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Fiona Dias Saxena

Gracy Andrew

Barefoot CounsellingA manual for community workers


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Sangath, a society for child development and family guidance, 2002841/1, Behind Electricity Department, Alto Porvorim, Goa 403521.

Reproduction and translation is authorised worldwide for nonprofiteducational activities and publications, provided that permission isobtained from the authors and that copies containing reproducedmaterial are sent to Sangath.

Published by Nirmaan (Program on Sustainable Intervention in Family Violence)with support from the Fund for Leadership Development - India of the John D. andCatherine T. MacArthur Foundation.

Reprinted by REACH - Resource center for Adolescent Child Health with supportfrom the MacArthur Foundation, 2003

SANGATH, 841/1, Behind Electricity Department, Alto Porvorim, Goa 403521.

Tel: 91-0832-2414916Fax: 91-0832-2411709Website: http://www.sangath.comEmail: [email protected]


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Barefoot CounsellingA manual for community workers

Fiona Dias Saxena

Gracy Andrew

SangathSangath, a society for child development and family guidance


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ACKNOWLEDGEMENTS

Deo Borem Korum:

The MacArthur Foundation for giving the space totry out different approaches to working with FamilyViolence and encouraging the concept of BarefootCounselling in the community.

Auda Viegas of Bailancho Ekvott for sowing seedsof the idea two years ago.

Madhuri Rao from Family Counselling Centre forcontacts with existing barefoot counsellors.

Bailancho Manch and Bailancho Saad for theirsteady supply of encouragement.

Dr. Pramod Salgaokar for her immense faith incounselling as a necessary measure for effectiveintervention with women in distress.

The team at Sangath and especially Dr. VikramPatel.

Illustrations: Nicky ThomasLayout: Anit Saxena


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Table of Contents

Preface 1

1 Counselling 3

What a counsellor needs to be 4

General counselling skills 6

2 Anxiety and Depression 11

When stress becomes a moreserious problem 11

Symptoms of Depression and Anxiety 12

The GHQ scale 15

3 Intervention 16

Common problems encounteredand how to intervene 20

Summary 26

Appendix 27


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Preface

Everyday, we find people helping one another deal with problems. Be it as aneighbour, colleague at work or more formally as a priest, family lawyer ordoctor.

All of us, in our own way, counsel other people when they have problems, with-out really knowing what it is that we are doing. Community workers, like headsof mahila mandals or the local anganwadi worker, on establishing a rapportwith the people of a village or community, often find counselling people to bemajor part of their work.

Being accepted as members of the community is a strength that can help them

take on the role of a community counsellor. We hope this manual helps thesehealers gather an insight into a few simple tools and skills that could help withthis.

Some details on stress-related illness and how one can help is also providedas we have found it important in our handling cases at the community level.

In 1998, both the authors were part of a study into the 'Treatment of depression'as counsellors. Dr. Vikram Patel, who headed the study, devised a simplemethod for counselling patients coming to general hospitals and public healthcentres with stress related illnesses.

The method was adapted, to suit actual ground realities, while being used bythe authors. The first author, Fiona Dias put these methods to use in dealingeffectively with women victims of family violence during a two-year project onfamily violence.

During the project period she came across lay people working in the commu-nity with the basic qualities of a counsellor, some of them, listeningempathetically to victims of violence, even assisting them work out their prob-lems. Struck by the revelation she decided to try training them through two

workshops "The barefoot counselling workshops", attended by various women'sgroup members and other people working in the community.

The simple skills that she and her team had been using in the clinic setting withvictims of violence were imparted to the participants. It is these participantswho called for a reference manual since they found themselves better equipped,as community counsellors, when they went back into the community.

This manual has been developed in response to this plea. It is hoped that it willhelp empower these healers add on to the skilful and invaluable assistancethey already render society.

The manual is in three sections. The first section deals with the general natureof counselling - its characteristics as well as some essential skills of counsel-ling.

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The second section describes the cycle of depression and anxiety, its symp-toms, and how one detects depression at the community level (a commonlyoccurring problem in the community).

The third section deals with Intervention - what the barefoot counseller cando for a person suffering from stress-related illnesses, i.e. anxiety and de-pression. The common problems encountered in the community, when andhow one can help, the type of advice that can help, and who to approach forhelp when necessary.

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1. COUNSELLING

Your basic dictionary defines 'Counselling' as'advice given by an expert'. However, the coun-selling that we speak of here does not mean justgiving advice.

Counselling is a two way process, involving aninteraction between two people - the counsellorand the counselee. The counselee being the

person who turns to the counsellor for help todeal with a problem (or problems), and thecounsellor who, through the process of counsel-ling, helps the counselee deal with his self.

We, in our society, are used to asking an olderor more experienced person for advice and,generally, advice is sought with the expectationof being told what to do. The advisor heredecides upon the best course of action, going byhis own experience, and the person is expecteddo what is told.

In advice giving, the advice giver neither tries tomake the person understand about why thesituation arose in the first place nor what theconsequence will be of taking a particularcourse of action.

The counselling process calls for the person tostop feeling helpless. It aims at making the

person become more aware of oneself, toaccept ones weaknesses, and identify onesown strengths. The person is assisted to form aclearer picture of the problems facing him, totake a look at the various options open to him orher and personally decide upon the course ofaction to be taken to change the situation.

Counselling aims at helping people believemore in themselves and in their ability to decideupon the future course of their lives. To become

individuals who can take on the responsibility ofbeing able to bring in change in their own lives,rather than just look at situations or persons thatcould be blamed for their present troubles.

Giving advice

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The main goals of counselling are to help thecounselee identify:i) Personal strengthsii) What prevents the counselee from usingthese strengthsiii ) The kind of person the counselee wants to beiv) What the counselee could do to improve thesituation

What a counsellor needs to be

1. A good listenerWe are always 'hearing others out'. However, ourlistening process is selective. A woodcutter willinstantly hear a dry branch break and a violinistwill hear the sounds of a violin among ten otherinstruments in a choir.

Similarly, while listening to people, we generallyhear what we want to.

Take the case of Clara, counselling Jayanthi, a65-year-old widow. Jayanthi spoke of the lossshe had to bear when the heavy rains destroyedher rice fields and went on to speak of herdaughter in law who did not care for her. Clara,the counsellor reacted to the second sentimentrather than the first one which was the problemdaunting Jayanthi at that moment.

In counselling one needs to listen with oneswhole self and not just with ones ears. One has tolisten to the feelings being expressed by thecounselee as well as to the words used to ex-press the feelings.

2. EmpatheticIt is the ability to put ones own self in the place ofthe counselee and feel what he or she could befeeling at the moment. The counsellor then feelsthe frustration, anger, indifference, and the fears

of the counselee. The counselee's words arethen reflected back to him/her to express the factthat he is accepted and respected. The process

Counsellor is yawning with boredom

instead of listening ...

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helps the counsellor understand the counseleeand his situation better. It is different from onesexpressing sympathy or pity where the listeneronly expresses the fact that he feels bad for thecounselee. It does not, in any way, make thecounselee feel that he is understood.

3. Be non-judgmentalHand in hand with empathy goes the ability tohave a non-judgmental attitude. The counsellorhas to accept the counselee for what he iswhatever his religion, caste, creed etc. In anideal situation, even if the counselee is a crimi-

nal the counsellor has to be able to accept himor her as a person seeking help and interactaccordingly.

4. Able to Generate trustThe counsellor has to understand that the coun-selee has come to him/her because the coun-selee trusts in him/her and the counsellor shouldrespect this trust placed upon him/her. Whateveris spoken of between the counsellor and thecounselee is confidential and if there is a need

to reveal anything spoken of during the counsel-ling sessions permission of the counselee has tobe sought.

5. PatientCounselling requires a lot of patience. Thecounselee may take a lot of time to understandoneself and ones strengths. An impatient coun-sellor will often feel tempted to give advice butthis does not in any way serve the purpose of

counselling.

6. Be ObservantThe counsellor needs to be very observant notjust about what the counselee puts into words,but also the body language used. The counseleespeaking with a smile on his or her face, but withfists clenched, or a lot of finger twisting going on,may indicate a build up of tension, which thecounsellor needs to observe.

In counselling one does not: ask direct questions provide direct answers

Counselee has just finished talkingand the counsellor is already sharing

her secret with another ...

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Always remember that the very basis of counsel-ling is built upon respecting the other individual,the kind of person he/she is and accepting thatpeople are capable of making their own deci-sions and managing their lives in general.

General counselling skills

Getting people to themselves talk about a prob-lem in all its dimensions, without your putting inyour own views on the matter is essential to

conducting effective counselling and calls forsome specific skills like Interviewing.

1. Attending Behaviour:A most basic, yet, a very important skill in coun-selling. As a counsellor it helps: let the counselee know that you are interestedin what is being said the counselee to stick to the point and stopneedless talk

There are four critical dimensions to the attend-ing behaviour:i) Eye contact: Maintain eye contact with the person, all thetime.

ii) Attentive Body language: Make encouraging gestures, show an expres-sion of interest on your face Sit facing the client with your arms opened out

rather than folded against your chest.

iii) Vocal qualities: Keep your tone gentle, speak slowly andclearly

iv) Verbal Tracking: Keep to the topic initiated by the client. If the person keeps on talking without keep-ing to the topic at hand gently get the person tofocus on the problem but do not start talkingyourself.

Counsellor is attentive to the counselee

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2. Questioning Skills:In the course of counselling one finds it neces-sary to employ questioning as part of getting theperson to talk further. If the person is talkativeyou may not need to ask many questions. How-ever, if you use questions effectively you can geta lot of relevant information.

Questioning helps you: begin an interview open new areas for discussions assist the counselee in self exploration

Types of questions:i) Open Questions:These are very useful in getting the person totalk. They are questions that cannot be an-swered in a few words or sentences. Theyencourage the person to talk and give maximuminformation.They generally begin with4 How?4 Why?4 Could?for e.g., "could you tell me more about that? /how did you feel when that happened?"

The first word of an open question often leads toparticular results e.g. 'What?' questions - lead to facts 'How?' questions - lead to feelings and ''Why?' questions - to reasons.

ii) Closed Questions:Are questions that can be answered in a fewwords, they help focus an interview and to bringout specifics. They generally begin with is, are ordo e.g., "Where do you live?"

A general framework for collecting the requiredinformation in the first part of counselling wouldbe the following:Who is the client? What are the key personalbackground factors? Who else is involved?

What is the problem? What are the specificdetails of the situation?When does the problem occur? What happens

The act of counselling ...

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immediately before or after the situation?Where does the problem occur, in what environ-ment and situation?How does the person react? How does she or hefeel about it?How does the problem occur?

iii) When does questioning pose a problem?8 Bombardment/ grilling - Never ask too manyquestions it can put people on the defensive. Toomany Questions can confuse a person8 Questions as statements8 e.g., 'don't you think it would be helpful if you

found a job?' - putting your own view ahead andcan put the person off.8 Why Questions - avoid asking a person"Why" questions - it can cause discomfort. e.g.,'Why are you feeling sad?

3. Observation Skills:The third most important skill is that of observa-tion. Observation needs to focus on counselee'snon verbal behaviour in three areas. These are:i) Client eye contact patterns

e.g. When a person breaks eye contact orshifts eyes in between it could mean that he isconfused and you have to probe.ii) Body language Leaning forward can mean excitement aboutan idea Leaning back and crossing arms wouldmean the person is closing off.iii) Facial expressions like brow furrowing, liptightening or loosening, flushing can indicate

tension.

Large-scale body movements may indicate shiftsin client reactions, thoughts or the topic.

4. Encouragers and Paraphrases:These are skills used to let the counselee knowthat the counsellor has been listening to what he /she has been saying, has seen their point of viewand feels the world to be as they experience it.

Encouragers are just words interspersed inbetween, like "um", "is it" "really" ah ha". Thesealso include head nods, open palms and non-verbal gestures. Sometimes just the repetition of

Observing carefully and closelyis a skill that needs practice ...

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a keyword could become an encourager. Thisusually leads to the person elaborating in greaterdetail on the meaning of that word to him or her.

These words and actions encourage the personto continue talking, while letting him or her knowthat he is being heard.

Paraphrases are the feedback given to thecounselee by the counsellor by shortening andclarifying the client's comments. Paraphrasing isnot just parroting of words. It is done by repeat-ing some of your own words alongside some

important words of the client.

Paraphrases help the process of counselling by: Clarifying for the client what he or she hassaid e.g. You appear to be saying..., Yousound like... Clarifying for the interviewer what the clienthas said - by feeding back what you have heard,you can check on the accuracy of your listeninge.g. Did I get you correct?, Am I hearing youcorrectly?

Helping clients to talk in more detail aboutissues of concern to them. Helping a talkative client stop repeating thesame facts or story.

5. Noting and reflecting feelings:This is a very useful skill that helps the counsleetalk and make him feel understood it helps inidentifying and sorting out client's feelings.

To do this one needs to observe: Emotional words used by the counslee e.g. "Iwas so angry that I felt like hitting him"

4 "You must have been really angry" Non-verbally expressed emotional words.

4E.g. To a person biting her lips - "youseem very anxious today"

Emotions can be observed directly or drawn outthrough questions, ("how do you feel about that?Do you feel angry?") Then reflected back

through the following steps:i) Begin with words such as, "you feel" or"sounds like you feel" or "could it be you feel?"Use the clients name.

Counsellor is silently judgingthe counselee ...

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ii) Feeling words may be added (sad, happy,glad, puzzled, uncertain, confused)iii) The context may be added through a para-phrase or a repetition of key content ("Looks like,you feel happy about getting a job"iv) A present tense reflection is more powerfulthan a past or future tense. 'You feel happy rightnow' rather than 'you felt'v) After identifying a feeling you can check out sothat the client can correct you if you are incorrect("am I hearing you correctly?")

You can sometimes gather specific information

after reflection e.g.: "you seem be angry with yourFather". "Could you give me one example of aspecific situation when you feel this anger?"

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Case Example:

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2. ANXIETY AND DEPRESSION

Anxiety and Depression are one of the mostcommon stress related illnesses that onecomes across in the community. This sectionwill deal with these in detail i.e. how it mani-fests itself, the symptoms that people experi-ence and how does the barefoot counsellorassess it's severity.

When stress becomes a more seriousproblem

Everyone has problems and all of us feel sad orlow when faced with problems but most peoplemanage to carry on with their lives, and some-times solve their problems either partially or fully,or even learn to live with it (like on the death of aclose relative). The feeling of sadness generallypasses away for most people.

But, sometimes people are brought face to facewith a situation that probably could be changed,but which has left them feeling stuck - as if itwere not possible to find a way through. Feelingthat the problem is unlikely to be solved, theymanage to carry on with their lives but livingunder stress. This also makes the person feelless good about him/herself.

They, very often, start blaming themselves -thinking, "if I were a better person, I would easilycope" or "if I were more hard-working I would beable to get out of this." Doing this only makesthem feel worse making it more difficult for themto deal with the problem. In this way they enterthat terrible cycle of sadness

When one continues in this cycle of sadness, itaffects their physical as well emotional health

and they start suffering from the stress relatedillnesses called depression and anxiety.

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I. Depression1. Aches, Pains and Other Physical SymptomsThe person suffers from headaches, aches andpains all over the body; indigestion and "acidity",disturbed bowel function, pins and needlessensations in arms and legs (in Konkani, oftendescribed as 'mueta', or the feeling of ants onthe skin) and general tiredness. Medical testsmay show no physical cause.2. Poor SleepThe person complains of loss of sleep. Somefind it difficult to fall asleep even though they aretired. The more they worry about getting off tosleep the harder it becomes. Some peoplewake up very early and are unable to get back tosleep. There are others who say they sleep toomuch.3. FatigueThe person feels tired most of the time andevery thing he or she does feels like a huge

effort even if they have worked hard and restedafterwards. The feeling tends to remain most ofthe time.4. Poor ConcentrationEven simple tasks like cleaning rice seems toneed a lot of mental effort. This causes theperson to make mistakes in her work creating alot of frustration.5. Loss of interest in sexThere is a loss of interest in sex, which causesdifficulties in relationships, especially if the

sexual partner does not understand the problem.6. Appetite and weight changesThere is either loss of interest in food resulting inweight loss or the person may start eating toomuch which may lead to weight gain and may inturn make them feel unattractive.7. Poor Self EsteemSelf-esteem is a term used to describe how wellwe think of ourselves. Everyone has a view ofhimself or herself, which is their idea of how

good they are in many different respects. Whenthe person enters the cycle of sadness he seeshimself as less worthy than other people. Hestarts feeling useless.

Symptoms of Depression and Anxiety

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II. AnxietyAnxiety is the sensation of feeling fearful andnervous. It is ok to feel anxious when faced withcertain situations, like an interview. One howevercomes across people who feel anxious almostall the time. These people then start complainingof the following physical problems: Dry mouth Palpitations in the chest Difficulty in breathing Butterflies in the stomach

This sometimes leads to people worrying about

their physical health.

Muktabai is a 58-year-old lady whose husband diedunexpectedly the previous year. Her children have allgrown up and left the village for better employment oppor-tunities, to Mumbai.

She had started experiencing poor sleep and loss ofappetite soon after her husband died and the symptoms

worsened once her children left the village after the fu-neral. She started experiencing headaches, backaches,stomachache and other physical discomforts, which ledher to consult the local clinic. There she was told she wasall right but was prescribed sleeping pills and vitamininjections (as a sort of "tonic").

She felt better immediately, particularly because her sleepimproved. However, within two weeks, her sleep gotworse again and she went back to the clinic. There, shewas given more sleeping pills and injections. This went onfor months, until she could no longer sleep without thesleeping pills.

In this case, Muktabai has a "physical" presentation ofdepression resulting from the death of her husband andloneliness because her children are no longer living withher. The doctor at the clinic had not bothered to ask abouther emotions and used sleeping pills instead, which leadto addiction in the long run. This kind of situation is one ofthe commonest ways in which depression and anxiety is

present in Goa.

Case Example:

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As in the above case most people who go to thelocal doctors with the above stress relatedsymptoms are prescribed vitamins and sleepingtablets. They get temporary relief from theirsymptoms but the symptoms do not disappear.

The key features of depression andanxiety are:

4A sad mood4Loss of interest in life, social interac-tions, work etc4Tiredness, and a feeling of fatigue andweakness4Vague aches and pains all over the body4A feeling of hopelessness about thefuture4Difficulty in making decisions4A feeling that one is not as good asothers (low self-esteem)4A feeling that it would be better if onewas not alive

4Disturbed sleep (usually worse, butoccasionally too much sleep)4Feeling worse in the mornings4Poor appetite (sometimes increasedappetite)4Change in weight4Feeling tense all over the body4Worrying too much about one's problemsor one's health4Feeling one's heart beating fast (palpita-tions), trembling, shaking all over4Feeling scared of specific situationssuch as crowds, and sometimes avoidingsuch situations altogether

Stress related illnesses like depression andanxiety can vary in their severity like any otherillness. The steps given in the next section willhelp the person get some relief from the illness.However, sometimes when it is more severe, the

person continues to be sick even one week afteryou have been working with the person.

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The GHQ scale given below is a set of questionswith a score. By asking the person these simplequestions the barefoot counsellor can access thepresence as well as the severity of the illness inthe person.

*A score of 5 and above indicates the presence of depression &/or anxiety

The GHQ scale

'GHQ' - GENERAL HEALTH QUESTIONNAIRE

0 11. Been able to concentrate on whatever you are doing? Yes No

1 0

2. Lost much sleep over worry? Yes No0 1

3. Felt that you are playing a useful part in things Yes No0 1

4. Felt capable of making decisions about things? Yes No1 0

5. Felt constantly under strain? Yes No

0 16. Felt you could overcome your difficulties? Yes No

0 17. Been able to enjoy your normal day-to-day activities? Yes No

0 18. Been able to face up to your problems? Yes No

1 0

9. Been feeling unhappy and depressed? Yes No1 0

10. Been losing confidence in your self? Yes No1 0

11. Been thinking of your self as a worthless person? Yes No

0 112. Been feeling reasonably happy all things concerned? Yes No

TOTAL SCORE

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3. INTERVENTION

This part of the manual covers the steps that thebarefoot counsellor can follow when the personinterviewed reveals the presence of the com-plaints explained on page no. 14 and when his/her score on the GHQ (Ref to pg. no. 15 ) con-firms that he/she is suffering from anxiety anddepression.

Step 1: Reassure the person Tell them you can provide some simpleremedies for some of the complaints; like sleepcomplaints and feeling of tiredness. That while they may be suffering from physi-cal complaints like headaches etc. (For whichthey may be under medication), these are not alife-threatening or dangerous illness

Step 2: Explain to the personExplain to the person the relationship between

his complaints and stress. You can tell him"when people have a lot of stress or tension intheir lives it sometimes creates so much pres-sure that they suffer from these complaints. Youtoo must be having some tension in your life dueto which you seem to be suffering."

Step 3: VentilationSome people at this point will start talking abouttheir problem. You should let them speak and

this is when you use all of the counselling skillsexplained earlier, to make him or her feel under-stood. Some people may not be very openabout their problems, with them you can then goon to the next step.

(Steps 1 to 3 are interchangeable. Sometimesthe person starts ventilating about his or herproblems right from the beginning. In such casesyou let him/ her talk and at some point give him/her the explanation)

Step 4: Advice for specific symptomsYou can say " You complain of these ........ see if

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this will help you" and than give him advice asper his complaints

a) Sleep Problems: Keep to regular hours for going to bed andwaking, irrespective of how the previous night'ssleep was Avoid daytime naps; Avoid sleeping tablets or alcohol to fallasleep Avoid tea or coffee after 5 p.m. Try relaxation exercises (refer box below) tohelp fall asleep

Drink a glass of warm milk before bed If the patient cannot fall asleep within 20minutes or so, they should get out of bed and tryagain later when feeling sleepy

b) Tiredness & Fatigue: Explain to the person how his/her stress ismaking him/her feel tired and weak and that theless he involves him/herself in activities the moretired he/she will feel. That is important for him tounderstand - that it is activity that will make him

feel less tired and improve his ability to think andsolve his problems Encourage the person to start with a simplepleasurable activity, of his choice, for a setamount of time every day for e.g., stitching for 15minutes every day in the morning. The 15 min-utes could then be increased to a half-hourgradually. Ask him/ her to notice the change inhim/ her after he does it. Do not advice goingback to a full day's activity, immediately. There

should be a gradual, increase in physical activitystepped up, very slowly, according to the needsof the individual.

c) Worry about physical health: Let him talk about his physical complaints, ifneed be even look at his prescriptions andmedications. Do not ignore or dismiss them. Emphasise that the medical doctor is deal-ing with some of his problems others may berelated to worrying or stress problems

Reinforce the idea, if more investigationssuch as X-rays and blood tests are called for.Make him realise the close connection between

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physical health and stress let him know justworking on his problems would reduce theintensity of the physical symptoms.

d) WorryIf it is personal problems that he is worryingabout all the time you can encourage him to talkabout it to help him to consider various solutionsand the consequence of each solution. You canrefer him/her to people, listed in the appendix,according to the kind of problem.

e) Irritability:

You can advise the patient of the following: Explain the link between anger and moodand the effect anger has on a persons mind andbody, for example, it raises blood pressure andpulse rate and makes solving problems moredifficult The first step in anger control is torecognise one's anger by paying attention tosigns such as tensed muscles and feelings ofirritability and frustration To try and identify the cause of the feelings

of anger and then to take positive steps toresolve the problem To try calm down before feelings of angerexaggerate into verbal or physical aggression. Aperson can calm down by expressing the rea-sons for anger to a close friend or relative, or byrelaxing alone till anger subsides. Breathingexercises may help the person calm down.

f) Suicidal Ideas:

This is a serious problem and such a personneeds to be referred to a professional counselloror psychiatrist. However you can Explain to the patient that many persons insuch situations experience such thoughts, thatthese thoughts are the result of being understress. That they should share their feelings withclose friends or relatives, and if the person isreligious, with their priest. They should share their feelings with their

doctor or any other health professional that theyconsult. Ask the patient whether it would help, if you

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talked to his close relative or his friend. See that you call on this person again withina week.

Panic AttacksPanic attacks are attacks of severe anxiety; theperson feels extremely afraid and starts breath-ing rapidly. You can: Explain to the person the relationship be-tween his feelings of fear and the rapid breath-ing. That he/ she should recognise that when thefears begin, physical symptoms start.

That as soon as the fearful thought starts he/she should start controlling his/her breathing.

The best way to do this is to do the breathingexercise (in box below) reminding oneself thatthere is nothing to fear, till one gains control overthe breath. Explain that you would be teaching them apractical and useful technique for relaxing thebody and mind by controlling breathing. Explainthat this technique is used not only in medical

clinics but also in yoga and meditation. Demonstrate the exercise after explainingthe steps outlined below - show him/her how tobreathe in the manner you are recommending. Then, ask the patient to do the exercise. It ishelpful, for the first time, to take the patientthrough the steps your self. Let the patient continue the breathing exer-cise in silence for about 5 minutes. Finally, tell the patient to do the exercise at

least once (preferably twice) a day for up to 10minutes.

The steps of the exercise are as follows: Relax by lying down or sitting in a comfort-able position, preferably in a quiet room with littlenoise. The person should close his eyes and afterabout 10 seconds, start concentrating on therhythm of breathing. For patients who complainof "pulsating heads", shift the focus of attention to

other parts of the body such as the toes or fin-gers. Now concentrate on taking slow, deep,regular, steady breaths through the nose, and

Relaxing exercise ...

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upon breathing out to mentally say, "relax" or itsequivalent in the language one uses Konkani orHindi or Marathi (e.g. shanti). NOTE: If a patient complains of palpitations,tingling-numbness in fingers or mouth, chestpain or any other physical discomfort during theexercise, it may mean that she/he is breathingtoo fast; slow down the rhythm to not more than20 breaths per minute. Explain that if practiced daily, they willexperience the benefits of relaxation in twoweeks. With adequate experience, they mayeven be able to relax in a variety of situations, for

example, even while sitting in a bus.

Common problems encountered andhow to intervene

The earlier section provides information on thesymptoms of stress related illnesses and as abarefoot counsellor what you could do to providerelief.However, in the course of the above steps the

person would be talking to you about their prob-lems and counselling the person wouldn't becomplete if you do not address the problemsand assist the person to whatever extent you canin solving them.

Problem SolvingProblem solving is a method that tries to makethe person reverse the cycle of sadness:

Steps that you could follow in addressing the

problems of the person:Step one: Get the person to list out variousproblems that are causing him to feel depressedor/ and anxious.Step two: Assist the person to then prioritise themost daunting problem.Step three: Assist the person in listing the vari-ous solutions that the person can think of in thecircumstances. The key is to define a goal, tomake it clear and explore various ways in which

the goal can be reached.

Sometimes the person may be stuck for want ofproductive alternatives. The counsellor could

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summarize the conflict for the client and use thebasic listening skills to facilitate the person in hisproblem resolution.

Some questions that could be used are:"Can you do some brainstorming for ideas thatcome up to resolve the problem?""What part of the problem can you solve now, ifyou can't solve everything right away?""What other alternatives can you think of?""Which of your ideas seem more workable toyou?""What would be the consequences of taking that

alternative?"

In systematic problem solving the counsellor andthe client might together generate or brainstormfor alternatives and set up priorities for the mosteffective possibilities.

One often finds that the clients generate theirown answers to the problem.

Some problems are very difficult to handle and

the community counsellor can think of referringthe same to professionals.

CASE HISTORY

Background:Geraldine is a 43-year-old woman, having 5children. Her husband is an alcoholic whodoesn't for provide the family. She sells jaggery

in the market and provides for the family. Herhusband doesn't physically abuse her but whenhe drinks he is verbally very abusive. Wheneverhe comes home drunk Geraldine doesn't openthe door for him. When the counsellor first seesher she is very depressed. She is finding itdifficult to make ends meet. She cannot sleep,gets very anxious at times, complains of weighton the chest and is scared that she may behaving a heart disease.

First encounter:The counsellor reassures her, gives her the'explanation' on the relation between her tension

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and her health and teaches her the breathingexercise. She gives her advice for specificsymptoms like sleeplessness. She asks her togo to the government hospital and get a x-rayand other investigations done to rule out a heartailment.

Second Encounter:After a week, Geraldine has completed all theinvestigations and the doctor has told her thatshe has no heart disease. She has been doingthe breathing exercises regularly and is feelingmuch better. She still finds it difficult to fall asleep

but once she does fall asleep she does not getup in the middle of the night as she used tobefore. The counsellor now moves on to problemsolving.

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After two weeks, when the counselor meetsGeraldine she has listed out her expenses.Geraldine has not been managing her incomeprudently. She never saves any money andwhenever she earns extra she spends on expen-sive eatables. The counsellor then teachesGeraldine on how she can save, where sheneeds to cut down on expense.

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1. Violence in the family Point out that every member of the family isa victim, including the perpetrator and particularlychildren. Thus, the violence has to be stopped.

Find out if she has support from any otherfamily member or spouse. Refer to women organizations or counsellingservices (address in Appendix)

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2. Bereavement Allow the patient to bring out in to the openfeelings for the lost relative or friend Explain that when in bereavement, it isnatural to feel shock, guilt and numbness forsometime. They may feel, at times, that the deadperson is still alive. It is common to go over andover in the mind events in the past involving thedeceased. Reassure the patient that these feelings aretemporary and, as time passes, the person willcome to terms with the loss.

Tell the person to consciously think of happymoments spent with the person who is no more. If the person indicates severe symptomseven six months after the death refer the personto (Counselling services - address in Appendix)

3. Alcohol AbuseGenerally the problem might be the alcoholism ofthe spouse or a close relative of the depressedperson Talk to the relative who is alcoholic.

Explain that the reason for drinking heavily isbecause alcohol is addictive and that there areways to stop drinking and controlling the with-drawal symptoms with medicines; Refer to Services to Alcoholics (address inAppendix) Refer the person to the nearest AlcoholicsAnonymous

4. Loneliness & Isolation

This is particularly a problem amongst olderpersons.Some possible solutions: Getting the person to contact old friends,neighbours or relatives whom the person has notbeen in touch with Getting the person involved in any commu-nity activity e.g. the pulse polio campaign or thechurch fair etc.

5. Relationship Problems

Many patients will bring up difficulties with theirpartners. These may be very difficult to deal within which case consider referring (Counselling

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services - address in Appendix)

6. Legal problemsSuch problem can be referred to the relevantaddress provided in the Appendix.

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SUMMARY

Counselling within our country, till recently, hasbeen thought of as something for the well off.This manual and the others of its kind are anattempt at change, to make it more widelyavailable to all sections of society.

A word of caution is however called for, it isvery important for a counsellor to remember

that he/she is dealing with human beings eachof whom is unique, special, with his or her ownexperiences, emotional make-up and abilities.

It is important to treat each counselee asspecialThroughout the relationship be empathetic,patient, observant, non-judgmental and trustworthy Listen with your whole self - don't just hearBuild a rapport by asking open ended ques-

tions and paraphrasingMake the person feel understood by reflectinghis/her feelings, clarifying his thoughts to him

If he / she is depressed or anxious and com-plains of lack of sleep, aches and pains etc.Reassure himExplain to him the link between his tensionsand his complaintsGive him information on how to deal with the

complaintsTeach him the breathing exercise

When he feels a little better:Help him identify the most worrying problems Facilitate him in looking for goals that he canachieveRefer him to specialists, when required

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Detoxification for alcoholics:

Alcoholics AnonymousContact Person- Peter D'souzaMapuca, Bardez- GoaTel. 250536.

Kripa

Drug and Alcohol RehabilitationDr. Rajyadeksha HospitalPanaji-GoaContact Persons Ms Toshi Malik.

AshiCommunity Counselling CentreDrug Detoxification CentreKhorlim, Mapuca Bardez- Goa.Contact Person: Dr. Victor D'souza.

Counselling services:

Family Counselling CentreOld GMC ComplexPanaji GoaContact Person: Madhuri RaoTel No:

Family Service Centre

Opposite Steamer JettyD.B. MargPanaji- GoaTel No: 224140

Sangath Centre for Child and Family Guidance,841/1, near Electricity dept., Alto PorvorimBardez, Goa

Sangath Centre for Child and Family Guidance,South Goa - Branch

Margao, Goa[For appointment Contact Gracy Andrew at700307( r )]

APPENDIX

(MAHITI - Services Available)

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Vocational Training & Guidance:

The DirectorE.D.C. House.Atmaram Borkar RoadPanaji- Goa.

Instiute of Social ServiceFibre Unit, St Joseph's ChapelNear Betim JettyBetim-Bardez, GoaContact Person - Sr. Julia Menezes

St Bridgets's Home of Home ScienceSantaxett AldonaBardez-GoaContact Person - Sr. Marie Christine Noronha.

Women's Entrepreneurs Association of GoaSurya Kiran, M-147Housing Board, PorvorimBardez Goa

Mahiti

Near the Collectorate OfficeJetty Bus StopPanaji Goa.Contact Person - Perviz Andani Kamat.

Shelter Homes for Women:

Home for Destitute WomenSisters Adores

Palacio de DeoQuepemTel No: 662425

Sisters AdoresBelloy, NuvemSalcette- Goa

Asha MahalTaleigaoTiswadi- Goa

Contact Person - Ms Lalitha KamatTel No:

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Women Organisations:

Bailancho Saad501 CiticentrePanaji -GoaContact Person - Adv. Albertine AlmeidaTel No: 432460

Bailancho ManchContact Person - Adv Caroline CollassoTel No: 250536

Bailancho Ekvott

Contact Person - Auda ViegasTel No:736589

State Commission for WomenDr. Pramod SalgaokarTel No: 420180

Directorate of Women and ChildrenOld GMC ComplexPanaji -Goa.

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