among two groups of lay counselors: community health volunteers (CHVs; N = 120) and teachers (N = 117). Counselors completed surveys following training and treatment delivery that assessed supervisory relationships, leadership, implementation climate, feasibility, and organizational climate. We applied Coincidence Analysis, a configurational method, to identify organization-level determinants of low STS. Among CHVs, a solution with three pathways was identified for low STS: high supervision relationship; high implementation climate with high implementation leadership; and high feasibility with high transactional leadership. Among teachers, a different solution with three pathways emerged: high implementation climate; high supervisory relationship with a positive perceived work environment; and low transactional leadership with high transformational leadership. No single organizational factor was necessary for low STS. Instead, multiple configurations were sufficient, and these differed across provider roles and their organizational contexts. These findings suggest that organizational strategies to prevent or mitigate STS should be tailored to provider roles and settings. As task-shifting models expand in LMICs, centering lay counselors’ well-being within organizational management and treatment development will be critical to sustaining the workforce and ensuring quality trauma-focused care.