S. Naeem ( The Aga Khan University, Karachi )
B. S. Ali ( Departments of Psychiatry and Community Health Sciences )
S. Mubeen ( Departments of Psychiatry and Community Health Sciences )
A. Iqbal ( Departments of Psychiatry and Community Health Sciences )
The beneficial effects of learning on the quality of life have been well documented. Dench and Regan1 have recognized that learning has wide benefits contributing to the health and social well being of individuals and communities.
This paper focuses on women from, a lower middle class community who were briefly trained in counselling skills for a project to assess the effect of counselling by briefly trained women on anxiety and depression in women of their own community (under review). It assesses the impact of learning counselling skills and of providing counselling on the counsellors themselves.
Subjects and Methods
A program to offer training in counselling skills to women was publicized in a lower middle class semi-urban community of Karachi, a mega-city of Pakistan. Out of the 73 women who responded, 21 were selected, on the basis of their motivation, attitude, communication skills and mobility required for the study. Two women dropped out and 19 completed the training. The characteristics of the 19 trainees are given in the table.
A total of 11 training sessions of three hours each were given at Qayoomabad Welfare and General Hospital thrice a week. The training encompassed communication skills, stress and anger management, information about common mental disorders (anxiety and depression) and counselling skills, the latter included supportive counselling, problem-solving and cognitive-behavioral techniques. The mode of training was mainly inter-active and participatory. The trainees worked individually as well as in groups. According to the initial criteria of selection, 11 best trainees were inducted for the study as 'community counsellors'. They provided 8 one-on-one counselling sessions, once a week for an hour to anxious and depressed women assigned to them.
The transformative effect of training on the community counsellors was assessed in three different ways, and at different times:
1) Pre and post training scores measured by the Aga Khan University Anxiety and Depression Scale (AKUADS)
2) Open ended feed back at the end of the training.
3) Focus group discussion (FGD) after having provided counselling.
AKUADS is an indigenously developed, validated screening instrument, which is a rank ordered 25 items scale; and at a cut off of 19 it has a specificity of 80.8% and negative predictive value of 85%.2,3 A sociodemographic questionnaire was also used.
After the training an open-ended feedback was obtained regarding the experience of, and the changes perceived by the trainees.
A focus group discussion using a semi-structured guideline was carried out to explore the change in the feelings, perceptions and the skills acquired after having learnt and applied counselling. Difficulties faced in the community, and from their own family members were also recorded.
Table gives the sociodemographic profile of the 19 trainees.
Figure indicates the direction of effect by comparing the pre and post training AKUADS scores of the trainees.
Feedback about training (n=19)
Learning different skills in terms of becoming more tolerant towards others and maintaining confidentiality was mentioned.
"…we have learnt to be tolerant and patient. The training taught us to be good listeners and to keep other's information confidential"
Other effects of training mentioned were, an increase in sensitivity to the needs of people around them, acceptance of difference of opinion among the group members, importance of working together, a sense of control over their lives and of being able to help each other in solving problems.
"…we have learnt to take care of others and respect their feelings".
"… the training taught us to look for solutions for our problems rather than allowing them to get on our nerves"
"…this training will not only help us but will also benefit others"
"…this training taught us to live our life in a new and different way"
Analysis of FGDs (n=11)
In the focus group discussion, community counsellors reported positive changes that occurred during this period. They mentioned personal changes and changes in their relationships with others.
"…initially I used to beat up my kids, but not any more, now if they act stubbornly I divert their attention".
"…I have managed to channelize my anger ".
Increase in confidence and tolerance was again reported.
"… I feel confident".
"…my thinking has become positive now"."…we feel we have improved our communication skills".
"…process of counselling has made all of us good listeners".
"…at times clients used to scold us and did not reply properly, but we pretended as if nothing had happened, and dealt with them patiently".
While discussing their experiences of providing counselling, the counsellors reported an initial resistance from the clients that gradually disappeared as empathy, trust and confidentiality developed.
"… clients were surprised that someone had actually come to help them"
"...initially they had a frown on their forehead but after some time they would smile when they saw us "
"…when clients were sure of confidentiality, they opened up and told us everything usually by the end of 4th session."
* The quotes provided above are translations of the originals expressed in Urdu.
This study demonstrates that psycho-education, training in communication and counselling skills and their application had a transformative effect on the trainees themselves. Education has been found to confer protection in many studies. It improves coping mechanisms, raises the self-efficacy/self-esteem of women, makes women feel less helpless in difficult situations and gives a greater sense of control over their environment.4-6 The role of psycho-education in assisting recovery from depression has been explored by Peden7 and our study supports this finding as the trainees exhibited a reduction in their levels of anxiety and depression after receiving training (Figure).
The training enabled them to deal with their life stressors more effectively and by practicing such skills they were able to gain more confidence and develop a positive approach towards life. Sevig and Etzkom. had also reported such a transformative effect of training.8
The generalizability of the study, even in similar socioeconomic strata is questionable due to the small numbers, the initial self selection bias and the response bias after having received training. The findings need to be confirmed in a larger randomized community sample. Non-pharmacological means of reducing depression have acquired importance due to the rising incidence of depression in Pakistani women.9-11 This study demonstrates that teaching women problem solving and supportive counselling skills could be beneficial.
We wish to thank the people of Qayoomabad, the administration of Qayoomabad Welfare and General Hospital, our trainees and/or counsellors who helped us in conducting this project. We are also grateful to the University Research Council of the Aga Khan University for having provided us the funds required.
1. Dench S, Regan J. Learning in later life: motivation and impact, DfEE Research Report RR 2000, 183, UK.
2. Ali BS, Reza H, Khan MM, et al. Development of an indigenous screening instrument in Pakistan: the Aga Khan University anxiety and depression scale. J Pak Med Assoc 1998;48:261-5.
3. Ali BS. Validation of an indigenous screening questionnaire for anxiety and depression in an urban squatter settlement of Karachi. J Coll Physicians Surg Pak 1998; 8:207- 11.
4. Mumford DB. Stress and Psychiatric disorders in the HinduKush: a community survey of mountain village in Chitral, Pakistan. Br J Psychiatry 1996;168:229-307.
5. Mumford DB, Minhas FA, Akhtar I, et al. Stress and psychiatric disorder in urban Rawalpindi: community survey. Br J Psychiatry 2000;177:557-62.
6. Dodani S, Zuberi WR. Centre-based prevalence of anxiety and depression in women of the northern areas of Pakistan. J Pak Med Assoc 2000;50:138-40.
7. Peden AR. Recovering from depression: a one year follow up. J Psychiatr Ment Health Nurs 1996;3:289-95.
8. Sevig T, Etzkom J. Transformative training: a year long multicultural counselling seminar for graduate students. J Multicult Counsel Dev 2001;29:1.
9. Mumford DB. Stress and psychiatric disorders in the HinduKush: a community survey of mountain village in Chitral, Pakistan. Br J Psychiatry 1996;168:229-307.
10. Mumford DB, Saeed K, Ahmad I, et al. Stress and psychiatric disorders in the rural Punjab: Br J Psychiatry 1997;170: 473-8.
11. Ali BS, Amanullah S. Prevalence of anxiety and depression in an urban squatter settlement of Karachi. J Coll Physicians Surg Pakistan 2000;10:4-6.
To identify the changes in community counsellors' own level of anxiety and depression as a result of learning counselling skills and to explore their subjective experiences after learning and providing counselling.
Quantitative: Repeated Measures./ Qualitative: Focus Group Discussions.
A lower middle class semi urban community of Karachi, Pakistan.
Twenty-one self selected women from the community.
Reduction was seen in the post training scores of anxiety and/or depression in the trainees. As a result of learning and then providing counselling the community counsellors' self esteem, self confidence and sense of competence were enhanced and they developed a more positive attitude towards life.
A minimal level of training in counselling skills and their application led to significant positive changes in the community counsellors themselves, though self-selection and information bias cannot be ruled out (JPMA 53:388;2003).