Let’s Talk About…Digital CBT and Cultural Connection

Let's Talk About CBT

In this latest episode of Let’s Talk About CBT, host Helen Macdonald is joined by two international guests- Tafi Mazikana and Sherrie Steyn who share their journey from CBT service user and therapist to CBT innovators.

Tafi, originally from Zimbabwe, opens up about his experiences with anxiety while working in a high-pressured job in finance and how a digital CBT intervention through IAPT (now known as NHS Talking Therapies) changed his life. He talks candidly about the cultural stigma around mental health, what it was like to try therapy for the first time, and his realisation that CBT is about learning practical, empowering skills.

We also hear from Sherrie, a clinical and community psychologist from South Africa and co-founder of the Vimbo Health app along with Tafi. She reflects on her friendship with Tafi, the surprising conversations that sparked their collaboration, and the importance of culturally adapted therapy.

Together, they describe how Vimbo Health was developed to meet the unique challenges and needs of people in South Africa, particularly in terms of language, cultural metaphors, accessibility, and affordability. They explore how therapy can be made more relevant and relatable, from replacing metaphors like “three-legged stools” with potjie pots to tackling barriers like mobile data costs and mental health stigma.

Whether you’re a therapist or someone curious about accessing help in a different way, this conversation shines a light on how CBT can be tailored, inclusive, and transformative.

Resources & Links:

Learn more about Vimbo Health: https://www.vimbohealth.com/

Information on CBT and how to find a therapist

If you or someone you know needs urgent help, reach out to Samaritans at 116 123 (UK) or visit samaritans.org

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Credits:

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This episode was produced by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies.

I'm absolutely delighted today to have some international guests for you. And in a moment, I'm going to ask, Tafi and Sherrie to introduce themselves. We're going to be talking with them about the experience of having CBT and then some really exciting developments that have happened since. But first, let's start with some introductions. Tafi, would you like to tell people who you are?

Tafi: Yes, definitely. Thank you, Helen, really a pleasure to be with you today on this podcast. So I'm Tafi Mazikana and I'm Co-founder and CEO of Vimbo Health, a metal health app that's operating mostly out of South Africa. My background as I've shared, is not as a practitioner. My background is as a patient, of CBT who became very curious, perhaps too curious. So I was living in the UK working in banking and finance, and I was just very lucky to come across the services of IAPT which allowed me to self-refer in this area of mental health. I never knew that one could actually reach out and do something, so that was game changing in itself. But I was offered to have a digital CBT intervention, which was very transformative for me but obviously just left question marks as someone born and raised in Africa to say, well, who's thinking about the African context? Because, as I'll share later, there are things and ways of thinking and speaking that are different and I was just curious about who is going to think about that. And so became more and more involved, in this area of CBT, and in particular digital CBT.

Helen: Thank you so much, Tafi. There's lots that we're going to talk about there. Before we start that though, Sherrie, can I ask you to introduce yourself please?

Sherrie: Hi Helen. Thank you for having me. My name is Sherrie Steyn and I am from South Africa. I'm actually very fortunate to be from the East coast, so the sunny side, and my background is in clinical and community psychology. I tend towards the behavioural types of psychology. So I've done some ABA or as we call it VBA now and of course a special interest in CBT. So having done that clinical and community psychology, I then went on to do one of the allied CBT training courses through UCL. So I was very fortunate, to have done that. And that's a little bit about my background and, yes, I'm also the co-founder and CSO of Vimbo, I like to say I'm the science, because it sounds cool and yeah, just very happy to be here and share some of our experiences with you today.

Helen: Thank you so much. So if I can come back to you, Tafi, I wonder if you would be willing to just tell our listeners a little bit about what it was that made you actually reach out to access CBT. Do you mind telling us a bit about what was happening for you that meant that you were seeking some help?

Tafi: Yeah, absolutely. I think what I with hindsight realise is that it was difficulties that built up gradually over time and came to a point where they sort of caught me off guard. At the time that I reached out for help, I was working in the banking sector there in London on very stressful, large projects, which brought on a lot of anxiety, but I traced back my difficulties to over 10 years ago in terms of when those little moments of a negative self-talk, which started as innocent, and then grew into something of its own life, sort of started to happen and without the right tools then entering into that professional world, I do think I was at a disadvantage. I had some great tools in terms of being quite active and taking part in sports and exercise. So that's amazing but definitely what I came to realise is that I was actually lacking other tools that could have helped me to not get into a situation where I'm feeling like I'm in a lot of difficulty. So yeah, so I always describe it as, for me, in my case, not one thing in particular, but I feel like a gradual buildup of life just happening or that negative thinking pattern becoming something of its own.

Helen: And I think it's quite important to notice that, that it doesn't have to be some one particular dramatic event or something key that changes. It might be a combination of things or a buildup over time. So can I ask you a bit about when you did access the CBT, what did you actually get? What happened in CBT for you?

Tafi: Yeah, so I think for me, I grew up in Zimbabwe in Africa, and there isn't a tradition of seeking help. So for us, therapy is something that we saw in movies, we know that movie characters in Hollywood have therapists and get help. Or we associated it with people who we knew in the community who are undergoing inpatient care. And those are the forms of help that we knew to be there. Things that are not related to us in terms of early intervention, it is more something that happens when you are at the stage of acute care, which is inpatient. So essentially when I reached out for help, I was a bit sceptical of what was offered because it didn't fit the moulds of what I thought help looked like. And when I chose the route of going for the self-guided digital option that I was given there. I was, again, sceptical because it was not what I thought therapy looked like. I chose it because it was, it felt like a lower barrier because I was still quite afraid to talk about my feelings and to talk about my thoughts and experiences. But yeah, but, needless to say, I was actually shocked and quite impressed at how effective it was. And so that, that introduced me into the idea that help is something you don't have to wait until you are at that acute phase of need. But also, it taught me that CBT is about, in my opinion, I guess I'm not a practitioner, so please take it with a bit of salt, but it taught me that CBT is about building skills, which is quite a positive thing. It's actually quite empowering is what I learned then, and I think that's what resonated the most with me and got me hooked onto this form of help.

Helen: Thank you. And I just wanted to emphasise that there's several things that you've said there. I mean, firstly, you're coming from perhaps a cultural context that's less familiar to some of us. I suspect a lot of our listeners will be in the UK, although there are people from elsewhere. But that experience of really not being used to talking about feelings will be very familiar to a lot of our listeners, that sense that it's got to be really bad before you seek help, I think will also be something that people out there might feel. And yet what you've said, it was an earlier intervention, and it wasn't nearly as bad as it might have been. So I just wondered if I can talk to Sherrie for a moment and ask about what it was like for you, getting to know Tafi and,from the CBT therapist's point of view.

Sherrie: Well, I think what the first thing that strikes me is that Tafi and I socialised fairly regularly. We were a bit younger in those days. So the socialising honestly did tend to focus on large groups, at the pub, at a museum, at a place, and even when we do have dinner time, so if Tafi would come over and just hang out and have a meal, you are still so preoccupied with the day to day that unless someone brings something to you, you might not actually know what's going on. Whilst all this was going on, I had no clue what Tafi was going through. So the first time we actually really got talking about this was when he was visiting me, so after he had completed his treatments and we were hanging out on the balcony that I'm looking at, and we were just talking. He was talking about what am I going to do in America. And I was talking about having left the NHS and working in CBT and that's how the conversation started really was after the fact.

And like a lot of conversations between Tafi and I, we of course got down to the pragmatics first before we got around to hey, this realisation that how is it that we see each other all the time? I'm a therapist, you literally went through the same service I used to work at, the same type of service and I'm only learning this about you now. And I think that's very telling and I don't think that necessarily has anything to do with Tafi and I as individuals. I don't think this is unique. I think this is really common, that it's part of that stigma that sometimes it's even difficult to say it to ourselves. And if it's difficult to say it to yourself, how do you then say it to someone else? So I think that's part of what that, that process is, that Tafi was in a space where he was at able to also recognise that this is something I can talk about because it's not something I need to feel ashamed of.

And Tafi gave me the opportunity to ask the kinds of questions you don't get to ask as a therapist. So what was that process of waiting actually like? What did it look like when you got to the website and you were being directed? What did that look like and what did that feel like and was it difficult to navigate those kind of technical questions that I do think massively impact your journey, so that was also just really fortunate.

Helen: Thank you, Sherrie, and I mean, one of the things that, that it was really telling there as well. I mean, sometimes, if I let people know what I do for a living, they'll ask me, are you reading my mind? And the point that you've just made there is that you've got a friend that you socialise with, you've known for years, and yet you didn't necessarily know what was going on until it came up in, and I think you used the phrase after the fact, and I think that might be a lesson for us as therapists as well, that not to assume that people will tell us because it might be hard or it might not come up.

Sherrie: Or they might be concerned that we're going to try and push them into therapy because it's literally our job. So Tafi really touched on this, where he had an idea about what therapy was. And I think so many of our decisions are based on these ideas and it's not necessarily what therapy is. So in my own life, I remember having a conversation with a friend of mine. I was on my way to therapy because everyone should have therapy. And my friend was like, oh yeah, therapy, easy peasy, you go and lie in a sofa and talk about your problems. And I was like, what? what sofa? And I was not doing psychotherapy, unfortunately, there was no sofa involved. But my point is it's just genuinely not having an understanding and not being in a society where we can be comfortable talking about these things and me going, actually no, there's no sofa, I don't talk about my feelings. It's very different. And then I guess for me, that was an opportunity to explain to my friend what I did as a therapist. Not necessarily what I was doing in therapy, but I was like, hey, just so you know, my clients don't lie on a sofa either. So again, just I think dispelling a lot of the mythology of therapy is a big part of it. And yes, that stigma does cling on us as therapists with our mind reading, and our desire to treat you.

And Tafi was amazing. He was so real with me about it too, about how scary it was. And it's not something you spend a lot of time thinking about as a therapist cause you're spending so much time thinking about making everyone comfortable. But why are you spending so much time making people comfortable? cause it's actually really scary and uncomfortable experience at first, and we learn about it, but it hits differently when it's someone like really genuinely sharing that with you.

Helen: Thank you. So Tafi, no sofas. What did you actually have to do if you weren't? I mean, I completely agree with Sherri, that image of lying on the sofa, telling someone your deepest secrets, that's not actually what therapy is really like. So for you, what was actually helpful? What was it that, that you benefited from when you accessed the therapy if it wasn't lying on a settee?

Tafi: No, that's a great, great question. I think the first, was the normalisation of it for me because as someone who hadn't had any previous contact with the concept of mental health assistance or what help looks like. I actually assumed that everybody is going through the same experience as me, which is that they have these feelings, they have negative thoughts that they deal with internally and externally you are presenting strength and just being happy and getting on with things and getting on with people. And then what you deal with is your own problem that you deal with by yourself. And I just assumed that everybody is going through the same human experience where they have their challenges, their difficulties, but there are theirs to deal with.

So that's what I assumed was happening. So it was actually quite helpful in itself just to understand that, actually my experience is more severe with some of these feelings than I should have to put up with. So not to say that I am not normal, but it's more than I have to put up with, and I could actually get rid of quite a lot of these things, and it's normal for a lot of people to feel that way. So when I was at the height of feeling like, ooh, I could, I can say with hindsight now that I will say I was struggling. I just thought this was normal. But the tension was so high that when I got to that escalator at Bank Underground Station, I would feel a lot of these physical sensations of, I guess now that I know are associated with the anxiety of the challenges that I had to then go tackle. So these are things that I notice now, and I think the normalisation of that and just understanding that these are things that you don't have to feel basically, if you are willing to try and go through these steps. So I was already hooked at module one and I could tell this is for me.

Yeah, so I really think there's, I believe a lot of people out there, like me for whom a lot of their need is a gap in information, just a gap in knowledge about how normal it is and the fact that there are things that can be done. So just those two things, as basic as they are, I think can have a lot of a big impact for people like me who just haven't been exposed to any therapeutic techniques or language or discussion.

Helen: And it's really interesting to hear you talk about that. At the same time, I do wonder whether there were any steps that you were expected to take that were actually really hard. I mean, you did mention that it was hard to get on the escalator at the Bank underground station. Were there things in the therapy itself that were particularly difficult?

Tafi: To be honest with you, when I self-referred through IAPT, the first step was to have a phone call with someone and that was very uncomfortable for me because I had never discussed these inner things with anybody. So that was quite daunting but because I had chosen the self-guided program from there it was up to me. I think as someone who resonates with academic things or from the finance world, you're used to learning that I was in a comfortable space once I was meeting those topics in a place where I'm having privacy. What it has done for me though, is that I am now open to face-to-face therapy because I understand the context, the language, I'm more understanding of that is normal. And also I understand better what therapy is about and what I can get from therapy. So I just needed an introduction, which gave me, I think a sense of being in control and also the privacy that I needed at this time to be able to unpack a lot of these things and understand them so that, years later, I can talk openly with you now. So yeah, so I think for me there was just quite a good fit between the form of help for the stage of my journey, which I was in.

Helen: Well, I guess the next question then really is how did you get from that and finding the guided self-help materials? How did you get from that towards developing the app? So you know, you've gone from being somebody on the receiving end to developing something that helps other people.

Tafi: Yeah, I think when I was on the receiving end, one of the things that I found really shocking and I didn't expect myself was that, for me, I struggled with a lot of automatic negative thoughts. Those I'm useless, or I can't do this, or I'll always be like X, Y, Z. I struggled a lot with those automatic negative thoughts. So developing that skill around identifying how thought, feelings, behaviours are connected and starting to do that repeatedly for myself and then doing repeatedly thought challenging. I found that over time, naturally I was having less of the negative thoughts without intentionally trying to not have them. I just wasn't having them, and I was having more of the balanced thoughts being my automatic thoughts. So I found that really transformative. I found the mindfulness exercises to also be really powerful as I practiced it more and more. I just, again, it wasn't intentional that I was thinking different. I just three months later realised wait a minute, I’m thinking differently, I’m not having the same experience of life, if you like, that I was having before. So that's what gave me a deep sense of that the science that's behind this, really works because I can say what I want about my ability to read and to understand what I'm reading but definitely there's some science that's happening in the background that is doing something to me here. I believed in the method, I believed in the science through my personal experience but then I also, at times, although it was an amazing intervention, it worked for me. I did feel like, I'm a bit of an accidental user. They didn't imagine this Zimbabwean, crazed kid, coming through and, and using this, which is fine because I think the interventions are developed with their whole audience in mind. It doesn't mean they can't be used elsewhere but there is definitely a person in mind, as the audience, which for me triggered the question of saying, well, who will think about the African context? Who's going to have enough of an interest to say if this is made for, with the metaphors, with the ways of thinking, talking, that we have here in Africa, that from living in both places I know are quite different. It became a question of who's going to think about that, but that's not something that I did alone because of course, Sherrie was herself resonating with that question to say, well, who's going to think about it? And obviously yeah, that's how things came about.

Helen: That's fantastic and I'm really curious to hear from you both, have you got any examples of the kind of metaphors or analogies that I might use because I'm based here in the UK that are different from the ones that would resonate with people that are from where you come from originally?

Sherrie: Yeah, so one of the metaphors we frequently use in the UK is talking about a stool when we are talking about balance, the stool needs three legs. Okay in South Africa, we're going to tell you about a potjie pot.

Helen: You are going to have to explain that, Sherrie.

Sherrie: So a potjie pot, it’s like a cauldron. It's a type of cooking pot. It's a very popular African cooking pot, it's used outdoors, but it's something that is a bit more familiar to us. It's a small thing. Of course, we have stools, but even the word stool is just very English. So yeah, we talk about potjie pots instead.And then just simple things like if we are talking about animals, I'm not going to talk to you about a fox, you don't have any foxes. I'm probably going to describe a different animal. Simple things like when we are talking about barriers, I’m not going to be speaking to people in London about rolling blackouts. They'll be like, what are you on about? But if I'm working with the clients or even within the app, if I'm guiding you through a particular skill where I need to think about your ability to follow through on that skill. I need to think about whether you have access and when you have access. And even if I don't think about that, I'm going to help you think about that. So when we're planning, we're going to think, okay, what are your barriers? Because they look different. Of course everyone has their own unique barriers, but I'm talking about social barriers. I'm not going to say, oh, pop down to the shops, if I know that you live in a location, and that you got to go to the spaza, I'm going to say go to the spaza. Those kinds of little differences. And then also in terms of broader differences, so acknowledging and bringing into the culture, bringing in those cultural aspects. So we are very big into Ubuntu, that's something I bring into the CBT. We put a lot of focus on, I guess more of a communal aspect and what does community mean to us as Africans? What do our networks look like because they might look a bit different. So for example, if I'm in England, I might suggest you go to a peer support group. If you're in South Africa, I might say, hey, go to your elders. We know what that means, there's someone in your community who's designated an elder, you can go and speak to them. That's kind of part of their role. So just thinking a little bit differently about what is life like for you? Yeah, we all human, but you know, these are the things that make us who we are, but also your environments. It's absolutely linked to everything. That's what the five areas model is. We don't put this all on you. This isn't all on you. You are part of this broader system. So we like to try and bring that in, and I think there's something about that is also quite African.

Helen: I'm loving what you're saying. And even though what you're saying, it is African, to me it's really relevant to everybody everywhere thinking about what actually is meaningful to you, in your context, wherever you are, whether that's the middle of London or the middle of nowhere, whichever continent you are in and something about using sort of images that are familiar to you, your community, your locality, and who are the people that you go to talk to that isn't the therapist, for example, who are the people who'll support you? To me it all sounds really relevant.

Tafi: Absolutely. If I could just add to or build on the cultural differences. They can be in ways that surprise us, I think people might not expect certain things. So for example, like Sherrie's saying, in our culture at a funeral, there are songs that are sung, and they're not necessarily downbeat songs as well. So it's just that idea that cultures can work dramatically differently. Another example is I always use this, my own experience of, we have the saying in the UK that a person changes like the weather. And for me growing up in Zimbabwe, I thought it meant that person is very reliable, isn't it? Because the weather hardly changes. It's 25 degrees, it's sunny. I can rely on that person.

Helen: That's a wonderful example.

Tafi: Yeah, it of course took one trip to Manchester and experiencing the weather changing in one day to know that, okay, that's not what that means. And so I wouldn't blame someone in the UK for assuming that statement has the same global relevance as it has in the UK, but clearly it would be a cultural disconnect for some of here.

Helen: Thank you. And I mean, as a therapist standing here, I'm making notes, about what you're saying and, we do talk about including people from different backgrounds and different cultures that always need to think more carefully and more broadly about what are the implications of the assumptions that I make without realising I'm making them. And I just love that one about being like the weather. I really love that one.

Sherrie: And again, I think the focus is as you said, I mean, it's not that it's not going to be relevant to someone else. I think that the process of therapy is hard graft. I don't still need you to put in the cognitive energy to figure out a metaphor that doesn't hit quite right. So again, it's not saying, oh, we need vastly different, no. All we are saying is, hey, let's just try and make it as accessible as possible and that does mean not spending an extra five minutes trying to figure out what on earth I'm talking about in a metaphor that is just weather.

Helen: So can you tell us a bit about how the app itself actually works? It's been developed for that context, but you said it may well have a broader relevance. Tell us a bit about what somebody expects if they're looking at the app.

Sherrie: So I would say it's important for us to think about our specific aims. So like most people, one of the big aims was to introduce some kind of intervention. So South Africa does tend to focus on, what I would call a late-stage intervention, so hospitalisation, inpatient care. And so we were recognising this massive gap. Obviously, Tafi and I are seeing that within our personal lives and that was one of the first things. So we really wanted to give something to plug the gap, so access. Tafi and I are absolute nerds, total geeks. We wanted it to be very scientific. Yes, we did want it to be something for the African context, but you know, specifically. we wanted it to be top quality for the African context. We didn't want it to be the forgotten, oh, okay, we made it for here, but you can have it anywhere, we wanted to actually do something that was ours. So I think that was the starting points which obviously leads you to thinking about the barriers. So what are the major barriers? Why is it that most people are receiving inpatient care? So you start there, you obviously start doing your research on the ground. Just ask people, don't make assumptions, what is your experience? Okay, do you have health insurance? Do you not have insurance? Those are two very different pathways, very different experiences. So starting to understand what that map looks like, and then thinking, okay, how do we plug this gap?

So our first iteration, we were actually looking at doing a completely text-based intervention. And we realised, look actually that's not going to be quite enough what for what we are trying to do. And so that's how we landed on the app. And then from the app, I basically just took therapy, it's not reinventing the wheel, honestly. There's no miracles happening here. I took what we do in therapy, so best practice and I applied that to an app. So the first point of call when you get to the app is to go through your symptom levels. We don't work with diagnosis, we tend to talk about symptom levels. Okay? I can't diagnose you, I don’t know your whole history, but I also don't need to know your whole history at this point. So we get you to start thinking. So this is what Tafi was talking about introducing a vocabulary, so an understanding that's your first points already. We're saying, okay, let's talk about what you're experiencing. The user then gets feedback on those measures. We use the PHQ, we use the GAD, we use the WSAS of course. So that gives us an idea of what you're experiencing and that allows us then to streamline them into a particular treatment module. Okay. So the different modules are, of course, for different presentations. At the moment, the app focuses on anxiety, depression, and we have two comorbid groups depending on whether the user feels that they want to focus on the anxious symptoms more, or they want to start with their depressive symptoms more. So what is the bigger focus for the user at the time? We've also included what we call our wellbeing group, which is for people who have come to the app, they're presenting as subclinical in terms of their symptom levels. But clearly you're here because you feel you need something or you want something, you want to do something. So we focus on resilience there. So yeah, fine, you're not presenting, and again, I use the word presenting because we know that sometimes we can withhold information, but also no scale is perfect. So we sort of then direct those people to what I consider the more resilient focused stuff. So a lot of mindfulness, relaxation practice, so still getting something but not quite the full treatment.

The user then goes through a process in the app. So generally, it's exactly like face-to-face therapy. Basically, the modules mimic a one-to-one session. So we start off with a joke, a little bit of dopamine to get you hooked. Yes, shameless in that. Little bit of dopamine, bring a bit of humour, get you to feel a bit relaxed so you can really engage with the content. The content's very short, it's very modulated, and any session, we start by reviewing what you've done. I introduce a rationale for what you're going to learn, so that skill or technique, we go through that and most crucially, we then focus on the practice. So that's one of the things we're very big on. I think one of the things Tafi hit on is this amazing thing where CBT is crazy in that I don't actually need you to understand why you are doing what you're doing. If you just do the stuff, you will eventually notice the benefits. And that's not just based on the data, that's based on Tafi’s experience, it's based on my own experience. So we very much focus on the behaviour because at the end of the day, it's, I do think it's not so much about what we think and what we say, it's about what we go and do. So we try to get the user to really focus on how are you going to integrate this? How do you make this part of your life? So very practice focused. We review the practice and the idea is that you get to a point where you feel you've mastered a skill before you move on. So that's where the self-guided part is. You can just go through it all, but the self-part is really in terms of thinking about, okay, I can give you all the tools, but you still have to make that decision for yourself if you've mastered it. And more importantly, do you find it helpful? Because you don't need to find everything helpful. We take least intervention first. I'm happy if you do one module and this is the thing that you need. Because I think that's the tricky part about any kind of therapy is finding what fits for you. What is your motivation. So for example, Tafi, he was very comfortable with the app because like he said, he likes learning so it was an environment he was familiar with. So that's really the focus on the app, is on those real world skills. And I guess ultimately we are trying to teach you that iterative process of being your own therapist. And that's really what the app is about. With some sign posting, of course, because I would be a terrible community psychologist if I didn't do some sign posting.

Helen: Tell me a little bit about what you mean by signposting, because I think I might have been about to ask you, sort of if somebody needs more or needs something different, how would they know?

Sherrie: Yeah. So one of the things about the app is we have designed it to be completely self-guided. So it can be a standalone intervention, but a tool should have more than one use. So it is also intended to be used as a therapeutic tool, not just with CBT therapists. So in terms of giving your client that literally in pocket support- you don't remember what I said in session. That's fine. Go to your app. So that's wonderful because it does free up a lot of space in your therapy sessions. We work with quite a lot of OTs. OTs absolutely love the tool. Again, it means that they can focus on something else in their session whilst also ensuring that their clients is getting that additional support because as we know, it's very rarely that you have some kind of long-term difficulty or even short-term health difficulty without that impacting your mental health. I think the main thing is find what motivates you. That's where the signposting comes in. So sometimes it's simple things like, I suggest some yoga stretching as part of your nighttime routine. Okay. I can literally signpost due to a YouTube video. Fabulous. Or I can signpost due to yoga institute that, and there are lots, that have free resources. That's the signposting.

Of course we also do crisis signposting. That's the reality if you're working with any kind of mental health. No intervention is everything and that's where I think signposting can come in handy is going, hey, we aren’t actually everything. Here are some other options.

Helen: And I'm really pleased that you said that I was going to ask you about, if there was a reason to worry about someone's safety or if there was some kind of emergency really, your app helps people to go to the right place for help.

Sherrie: Unsurprisingly, it's one of the first things that we thought about. So when it comes to crisis support, most systems have their own particular way of dealing with it, who you refer to, who you deal with, you've got a supervisor, whatever the case is. An app doesn't necessarily perfectly fit into that, especially if you're an app working across multiple use cases So that was one of the first things that we thought about.So the app includes a little logo at the top of each page. So it's always there. It's quite subtle, but it's easily seen so it doesn't feel doom and gloom. It's just a little red phone, but you hit the little red phone and it's going to take you to that support immediately. And the first thing we do is we just give a normalising message. So simply say, okay, you've come to this page, you clearly need some support. You might be going through something that's absolutely fine. It's normal. But the important thing is that you get the help that you need. Here are a list of options. What do you want to do? I think it's also important that we don't just include telephones because again, I know that when we say one-to-one, we tend to think of that as a conversation, but that is, can be very generational. One to one can also be via an online chat. It can be via email. So again, I think just as a heads up to anyone who's thinking about getting into this, if you are going to be signposting, just think about different types of access. There are different ways that people like to communicate. So yeah, that normalising message and that instant support, and most crucially, make sure it's visible at all times.

Helen: You just mentioned there's a generational difference between people, so you are talking to me- I grew up listening to music on cassette players, so if you've got people out there who are maybe not so familiar with the technology, that they wouldn't necessarily automatically go to an app or might absolutely assume that if you need some kind of help, you need to talk to a person, even if you're not lying on the sofa. You might want to talk to a real person. What would you say to somebody who's maybe less comfortable with doing everything on their phone?

Sherrie: So I get the hesitation there. I think it's important to not get hung up on the delivery method. So in our research we actually found that, we had participants aged 18 to 69. And when we looked at the data, obviously we keep doing the research, but as it stands, age actually had no impact on usage or recovery.so I think a lot of the times this ties back into the ideas about therapy, is don't do yourself dirty. You don't know what your experience is going to be until you try. And it's okay if you try and it's just not for you, but you might be very surprised at just how easy and comfortable it is, and even though you're not talking to someone, one of the big things that we get in terms of feedback is that it feels like you're speaking to someone.

And then finally. We do have you in mind. We have everyone in mind. It's okay if you're not technologically advanced. I don't need you to be, that's Bernard's problem. By the way, Bernard is the other co-founder. He's the tech. It's Bernard's job to make it accessible, but we do really think about just making something that's easy. Again, it's always about reducing that cognitive load. So I would encourage anyone to just give it a try, and that goes for all therapy. So give it a try. If it doesn't work, that's also okay, but you might be very surprised.

Helen: Thank you Sherrie. And I think one of the things that you've told me before we started recording this Tafi is that one of the things that you were bearing in mind when you were thinking about accessibility, I think I understood from you that many people do have a mobile phone, but things like access to data can be an issue. So tell us how you address that as part of the project.

Tafi: Yeah, no, absolutely. And I think, I'll even broaden it to say when we think about our role, in a business journey, we are definitely not replacing face-to-face therapies or tele therapies. And actually, I always start a lot of presentations and conversations by saying if someone has the confidence, as well as the financial means to engage in face-to-face therapy, I 100% recommend it as because now at this stage in my journey I understand the benefit and the power that's to be gained from talking therapy, so that's the starting point. And then of course, for some people the confidence is an issue in which case perhaps regardless of their age, as Sherrie pointed out, they might persevere and figure out how the app works, even though we do try to make it simple. Unfortunately, in our African context, the affordability plays a bigger role because in the UK there's of course the very well, to us, very well resourced NHS to British people under resourced, which it is. but from our perspective, there's a well-resourced public health service that can give you a full dosage of help. And then maybe you can guide me in terms of when you have someone who typically has maybe moderate or moderately severe difficulties, how many sessions would they be allocated by the NHS.

Helen: Well, that's a very good question, but I would say a starting point of at least six and maybe 12 and sometimes more if the difficulties are more severe than that. Yeah, there, there is definitely the possibility of seeing someone who understands and can listen to you and even at what we call low intensity level, that would be probably six sessions. And then at high intensity, probably quite a few more.

Tafi: Okay. And, and so in South Africa we find that the people who do have access to that form of health are those who have private medical aid insurance, private health insurance, which I think is something like 20% or less of the population. And those people form pretty much the wealthier parts of society and they get typically three sessions of face-to-face therapy as what they get through benefits, unless of course unless it is, it's under what they call prescribed minimum benefits where they just have to help you. But if you are getting generally help, at an early stage, you're getting three sessions and that's often what you get either through your employer or your insurer. So there's a huge underdosing that's happening, which means people don't have the affordability barrier before we even get to the other costs. The affordability is just out of there for everybody. And then we do, as you mentioned, try to address other aspects of accessibility, and one of them is mobile data costs, because when I lived in London, you can sit next to someone on the train and there'll be streaming Game of Throne in HD, and watching the full hours episode. For someone in Africa that could be their entire year's budget for mobile data costs, the cost of streaming that. So then we have to make it sensitive to that with a lot of accessibility of the treatment when you're offline. So there's a lot of relevancy that we've built in, but I think the biggest issue we have is just sheer affordability and then the huge amount of underdosing that happens as a result of affordability. And then we also have, of course, the technical barriers of data costs, mobile phones that don't have a lot of storage capacity, things like that. So we address those challenges as well.

Helen: I mean, it sounds like an awful lot of thought has gone into the practicalities of it as well as including the science, and I'm just standing here thinking that although you've designed that for the African context, it really does sound like there's a lot of those things that could well be relevant in the continent of Europe, Britain, where I'm based. I know that Sherrie's not in Africa at the moment. How relevant is it to people who aren't in Africa or from African heritage, let's say?

Sherrie: Absolutely. I mean, as relevant as it was for Tafi when he was in the UK. At the end of the day, these are universal experiences. The only thing that's being changed is the way we communicate the ideas to you, but it's all based on the same science. I mean, none of the metaphors are going to be that wild especially in the age of Google. You might be like, what is a potjie pot? And you Google it and it says cauldron. You might say, what is a hyena? And you can be Google it and it's like an ugly dog, but you know the main idea is there. So I would say it's still relevant.

Helen: Thank you, Sherrie. I am really grateful to the two of you for coming to talk to me today and we're going to finish in a moment, but before we go, Tafi, can I ask you if there's people out there listening who are having similar experiences to the ones that brought you into contact with CBT and everything that's happened since, is there one key thing that you want people out there to know or to remember from our conversation today?

Tafi: Yeah, certainly. I think I can speak from the perspective of a man and our preconceptions of what reaching out for quote unquote help is, and it's just to say it is not a weakness, it's not a weak act. It's actually arming yourself with skills, with tools, that will only better you. So that was the key revelation for me. I always say to people, would you rather your plumber turned up with one spanner or a belt full of tools. And I think it's just gives us that belt full of tools to really just get through life better professionally, and personally as well. So I just encourage them to see it as an upliftment as opposed to an act of weakness.

Helen: Thank you so much. And Tafi and Sherrie, thank you again for coming to talk to me today. It's been an absolute pleasure speaking with you and a privilege to hear about your stories. Thank you.

Sherrie: Thank you so much for having us.

Tafi: Thank you Helen.

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