|Year : 2021 | Volume
| Issue : 1 | Page : 121-124
Problem Management Plus When You Can’t See Their Eyes: COVID-19 Induced Telephone Counselling
Shomoa Sabry1, Nancy Baron2, Fatuma Galgalo3
1 Counselling Centre Coordinator, Psycho-Social Services and Training Institute, Cairo, Egypt
2 Director, Psycho-Social Services and Training Institute, Cairo, Egypt
3 Diploma of Social Work, Counsellor, Psycho-Social Services and Training Institute, Cairo, Egypt
|Date of Submission||30-Sep-2020|
|Date of Decision||11-Jan-2021|
|Date of Acceptance||08-Jan-2021|
|Date of Web Publication||31-Mar-2021|
Director, Psycho-Social Services and Training Institute (PSTIC), Cairo
Source of Support: None, Conflict of Interest: None
The COVID-19 pandemic turned our world upside down. This included an immediate need to transition our Problem Management Plus (PM+) counselling from our counselling centre offices to the telephone. In this personal reflection, we explain how our counsellors made this transition and are able to offer a modification of PM+ by telephone even without seeing the eyes of those they were trying to counsel.
Keywords: PM+ during COVID-19, refugee mental health, telephone counselling, urban MHPSS
|How to cite this article:|
Sabry S, Baron N, Galgalo F. Problem Management Plus When You Can’t See Their Eyes: COVID-19 Induced Telephone Counselling. Intervention 2021;19:121-4
| Introduction|| |
In our counselling centre in Cairo, Egypt we counsel refugees and asylum seekers mostly from the countries of Eritrea, Ethiopia, Iraq, South Sudan, Sudan, Syria and Yemen. In respect for culture and context, we chose to train a team of five counsellors who are refugees and speak six refugee languages. It was a test project; assessing whether refugees would find their way in the chaos of urban Cairo, home to 20 million people, to the counselling centre and whether PM+ was an effective technique.
The counselling centre joined the comprehensive mental health and psychosocial activities already existing in the Psycho-Social Services and Training Institute in Cairo (PSTIC) (a programme of Terre des Hommes). Since 2009, PSTIC has trained teams of refugee workers to offer 24 hours a day 7 days a week community and home-based support to vulnerable refugees. In Cairo’s chaotic metropolis, a community-based model where our trained refugee workers live and work closely with their own communities and go to clients’ homes rather than require they come to an office has been an effective means to access the most vulnerable. Over the years, as problems evolved, the programme evolved and its 188 workers, of whom 87% are refugees, offer support at all levels of the pyramid of intervention, as designed by the Inter-Agency Standing Committee (IASC) Guidelines for Mental Health and Psychosocial Support in Emergency Settings (2007). PSTIC activities include support for: basic needs, 24 hours 7 days a week HELPLINES, a field-based Information Team, a professional refugee Health Team advocating for medical care and a Housing Team assisting access to safe housing. We never say no to people in need, but rather try to help them to access whatever services are available. All our teams work closely with refugee communities and families. The psychosocial workers offer home-based, problem-solving counselling and respond 24-7 to emergencies including people experiencing mental health crisis and suicide risk, as well as protection issues, gang violence, gender-based violence and child protection. People with serious mental illness are assisted using a multidisciplinary approach. The PSTIC team of Egyptian psychiatrists run mental health clinics inside refugee focused primary health care units. Psychosocial workers work alongside the psychiatrists during therapy and in the implementation of treatment plans that are organised with families and friends to facilitate support and compliance with treatment.
Despite all these PSTIC activities, we felt there was a missing piece. People with psychosocial issues needing support and problem-solving and those needing treatment for serious mental illness were assisted. However, some of the people needing assistance required something else. They were not all comfortable to talk at home and some needed a safe private place to talk to a skilled counsellor in their own language. Though the government and other organisations provided office-based counselling for refugees, no one had a team of refugee counsellors. The PSTIC experience is that refugee-to-refugee support has many advantages. The workers have a strong commitment to tirelessly help those in need in their communities as well as a clear understanding of culture, context, local issues and most importantly language − with no need for a third party to be involved as an interpreter.
| A New Counselling Centre|| |
In 2018, PSTIC participated in a PM+ Training of Trainers (TOT) and decided to start a counselling centre. A little more than a year has passed since we opened the doors to our centre.
The authors of this personal reflection are the counselling centre coordinator, an Egyptian psychologist, a refugee counsellor from Ethiopia and the PSTIC founder and director.
The hiring of the five refugee counsellors was an important beginning. They are two men and three women from Sudan, South Sudan, Eritrea, Ethiopia and Syria. Two are psychology graduates with no previous counselling experience and three were PSTIC-trained psychosocial workers with years of field experience. As the PM+ training began, the two inexperienced counsellors easily accepted all that was presented in the training. However, the psychosocial workers had to make a shift from a problem-solving mind set of a psychosocial worker to a counsellor, being more focused on understanding the feelings that lead people to be unable to solve their problems. As psychosocial workers, they knew how to find someone a job. As counsellors, they had to learn how to identify the underlining issues, like depression or anxiety, causing people difficulties in finding jobs. As psychosocial workers, they could take someone by the hand to find a job. As counsellors, they had to learn to help someone manage the underlying reasons they were unemployed so they could go out on their own to find a job. Both roles have value for different kinds of clients.
| PM+ Training and Supervision|| |
The PM+ training of the counsellors was intense and was for 6 hours a day for 10 days. The counselling centre coordinator was the trainer and used the PM+ Trainer’s Guide to organise the sessions. With previous experience as a cognitive behavioural therapist and trainer, she found the PM+ Guide easy to follow. Her previous experience as a therapist with refugees allowed her to fill the training with case examples. Having three of the five counsellors with extensive case experience allowed for immediate integration between the skills they were learning and practical application with real cases.
The counsellors began to use PM+ in the counselling centre for 4 months before the COVID-19 pandemic restricted their activities. Referrals came from the psychiatrists in the PSTIC mental health clinics and psychosocial workers. Most often the people asking for counselling had issues adjusting to life in Egypt, psychosomatic complaints, feelings of stress, struggles with problem-solving practical issues like paying rent or finding a job, marital conflicts, experiences with bullying and discrimination in their neighbourhoods and an inability to find ways to relax, be happy and have a social support system.
Supervision was fundamental to building the capacities of the counsellors. After the training, they continued to meet twice a week for supervision. Often, they were so excited discussing cases that meetings went for more than 5 hours. As the counsellors’ caseloads grew slowly, every case was discussed after every counselling session. Being able to immediately share the dialogue of the sessions and work together to figure out how to use PM+ was an ideal way to learn.
We made a few modifications in our use of PM+. First, we adjusted the problem-solving technique to our available resources. Next, we struggled with the PSYCHLOPS assessment in defining the problem and setting goals. This made the pre and post assessments difficult for counsellors and clients. If goals were not clear from the beginning, then it was hard to evaluate the outcome. Counsellors needed much more practice to learn this. Clients found it difficult to understand the assessment scales, so we needed more time to explain them. Unfortunately, many of the clients’ problem were chronic and could not be solved, so it was important to find ways to measure how PM+ helped to increase their capacities to manage problems rather than make them disappear. Over time, we had some complex cases and found the problem-solving technique needed two sessions, rather than the recommended one session.
Additionally, we modified the structure of the first session. We wanted more time to build trust with the clients, so we prepared a more standard first interview, asking questions that clients expected so that they felt more comfortable before jumping to the PM+ structure using assessment tools. In our first session, counsellors ask for some basic information including education, occupation, pertinent medical history and family structure and about how long they had been in Egypt and why they came as refugees. Clients are asked to explain their problems and their history and previous ways they have tried to cope. They are asked to explain their goals and how they hope to manage their problems. Importantly, counsellors collect information about family and other social supports, so we know who is available for support.
Overall, the counsellors feel PM+ works magically. It gives structure to our interventions and this helps the counsellors to design and follow plans of action. It prevents dependency and directs all counselling towards helping people to become self-reliant. The clarity of the PM+ process that counsellors followed for each session makes it easier to supervise their work. Most importantly, our clients share positive feedback saying that it is their first time to have someone really listen, understand their issues and teach them how to help themselves.
A few additional factors that help us appeal to clients. The actual counselling centre is a quiet cheerful apartment with a lovely garden where people feel safe and can relax and have a cup of tea. The cases referred to us are filtered since the PSTIC workers know our capacities and there are other services to manage people with other needs. Most importantly, our team is made up of refugee counsellors and have a personal understanding of the culture and life situation of refugees living Cairo.
| Flip to Telephone Counselling|| |
Like the rest of the world, COVID-19 turned our world upside down. By mid March, the counsellors were locked down and restricted to home. Our lovely counselling centre was closed, so we needed to figure out how to continue our work. We organised a series of training sessions for the counsellors to plan how to modify PM+ for telephone sessions.
First, we made a list of the psychological issues we predicted would arise due to the quarantine and lockdown and the reasons people might ask for counselling. We guessed:
- COVID-19 related issues including: Fear of getting sick, actually being sick, having a sick family member or the death of a loved one.
- Stress caused by the loss of stability including: Lost jobs, financial uncertainty, tensions with roommates or family members, overwhelmed by children at home or boredom.
- Past revisited: Too much time to think and the uncertainty of the future might provoke refugees to remember their past traumatic experiences and times when they felt a loss of control over their lives and lost hope.
- Loss of confidence: Though being a refugee is a struggle, by coming to Egypt they did save their lives and did create a safer new life for themselves and their families. They might feel a loss of confidence or motivation and forget the personal strengths that got them out of the past situation.
- Isolation and alienation due to being forced to stay at home and away from social supports.
We decided that using the full PM+ protocol was too much for telephone counselling and the issues of the clients. Clients had no money and poor internet networks, so we needed to use the telephone and voice only, rather than video or Zoom contact. The length of the usual PM+ sessions of 90 minutes was too long, so we held 45 to 60 minutes sessions. We chose to concentrate on teaching clients practical PM+ skills such as managing stress to control anxiety; managing problems to handle the practical issues; get going, keep doing to help people stay active inside the house; and strengthening social support to prevent isolation and keep people connected to others. Most often, we did not apply the “Staying well” session since the situation was so unstable.
With the cases already engaged in PM+, counselling by telephone was not so hard. At first, it was novel − almost fun. Since we knew the people, we could imagine their eyes, looks of sadness and even their smiles. We decided not to limit the number of sessions and not to close cases until we could return to the centre because every day was a new stressful situation.
We continued to do our psychosocial initial interview to decide whether or not the client fitted PM+ but did not use the assessment scales, since they were just too difficult on the telephone. With new clients, counsellors shared a photo of themselves so the clients could imagine who they were talking to and clients did the same.
Building a relationship with new clients and actually understanding the issues was complicated with new cases. Counsellors questioned how they could feel the experiences of new clients without looking into their eyes and without body language as a guide.
The retraining of the counsellors included ideas for how they could manage a session without body language. For example:
Trainer says: “Imagine. You hear a catch in Fatima’s voice. She talks more quietly. How can you respond to that change in emotion?”
Trainer suggests: “The counsellor can ask: ‘I hear a change in your voice. Can you share with me about how you are feeling?’”
Trainer says: “Imagine. She says, ‘I feel like crying.’”
Trainer suggests: “The counsellor could say, ‘It sounds very difficult for you. If I were sitting with you, I’d be looking into your eyes and feel your sadness. I would hand you a tissue.’”
Trainer explains: “This is an alternate way for the counsellor to show empathy. What else can a counsellor do to show her empathy? The counsellor might ask the client, when you feel this sadness, ‘What do you do? How can you get support?’”
The counsellor might move the conversation to talk about how the client can get support and not dwell only on the sadness because the counsellor is trying to help her find her strength.
Without body language, counsellors needed to learn to express their empathy in words rather than through a kind look. They also needed to learn to ask and use words to check a client’s feelings like, “I wish I could look into your eyes now. I feel it would help me to understand better how you feel. Please, can you tell me what feelings I would see if I looked into your eyes?”
The transition to telephone counselling was possible for the counsellors, since their knowledge and experience with PM+ gave them structure and grounding and a protocol with skills that could be adapted. We found that the full step-by-step PM+ protocol was useful for those people whose lives were affected by COVID-19. However, following all the PM+ sessions was not useful to those people who were sick due to COVID-19 or had sick family members or had lost family members and were grieving. They benefited from counsellors teaching them practical stress management and problem-solving skills and being referred to PSTIC psychosocial workers to manage the practical life issues.
For example, telephone PM+ worked well in assisting a single mother with a child who was autistic. Before COVID-19, the child went to school and the mother went to work. With the lockdown, both were home 24 hours a day 7 days a week together. The mother asked for help since she was continually losing her temper and feared harming her child. The counsellor taught her PM+ skills of stress management, problem-solving for her financial situation and lost work and helped her how to plan time for herself to relax away from her child.
PM+ did not work well with a couple suspected of having COVID-19 who needed medical care and to quarantine at home for two weeks. Their neighbours stigmatised and threatened them after a COVID-19 identified ambulance took one family member to the hospital. They were referred to a PSTIC health worker for health advocacy and a psychosocial worker to organise practical ways for them to get food and be supported by their community.
As the time in lockdown continued, we had increasing numbers of clients reporting symptoms related to old traumas. Counsellors felt the need to have additional skills to know how to manage this depth of distress. It was decided that telephone counselling was not best for this so counsellors referred these people to the PSTIC Mental Health Team.
To broaden our reach to more people in need, we set up a Facebook page with mental health information and tips in six languages. On this page, we offer people the opportunity of leaving a message asking to speak to a counsellor. For example, on World Suicide Prevention Day, our post led to people at risk contacting us to seek counselling.
Our page: https://www.facebook.com/RefugeesTogether
| Back to the Office|| |
This month, the COVID-19 situation in Egypt is reported to be less risky and life is mostly back to normal. For the moment, the COVID-19 crisis has passed. We are hopeful that it will not return. The counsellors were elated to reopen the counselling centre. With masks and disinfectant, they returned to sit in the office with their clients respecting social distancing. Old clients were eager to return and new clients were interested to look into the eyes of the counsellors they had never seen. We have learned that phone sessions can be useful and will be continued for people who have difficultly accessing the centre due to security concerns, disabilities, residential job placement, faraway residence or other issues.
At the beginning of this personal reflection, we mentioned that starting this counselling centre was a test. Certainly, despite the shake-up due to COVID-19, the counselling centre is a success. Our first question was whether clients would make their way through the chaos of Cairo and find the counselling centre. They most certainly do. Next was whether PM+ is an effective technique. Counsellors and clients confirmed this when we were office based. During the crisis, counsellors and clients also confirmed that our transition to telephone counselling maintained an effective response due to having a culturally and contextually knowledgeable team trained to use PM+ which proved to be a practical model easily adjusted to fit the situation.
Financial support and sponsorship
Conflicts of interest
These authors confirm that all that is written honestly describes their work.
The authors confirm there are no conflicts of interest issues in submitting this personal reflection.