Western society has come to take for granted the availability of counseling and psychotherapy, along with urgent care for mental health emergencies and long-term care for the more serious problems. In many other countries around the world, however, even the basic services may be severely limited. Even in the US, which has modestly good services, there are serious gaps for minorities and those who cannot afford to pay privately for services. Innovative new initiatives to fill some of these gaps are being developed in the US and Africa. This article discusses mental health needs, available services, and new initiatives to help fill these gaps.
Key words: counseling, psychotherapy, friendship bench, grandmothers
There are problems and limitations in making psychological services available to everyone who needs them. Treatments may require several weeks or months (sometimes years, with more difficult problems), are expensive, are usually not covered for more than a few weeks or months by healthcare plans, and decreasingly available for those who have to rely on government-provided or other public services (due to ongoing budget cutting).
In many countries, psychological problems are often present in far more people than there are resources to help them deal with them. Professional services are often severely limited relative to the numbers of people in need. This is particularly true for people who have to rely on government, charitable or religious institutions for psychological services. For instance, in developing countries there may be one psychiatrist for hundreds of thousands or even millions of people.
This discussion focuses on innovative ways to broaden the varieties and availability of psychological interventions for underserved populations.
Current therapies and therapists
There is a spectrum of conventional interventions for dealing with psychological and relationship problems.
– Coaching helps people identify and clarify problems that arise in their lives, and then to sort out the best ways to deal with their problems. Coaching focuses primarily on what is happening in the present. Much of what is offered in coaching has to do with enhancing understanding of current day problems and identifying approaches and skills that may improve peoples performance and satisfaction. Coaching is often focused on specific settings and activities, such as sports, professional services and businesses.
– Counseling takes this several steps deeper. Counselors help people to identify issues arising out of unidentified, unresolved and/or unexpressed feelings, residues from past experiences, attitudes, habits and blind spots, and to acquire new understandings of their situations in order to sort out their challenges.
Most counselors are required to have an undergraduate degree in education, counseling or psychology. To work as a school counselor, a master’s degree in school counseling or education psychology may be required. Other training may be required to work as a rehabilitation, substance abuse, school, mental health or pastoral counselor.
Group counseling is similar, but includes small groups of people who share their issues in regular meetings. The term, group counseling is generally used to describe what is often a lighter form of the more accepted term, group therapy. It is most often applied to such groups in university and other school settings (e.g. University of Iowa, Web ref.)
Co-Counseling is a variation in which laypersons, untrained in psychotherapy, are guided through a process of talking in pairs in order to better understand and deal with problem issues, with the help of various protocols. People in pairs take turns talking about their problems, while their partner listens without criticism and provides general guidance. For instance, Co-Counseling International
(Web ref.) suggest the following steps to help in dealing with problems:
Discharge can be brief or a long draining of distress (perhaps equivalent to the distress which would have been appropriate to the original experience). Experiencing our feelings relieves the pressures of holding back the distress. The length of time used to discharge feelings can assist us in gaining information about our distress patterns.
Re-evaluation is the use of the intellect and thinking to sort out an experience. We especially use it to sort out the different perceptions given by the one foot in, one foot out experience. In Co-counseling Fundamentals worksheets are provided to assist the practitioner in gaining information to aid the process of re-evaluation.
Validation is the process of exploring and discovering qualities about ourselves that we appreciate. It is similar to the delighted exploration that a small child does of his/her feet, toes, fingers or the environment. It can be experienced as joyful exploration.
– Psychotherapy includes a broad spectrum of approaches that help people identify and better understand the problems in their lives. It includes the items noted above under counseling, and goes further and deeper in varieties of ways.
Rogerian therapy reflects what clients are saying back to the clients, in a totally accepting, non-judgmental way. This sort of uncritical acceptance is very calming and supportive.
Psychodynamic psychotherapy reflects back to the clients what the therapist observes, along with the understandings and interpretations of the therapist about how the clients are presenting themselves. This gives clients new insights, suggestions and experiences in how to deal with their thoughts, feelings and relationships.
Cognitive Behavioral Therapy (CBT), the prevalent favorite in Western psychology, focuses on behavior modification through diminishing negative elements of cognition and behavior and then building and strengthening of positive ones.
Jungian psychotherapy explores peoples emotions, memories and archetypal awarenesses that connect them with the collective consciousness.
Mindfulness meditation offers a systematic way to calm ourselves and to detach from stress, worries and trauma.
Energy Psychology (EP) teaches people to clear negativity and install positivity through self adjustments in their acupuncture meridians, chakras and biological energy fields, combined with systematic reprogramming of thoughts and emotions to achieve agreed goals.
Marital and family therapy addresses peoples relationships with those who are close to them.
Past life therapy explores residues of memories and traumas from previous lives that impact people in their current lives.
Family constellation therapy identifies issues from members of the extended family on individual family members, including residual traumas from members in previous generations who are no longer alive.
Wholistic healing broadens peoples awarenesses of their body, emotions, mind, relationships (with other people and the environment) and spirit. This teaches people to clear blocks to awareness, deepen their entire interconnectedness of themselves and their relationships with life, the universe and everything, and integrate themselves on every level of their being.
Religious institutions often offer counseling or therapy of various sorts for their congregants.
Psychiatrists, focusing narrowly on physical and genetic contributors to psychological problems, offer medications. These may help to manage the symptoms, but rarely address the causes of the problems.
The above are just a few of the more prominent from over 400 identified forms of psychotherapy for dealing with psychological problems (Beutler, Bongar & Shurkin, 2001; Brazier, 2017). See also detailed discussions of some of the more prominent therapies in Sommers-Flanagan and Sommers-Flanagan, Rita (2015).
The principal differences between counselors and psychotherapists are in their academic training. Generally, counselors focus on more limited life issues, such as relationships and grief, while psychotherapists help deal with more complex, long-standing mental health issues. In practice, there is great overlap between the two, and there are counselors and psychotherapists doing both.
There are many professional caregivers in Western society who provide counseling and psychotherapy, such as medical doctors, psychotherapists, social workers, nurse practitioners, coaches, and schoolteachers. Each professional group may have specialized own trainings, which includes theory and supervised practice. These practitioners are also required to practice under supervision for specified numbers of hours in order to obtain their licensing, so that instructors can mentor them into deeper awarenesses and understandings of peoples problems, and help them hone their caregiving skills to the standards of their chosen profession. In addition, many therapists and counselors also undergo counseling or therapy for themselves, in order to understand the process better, as well as to identify and work through personal issues (such as trauma, interpersonal boundary unclarity, emotional instability, and more).
Members of each professional group may include a single psychotherapy approach or numerous options and combinations of eclectic approaches in their work with clients. Some professional groups are more inclusive than others; other professional groups are narrowly focused on one or several approaches. More on this below.
What are the benefits of counseling and psychotherapy?
These forms of interactions offer psychological supports, social skills learning and insights into feelings and behaviors for people who have limited or no family or personal support systems to provide the help they need to sort out the personal and interpersonal life issues that are challenging them. While counseling tends to be a lighter form of intervention, there are broad areas of overlap with psychotherapy. Many people may be helped by either approach, depending on the intensity and severity of problems and the skills of the therapist.
Support – Simple listening is a form of support. This person-centered therapy was developed by Carl Rogers, a psychologist, in the middle of the 20th century. It is based on the understanding that by offering unconditional positive regard to people, their belief in themselves is markedly strengthened.
You may find it hard to believe, but this simple atmosphere of deep acceptance has been found to be a distinctly healing experience for many people. Joseph Weizenbaum created a computer program in 1966 in an artificial intelligence lab at MIT. He named it Eliza. The program would reflect back phrases that were similar to those typed by people who interacted with her.
Many people felt the computer truly and deeply understood them, although the computer had very basic programs that made this completely impossible. The computer was just responding in the most simple ways to the inputs it received, according to the automated program Weizenbaum had written. It would rephrase and reflect back the feeling words and phrases the human used, or ask simple questions that invited the human to expand upon what he had written, thereby giving the impression that it understood and sympathized with the human. In one situation, the Eliza program was offered as an alternative to people having to be on a waiting list to see a psychotherapist at a clinic. At the end of the waiting period, to the surprise of the researchers, some of the people said they would be happy to continue with the computer rather than to speak with a human therapist. You can explore this yourself with an on-line versions of Eliza, a computer therapist (Web ref).
Emotional awareness – People often focus on what they are saying and doing but overlook the how of their behaviors and responses towards others. A counselor can reflect back to the client how the counselor feels in response to what the client says and does. People are guided to look at how they feel in problematic situations and are helped to deal with these feelings. Group counseling multiplies the varieties of responses and broadens the spectrum of interactions, offering more varied opportunities to learn and grow
Problem resolution Is easy to get stuck in patterns of thinking and behaving. This may simply be out of limited exposure or education in perspectives and life skills. It may be within family, religious and cultural systems of belief and disbelief. Our patterns of (sometimes rigid) thinking, feeling and behaving are habits. Whatever we practice repeatedly, through the mechanism of neuroplasticity, becomes reinforced and ingrained over time. Counseling invites us to consider alternatives to our habitual ways of perceiving the world and responding to it. Interactions with the therapist and with other participants in group counseling also offer us opportunities to practice new ways of behaving and of responding to others.
Connection and development of rapport within the therapeutic encounter are important experiences that can help us develop our relationships outside the therapy. Many mental health issues appear to be a result of dislocation or disconnection. Conversely, people who feel connected to their partners, family, careers, community and to their Higher Selves generally are mentally healthier, and less likely to become addicted, depressed, or suicidal. Therapists help to identify blocks and other problems in these areas, and help people to expand their awarenesses and skills in improving emotional satisfactions in life.
When family members offer couseling
In days of old in modern societies, in the generations before people commonly moved far away from home, and still, currently, in traditional societies (as in Africa, Asia and some parts of the Americas), family members have been available to meet many of the counseling needs in their communities.
Parents, grandparents, uncles, aunts, cousins and other family members live close enough so that people in distress can find an empathetic and understanding ear, heart, and a calmer, wiser head and spirit to provide the supports they need when they are distressed or in emotional overwhelm.
In Western societies, despite our geographical distancing from family, modern communications and social networks are increasingly reconnecting us with distant family members. However, we often lack the emotional closeness that comes from living together and rubbing elbows frequently, which would encourage us to seek their counsel and support.
Tami, at the age of 5, the youngest of 3 children in a farming family, was upset when the familys 5 month old puppy, Joey, was carried off by a fox. Tamis parents and older brothers shrugged this off, but she was just devastated. Neither Tamis parents nor her brothers had the time to do more than to reassure her they would get another puppy sometime soon.
Her aunt Jenny was staying in Tamis home, caring for her 1 month old baby with the support of Tamis family, as Jennys husband was a soldier, serving far from home. Jenny was able to hug and console Tami with her free arm, while she held her baby to her breast with her other arm.
They had a long talk about how Tami missed Joey; how sad she was that he was dragged off that way; how she missed Lola, their aged collie who had died six months earlier; and other issues of these sorts. Tami was much calmer after this talk with Jenny. She was particularly thoughtful over Jennys telling her she was sure Joey was in heaven.
Vanessa was sobbing when she phoned her mother, who lived half a continent away. She had been up for many hours, night after night, doing her best to comfort Sharon, her three-month old first baby, who woke often at night and wouldnt stop crying. Bob, her husband, worked long hours in a stressful job and could only help with Vanessa on the weekends. Her pediatrician had examined Sharon twice and found nothing wrong, diagnosing this as a common case of colic.
Suggested changes in diet had had no effect. Reassurances, with predictions that this would eventually clear, very probably by the time Sharon reached six months old, were promising but in no way helpful with the immediate, highly stressful situation.
Her mother reassured Vanessa, yet again, that this would, indeed, pass, as it had with Vanessas older brother when he was a baby. They chatted for a while, as Vanessa calmed down.
Her mother shared a suggestion from another grandmother: Use earplugs while holding Sharon (not while sleeping, when Vanessa might not hear her daughter needing comforting). Though this would not change anything for Sharon, lowering the intensity of the sound of her crying might lessen the intensity of Vanessas distress. And her mother reassured her that she not only didnt mind, but would feel pleased to offer her support at any time of day or night when Vanessa felt overwhelmed. And so it was, with Vanessa feeling less upset over the following six weeks, till Sharons colic stopped. Just knowing her mother was available had been calming, and she only needed to call her a few times
Bill and Doris had been happily married for three years. In their first two and a half years together, Doris had not minded Bill going out for a long evening of poker with his buddies every Friday, as she, herself, enjoyed the personal time on such evenings for getting together with two unmarried girlfriends for some womens time. But their arrangement came apart after their son was born, and Sharon no longer had the energy for a night out. She wanted Bills help at home for the full weekend, since she never had any time off for herself. Bill, however, wanted to continue with his poker evenings, feeling he needed some man time and down time after a weeks work, combined with an hours commute to and from his job. They found themselves in an escalating battle of wills and wonts that was getting increasingly bitter.
Bills parents came to their rescue, coming over to mediate their negotiations and help them come to a mutually satisfying agreement.
Sally and Charlie had three children of their own, 8, 11 and 13 years old. They agreed to be foster parents for Joe, a troubled 10-year old boy whose family had been members in their church, when Joes parents were both killed in a car accident caused by Joes father, who had had a serious drinking problem. Joe had had psychological and behavior problems prior to his parents deaths, but they were markedly worse following the accident. Sally and Charlie both had to have jobs in order to make ends meet, and had little resources for the psychotherapy that Joe clearly needed. They were fortunate to find their way to an Energy Psychology (EP) therapist who taught Joe and these foster parents how to use Emotional Freedom Techniques (EFT) for self-healing (ACEP, Web ref). With a minimum of ongoing phone guidance from their therapist, they were able to guide Joe in using EFT to clear his grief over losing his parents and to deal much better with his behavior problems at school.
So the good news is that warm, supportive family members can provide encouragement, information, shared life lessons, insights and many other forms of support that can produce effects which are similar to what people get in counseling. (See also more on Energy Psychology below.) The bad news is that families may also include people with limited insight and understanding, who may lack the empathy and wisdom needed to offer support and healing for what is bothering and hurting other family members. And many in modern society dont have the closeness with their families that would encourage them to seek this family support.
Enhancing family members’ counseling
What if people who are naturally inclined towards counseling were offered training to enhance their counseling skills? This sort of counseling was highlighted in a recent Ted Talk by Dr. Dixon Chibanda (Web ref.). Chibanda, a psychiatrist, has been concerned and frustrated by the absence of human resources to deal with serious depression and suicide in Africa.
Dr. Chibanda is one of 12 psychiatrists in Zimbabwe for a population of more than 16 million. Realizing that his country would never be able to scale traditional methods of treating those with mental health issues, Chibanda helped to develop a beautiful solution powered by an abundant limitless: grandmothers. In this extraordinary, inspirational talk, learn more about the friendship bench program, which trains grandmothers in evidence-based talk therapy and brings care, and hope, to those in need.
Dr. Chibanda started the Friendship Bench in one of Harares townships called Mbare in 2007 and conceptualized the first Friendship Bench intervention that has now been refined and adapted considerably (Web ref.).
Grandmothers, who are trained in psychological interventions, meet with people on an outdoor bench to discuss their problems and explore various possible solutions. Not only is this culturally congruent in Zimbabwe, but it makes use of a major, hitherto untapped human resource. The grandmothers are also instructed to watch for signs of suicidal thoughts and to refer people to the nearest professional mental health facility. Even though support services may be several hundred miles away, this is far better than the situation before grandmothers were available on their benches. Early research confirms this is a beneficial intervention (MHIN, Web ref.)
This approach is particularly effective in Africa and other countries where grandmothers counsel is honored and respected in peoples families.
Several US and Canadian schools have placed a bench in a prominent spot, where anyone who is feeling in need of support can sit. Passers-by are encouraged to stop and provide a listening ear and whatever support they can offer (9News, Web ref.; The Friendship Bench, Web ref.; HereToHelp, Web ref.). There is generally no training associated with this sort of bench for school students, but there are various ways in which the school students are educated about depression and the potentials for suicide.
The Friendship Bench is a destination where secondary and post-secondary students who are struggling to connect with others, and find it difficult to ask for help, can talk with someone willing to offer an ear to listen with, a shoulder to cry on or just a hello.
Developing new initiatives for psychological support and counseling outside the family
Howard C. Stevenson (Web ref.) has developed similar initiatives in the US for dealing with racial empowerment for African-Americans and more.
With the help of my many colleagues at the Racial Empowerment Collaborative, we use in-themoment stress-reduction in several research and therapy projects. One project is where we use basketball to help youth manage their emotions during 60-second eruptions on the court. http://www.heretohelp.bc.ca/visions/social-support-vol6/social-support
Another project, with the help of my colleagues Loretta and John Jemmott, we leverage the cultural style of African-American barbershops, where we train black barbers to be health educators in two areas: one, to safely reduce the sexual risk in their partner relationships; and the other, to stop retaliation violence. The cool part is the barbers use their cultural style to deliver this health education to 18- to 24-year-old men while they’re cutting their hair.
Another project is where we teach teachers how to read, recast and resolve stressful moments in the classroom.
And a final project, in which we teach parents and their children separately to understand their racial traumas before we bring them together to problem-solve daily microaggressions.
I believe that these brilliant initiatives have vast, global potentials for filling serious gaps in healthcare systems.
Energy Psychology (EP) in Africa
EP teaches people to tap on specific series of acupressure points, while focusing their minds on problem issues. Following their statement of their problems, they focus on a strongly positive thought and/or feeling. This provides people with tools to address their problems, even when they are of serious nature (such as post traumatic stress) and have been present for a long time. Again, this is a method that people can use on their own.
Suzanne Connolly (2016) and others have taught survivors of the 1994 Rwanda genocide to clear their post traumatic stress disorders. People have been successful even in severe cases, where previously they had suffered for over a decade with incapacitating flashbacks, temper outbursts, addictions, nightmares, insomnia, inability to get along with their family and friends and more. Most encouraging of all, they have been able to pay it forward, teaching others to use this method (Jenny
Edwards, 2016). They estimate that over 30,000 people have been helped, with a very modest input from professional therapists, and research is beginning to confirm the efficacy of these EP interventions (Connolly, Roe-Sepowitz, Sakai & Edwards, 2013).
Gunilla Hamne and Ulf Sandstrm (2017) have sometimes combined Thought Field Therapy (TFT), a variant of EP with songs and dances, calling this the Trauma Tapping Technique. They have taught it n numbers of countries in Africa and other parts of the world. Their article includes links to videos of their work.
In the footsteps of conflict there is often more conflict, because hurt people hurt people. Experiencing emotional and traumatic stress can cause our nervous systems to go into a state of hypervigilance, triggering defense and attack reactions in situations where they no longer are necessary. In areas of conflict and post-conflict there is rarely an infrastructure allowing conventional treatments for trauma on a one-to-one basis. An optimal solution is one that can be carried from peer to peer by non-specialists, empowering each individual to be able to stabilize
themselves and their community. One such method has been taught in over 20 countries since 2007 in a model that allows it to spread efficiently, at the lowest cost possible, with maintained integrity and a minimum of spoken interventions. It is called the Trauma Tapping Technique.
EP is particularly helpful because it empowers people to treat themselves, whenever they feel the need for stress and trauma relief. It is so simple that one person can teach another. Each one teach three has become their motto.
Possible problems with in-family counselors and lightly trained counselors
There are significant differences between the professional practices of counseling and psychotherapy and talking with a family member or a lightly trained grandmother on a bench.
In professional interventions there are rules, defined therapeutic techniques and a clear agreement regarding the therapeutic relationship.
The counselor or therapist will:
- Work with the careseekers with clear interpersonal boundaries, with the caregiver providing the interventions detailed above in a professional manner
- Maintain objective points of view, reflecting on possible actions and outcomes but not dictating actions, choices, or taking sides in disagreements
- Encourage the careseekers to develop their own solutions to their problems rather than immediately suggesting courses of action
- Help careseekers set and pursue goals in a stepwise manner to the point of resolving their presenting problems
- Understand and be alert to dangers of serious depression and suicide potential, trauma and situations where trauma residues could be triggered (with anger, violence towards self and others), and psychotic disorders
- Be familiar with local backup resources, if any, for serious problems
Grandmothers may or may not be able to understand or adhere to the standards expected of Western trained counselors and psychotherapists. However, they have various capabilities and gifts in natural intelligence, personal life experience, and participation in their own family dynamics and local traditions and expectations. They are very likely to be capable of teaching self-calming methods such as relaxation, meditation and other self-help skills. Energy Psychology, in particular, is proving to be very amenable to this sort of caregiving intervention (Connolly, 2016; Connolly, Roe-Sepowitz, Sakai, & Edwards, 2013; Edwards, 2016; Hamne & Sandstrm, 2016).
Potential roadblocks to deploying grandmother caregivers
The attitudes of conventional therapists towards grandmother caregivers may create difficulties in the acceptance of these new mental health specialists in countries where the existing therapists are well established. A good deal of this may be due to concerns over economic competition. But much of this also relates to the problems of adjusting to new ideas and new ways of doing things.
We put things away in boxes to keep our spaces neat. This is as true of our inner worlds as it is of our outer environments. On the one hand, this makes life feel easier and tidier in many ways.
- Professional therapists, particularly medical doctors, nurses and psychologists, are cautious in prescribing and administering therapies unless these are validated in rigorous research. They will not endorse a new therapy without evidence of efficacy from studies comparing effects of a clearly defined intervention in one group of people with a clearly defined problem, matched against a control (comparison) group of people who are as near to identical to the first group but who receive no therapy or therapy with a treatment that is already validated in this way.
- These therapists have been trained to believe that approaches which are unvalidated in rigorous research may be no more than placebos (effects of suggestion), and therefore they are to be avoided.
- These therapists tend to ignore and even to disparage, placebo effects.
- These therapists are likely to caution against using in-family counselors and lightly trained counselors, or even to disparage them.
On the other hand, the above attitudes and approaches can be terribly misleading when we go to retrieve items from our inner boxes, or to store new information in our old boxes. We may mislead ourselves and may be sorely served by conceptualizing particular interactions as belonging in one of these boxes or another. The boxes into which we put items originally may not be the right ones for new items we wish to store away, nor for identifying and applying old items that will be helpful when we fetch them out of storage. It is helpful, at times, to re-examine our inner boxes and to re-label them, taking into account our more recent and more mature awarenesses in how we label them
(Benor, 2017b). This is a problem to be anticipated when we consider the benefits that can be achieved with the help of counseling, group counseling, psychotherapy, grandmothers on benches, and life in general.
I have a large inner filebox for self-healing, probably larger than most people in general, and certainly larger and more eclectic than the vast majority of my medical and psychotherapy colleagues. For instance, in contrast with my colleagues in these professions, who usually view placebo reactions as a nuisance in evaluating real therapies, I view placebo reactions as one of the best approaches for healing available. The belief and will to live, the will to recover) may be THE essence of healing
I see placebo reactions as the activation of the incredibly vast and potent abilities we have for selfhealing. For instance, remarkable recoveries have been seen with placebo/self-healing reactions (Benor, Web ref.) in
- physical and psychological pains of all sorts
- arthroscopic surgery of the knee (Moseley, OMalley, Petersen & Menke, et al., 2002).
Many of our interactions with others are essentially co-counseling and group counseling. We miss much of the value of interactions in our lives when we fail to acknowledge this. On deeper levels of our being, we are incarnated in series of lifetimes. Each life we live has its own lessons in our personal, family and collective soul journeys.
My recommendation is that grandmother friendship bench therapists are a very welcomed addition to the support systems that can help us on our life journeys. And I wouldnt refuse a patient, wise grandfather who is a good listener a place on such a bench, either.
Lets put our grannies and granddads to work!