Counseling in BurundiPreliminary Results of a Single Case Study

Mark Jordans1/3

Eva Smallegange2 Ivan Komproe1

Wietse Tol1/3

Joop de Jong3/4/5

1: Healthnet TPO; 2: Healthnet TPO Burundi; 3: Vrije Universiteit Amsterdam; 4: GGZ Amsterdam; 5: Boston University School of

Medicine

Thanks to:

Thanks to Peter Ventevogel, Healthnet TPO Burundi, James Nsereko and all children involved

This project and research was conduct with financial assistance from PLAN Netherlands.

Child Thematic Project (CTP)

Development of comprehensive research informed community based psychosocial care model (“best practice model”) (Burundi, Sudan, Sri Lanka, Indonesia and Nepal)

Step 1: Capacity building for research and psychosocial care

Step 2: Provision of psychosocial care for children in areas or armed conflict

Step 3: Research into impact of violence on children, efficacy of CBI, validation of tools

Step 4: Adaptation of interventions based on research and clinical practice

CTP Implementation

Community Awareness Raising

Non-therapeutic group activities

Screening

Classroom Based Psychosocial Interventions

(CBI)

Counseling

Referral to other services

Community –level Psycho-education

Counseling Intervention

Para professional service Skills based and practice oriented

training process More specialized and individualized

psychosocial care for more severe cases

Provision of emotional support, problem solving and therapeutic relation

Counseling development proces I

Treatment modality has been developed and adapted in non-Western settings o Long term training courses o Cultural adaptations o Training and service-provision by local staff o NGO-based intervention model

Counseling development proces II

But what do we know about the theoretical framework of this intervention in the non-west o How does verbal-based healing for

psychosocial work in non-western context? o What are the working ingredients and

therapeutic processes underlying counseling?

o How can existing therapeutic schools contribute to the development and adaptation of counseling in non-Western contexts?

Research methodology: N=1

Why n=1? Evaluating the effect of the intervention on an individual

level: how and what changes occur as opposed to that they occur

Understanding the intervention’s working mechanisms: what causes clinical changes

Looking into how the intervention can be improved; what intervention strategies are effective for what (trends of) changes

So focus on process and mechanisms of change and monitoring client progress emphasize clinical usefulness

Research design

ABA designo Pre- (A), during- (B) and post-intervention (A)

Repeated measurementso Weekly; before and after every sessiono Child, counsellor and care-taker questionso Approximately 16 measurements (4, 8, 4)

Series of n=1o Burundi (and Sudan) o 11 respondents completed fileso Age 11-14o 9 Female/ 2 Maleo Inclusion based on screening for depression, anxiety &

PTSD and psychiatric indication for treatment

Measurement Schedule

Measurements A1 – A4 (waitlist)Outcome measuresMajor life events

Measurements B1 – B8 (pre-session)Outcome measuresMajor life events

Measurements B1 – B8 (post-session)Perception of treatmentCounselor log-book

Measurements A5 – A8 (follow-up)Outcome measuresMajor life events

Instruments: a multi-indicator approach

Outcome variables o Symptoms checklists (CPSS; DSRS; SCARED; SDQ; CHS;

DF)o Personalized Outcome Measureo Behavioural Changes (observed by parents and/or

teachers) Intervention variables

o Generic intervention strategies (rapport building, problem assessment, practical assistance, problem-solving, symptom management)

o Specific intervention strategies (Psycho-education, relaxation exercises, drawing, behaviour modification techniques)

o Session contento Treatment perception o Life events

Analysis

Visual inspection Looking for sustained trends of change after start of

intervention (positive, negative or no change)

Inspection of changes Interpretation of qualitative data per session to explain changes

and link individual changes with counseling ingredients Creating subgroups based on shared ‘explanations of change’ Draw hypothesis on working mechanisms of counseling – to be

confirmed by comparisons over cases

Added in this study: Statistical procedures to; Compare profiles (T-tests comparing Regression Coefficients) Explain profiles (Longitudinal multi-level analyses)

“What variables can explain change or no-change?”

• Can change be explained by certain intervention strategies (for example concrete, ritualistic or advice oriented)

• Can change be explained by type or severity of problem (for example counselling especially effective for anxiety reduction; are different strategies used for different problems)

• Can change be explained by counsellor characteristics (for example traumatic history; M/F)

• Can change be explained by therapeutic relationship (for example the level of trust)

• Can change be explained by context factors (for example exposure factors or life events in the week before a measured change)

• Can no-change be explained by the exclusion of intervention strategies, counsellors or type, context and severity of problem

Preliminary Results: visual inspection

Resp CPSS DSRS SCARED

SDQ CHS DF POM 1

POM 2

3 + 0 0 0 0 0 0 0  

4 + + + 0 - - 0 0  

5 0 0 0 - 0 - 0 0

8 + + + + + 0 + +

11 + + + + + 0 + 0

13 ^ + + + + + + +

15 + ^ + + 0 . 0 +

17 + + + + - + 0 +

19 + + + + 0 + + +

23 + + + 0 0 0 + 0

27 + + + + + + ^ +

Example of Multi Indicator Pos-Change

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Case Number

0,00

10,00

20,00

30,00

40,00

50,00

60,00

Va

lue

dsrs total 18 items (recoded)

cpss total 17 items

anx total scared 37 items

sdq total (recoded)

Example of Multi Indicator No-Change

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Case Number

10,00

20,00

30,00

40,00

50,00

60,00V

alu

ecpss total 17 items

sdq total (recoded)

anx total scared 41 items

dsrs total 18 items (recoded)

chs total 6 items

Single-indicator change with ‘milestone’

Explanation of Change:

Start of Intervention

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Case Number

4,00

6,00

8,00

10,00

12,00

14,00

16,00

18,00

Valu

e c

ps

s t

ota

l 17

ite

ms

Single-indicator change with ‘milestone’

Explanation of Change:

Involvement of father in counseling session: psycho-education and normalization of children complaints make father reassured

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Case Number

5,00

10,00

15,00

20,00

25,00

30,00

35,00

Valu

e c

ps

s t

ota

l 17

ite

ms

Multi-indicator change with ‘milestone’

Explanation of Changes:

Change 1: Life event, ‘testing effect’, social desirability, increased awareness towards problem

Change 2: Start of intervention Change 3: Problem solving, feeling at ease & family involvement

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Case Number

0,00

10,00

20,00

30,00

40,00

50,00

60,00

Valu

e

dsrs total 18 items (recoded)

anx total scared 37 items

sdq total (recoded)

cpss total 17 items

chs total 6 items

Multi-indicator change with ‘milestone’

Explanation of Change:

Phase of coping strategies, ‘solutions’ and ‘advice-giving’

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Case Number

0,00

10,00

20,00

30,00

40,00

50,00

60,00

Valu

e

dsrs total 18 items (recoded)

anx total scared 41 items

cpss total 17 items

Conclusions

Single case methodology demonstrates multitude of changes during a counselling process

This method provides information about factors related to changes

Clearest changes are observed on symptoms of depression, anxiety and PTSD

Thank you for your attention