Counseling in Burundi Preliminary Results of a Single Case Study

1. 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

2. 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.

3. Child Thematic Project (CTP) Development of comprehensive research informedcommunity 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

4. CTP Implementation Community Awareness Raising Screening Non-therapeutic group activities Classroom Based Psychosocial Interventions (CBI) Counseling Community –level Psycho-education Referral to other services

5. 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

6. Counseling development proces I • Treatment modality has been developed and adapted in non-Western settings • Long term training courses • Cultural adaptations • Training and service-provision by local staff • NGO-based intervention model

7. Counseling development proces II • But what do we know about the theoretical framework of this intervention in the non-west • How does verbal-based healing for psychosocial work in non-western context? • What are the working ingredients and therapeutic processes underlying counseling? • How can existing therapeutic schools contribute to the development and adaptation of counseling in non-Western contexts?

8. 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

9. Research design • ABA design • Pre- (A), during- (B) and post-intervention (A) • Repeated measurements • Weekly; before and after every session • Child, counsellor and care-taker questions • Approximately 16 measurements (4, 8, 4) • Series of n=1 • Burundi (and Sudan) • 11 respondents completed files • Age 11-14 • 9 Female/ 2 Male • Inclusion based on screeningfor depression, anxiety & PTSD and psychiatric indication for treatment

10. Measurement Schedule • Measurements A1 – A4 (waitlist) • Outcome measures • Major life events • Measurements B1 – B8 (pre-session) • Outcome measures • Major life events • Measurements B1 – B8 (post-session) • Perception of treatment • Counselor log-book • Measurements A5 – A8 (follow-up) • Outcome measures • Major life events

11. Instruments: a multi-indicator approach • Outcome variables • Symptoms checklists (CPSS; DSRS; SCARED; SDQ; CHS; DF) • Personalized Outcome Measure • Behavioural Changes (observed by parents and/or teachers) • Intervention variables • Generic intervention strategies (rapport building, problem assessment, practical assistance, problem-solving, symptom management) • Specific intervention strategies (Psycho-education, relaxation exercises, drawing, behaviour modification techniques) • Session content • Treatment perception • Life events

12. 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)

13. “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 oftrust) • 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

14. 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 + + + + + + ^ + Preliminary Results: visual inspection

15. Example of Multi Indicator Pos-Change

16. Example of Multi Indicator No-Change

17. Single-indicator change with ‘milestone’ Explanation of Change: • Start of Intervention

18. Single-indicator change with ‘milestone’ Explanation of Change: • Involvement of father in counseling session: psycho-education and normalization of children complaints make father reassured

19. 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

20. Multi-indicator change with ‘milestone’ Explanation of Change: • Phase of coping strategies, ‘solutions’ and ‘advice-giving’

21. Conclusions • Single case methodology demonstrates multitude of changes during a counselling process • This method provides information about factors related to changes • Clearestchanges are observed on symptoms of depression, anxiety and PTSD

22. Thank you for your attention