Gilbert/CROSS-CULTURAL ISSUES IN COUNSELLING SKILLS issues in counselling skills Cross-cultural training: lessons from Lesotho JANE GILBERTI ABSTRACT "Counselling" in many forms is now endemic in the cultures of the North Such ways of assisting those with emotional difficulties are underpinned by very specific cultural assumptions about the "self', based directly on the individualistic assumptions of those cultures. However, other cultures hold very different beliefs about the "self', compared with the assumptions on which counselling theory and coun- selling training courses are based. Thispaper questions the relevance of the theories underlying counselling practice to such cultures. The individualistic cultural assumptions underlying counselling theory are reviewed and some of the practical and theoretical challenges in designing a workshop for counselling skills training for Basotho mental health professionals in Lesotho are outlined. Highlights of the workshop content are described and reviewed and specific suggestions from what was learned are put forward to ensure that such training can be more culturally appropriate. IN THE NORTH IN RECENT YEARS there has been as astonishing increase in the provision of "counselling" in many different fonns and for many different kinds of problems. Although the empirical evaluation of the effectiveness of counseIling remains complex (and is not discussed in this paper) there is now a plethora of counselling skills and counselling training courses in the North, some of which have been exported to I Consultant clinical psychologist with the National Health Service, UK. The author invites interested readers to contact herfor a detailed programme and content of the workshop described in this article VOL 17 NO 1 JANUARY 2002 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 123 countries in the South, particularly as part of trauma and psychosocial programmes. Training in counselling and counselling skills is thus being offered to those whose cultural backgrounds are very different from the culture in which such approaches to helping others were initially developed. issues Theoretical Although counselling skills are primarily taught through practical and experiential learning, these practical approaches to working with people are based on specific theoretical and cultural assumptions, particularly in relation to the "self'. This "self' constitutes the client's inner world, that needs to be understood. The "self' also is an important consideration when it is necessary to develop the personal skills and self-knowledge of the helper.All counselling training, of whatever theoretical orientation, is based on the premise that greater knowledge and understanding of one's own self determines one's capacity to help and understand another. These theoretical understandings of "self' are rooted in North American/European culture and it can sometimes be forgotten that these assumptions regarding the experience of "self' may not apply to those from very different cultural backgrounds. Some cultures, such as Japanese, Chinese, and tribal cultures socialize their peoples predominantly in an interdependent view of self. This view of self prioritizes the relatedness of individuals to each other; the way they attend to others and fit in with them and their harmonious interdependence with each other. On the other hand, cultures of the North assume an independent view of self in which establishing and maintaining independence from others and discovering and expressing one's unique inner attributes is given priority. These cultural assumptions have profound implications for how individuals experience themselves and set standards for what is considered emotionally mature adult behaviour. Incultures with an interdependent view of self, maturity is considered to lie in the control and reduction of one's own individual views and needs, and one's ability to establish a social position within a host of inter-relationships In cultures with an independent view of self, separateness and independence are culturally and networks. 124 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 17 NO 1 JANUARY 2002 Gilbert/CROSS-CULTURAL ISSUES IN COUNSELLING SKILLS valu~d and the capacity to express one's own views and opinions is considered an essential part of self-development. (For an extensive overview ofthese issues see Markus and Kitayama 1991). self is intrinsically Applying counselling theory to cultures with different assumptions about problematic because all the underlying theoretical assumptions stem from the individualistic culture of North AmericalEurope, in which an independent view of the self is implicitly assumed. Can such theoretical assumptions have relevance to a culture with an interdependent view ofsel£: such as that of the Basotho people in Lesotho? Can counselling skills training developed in the North have any value in a culture with very different implicit assumptions and, ifso, how should such training be modified? Background to the workshop The workshop on counselling skills described in this paper was part of year three of the Dolen Cymru-Lesotho Mental Health Project. Wales and Lesotho have been twinned since 1985 and many kinds of exchanges of skills and experiences have taken place. In 1997 it was decided to embark upon a mental health project to develop the skills of village health workers. As part ofthis programme a community mental health nurse from Lesotho visited Wales to assess what services were available and training in generic counselling skills was identified. Because of her prior experience in teaching mental health in an African context, this author was approached to design and deliver a five-day counselling skills workshop for personnel in the mental health services in Lesotho who, following the workshop would then train village health workers. Planning and reservations I have some experience in combining both Western and t~aditio.nal approaches within cross-cultural teaching in mental health m Africa, but not specifically counselling skills training. I was privately sceptical about the topic chosen for the reasons discussed above, but I was also enthusiastic about the challenge of preparing a programme that would be culturally appropriate. The preparation was further complicated by VOL 17 NO 1 JANUARY 2002 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 125 difficulties in communicating directly with staff in the Mental Health Services in Lesotho to establish what their contribution and expectations might be. A list of 29 participants, comprising psychiatric nurses, psychiatric social workers, some general nurses and senior staff within the Mental Health Services was provided a short time before departure, but without specific information on job responsibilities or previous experience. Workshop methods How to prepare a workshop on counselling skills for those in Lesotho, a culture with very different underlying assumptions from mine and whose home language is Sesotho? Counselling skills are "people skills", so what can be learned by lectures or reading is very limited. Thus, experiential methods of devetoping self-awareness and personal skills are always the predominant modes of learning used in such courses. To what extent could these theories, and methods be appropriate or relevant? I believed that priority must be given to experiential learning, but that the programme needed to be open-ended and flexible, so that the participants could give guidance themselves as to what seemed to them relevant and appropriate. This involved the risk of having to adapt and change much ofthe prepared material on arrival and during the workshop. assumptions Although I had serious doubts about the cultural appropriateness of counselling theory, I had no doubts as to the crucial importance of language. My previous experience had taught me that in the area of mental illness and emotional distress, many common English words such as "stress" and "anxiety" have no direct equivalent in African languages. Not only is it impossible to translate some English words, but the fundamental way in which emotional distress and mental illness is understood and labelled is totally dependent on the cultural context (Patel et al. 1997,Witzkum et aI.1996). Outside the North American and European context there are also specific emotional problems which are unique to that culture and cannot be translated into English. The workshop therefore had to be designed in such a way that exploration of language differences was an integral part of the work. It was hoped 126 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 17 NO 1 JANUARY 2002 Gilbert/CROSS-CULTURAL ISSUES IN COUNSELLING SKILLS that, through the creative exploration of the Sesotho language and the workshop experiential tasks, emotional expression and language use among the Basotho people could be more clearly understood both by the participants and the facilitators. The participants would be carrying out their own further teaching in Sesotho, so it was essential that this language be used as much as possible for all experiential and small group work. I also hoped that a Sesotho dictionary of counselling terms and words used to describe feelings could be developed by the participants to match those that I had provided in English and that this might be a useful additional teaching resource for the participants. As I am a psychologist with therapeutic training, I consulted with my counsellor colleagues within my National Heath Service workplace as to the content of counselling skills training courses in the UK. I then selected some of what I thought might be relevant and could be adapted rewrote for Lesotho, deleting as much jargon as possible, and designed a workshop programme. psychological theoretical handouts, The workshop programme In teaching situations there is often an implicit expectation that lectures will be given, and participants are often less familiar with participatory or experiential methods of learning. participants can thus feel daunted introduces when a facilitator these participatory methods. In this workshop it was also crucial that the focus was predominantly on Basotho culture and the circumstances of the participants themselves, rather than on imported theories and experience from the North. This focus had also to be empowering and validating so that the participants became proud of their own experiences and could share them openly. Although I was very aware of these potential difficulties, I also knew that the success or failure of the first day would set the tone for the rest of the week. It is impossible to summarize accurately the detail of a .five.day, primarily experiential, workshop but I hope what follows WillgIve a flavour of what took place. The first day began with the customary formalopening, includingprayers the and a hymn, followed by brief introductory comments about VOL 17 NO 1 JANUARY 2002 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 127 workshop and the methods to be used. I highlighted to the participants the fact that counseIling theory had been developed in a very different culture and that the workshop could thus be seen as "experimental", and I emphasised the essential role of the Sesotho language. I also indicated that their own personal and professional experience was of paramount importance and that whatever we learned together had to be relevant to their own professional work. Wethen began the smaIl group- work that would be the core teaching approach throughout the week. SmaIl groups were given tasks, then asked to present their discussions to the large group. Some of the tasks for the first day (summarized here) focused on the notion of "helping" in Lesotho: what kinds of help are acceptable; by whom, to whom; what can be talked about; what needs to be hidden? What kinds of help do you give in your own profession? What is expected of you? What kinds of help do you aIlow yourself to receive? Discussions in the larger group also included the exploration of the Sesotho language. Identifying a Sesotho word for "counselling" (no direct translation exists) provoked humorous heated debate before the participants suggested three possibilities: ho tastaisa motho fihela qeto (IiteraIly,to guide someone to reach a conclusion); ho thusa motho ho hlokomela (literally, to assist a person to realize a problem, to solve it it and ho tsehetsa motho (literally, and accept to support). The participants showed great enthusiasm in trying to find accurate translations of concepts for words that had no direct equivalent translation in Sesotho. By the end of the first day almost all participants seemed enthusiastically involved and appeared to have enjoyed the somewhat unusual teaching methods, to the relief of the facilitator. tasks Experiential Two days ofthe workshop had been allocated to experiential learning, but it had been difficult to plan this exactly. I had not been told what the levels of experience and prior training of the participants were and I was unsure before the workshop started as to what might be culturally relevant. When reviewing this with the participants, some commented that they had already received some type of counselling skills training. 128 JOURNAL OF S~CIAL DEVELOPMENT IN AFRICA VOL 17 NO 1 JANUARY 2002 Gilbert/CROSS-CULTURAL ISSUES IN COUNSELLING SKILLS that is, However, they did not seem to have engaged in what could be called "personal their own understanding of their own self, a fundamental element of all such training in the North. development increasing work", The aims and content of the two days of experiential work were both ambitious and complex because a number of elements hadto be included simultaneously: first, some of what would be considered essential for such a programme in the North; for example, listening skills, asking questions, dealing with feelings, judgments and stereotypes, self- reflection; some theoretical underpinning of the tasks of second, counselling. In addition the content had to be simultaneously adapted to what was appropriate in Basotho culture. Part ofthe facilitator's task was thus continuously to learn and be alert to both the parallels, similarities and differences in the ways "client" and "counsellor" might relate to each other in the context of the participants' own selves, their own life and work experiences and continuously to adapt the sessions accordingly. One detailed example gives a flavour of the work. Thetopicof "asking questions" was introduced. The types of questions that can be asked in English were then considered and the underlying rationale from counselling theory for types of questions was outlined (supported by a handout). In small groups, the participants then reviewed this in Sesotho and identified for themselves which types of questions would "fit" (that is, serve the same purpose) in the Sesotho language and which did not, and then suggested their own alternatives. Practical work in fours, when participants could practise with each other in Sesotho, then took place, followed by feedback and discussion with the larger group. There was much humour as the participants used role playto illustrate the nuances of Basotho personal interaction, including the positioning of furniture both in offices and in traditional village settings, and "personal that is, the culturally acceptable distance between people for conversation. Not only did the facilitators learn a great deal, but, through the facilitation and role play, the participants were able to look at themselves and their own professional work in ways that they space", VOL 17 NO 1 JANUARY 2002 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 129 • ~ the participants had become increasingly had not done previously. Itwas very clear after the first day of experiential work that confident, contributed extremely actively to discussions and began of their own accord to challenge their own thinking and ideas in very constructive ways, thus spontaneously engaging in what, in counselling terms, would be called "personal development". the participants themselves about and eventually, as hoped, a glossary actively engaged the cultural Overview Language From the first day when they were asked for the Sesotho word for "counselling", in developing 'further mutual understanding and language issues which arose during the workshop tasks and discussions. This information was written up by the participants on flipcharts as the workshop progressed, of counselling terms in Sesotho was produced, as well as Sesotho words relating to feelings and emotional expression (this is available from the author on request). Use of handouts The preparation of handouts before the workshop had been completed to minimize jargon and theory, but was intended to be useful both for the participants themselves and as future teaching materials for them. The handouts were most often distributed after a particular topic had been discussed, to maximize the contributions of the participants and their presentation of their own circumstances. In any cross-cultural work, iftheoretical ideas from the North are presented before discussion it is often difficult for participants to develop sufficient confidence to express their own views and share their own experiences. It is therefore preferable to facilitate the expression of the participants' views and experience first. Mutual support One of the factors that contributed significantly to the success of the workshop was the support that the participants were able to give to each other. The practical workshop tasks provided a forum whereby both personal and professional experiences could be exchanged in a 130 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 17 NO 1 JANUARY 2002 Gilbert/CROSS-CULTURAL ISSUES IN COUNSELLING SKILLS supportive ~nd. caring environment. The majority of the participants were psychlatnc nurses who were based in each of the health service areas in Lesotho, most often located at a local general hospital alongside general nurses but with no other mental health service staff. Many carried the sole responsibility for identifying and caring for those who were mentally iIIin a particular geographical area, apart froma visit from one of the two psychiatrists in Lesotho at approximately three-monthly intervals. Thus they did not receive on a regular basis this kind of peer support-an essential part both of professional development and maintenance of morale in very difficult working environments. As we all lived together for five days, many informal discussions also took place regarding personal development, the workshop content andthe practical realities of very demanding work with patients in a mental health service that, in common with many such services in emerging economies, receives limited funding and support. Implementation teaching The participants were extremely enthusiastic about whatthey had learned and experienced during the workshop and many commented that they were looking forward to telling their colleagues about their experience and increased knowledge and awareness. However, overall many of the felt pessimistic about the possibility of being able to participants implement teaching in their own working environments. Their major concerns related to anticipated lack of support from senior staff in their own local hospitals. It became clear that not only were many of the psychiatric nurses in a management structure in which mental health service staff were managed by general nurse managers but the participants line managers had very little understanding of, or commitment to, mental health. also felt offurther that their This was disappointing, but the participants were open about their own disillusionment with a management structure that did not seem to give priority to the need for dedicated mental health services, a common experience in emerging economies. Their comments also showed very clearly the gap between what had been seen as a "good idea" and the reality of practical implementationwithin adifficultworkingenvironment. Formal evaluation VOL 17 NO 1 JANUARY 2002 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 131 The participants completed a written evaluation at the end of the workshop. Most commented on the shortage of time for so much work and felt that other staff, including those in management, should have the opportunity for a similar workshop. Many also requested that such workshops take place regularly, for example, every year, so that skills could be further developed. It was particularly heartening, in terms of the workshop design, that participants had felt that the approaches had been sufficiently relevant to their own culture and language to be useful and that the experience had contributed significantly to both personal and professional development. Some examples give a flavour of the feedback. The workshop has been relevant because we translated some of the words to what our people could understand Thefacilitators really did their best, so much that Ifelt they were under pressure to perform at their best in making sure they did not impose what was culturally acceptable to them on to us. This was really interesting, especially when it came to self- understanding. This workshop has been thrilling to me. I'm now a changed person. Hopefully I will be an agent of change in my work. This workshop was really very good, especially to me as an individual. It gave me the chance to talk about myself, explore my feelings in a relaxed atmosphere, knowing I am talking to people who understand Again I think I am going to be productive to my colleagues and other people in my church and community. Counselling theory and practice In reviewing my initial reservations about the topic, content and design of this counselling skills workshop, were my fears about its relevance to a very different culture confirmed? It was clear from the beginning that the participants were highly educated, experienced professionals. Many, outside Lesotho and their proficiency in English was excellent. This made them an elite and unrepresentative group in their own culture. They were also already though not all, had travelled 132 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 17 NO 1 JANUARY 2002 Gilbert/CROSS-CULTURAL ISSUES IN COUNSELLING SKILLS familiar with some of the terms and concepts used in counselling theory, However, in the beginning they were hesitant about the experiential ~~t.hods, pa~icularly in reflecting on themselves and, understandably, Initially suspicious of the facilitator. However: probably because of their own professional experience, all participants gradually became more open and confident in their contributions.' I am unsure to what extent this would have been possible with a less well-educated and experienced group. In relation to specific counselling theory and cultural assumptions about the self, there was insufficient time to examine this in the depth that I would have wished. However, as might be expected, I felt the participants to be between cultures, that is, they seemed to think about themselves and their circumstances with both independent and dependent views of self which they held at the same time. In private discussions it became clear that this "in between" could be a source of conflict within themselves; being pulled both by their traditionalcultural beliefs and their experience of the very--differentcultural assumptions of the North. It would also be extremely important to establish how being "in between" cultures would affect their teaching of village health workers. An example of holding together aspects of both independent and interdependent views of self was shown by the reaction of some participants to Maslow's Hierarchy of Needs (a fundamental premise of counselling theory). While accepting the theory, they felt that self- actualization (the apex of the hierarchy intermsof personaldevelopment) could be achieved through one's children, notjust as an individual. for cultures with an independent view of self this would not be considered appropriate, as self actualization has to involve the development of a person's own inner attributes. The participants also considered Roger's core conditions (warmth, empathy and positive regard, the essential building blocks of a therapeutic relationship in counselling t~eory), to be essential for their own work, but how they were conveyed 10 one-to- one relationships was specific to Basotho cultural norms of social interaction. VOL 17 NO 1 JANUARY 2002 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 133 theory between Basotho culture counselling A detailed analysis of the possible similarities and differences in applying and the individualistic cultures of the North and its relevance to Basotho culture as a whole, could not De explored in such a short workshop and is beyond the scope of this paper. However, the work did indicate that counselling skills training could be given in a different culture-with great care. Principles to guide future work The principles that follow are given with the reservation that such training may be less appropriate, or certainly more challenging, of those who do not have a knowledge and awareness of some of the cultural assumptions of the North, particularly relating to the self. • An atmosphere must be created from the beginning of any counselling skills training in which the local culture is assumed to make the dominant contribution. The participants need to feel that they are the experts on themselves and their own culture, not the "qualified, higher status" external facilitator. This also requires that the facilitators make every effort to step down from the pedestal that participants, who may lack self confidence, may try to put them on . • The programme content must be flexible in order to adapt and reflect the personal and professional experiences of the participants. Any theories stemming from the North must be presented tentatively, with a clear message that relevance to the culture of the participants may be limited. their • Language and emotional expression within the local culture must be examined by the participants extremely carefully to minimize the likelihood of one culture's assumptions being taken as universal. • Nuances of interpersonal relationships within the local culture need to be explored in as much detail as possible, particularly through practical methods such as role play and discussion of personal experience. 134 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 17 NO 1 JANUARY 2002 Gilbert/CROSS-CULTURAL ISSUES IN COUNSELLING SKILLS that the participants themselves are taken to validate Concluding comments of skills" can be a value-laden expression, making the The "transfer those receiving the transfer do not have skills and assumption expertise of their own. This workshop indicates that facilitating and developing the counselling and interpersonal skills that someone already important requirements would seem has is possible, with care. The most to be that take the major role and that all opportunities knowledge, their pre-existing and the concepts embedded in their own language. Within experience new ideas can be introduced without undermining or this framework implicitly cultural assumptions by the teaching from a very different of theories the of this workshop were able to extract what has been participants and professionally personally they subsequently had greater confidence to carry out the very difficult and challenging work that each of them continues to do. It is hoped that cultural base. for them and that devaluing indigenous relevant emotion References Marcus, H.R. and Kitayama, S. 1991. Culture and the self: implications and motivation. Psychological Review 98 2 for cognition, 224-253 Patel, V. 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