Counseling in Burundi
Preliminary 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
Screening
Non-therapeutic
group activities
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
o
o
o
Long term training courses
Cultural adaptations
Training and service-provision by local staff
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 design
o Pre- (A), during- (B) and post-intervention (A)
 Repeated measurements
o Weekly; before and after every session
o Child, counsellor and care-taker questions
o Approximately 16 measurements (4, 8, 4)
 Series of n=1
o
o
o
o
o
Burundi (and Sudan)
11 respondents completed files
Age 11-14
9 Female/ 2 Male
Inclusion based on screening for depression, anxiety
& PTSD and psychiatric indication for treatment
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
Instruments: a multi-indicator
approach
 Outcome variables
o Symptoms checklists (CPSS; DSRS; SCARED; SDQ; CHS;
DF)
o Personalized Outcome Measure
o 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 content
o 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
SCA
RED
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
dsrs total 18
items
(recoded)
60,00
cpss total 17
items
anx total
scared 37
items
50,00
sdq total
(recoded)
Value
40,00
30,00
20,00
10,00
0,00
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16
Case Number
Example of Multi Indicator No-Change
cpss total 17
items
60,00
sdq total
(recoded)
anx total
scared 41
items
50,00
dsrs total 18
items
(recoded)
chs total 6
items
Value
40,00
30,00
20,00
10,00
1 2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20
Case Number
Single-indicator change with ‘milestone’
18,00
Value cpss total 17 items
16,00
14,00
12,00
10,00
8,00
6,00
4,00
1
2
3
4
5
6
7
8
9
10
Case Number
Explanation of Change:
 Start of Intervention
11
12
13
14
15
16
Single-indicator change with ‘milestone’
35,00
Value cpss total 17 items
30,00
25,00
20,00
15,00
10,00
5,00
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Case Number
Explanation of Change:
 Involvement of father in counseling session: psycho-education
and normalization of children complaints make father reassured
Multi-indicator change with ‘milestone’
dsrs total 18
items
(recoded)
60,00
anx total
scared 37
items
50,00
sdq total
(recoded)
cpss total 17
items
Value
40,00
chs total 6
items
30,00
20,00
10,00
0,00
1 2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20
Case Number
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
Multi-indicator change with ‘milestone’
dsrs total 18
items
(recoded)
60,00
anx total
scared 41
items
50,00
cpss total 17
items
Value
40,00
30,00
20,00
10,00
0,00
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16
Case Number
Explanation of Change:
 Phase of coping strategies, ‘solutions’ and ‘advice-giving’
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