Saturday, May 1, 2010

Training the VHWs as counselors: once again appreciating the importance of being comprehensive

For the past 5 months I have been weekly training the village health workers (VHWs) about depression, anxiety and counseling. Yesterday I finished a month and half long training on counseling - a project I had begun to hopefully develop the VHWs into counselors able to treat the depression in their village. Throughout this time I wasn't certain what the village health workers' job as counselors would look like because I had never seen barefoot counseling in action and was drawing instead on the models provided in books. These books were written by psychiatrists working within hospitals and seeking to provide the important benefit of counseling to their patients yet not having enough time for the high caseload. The system they designed of training high school educated workers in counseling is indeed useful, but probably not as good as CRHP's approach because it lacks the comprehensiveness to deal with the social and economic factors producing mental illness. It remains within the confines of the hospital. Let me explain.

First of all, the counseling I am describing is not any sort of psychotherapy in which the counselor has a deep understanding of the workings of the human brain and is able to guide the person through the experience to mental health. Instead, barefoot counseling is much simpler: reassuring the person that they are not going crazy and their illness is common; providing an explanation by connecting the illness to some stressful life event' providing relaxation exercises and advice for difficulty sleeping, tiredness, panic attacks, etc.; and engaging in problem-solving by discussing problems in people's lives and seeking solutions to them. The first three are useful to the patient in that they calm the person down, help them to realize where their illness came from, and provide some relief, but they don't require a very sophisticated education: these women have been aware for a long time that the stresses of poverty, gender inequality, and violence create serious problems in people's lives. They may not have expressed it as a mental illness, but they certainly understood the physical and mental effects. Now they have the knowledge set to understand more explicitly the connections between stressful life events and depression and anxiety and impart this knowledge to their fellow villagers. I think this has been the major achievement of the training thus far.

It's the last part - problem-solving - that showed me the problem with the hospital-centered approach. Basically problem-solving is creating a space to discuss problems in people's lives and possible solutions for them. When I introduced the idea I asked how the VHWs do this in the villages and they came forth with a plethora of answers: providing a loan to a family in need of medication, cooking up a community-sponsored wedding feast to relieve the pain of a poor woman's shame at marrying her daughter without food, and bringing an unemployed and lonely woman to the fields with them to work. In effect, the VHWs strike at the roots of the problem while concomitantly providing emotional support.

I feel this is the mental health worker's dream: providing therapeutic treatment (medication and counseling) while also providing community-based emotional, social, and monetary support. One VHW told me while we both interviewed a depressed woman that this woman needs four things: a house, money, a family, and treatment (medication and counseling). Through the VHW model woman can receive help from the Women's Groups and Self-Help Groups to buy a house or start a business as well as receive treatment, and therefore seek mental health through tackling three of her problems. In the hospital-based model, all that the counselor sitting in the clinic can do is provide treatment and help the person to think through how to solve their own problems. To me it's clear that the VHW-, community-centered approach is better. Now I feel I understand why the WHO asked CRHP to write a chapter for its book on promoting mental health around the world: by focusing on social change (reduced casteism and increased status of women) as well as economic upliftment (reducing widespread poverty) while also providing in-village health workers and a central clinic this place went far in promoting mental health and preventing mental illness.

It's once again been quite an honor to be here.

2 comments:

  1. I am an undergraduate student studying international development and I am working on a project proposal concerning mental health care for those affected by conflict in Jos, Nigeria. I was wondering if you could give me the titles of the books you mentioned on barefoot counseling.

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  2. Hey Hannah,
    I can indeed. "Barefoot Counseling" by the organization Sangath, "Where There is No Psychiatrist" by Vikram Patel, and "Mental Health for Community Health Workers" by Michelle Kermode and the organization Basic Needs/Basic Rights. I hope this helps!
    Edgar

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