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| PERSONAL REFLECTION |
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| Year : 2021 | Volume
: 19
| Issue : 1 | Page : 125-130 |
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Personal Reflections on Group Problem Management Plus in Nepal: The Importance of Cultural Adaptation and Supervision
Renasha Ghimire1, Pragya Shrestha2
1 Clinical Supervisor, Transcultural Psychosocial Organization (TPO), Nepal
2 Diploma in Gestalt Therapy, Clinical Supervisor, Transcultural Psychosocial Organization (TPO), Nepal
| Date of Submission | 30-Sep-2020 |
| Date of Decision | 06-Dec-2020 |
| Date of Acceptance | 12-Jan-2021 |
| Date of Web Publication | 31-Mar-2021 |
Correspondence Address:
Renasha Ghimire
Clinical Supervisor, Transcultural Psychosocial Organization (TPO), Kathmandu, G.P.O. Box 8974/C.P.C. Box 612
Nepal
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/INTV.INTV_37_20
Two clinical supervisors supported the implementation of Group Problem Management Plus (PM+) in feasibility, acceptability and effectiveness trials in Nepal. In this personal reflection, they share lessons learned and experiences on the importance of cultural adaptation and supervision in implementing an intervention delivered by lay community workers. They outline how they made these adaptations and what they learned from doing trials in a new setting such as Nepal. Interventions such as PM+ are simple and effective in any community and work even better in communities affected with adversities. The personal reflection discusses best practices for training, the challenges faced, and the impact that the project had on the clinical supervisors and the Group PM+ facilitators.
Keywords: cultural adaptation, research-based psychosocial intervention, supervision
How to cite this article:
Ghimire R, Shrestha P. Personal Reflections on Group Problem Management Plus in Nepal: The Importance of Cultural Adaptation and Supervision. Intervention 2021;19:125-30 |
| Introduction | |  |
From 2016 to 2019, we were clinical supervisors for the implementation of Group Problem Management Plus (PM+) feasibility, acceptability and effectiveness trials in Nepal. Author 1 was the field-based supervisor − a psychologist by training and with PM+ being her first experience with research-based work. Author 2 was the central office-based supervisor − a therapist with more than a decade of experience in mental health and psychosocial services. She also did not have much experience of research-based psychosocial interventions prior to PM+. She was a trainer and travelled once a month from Kathmandu to support the field clinical supervisors.
In this personal reflection, we share our lessons learned and experiences on the importance of cultural adaptation and supervision in implementing an intervention delivered by lay community workers. We also discuss best practices for training, the challenges we faced and the impact that the project had on us and on the Group PM+ facilitators.
| Cultural Adaptation | | |
Training and the Importance of Practice
We were trained in Group PM+ by a master trainer from Pakistan. The training focused on both theory and practice. It was a milestone to start Group PM+ in Nepal, which helped both of us build confidence as PM+ supervisors. We personally liked the training of trainers (ToT), which was designed so well with many interactive activities instead of lectures. The methodology was fully experiential with enough time to practise skills.
After receiving the initial training, we were unsure about the programme because we had never delivered such a structured intervention. However, after several practices, we saw its effect on people and on us individually. As part of the adaptation process and after the ToT, we decided to run Group PM+ with two female groups and one male group to familiarise ourselves with the manual and to help in the process of adapting the manual to the cultural context in Nepal.
For the first group, we selected a temple as the venue for the training, but soon realised that it was not appropriate because people came to pray during our sessions. We learned how important the selection of a venue is to the success of a session. From this first practice group, we also learned that sessions took longer if people with limited literacy were in the group. Delays in sessions occurred when participants sometimes forgot when the sessions would be held and female participants over 50 would commonly share about physical complaints. The second group of women had a higher level of literacy and we found we could complete the sessions on time because we did not have to provide as many explanations. One of the women shared that being in the group and listening to solutions given by the group was very helpful for her. We learned from the male group that a helper or co-facilitator was needed for training. The helper would arrange refreshments, training materials and support any distressed participants separately from the group. These practice groups helped us to train lay facilitators and supervise them. We learned the importance of conducting at least three rounds of PM+ practice groups regardless of the clinical supervisors’ years of experience to enable everyone to fully understand PM+ concepts and processes.
Similarly, we helped the Group PM+ facilitators to learn the importance of social mapping and linkage with existing resources during the practice rounds before implementation. For example, during one of the women’s groups practice sessions, the husband of one of the participants came to the session to search for his wife. He was drunk. The participant took her slippers and hid from her husband in another room. The facilitator did not know what to do. The helper went to support the participant hiding in the other room. The facilitator contacted a local counsellor immediately to find a organisation dealing with domestic violence. The counsellor said that she knew the husband and that this had happened before. She gave the name of an organisation and fortunately the organisation was nearby. This practice training showed the importance of connecting to local resources and facilitators also learned how to deal with unexpected situations such as this one.
Metaphors for Each Strategy
Because metaphors are often used in Nepal to clarify concepts, we used many metaphors within the intervention for each of the strategies. The facilitators voted on calling the whole intervention, kulla mann karyakram (open heart-mind programme). One of the participants even shared that hearing the words kulla mann lessened her sadness. We used other metaphors for other activities and concepts. For example, we used the metaphor of a pressure cooker instead of tangled wool. If a pressure cooker is not released, it explodes − this is similar to our feelings and difficulties if we do not express ourselves. Participants understood this metaphor well. It also fits well with other concepts such as mann ko kura pokhne (sharing), especially in the session about strengthening social connections. Participants also expressed how difficult it is to keep things within themselves and live with those thoughts alone.
Another metaphor we used in the ‘Get Going, Keep Doing’ session was the turtle. Just as the turtle from a well-known story here in Nepal is very determined to reach its goal, so we can set and reach our goal in life. This metaphor provides participants with a powerful example of the importance of keeping on moving, especially during times of distress. Likewise, we gave everyone a thaili (a Nepali pocket − see [Figure 1]) in session 3 to collect stones/sticks/corn for each activity completed. We remember at the beginning of session 4, one of the women (with limited literacy) bringing seven small pieces of stone and sharing that she had watered and taken care of her flowers seven times since session 3. She was very excited to share this with us.
Another key metaphor arose out of a discussion over a meal in a local restaurant in Sinduli together with the PM+ team (including the principal investigators, co-investigators, project coordinator and district coordinator). We came up with the ‘tension framework’ (see [Figure 2]) as a result of this informal discussion to explain the concept of PM+ in one picture. Based on this framework, we then went on to develop the tension toolkit (see [Figures 3],[Figures 4],[Figures 5],[Figures 6]). This toolkit helped us as PM+ facilitators and as participants in many ways. For example, it acted as a reminder to practise each strategy at home, providing take-home messages for each session and giving motivation to adhere to the treatment.
Supervision
As clinical supervisors, our role included the supervision of counsellors, Group PM+ facilitators and community informants. We were devoted to staff motivation and wellbeing because if the staff have good connections with each other, work and communication are more effective. We would start each facilitator supervision session with a personal reflection, which helped build trust among the group and strengthen our resilience to the challenges faced when conducting sessions. We believe that regular supervision helped the success of the programme and therefore it was necessary for a field-based supervisor to live in the community and conduct regular sessions there.
The core supervision work addressed the challenges that facilitators faced with the manual, the intervention itself, group management skills and interacting with community members. Each participant would discuss their experiences and others would relate and share their tactics to address these challenges. All of the facilitators learned to take both positive and negative feedback with acceptance and positivity. It was so encouraging and satisfying to see this as a supervisor and it felt like an achievement to see the facilitators apply their feedback into their work. At the end of each supervision session, each of us shared what we took away from that supervision session. Using these methods, the facilitators were able to ventilate their feelings and difficulties. Experiences interacting with community members impacted facilitators and their work performance. For example, a facilitator was once yelled at by a local community member for asking about their mental health. The facilitator felt discouraged by this event but was able to process it because of the personal reflection and support provided at supervision sessions. At the end of each supervision session, we always ended with good food. Eating together was also one of the things that motivated us and created a sense of belonging as a team.
Despite being supervisors, we also had our own supervision with the master trainer of PM+. Since the master trainers were from a different country, the cultural context was different, and we were not sure if they would understand us. But they were helpful and it was so nice to see them curious and enthusiastic to answer each question and address every challenge we went through. The supervision with the master trainer happened once in a while, but we also had a local level supervisor who would visit us often for immediate support. As both supervisees and supervisors, we learned to take a stand for our beliefs and advocate for our facilitators and community level staff.
Challenges
One of the main challenges for us was community stigma. Mental health awareness in Nepal is lagging and the related stigma is huge. Many community members were not willing to open up. Emphasising the importance of mental health as much as physical health was difficult to relay in the community. People had a strong belief in traditional healers and initially did not fully understand our intervention. We had to think of many alternatives to minimise these challenges. We conducted community sensitisation events to reduce stigma. We were also careful about the language we used when discussing mental health to make sure it wasn’t stigmatising. Due to stigma related issues, we also faced challenges during the family meeting. Despite a person being willing to attend the programme, for example, some families would hesitate and initially would not allow them to attend it. Convincing the family members and making them understand our programme was a huge challenge faced by the staff. During community sensitisation events, we worked hard to clarify myths and negative beliefs that some community members held about mental health. We also found that alcohol-based issues were one of the common problems that led to problems such as domestic violence, gambling and unemployment. Hence, there is a great need to address alcohol misuse while doing any kind of intervention.
There were several other challenges in relation to attending the sessions. It was usually the case that some participants did not arrive on time for the sessions. Because of this, those participants who were on time had to wait before we could begin the session. After joining late, some participants would then try to rush and ask to end the session early in order to complete their household chores. (See box 1 for a Group PM+ facilitator’s experience). Because of punctuality issues, it was necessary for the facilitators to be very engaging and have strong group management skills. Facilitators also found it supportive to have well trained helpers that they knew from the community to gather participants on time.
Another major challenge was that community members were used to NGO/INGO culture where community programmes include monetary incentives for attending training and meetings. Some participants in Group PM+ therefore also had expectations of monetary incentives. We had to clearly specify the objectives of our programme and clarify the potential benefits from the intervention that could not be provided by money.
We also conducted the first Group PM+ trial with male participants. We did not anticipate the challenges associated with gender differences. First, it was difficult to recruit enough males, since many men with mental distress also suffer from severe substance use. Other men did not have enough time as they were the primary breadwinners of their families. Indeed many men in the villages had migrated to more urban areas or to other countries for work. Despite these challenges, we used various strategies and were successful in running male groups. Compared to the female groups, male participants did not open up as much to share their emotional problems and sometimes hesitated during icebreakers and other Group PM+ activities. It was also difficult for them to give enough time for the session as they had various work commitments. These gender-based challenges should be addressed in future trials, including in the adaptation process.
Box 1. Comments from a Group PM+ Facilitator
There are many challenges that I faced in PM+ programme. Some of the main challenges are as follows:- In one of my groups, the participants had some issues with each other because they were of different caste groups and different ages.
- Although participants faced similar problems, they did not open up easily in the initial phase, which made the work difficult.
- Some participants did not give enough time to the programme.
When I faced these challenges, I talked about the good aspects of the PM+ programme to motivate the participants.
| Discussion | | |
For Author 1 who has always lived a city life, although she has vivid memories of visiting her family’s village during her childhood, this was a completely different experience working in a village as an adult. It was not as easy as she had imagined and being in a position where other people’s work solely depended on her was a challenging yet important experience. The everyday struggles that villagers went through were unimaginable. Reflecting on those real struggles taught her the skill of compassion and lots of self reflection that helped her to understand herself better.
The skills in Group PM+ not only benefitted the participants but also helped us individually. We still include some of the strategies in our counselling and use examples and metaphors from PM+. These strategies work well in sessions with personal clients as well. Also, working in group counselling was a new experience. Since the programme, we have conducted several groups and PM+ has taught us the skills necessary for them to succeed. Recently, during the COVID-19 lockdown, we used PM+ techniques with clients who were having a difficult time dealing with the effects of the lockdown. We also used the techniques ourselves, especially for low mood and inactivity at the personal level and also with our recent clients who may be having a tough week, feeling low and hitting inactivity in their daily routine. Spending more than a week with low mood and inactivity, we pushed ourselves to do activities we enjoyed and this eventually helped us and our clients to overcome those phases. Experiencing these emotions ourselves, we realised how important getting active and being engaged in activities are in our lives to function well. (See box 2 for an account of the impact of the intervention on Group PM+ facilitators).
Box 2. The Impact of the Intervention on Group PM+ Facilitators
- Group PM+ facilitator
- Speaking about PM+, I have to say that it has made living easier for me and sometimes for others as well. The training provided by you all was a new experience for me. This is some precious knowledge I have received in life. Thank you and all trainers. At times when I meet some young boys and girls who feel sad, I am able to make them feel positive
- Group PM+ facilitator
- I have adopted the techniques of PM+ programme in my life as well since these kinds of problems can be faced in any circumstances. If someone faces similar problems, I share about the techniques I have learned in PM+ programme to my relatives, neighbours and family. I personally have experienced many good things while conducting the PM+ programme in groups. I have also felt that the techniques of PM+ programme are really beneficial for the people who have mental problems.
- Group PM+ facilitator
- I have experienced practical life skills and positive changes in my personal and social life having participated in the PM+ programme’s group and worked as a facilitator. The changes are listed below:
- Development of my own social and personal interactive skills
- I found new ways to handle my stress and solve my problems
- I felt motivated and positive changes in my behaviour
- I developed skills to identify different problems in people, and support them in solving their problems in a civil, social and polite manner.
Talking about the learning we received during the programme is infinite. The experience has helped us in our personal as well as our professional growth and that experience is something we shall always carry with us as clinical supervisors.
Financial support and sponsorship
No financial support or sponsorship was provided.
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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