Counseling Intervention for Rural Women With Psychological Distress Vanguri Prameela *, Veena, A.S.**, Kiran Rao** & Smita Premchander*. *: Sampark, Bangalore, ** NIMHANS, Bangalore. Introduction Stigma, poverty and lack of access to care often result in psychological distress in women being unrecognized and untreated. Using a development framework, the primary objective of the project was to study the effectiveness of mental health intervention in reducing psychological distress and disability. This paper describes the counseling intervention used in the study. For the purpose of this project, mental health was defined as the absence of psychological illness. Psychological distress was measured using the General Health Questionnaire (GHQ). The GHQ is one of the most commonly used tools to measure probable cases of psychological illness in the community and has been used in several studies in India (Goldberg et al, 1997). The design of the study was based on a non-labeling, non-medical approach to the treatment of psychological illness. In the study, psychological illness was used to refer to common mental disorders such as anxiety and depression which often go unrecognized and un-treated in the community (Patel et al, 1998). They are not perceived as mental illness, but as physical problems which may be related to stress. This is largely due to the stigma attached to mental illness (Raguram et al, 1996). Getting help for common mental disorders is poor and even when individuals are identified; their compliance with treatment is low. More women than men suffer from common mental disorders (CMD), such as anxiety and depression (Dennerstein et al, 1993). Counseling as a mental health intervention was offered to all women attending Self Help Groups (SHGs) in the Katarki Panchayat area of North Karnataka. Such interventions have been reported to be effective in the management of psychological distress (Sumathipala et al, 2000). Objective The primary objective of the project was to study the effectiveness of mental health intervention in reducing psychological distress. This paper describes the counseling intervention and outlines some of the common themes that emerged in the sessions. The challenges faced in carrying out the intervention and the participants feedback are highlighted. 1
Method Sample The sample comprised of women from the SHGs in Katarki Panchayaths of Koppal district, North Karnataka. Since three years these women are actively involved in microcredit and enterprise and other development programmes. A total of 290 women from 22 Self Help Groups participated in the intervention. Tools A socio demographic data sheet and a standard of living index were used to obtain background information. The General Health Questionnaire -28 ( Goldberg & Hillier,1979) and the Psychological Wellbeing Scale ( Bhogle & Jaiprakash,19 ) were used as baseline and outcome measures. Procedure The study was conducted in four phases. In the first phase the training of the project staff was undertaken. In the second phase, the base line data was collected and the pilot interventions were carried out. In the third phase, the interventions for the main study were conducted. In the fourth phase, the repeat assessment was carried out. The paper describes the training and intervention carried out in the first three phases. Training Training programs were held for counselors and interviewers who would participate in the study. Three staff members were selected to be counselors and six part time staff members (of whom four were women SHG members) were recruited to be interviewers for the pre-intervention data collection. This was done in order to ensure that the counselor team was blind to the data collected by the interviewers. Moreover, the SHG women were involved right from the beginning of the study in order to promote their ownership and to enhance the sustainability of the project. The first training was conducted in Bangalore for the counselors as well as interviewers. The content for the trainings focused on the following subjects: Understanding the functioning of body and mind and exercise on body mapping Understanding the relationship of body and mind Common physical ailments and symptoms 2
Recognizing and identifying severe mental disorders Understanding common mental health problems Lifestyle management: Personal care and hygiene Lifestyle management: Diet and activity Concept of Counseling and communication skills Coping skills: An introduction Coping skills: Problem solving skills Coping skills: Emotion focused skills The training covered the task differences between the interviewers and the counselors. The pedagogy of training included didactic presentations and participatory exercises such as role plays, story telling and group exercises. Relaxation exercises using breathing techniques (to aid stress relief) were practiced at the end of each morning and afternoon session. During the training, the participants were given handouts and other reading materials. The counselors were asked to complete four pilot counseling sessions in SHGs not included in the study. They were requested to maintain detail notes of their sessions and observe the difficulties they experienced during the counseling sessions. Subsequently, a review training program was conducted. During this training program, the mental health professionals discussed the experiences of the counseling team and provided further inputs. Supervision Throughout the period of the main intervention the counselors maintained notes for each group counselling session that was conducted. These notes are being transcribed and will be analyzed later. They were provided ongoing supervision by a trained social worker and periodic supervision by mental health professionals. Supervision also functioned as a debriefing exercise as the counsellors were encouraged to articulate the difficulties they had encountered in the field as well as supported for the work that they were doing. The progress of the middle phase of the intervention was reviewed and the counselors were prepared for the termination phase of the intervention. 3
Intervention The intervention was a group based counseling mediation carried out over ten sessions on a fortnightly basis. Each group had 12 to 15 participants and the duration of each session was approximately two hours. The project staff who were trained as counselors already had rapport with the sample population as they coordinated and facilitated the savings and credit programmes. In order to avoid bias, the facilitator of a particular SHG was the counselor for a different SHG. The session formats were as follows: Session 1: The intervention program objectives, purpose and ethical considerations were introduced in the first session. Session 2: The session dealt with psycho-education on mind and body relationships and how psychological problems and illness affected the body and vice-versa. Session 3-8: These six sessions were the main counseling sessions where the group counselor facilitated the sharing of problems, reviewed coping strategies and encouraged alternate more adaptive ways of problem solving and coping. The focus was to encourage the group members to support and help each other through the process. Session 9 and 10: The group counselors prepared the group in Session 9 for the termination of sessions after Session 10. The counselors encouraged and facilitated the group to continue to meet on a fortnightly basis. Session 11 and 12: Counselors added two follow up sessions of which the 11 th session was done by the women themselves without the presence of a counselor. The 12 th session was conducted by the counselor as a booster session. Results Twenty-two groups participated in the mental health intervention programme over the past year. Out of these groups, eight groups had members belonging to the Scheduled Caste (SC), 12 groups had members belonging to the general caste, and two groups were mixed, having members belonging to both the SC and general caste. Out of the 22 groups, one group (general caste group) dropped out after the completion of the second session, stating that they had no health concerns and hence were not interested in participating the project. 4
In all 290 women participated in the study of whom about 130 women belonged to the SC category and the remaining were from other castes. The women in the age group of 18 to 70 years with the mean indicating that most of the women were in their mid-thirties ( Mean=34.33, SD=11.38). Majority were illiterate ( N=232, ), married (N=205, ), hailed from nuclear families (N=220, ) and had about three children on the average ( M=3.18, SD=2.35). Using the standard of living index of the Govt. of India, majority had a low living standard (N=171,). At the time of the baseline survey, 160 of the 290 (55%) obtained scores above the cutoff on the GHQ indicating the presence of psychological distress. The number of individuals who move from being a probable case to non case will be determined at post intervention. Individuals whose GHQ scores continue to be high at the end of the intervention program will be interviewed using a structured clinical interview schedule to generate a psychiatric diagnosis based on DSM IV/ ICD 10 criteria. They will then be advised to consult a psychiatrist at the closest facility. Qualitative Results Based on the feedback of the counselors and from the participants in the booster sessions (12 th session), the following results have been outlined in three phases: initial, middle, and termination of the main intervention. Initial Phase On average, attendance in the health meetings ranged from 47% to 100%. The reasons for absence were because of illness, migration, visit s to mother s/ parents place/koppal town, function/death in the family. A. Participant perspective Initially, women who participated in the groups had difficulty in making the connection between emotional problems and physical symptoms. Some of the women did understand that having good food habits and cleanliness are important for maintenance of good health. B. Counselor perspective As majority of the participants were unable to relate the physical symptoms they were experiencing to their current emotional state, many in the beginning perceived their problem as a physical illness and consequently expected medical treatment. Gradually with the help of counselors who were able to show the link between mind and body, many participants were willing to talk about their emotional problems and began to view their problems from a psychological perspective. During the group sessions, the counselor also got a knowledge of the various health problems faced by the participants 5
and their help seeking behaviour. Religious beliefs were a significant part of the respondent s lives and worship was often used as a remedy for ill health. In this phase, counselors used several techniques such as listening, ventilation, confidence building, encouragement, reflection/feelings, acceptance and guidance. Middle Phase As the groups reached the 5-7 th session, most of the members felt comfortable in a group setting and began to actively to participate in discussions concerning mental health issues. A. Participant perspective Some of the psychological issues raised by women members of the group related to: alcoholism in husband, domestic violence, interpersonal problems with in-laws, and loneliness, particularly among single women and devadasis. Some women also expressed difficulties with managing and providing suitable care to their children, and talked about multiplicity of roles resulting in role strain. Although during the middle phase, group members began to take on a more active role in group discussions, in majority of the groups (14 out of 21), women were not confident enough to facilitate the mental health meeting without the counselors presence and support. During the midterm feedback, majority of the participants (60%) perceived group counseling sessions as useful. Ventilating their feelings and able to discuss their problems in a free and frank manner helped them to cope with adverse life circumstances and increased their sense of self esteem and self confidence. In addition, the participants had been taught breathing exercises to help them cope with stress. Out of 21 groups, 11 groups practiced the deep breathing exercises during the sessions and continued to do so at home. Members who practiced the breathing exercises regularly reported feeling better, less tense and slept better. Some members could not practice at home due to lack of space and privacy. B. Counselor perspective In majority of the groups, there were separate group sessions to discuss matters related to financial management and issues concerning mental health. The strategy of having separate meetings, one for mental health and one for financial SHG meetings, helped because even though in the first two sessions the women talked more about financial issues they slowly realized that there were many other issues to talk about. Out of 21 groups, only three groups were unwilling to spare an extra day for discussion of health related matters. Instead, they included the health agendas in their regular financial meeting. The counselors reported that by this phase, the participants were able to discuss freely about their problems. The counselors had a better grasp of various difficulties that the 6
members faced in their daily lives, especially issues within the family and how it impacted their physical and emotional well being. This afforded counselors to offer effective coping strategies to their respondents. Counselors also gained greater knowledge of local customs and belief systems that helped them to use innovative strategies such as use of metaphors and parables during the counseling sessions. It must be mentioned here that some members did not feel comfortable discussing personal issues and the counselor had to see them in individual sessions. Finally, many counselors began to apply some of the coping strategies that they learned during the group sessions to deal with difficult issues in their own personal lives. Termination Phase A. Participant perspective Majority of the participants were able to transfer the knowledge accrued during the sessions to their daily lives. This helped them to cope better with problems and reported obtaining considerable relief. In addition, listening and sharing problems in a group setting helped women to realise that their problems were not unique and that they were not the only ones who were facing difficulties in life. These perspectives helped them to better cope with stress in their lives. B. Counselor perspective Many groups were able to conduct the sessions themselves without the help of the counselor. Only two groups needed the presence of a counselor as a facilitator. It was also a tremendous learning experience for the counselors who by this stage were better able to facilitate discussions, support group members and offer effective coping strategies for stress related problems. Challenges Some of the difficulties encountered were related to inadequate infrastructure facilities. For instance, many group sessions had to be conducted in the open such as in temples or in front of group member s houses. This resulted in group sessions being constantly interrupted by the presence of others such as children or other male members. Several times the meetings had to be postponed due to lack of place to conduct meetings or due to power failure or inclement weather. Yet another difficulty related to the continuity of groups. On many occasions group members could not attend all the sessions due to work, or as their presence was required elsewhere such as a family function. In addition, some members had to travel to different place in search of jobs. Some members were reluctant to discuss personal problems in a group setting either because of the presence of other family members within the group or the meeting 7
was being held in one of the group member s house. In addition, sharing and disclosing personal problems in a group setting was particularly difficult for some participants. Conclusions & Recommendations The salient findings from the present study was that 50% of the women who participated in the study reported significant psychological distress. Somatization of psychological distress was common and most members had sought medical intervention for their problems in the past without much relief. The present paper deals with the process of helping such women living in a relatively difficult to access geographical area and coming from impoverished background. Psychological help was provided in a group setting conducted and facilitated by trained counselors. Over all, the group sessions were perceived as useful by majority of the members. Most of the women who were able to practice the deep breathing exercises regularly reported improved sleep and relief from their bodily aches and pains.there were, however, many challenges in the implementation of the program. Lack of adequate infrastructure in rural settings was a great impediment. Plans for the future include, training some of the SHG women themselves to become counselors. References Bhogle,S. & Jaiprakash,I. (1995). Development of the Psychological Well-Being (PWB) Questionnaire. Journal of Personality & Clinical Studies, 51, 5-9. Dennerstein, L., Astbury, J.& Morse,C. (1993), Psychosocial and mental health aspects of women s health, World Health Organization, Geneva. Goldberg,D.P. & Williams,P. (1988). A user s guide to the General Health Questionnaire. Windsor; The NFER-NELSON Publishing Company. Goldberg, D.P. & Hillier, V.F. (1979), A scaled version of the General Health Questionnaire. Psychological Medicine, no 9, pp139-145. Patel,V. Pereira,J. & Mann, A.H. (1998), Somatic and psychological models of common mental disorders in primary care in India, Psychological Medicine, vol. 28 pp 135-143. Raguram,R.,Weiss,M.G., Channabasavanna,S.M. & Devins,G.M. (1996). Stigma, depression and somatization in South India. American Journal of Psychiatry,153,1043-1049. Sumathipala,A., Hanwell,R., Hewega,S. & Mann, A.H.(2000), Randomised controlled trial of cognitive behavior therapy for repeated consultations for medically unexplained somatic symptoms: A feasibility study in Sri Lanka, Psychological Medicine, no. 30 pp 747-757. 8