Impact of Mental Health Training on Mental Well-being of Lay Counselors in Northern Uganda
Corresponding author: Dr. Emilio Ovuga Department of Mental Health, Faculty of Medicine, Gulu University, P.O. Box 166, Gulu, Uganda. Tel, +256-793-210820; Email:firstname.lastname@example.org
The training of lay counselors to provide mental health first aid and psychological support to people in distress has been conducted or evaluated in different settings for college students[ 8 -10 ], community peers [10-12 ] and in emergency care settings . However data on the mental health of counselors in different settings is limited as the evaluation of training lay counselors has focused mainly on their effectiveness in the recognition of mental disorders and, impact on outcomes of interventions delivered by peer counselors [8,14].
In our case VHs were drawn from the same communities that had the same lived experiences of armed conflict in Northern Uganda as individuals that live with mental health and psychosocial problems. We hypothesized that the trainees also would have unrecognized psychological problems as the rest of the community members. We therefore built in a mechanism and system of identifying trainees with pre-existing mental health problems on the hypothesis that the process of training community representatives in the provision of psychological first aid might have protective and therapeutic effects on the personal mental health of the trainees. Our approach aimed to relate the overall goal of training not only at imparting helping and listening skills in our trainees, but also imparting skills for introspection and understanding of oneself as a pre-requisite to helping other persons in distress. Once we detected any evidence of general psychosocial distress, mental disorder and or suicide risk, we also provided appropriate personalized psychological support during and after the training, as a moral and ethical obligation. In this paper we report: a) the impact of training on the psychological well-being of trainees in the immediate post-training period, b) assess the probability that VHs would be able to cope with personal difficulties in their own lives, and c) and assess the impact of training on social functioning of lay counselors.
Materials and Methods
We held several consultative planning meetings with District Local Government leaders, civic and political leaders, religious leaders, and sub-county officials in Gulu district. During these rounds of meetings, our planned emergency response strate-gies were discussed and agreed upon by all parties. The district community development officers (CDOs) under whose docket the emergency response was placed appointed their assistant district officers (ACDOs) in all sub-counties to coordinate the implementation of planned training and suicide prevention programmes in each sub-county. The Sub County teams then selected two community representatives per Parish for training as VHs using the following selection criteria; each person being: kind, friendly and approachable to people; willing to help distressed individuals; trusted; of good social standing; male or female; a youth or of older age and being willing to work on voluntary basis. These criteria were meant to provide for the needs of people of all categories and backgrounds in the community. The selected trainees represented participants of all socio-demographic backgrounds, and who had the full range of everyday experiences in Northern Uganda.
Training was residential and consisted of 8 hours of short introductory lectures followed with interactive experiential discussions every day for five working days. We provided exercises in ascending levels of complexity and difficulty based on common village life problems for trainees to solve in groups. We then provided detailed solutions and feedback to trainees during plenary sessions. The training approach permitted trainees to spontaneously narrate their own personal experiences to the group; this offered a good opportunity for us to impart listening, analytic, empathic, non-judgmental problem-solving skills to trainees. We exhaustively discussed ethical considerations and concerns during expected client-VH interactions to ensure full appreciation of issues of privacy and confidentiality. We conducted trainings at three sub-county headquarters. Each class comprised an average of 20 trainees, which enhanced full participation of every trainee, and allowed trainers to closely observe each trainee during the training. At the end of each day’s training we discussed the process of training in order to better conduct training on the subsequent days. We used a standard teaching methodology adopted in Ugandan training institutions.
Instrument and Assessment of Mental Status
The Response Inventory for Stressful Events (RISLE)
At the beginning and end of the training program we conducted screening exercises on every VH trainee using the revised 32-item Response Inventory for Stressful Life Events (RISLE) [15,16]. The RISLE was constructed using hypothetical case scenarios depicting common stressors and hardships in daily life in rural settings in Africa. The scenarios chosen for inclusion on the instrument indicate the respondent’s adequacy of social support, type and level of stress tolerability, coping ability and adaptive behavior in the face of difficulty. The RISLE derives its usefulness in eliciting reactions to examples of real- life experiences. A high score on the instrument indicates poor stress tolerance, inadequate coping skills and poor social, material and emotional support. A low score on the RISLE indicates good mental well-being with adequate ability to cope with the stresses of daily life. Validation of RISLE against clinical interview using the Mini International Neuro-psychiatric Interview (MINI) showed that the instrument can be used to screen for any psychiatric disorder. At the cutoff point of 10, the RISLE can correctly detect individuals with depressive disorder in 79% of the time, and past month suicidality and any current psychiatric disorder each in 83% of the time. The RISLE’s sensitivity and specificity are 74.6% and 77.1% respectively; its negative predictive value is 83.6; false positive rate is 30.1% and, the false negative rate, 23.8% for any current psychiatric disorder in the general population . A high score on the RISLE indicates poor mental health and a low score, good mental health. Subsequently the validated 36-item RISLE was further reduced to 32 items as four of the items were repetitious and redundant. Appendix I depicts details of the 32-item RISLE questionnaire.
We computed socio-demographic characteristics and present frequencies in table 1. We ran Multivariable logistic regression analysis using STATA version 11.2 to determine if there was a significant difference mean scores on the RISLE between males and females; the married and unmarried, widowed or separated; and those aged 35 years and older and respondents aged 34 years or younger to determine the potential impact of training on the mental wellbeing of trainees. We indicate the mean score changes on the RISLE to determine the impact of training on the mental wellbeing of trainees by the three variables in table 2. Three months after training we conducted in-depth interviews and assessment of the mental wellness of three of trainees that screened positive for depression and suicidal ideation using the RISLE before training. Qualitative descriptions of the changes that occurred in the lives of the three trainees, and that illustrate the probable ability of the VHs to cope with the daily stresses in life are presented as case vignettes 1, 2 and 3. Lacor Hospital Research and Ethics Committee approved this research (054/09/14) and the Uganda National Council for Science and Technology provided ethical approval (Clearance number UNCST ref SS 3678).
Twenty eight per cent of the respondents were female, and 78% were male. The mean ages of males and females were not statistically significantly different. The rest of the socio-demographic characteristics of trainees appear in Table 1. Sixty trainees participated in the training but only 48 had complete test scores for pre- and post-test scores. Of the 12 trainees that
missed either pre- or post-test screens, 6 were absent at the time of the post-test assessment while 10 missed the pre-test assessment. Of the 54 trainees that took the pre-test assess assessment, 5 (9.3 %) screened positive for medium to high suicide risk. At post-test assessment, 6 trainees out of 54 (11.1%) screened positive for suicidality. Part of the explanation for the higher proportion of trainees screening positive for medium to high suicide risk lies in the respective trainees having joined the training on the second or third day of training.
Immediate post-training assessment indicated statistically significant overall reductions in RISLE mean scores based on gender (-2.11, 95% CI -4.21 to -0.02, P=0.05), and marital status (-3.36, 95% CI -5.22 to -1.49, P=0.001). There were statistically significant RISLE mean score reductions at the end of training on a number of individual test items as follows. The reductions in test items based on gender occurred for “life is intolerable” (-0.32, 95% CI -0.32 to -0.49, P=0.000), “wish to be out of this world” (-0.11, 95% CI -0.22 to -0.01, P=0.04), “kill myself before the authorities execute me for alleged murder” (-0.17, 95% CI -0.34 to -0.001, P=0.05), “relieve my relatives of my problems” (-0.17, 95% CI -0.32 to -0.01,P=0.03), “punish my relatives” (-0.14 95% CI -0.25 to -0.040, P=0.01), “kill myself before the full features of HIV/AIDS show up” (-0.16, 95% CI -0.29 to -0.04) and “wish to be dead than alive” (-0.16, 95% CI -0.31 to -0.01,P=0.04). Based on marital status, the following significant reductions in RISLE mean scores occurred post-training; namely: “during difficult time” (-0.17, 95% CI -0.32 to -0.01, P=0.04), “kill myself before they do so for alleged murder” (-0.21, 95% CI -0.36 to -0.07, P=0.005), “if there is no way out” (-0.13, 95% CI -0.26 to -0.004, P=0.01), “relieve relatives of my problems” (-0.17, 95% CI -0.30 to -0.04, P=0.01) and “lost control” (-0.17, 95% CI -0.32 to -0.01,P=0.04). However RISLE mean score increased significantly for respondents aged 35 years and older over those aged less than 35 years for the test item regarding social support from significant others (“remind relatives of their responsibilities” (0.22, 95% CI 0.03 to 0.41, P=0.02). See table 2 for details.Vignettes
The observed differences in mean score reductions on the RISLE suggest that the training appeared to have imparted the required skills in trainees for introspection and, and for trainees to take action for their personal growth, as depicted in the following vignettes.
“My life was full of family problems; the problems were out of control. My husband and I separated. My husband used to drink a lot of alcohol; he did not always stay at home. If he returned home he was rude, used abusive language; he used to give orders only and used to fight. Out of fear I left the bedroom to him and I used to sleep with the children in the food store. We had no sexual relations. After our separation my husband brought two more women to be his new wives, and they lived in my former house. After the training I went to my husband and talked to him and counseled him. We reconciled (smiles). We are now living together with my husband and the other two wives. (Suddenly she appears thoughtful). I wish we had this training earlier. I would not have separated from my husband then. I am now happy. I am now recognized in my community I feel important to my community. People even follow me home to bring me gifts once they have recovered from their problems.”
“Before the training I had many personal problems. My husband was a drunkard and he used to quarrel a lot. My husband’s relatives were telling him to marry another woman because I am a lame woman and useless. I used to think a lot about suicide. I wanted to go away to be alone and stop seeing my husband drink and quarrel. I had no desire for sex and we had no sexual relations. After the training I am now happy and my husband no longer drinks alcohol after I talked to him. I like my work as a volunteer counselor. I now feel stable and I can handle personal problems. I no longer think about death. I use my personal life story to help people in difficulties. I have many friends as a result of my service to my community.”
“Before the training I was mentally disturbed. I was not happy at home. I used not to sleep. I had many thoughts about my problems. I used to suffer from muscle cramps during my sleep. My wife and children were not happy because I was rough with them, and I used to shout at them and quarrel a lot. I was thinking about dying or going away from my home, or going to take alcohol to feel well. One time I told my wife that I was living between two spirit worlds; one spirit was telling me to go and hang but the other was telling me not to. I am now happy without any worries. I am a role model man in the community. I have no work now in my community, as everyone is happy and there are no problems of alcohol abuse.”
We developed an emergency suicide control program in Gulu district in Northern Uganda. We trained 60 lay community representatives as village helpers (VHs), known elsewhere as lay counselors, to provide mental health first aid to distressed individuals at household level. Based on our concerns for the mental well-being of and suicide potential among the trainees, we assessed the mental health and suicide risk of trainees immediately before and after the training. We used an experiential, interactive and problem-solving approach in the training aimed to foster self-awareness and reflection on personal circumstances. Experiential training in this context refers to a method of instruction that utilizes personal lived experiences and observations to create relevance, meaning and understanding of mental health concepts in the course of learning.
As anticipated, 9.3% of trainees were suicidal at pre-test while 11.1% screened positive for suicidality at post-test assessment. These rates, which refer to the prevalence of suicide ideation in the past two weeks based on the RISLE are some-what similar to what Ovuga and colleagues reported . Research in suicidal behavior poses serious ethical challenges. It is generally accepted that there is limited available data for the effective assessment of suicide risk . Suicidal behavior is highly fluid and dynamic; its risk and occurrence may be difficult to determine accurately. It is therefore recommended that research with suicidal individuals should not be conducted without adequate precautions to minimize the occurrence of suicide among research participants. In the course of our training program, we assumed an active and vigilant stance to promote personal growth among trainees by encouraging group support and individual self-disclosure in a helping, non-judgmental, understanding and empathic atmosphere as a strategy to prevent suicide among the trainees in the course of our study. Consequently an overall improvement in mental wellbeing appears to have emerged suggesting that within a small group training, it is possible to use mental health training experience to promote mental wellness and even reduce suicide risk among suicidal VHs. Logistic regression analysis of RISLE overall RISLE item mean scores revealed that significant overall reductions occurred at the end of training based on gender and marital status. Significant reductions also occurred at certain individual RISLE item levels in the areas of stress tolerability (“Life is intolerable”), and responses to (“During difficult times”); coping strategies used in the face of a range of stressors (“Confusion”) and (“Lost control”); lack of social support (“Relieve relatives of problems”, “Remind relatives of their responsibilities”, “Punish my relatives”), and escape in the face of stressors (“Wish to be out of this world”), (“Kill myself after business collapses”), (“If there is no way out”) in case of terminal illness and, (“Wish to be dead than alive”) when faced with general difficulties in life. These findings appear to suggest that males benefitted from training more than female participants did while the married also benefitted more from training than the unmarried, divorced or separated combined. Possible explanations for these results are that males might have learned to handle personal stresses faster than females, and were able to take responsibility for and face problems and challenges in life readily. It also appears that the married, based on their ability to relate the occurrence of suicidal feelings to everyday experience of stressors in marriage, and to analyze and appreciate their individual roles in marital problems, achieved better mental health as a result of training. A first appropriate example was the 27-year-old woman that wished she received the training before she left her house for her husband and his two new wives, the cause of her marital problems. After the training, the 27-year-old woman, as the 38-year-old woman that we conducted in-depth interviews with three months after training both discussed with their respective husbands their marital woes successfully and each was able to settle down to a happy married life. It is possible that the change in mental well-being we observed was the outcome of personal growth that facilitated trainees to handle personal problems adequately. Additionally, each of the trainees apparently acquired the necessary skills to facilitate conflict resolution efforts at community and household level. Each of our three interviewees reported that there was less domestic violence, and less alcohol abuse. The three trainees became role models in their respective communities, which provided them with respect.
Some limitations are worth noting. Our data is not based on a large randomized community trial but a naturalistic observational study in the course of an emergency setting. Not every one of our 60 trainees participated in the pre- and post-test screening exercises for various reasons including domestic and social responsibilities. The small number of “research participants” that took part in the screens undermined the true impact of training. Though we aimed to train more lay counselors, the emergency nature of our preliminary response program limited us to only 60 trainees that Community Development Officers selected. These problems obviously limited the significance levels of our results and, hence generalizability of our impressions at this stage. Forty hours of training over the course of five days may be considered inadequate to promote mental wellbeing among community members who had been exposed to intense psycho-trauma for two decades. However the experiential nature of our methodology might have genuinely promoted the degree of psychosocial wellbeing that we have demonstrated. We have demonstrated preliminary indications that tailored training to deliver counseling and psychosocial support skills to VHs without prior training in mental health can improve their mental wellbeing. Our findings at three months post-training suggested that the VH trainees that had poor mental health were doing well on their volunteer assignment. We recommend future controlled and well-designed studies with ample sample size and for a longer period of training to verify our findings. There is a strong case to use lay village helpers to deliver mental health first aid and promote mental health at household level in settings where psychiatric services are inadequate. However, using lay village helpers will require that such volunteers are of sound mental health and stable personality as they deliver support services to individuals that see no hope in their lives. In our view, the use
of VHs augments the use of multidisciplinary and integrated approach to suicide prevention [19 ].
We are grateful to Mr William Odur and Ms Alice Kipwola for their participation in conducting training; and Mr Odur for providing clinical care for individuals referred to him and Ms Dorine Oyella for counseling services, data collection and follow- up.
The authors declare no conflict of interest.
The Danish Fellowship Center (DFC) provided support for this study as part of the larger Primary Health Care Project of Gulu University.
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