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Mental Health Practitioners' Reflections on Psychological Work in Uganda: Exploring Perspectives from Different Professions

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Title: Mental Health Practitioners' Reflections on Psychological Work in Uganda: Exploring Perspectives from Different Professions
Language: English
Authors: Hall, Jennifer, d'Ardenne, Patricia, Nsereko, James, Kasujja, Rosco, Baillie, Dave, Mpango, Richard, Birabwa, Harriet, Hunter, Elaine
Source: British Journal of Guidance & Counselling. 2014 42(4):423-435.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 13
Publication Date: 2014
Document Type: Journal Articles
Reports - Research
Descriptors: Mental Health, Reflection, Psychological Services, Psychotherapy, Focus Groups, Psychologists, Psychiatry, Counselor Attitudes, Qualitative Research, Professional Education, Delivery Systems, Media Adaptation, Cultural Relevance, Work Environment, Interpersonal Communication, Stakeholders, Partnerships in Education, Educational Needs, Client Characteristics (Human Services), Access to Health Care, Counselor Training, Cultural Influences, Foreign Countries
Geographic Terms: Uganda
DOI: 10.1080/03069885.2014.886672
ISSN: 0306-9885
Abstract: The Butabika-East London Link collaborated with Ugandan mental health services to train mental health professionals (psychiatric clinical officers, "PCOs", and clinical psychologists and psychiatrists, "Core Group") in psychological therapies. The aims of this research were to investigate how professionals were applying and adapting psychological therapies to the Ugandan setting and to gain ideas to inform future training. Focus groups were used to explore the PCO's (N = 13) and Core Group's (N = 8) thoughts. Recordings were transcribed and thematically analysed. Themes identified were: issues affecting psychological therapy provision; cultural adaptations; voices of service users; and training. Different professional groups share similar concerns about implementing psychological therapies in a country where psychological services are just emerging. Future directions are suggested.
Abstractor: As Provided
Number of References: 34
Entry Date: 2014
Accession Number: EJ1031600
Database: ERIC
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  Value: <anid>AN0096711173;bjg01aug.14;2019Mar28.13:49;v2.2.500</anid> <title id="AN0096711173-1">Mental health practitioners' reflections on psychological work in Uganda: exploring perspectives from different professions. </title> <p>The Butabika-East London Link collaborated with Ugandan mental health services to train mental health professionals (psychiatric clinical officers, 'PCOs', and clinical psychologists and psychiatrists, 'Core Group') in psychological therapies. The aims of this research were to investigate how professionals were applying and adapting psychological therapies to the Ugandan setting and to gain ideas to inform future training. Focus groups were used to explore the PCO's (N = 13) and Core Group's (N = 8) thoughts. Recordings were transcribed and thematically analysed. Themes identified were: issues affecting psychological therapy provision; cultural adaptations; voices of service users; and training. Different professional groups share similar concerns about implementing psychological therapies in a country where psychological services are just emerging. Future directions are suggested.</p> <p>Keywords: clinical psychology; Africa; professional development; psychological therapy; cross-cultural issues</p> <hd id="AN0096711173-2">Introduction</hd> <p></p> <hd id="AN0096711173-3">Country background</hd> <p>Data on the prevalence of mental illness in Uganda have been reported as 'unreliable' due to the few epidemiological studies conducted (The WHO Mental Health Consortium, [<reflink idref="bib27" id="ref1">27</reflink>]). Researchers have estimated the prevalence of mental illness in Uganda to be higher than the global average of 13% (The WHO Mental Health Consortium, [<reflink idref="bib27" id="ref2">27</reflink>]), with estimates of 31% (Kasoro, Sebudde, Kabagambe-Rugamba, & Ovuga, [<reflink idref="bib12" id="ref3">12</reflink>]), 20% (Kagolo, [<reflink idref="bib11" id="ref4">11</reflink>]) and 35% (Basangwa, 2004, as cited in Ssanyu, [<reflink idref="bib26" id="ref5">26</reflink>]). There are many psychological stressors that may account for these high estimates. There has been a high level of conflict, both in Uganda and in its neighbouring countries, over the past four decades. This includes a violent dictatorship led by Idi Amin from 1971 to 1976 (Keatley, [<reflink idref="bib13" id="ref6">13</reflink>]), and more recently, a civil war caused by the Lord's Resistance Army in Northern Uganda between 1987 and 2006 (United Nations Uganda, [<reflink idref="bib31" id="ref7">31</reflink>]). The numbers of refugees fleeing from Somalia, the Democratic Republic of Congo and South Sudan into Uganda are estimated to increase to over 200,000 by December 2013 (UNHCR, [<reflink idref="bib30" id="ref8">30</reflink>]). Other psychological stressors include high levels of poverty (Uganda Bureau of Statistics, [<reflink idref="bib29" id="ref9">29</reflink>]) and illnesses such as malaria (Yeka et al., [<reflink idref="bib34" id="ref10">34</reflink>]) and HIV (Uganda AIDS Commission, [<reflink idref="bib28" id="ref11">28</reflink>]).</p> <p>Mental health services in Uganda are scarce. Several positive steps have been made in the provision of mental health care recently, such as decentralisation of services and re-drafting of mental health policies (Ndyanabangi et al., [<reflink idref="bib18" id="ref12">18</reflink>]). Despite this, problems remain, with reports of human rights violations and stigmatisation (Cooper et al., [<reflink idref="bib6" id="ref13">6</reflink>]). A possible reason for this is the lack of mental health staff catering for the needs of the population of 34 million (Population Secretariat & United Nations Population Fund Uganda, [<reflink idref="bib22" id="ref14">22</reflink>]). Mental health professionals in Uganda include psychiatrists, clinical psychologists and psychiatric clinical officers (PCOs). The number of consultant psychiatrists in Uganda has grown from 1 in 1950 to 32 in 2012 (Kagolo, [<reflink idref="bib11" id="ref15">11</reflink>]; Ovuga, [<reflink idref="bib21" id="ref16">21</reflink>]), with some of these being employed in universities. The Clinical Psychology Masters' Programme at Makerere University has produced 35 graduates since it started in the early 1990s (R. Kasujja, personal communication, July 20, 2012), of which only 5 are currently government employed practising clinical psychologists (Hall, [<reflink idref="bib10" id="ref17">10</reflink>]). Almost all of the practising clinical psychologists and psychiatrists are based in either of the two national referral hospitals in the capital, Kampala (Hall, [<reflink idref="bib10" id="ref18">10</reflink>]). This means that government-funded psychological therapies are only offered in Kampala, making access to psychological therapies in other parts of the country very poor.</p> <p>Secondary mental health services outside Kampala exist in 11 districts and are run by PCOs (Ovuga, [<reflink idref="bib21" id="ref19">21</reflink>]). In 1979, Uganda was the first country in sub-Saharan Africa to begin training PCOs, a senior nursing profession trained in diagnosing and treating mental health problems, including prescribing medication. Since the training course began, 219 PCOs have qualified, 79 of whom work in government-run hospitals (Nampogo, [<reflink idref="bib17" id="ref20">17</reflink>]). It is the PCOs who provide the vast majority of mental health services in Uganda (Kigozi et al., [<reflink idref="bib14" id="ref21">14</reflink>]), making medication the most common treatment method for mental health problems, with few opportunities for psychological therapies.</p> <p>It is widely acknowledged that psychological therapies form a vital part of treatment for mental health problems (e.g. NICE, [<reflink idref="bib19" id="ref22">19</reflink>]). In order for mental health services to be able to cater to the needs of people living in Uganda, it is essential to incorporate culturally appropriate and accessible psychological interventions as well as pharmacological treatments. For this to occur, access to psychological therapies needs to be increased. One way to do this is through training government-employed mental health professionals. With Uganda mental health services increasingly collaborating with UK-based health institutions to develop services (e.g. Butabika-East London NHS Foundation Trust, [<reflink idref="bib5" id="ref23">5</reflink>]; Davies, [<reflink idref="bib9" id="ref24">9</reflink>]; Sharkey & Tindall, [<reflink idref="bib23" id="ref25">23</reflink>]; Sheffield Health and Social Care NHS Trust, [<reflink idref="bib24" id="ref26">24</reflink>]; University Hospital of South Manchester, [<reflink idref="bib32" id="ref27">32</reflink>]), it is becoming more relevant and essential for psychological therapies in Uganda to be further understood, to inform ideas for future training.</p> <p>The aims of this study were (i) to understand how two different groups of mental health practitioners who had been trained in Western psychological therapies were applying and adapting these to the Ugandan setting and (ii) what future training would be most beneficial to the mental health professionals practising psychological therapies in Uganda.</p> <p>Overall, three different professions (PCOs, clinical psychologists and psychiatrists) were included in this study, with the hope of gaining a wider and richer perspective on the provision of psychological therapies in Uganda. The PCOs, who work primarily in community settings and have a training background in nursing, were hypothesised to offer a different perspective to that of the clinical psychologists and psychiatrists, who were already familiar with psychological models and worked predominantly in hospital settings in Kampala. It was thought that the PCOs might talk about applying psychological therapies at a community-based level, using community resources and a tendency to rely on 'medical' mental health diagnoses as a framework, whereas the clinical psychologists and psychiatrists may talk about psychological therapies on a one-to-one basis and, due to their training, may offer perspectives on the psychological models themselves.</p> <hd id="AN0096711173-4">Method</hd> <p></p> <hd id="AN0096711173-5">Context</hd> <p>In 2012, two training projects led by the Butabika-East London NHS Global Mental Health Link (Baillie et al., [<reflink idref="bib1" id="ref28">1</reflink>]) came to an end. These projects aimed to increase psychological therapy provision in Uganda through training (i) PCOs (a three-year funded project by the Tropical Health Education Trust – THET, Butabika-East London Link, [<reflink idref="bib4" id="ref29">4</reflink>]) and (ii) a mixture of clinical psychologists and psychiatrists (the Core Group – CG) in 'Western' psychological therapies. Both sets of groups received different trainings, with the PCOs being trained in adapted solution focussed therapy, motivational interviewing and trauma focussed cognitive behavioural therapy (CBT) (d'Ardenne, Robjant, Kasujja, Nsereko, & Hunter, [<reflink idref="bib8" id="ref30">8</reflink>]). The CG, who had all received previous training in psychological therapies, were not only involved in the training of the PCOs, but also received additional training in CBT over a six-month period and attended a weekly supervision group. These professionals were ideally placed to offer their experiences and thoughts of applying these psychological therapies to the Ugandan setting, as well as to give their opinions on future training.</p> <p>The authors have all been involved in teaching and working in the Ugandan government-run health system and so understood the context and content of the mental health professionals' clinical work. This was important to understand the attitudes that emerged in the focus groups.</p> <hd id="AN0096711173-6">Participants</hd> <p>Two separate focus groups were held. The first focus group was held with the PCOs in Kampala in October 2012. Overall, 120 PCOs participated in the Butabika-East London psychological training project, 80 of whom attended the showcase conference in Kampala (d'Ardenne, Robjant, Kasujja, Nsereko, & Hunter, [<reflink idref="bib7" id="ref31">7</reflink>]). At this conference, PCOs were invited to volunteer for the study, and 13 (males = 6, females = 7) were selected. The facilitators (R. K., R. M. and J. M.) and observers (P. dA. and J. H.) were authors of this paper. Notes were made by the observers to begin identifying salient themes.</p> <p>The second focus group, with the CG, took place at Butabika National Referral Hospital in November 2012. All those who were involved in the training were invited to participate (five state-employed clinical psychologists, one clinical psychology lecturer, one psychiatrist, one PCO with clinical psychology training, one NGO-employed clinical psychologist), and two additional mental health staff who had previously been trained in CBT (one volunteering psychiatrist and one volunteering clinical psychologist; <emph>N</emph> = 11). Eight volunteered to partake, including six clinical psychologists and two psychiatrists. The gender balance was equal. Two of the authors of this paper (D. B. and J. H.) were facilitators and made observational notes.</p> <p>In both groups, informed consent was sought, and all were told that their identities would be kept confidential. Participants were encouraged to be honest with the facilitators, and the facilitators made themselves available for questions at each step of the research process. It was made clear that participants were able to withdraw at any point. A reflective commentary of emerging themes and ideas was kept (author J. H.) from the start of the research.</p> <hd id="AN0096711173-7">Material</hd> <p>Themes for the focus groups were derived by reviewing ideas from previous informal Ugandan mental health practitioner meetings. Emerging topics were analysed and streamlined to develop simplified focus group questions and prompts by three authors (J. H., D. B. and P. dA.). The prompts and questions used in both focus groups were different, but centred around how the practitioners were applying and adapting the Western psychological therapies for the Ugandan settings, and what future training would be beneficial.</p> <hd id="AN0096711173-8">Qualitative analysis</hd> <p>Thematic analysis with a realist theoretical framework was used (Braun & Clarke, [<reflink idref="bib3" id="ref32">3</reflink>]). This fit best with aims of this study, to report the experiences of the participants. The two focus group recordings were transcribed verbatim by different authors (P. dA. and J. H.) and anonymised. The content of the focus groups was initially analysed separately by these two authors, both trained clinical psychologists with expertise and experience of applying psychological therapies in Ugandan settings. The two transcripts were originally analysed using a 'bottom-up' thematic analysis, whereby the researchers were not trying to fit the data into a pre-decided theoretical framework. The researchers re-read the transcripts to re-familiarise themselves with the material. The data were then coded by giving priority to data that captured an important element of the study questions, and those which were most prevalent in the transcripts. These codes were initially generated for each focus group separately and were shared between all of the researchers (<emph>N</emph> = 7) who were asked to evaluate whether the codes accurately encapsulated the themes that emerged in the focus groups. The researchers (P. dA. and J. H.) then collated the two sets of focus group codes, which were revised, discarded or kept the same until a coding scheme was devised which spanned across both focus groups. This single combined coding scheme was then used to code both the transcripts line by line and additional codes generated where none fitted. An example of this coding is given in Table 1. In this process, it transpired that some of the data being coded were irrelevant to the study aims, for example participants talking about disagreements among other staff. This small amount (approx. 3%) of data was discarded. It also transpired that codes that did not span across the two focus groups existed, but were deemed relevant to the study questions, so were not discarded. Superordinate and subthemes were created depending on the relevance to the research questions and the prevalence of those topics. Each of these superordinate and subthemes were debated with the rest of the research team, revised, eliminated or new ones created, until the research team judged that they encapsulated the relevant aspects of the participants' conversation.</p> <p>Table 1. Examples of data excerpt and coding.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Data excerpt</td><td>Coding</td></tr></thead><tbody><tr><td>One other thing is sometimes what I will try to do knowing that this person may not, may fail to come back, may fail to get transport, I don't use time limited to one hour on the dot, I try to give much longer time so that at least we try to maximise the help that we can.</td><td><list list-type="Bullet"><list-item><p>Cultural barriers to therapy</p></list-item><list-item><p>Adaptations made for the Ugandan setting</p></list-item></list></td></tr><tr><td>Why don't psychologists teach psychological therapies at the PCO school so nurses start with knowledge? Also, supervision is needed, introduce psychology into PCO curriculum.</td><td><list list-type="Bullet"><list-item><p>Training</p></list-item><list-item><p>Roles of professions</p></list-item></list></td></tr></tbody></table> </ephtml> </p> <p>Once the researchers had an agreed set of themes, all commented on the interpretation and collation of the themes between the two groups. They were asked to use their own prior knowledge and experience of the context (the professional groups, the Ugandan context and the psychological therapies), observational notes and any notes or commentaries they had been keeping to reflect on what these themes meant in the wider context. These were then discussed openly between the researchers with the hope of creating a deeper understanding of the data.</p> <p>The analysis process was performed with Braun and Clarke's ([<reflink idref="bib3" id="ref33">3</reflink>]) Good Thematic Analysis checklist in mind.</p> <hd id="AN0096711173-9">Data collection</hd> <p>Open-ended group questions and prompts were used to facilitate the discussions. Facilitators chosen worked within Ugandan mental health settings and were familiar to the participants, with the hope that this would help them feel comfortable about self-disclosure. Recording devices were used in both focus groups for transcription, and observational notes made. Both focus groups lasted approximately 90 minutes.</p> <hd id="AN0096711173-10">Results</hd> <p>Analysis and identification the two focus groups resulted in four superordinate themes relating to existing psychological practice and psychological training in Uganda: (i) issues affecting psychological therapy service provision in Uganda; (ii) Cultural adaptations of psychological therapy for the Ugandan setting (iii); voices of service users and (iv) training.</p> <hd id="AN0096711173-11">Issues affecting psychological therapy service provision in Uganda</hd> <p>This superordinate theme taken has been divided into six subthemes:</p> <p></p> <ulist> <item> Overwhelming workload</item> <p></p> <item> Inability to conduct regular therapy</item> <p></p> <item> Communication and language</item> <p></p> <item> Cultural beliefs and knowledge of psychological therapy</item> <p></p> <item> Engaging stakeholders</item> <p></p> <item> Personal beliefs.</item> </ulist> <hd id="AN0096711173-12">Overwhelming workload</hd> <p>Both groups spoke about being overwhelmed with the workload, with there being too many clients referred. The PCOs spoke about having 'low levels of staff', and the CG said that clients turned up unexpectedly wanting to be seen immediately, which led them to feel 'burnt out', 'demoralised' and to 'stop caring'.</p> <hd id="AN0096711173-13">Inability to conduct regular therapy</hd> <p>Barriers to conducting regular therapy came from both the clients' and the service providers' side. Clients' ability to regularly attend therapy was spoken about by both groups, and a clinical psychologist stated, 'telling them to come back every week is like telling them ... don't come'. Barriers to clients attending therapy included having insufficient money for fuel or transport to get to the mental health clinic, the roads being bad and the mental health clinic far away, and the clients' other commitments such as work or farming, meaning they did not have the time. Both groups said that this made follow-up of clients difficult.</p> <p>The PCOs stated additional problems in that they did not have a safe place to conduct regular therapy, they suffered from fatigue when they travelled to villages to do follow-ups and there was 'not enough time for psychological therapy'.</p> <hd id="AN0096711173-14">Communication and language</hd> <p>The PCOs mentioned difficulties with interpreting some of the treatment outcomes into the local languages, and the CG described problems with interpreting psychological terms, for which there is no direct interpretation into the local language. The PCOs discussed not having access to resources that allowed them to communicate with their clients, such as information leaflets, telephones, paper and pens and email access. The CG raised concerns about using CBT tools such as thought records, mood and activity diaries with clients who were not able to read or write.</p> <hd id="AN0096711173-15">Cultural beliefs and knowledge of psychological therapy</hd> <p>The PCOs said their colleagues had negative attitudes to psychological therapy, believing drugs to be better and quicker. This had resulted in other professions not referring clients on to PCOs for psychological therapy, or even acknowledging the therapy process. The CG said their clients were not aware of psychological treatments, instead preferring to take medication, or believing their problem was caused by witchcraft or spirit possession. Levelling the power difference between doctor and client for collaborative psychological working was seen as a difficulty, with one member of the group remarking that in Uganda, 'a Doctor is next to God'. It was felt that education and poverty accounted for differences in clients' knowledge and engagement for psychological therapy, with those less educated and/or of a lower socio-economic status, finding it harder to engage with psychological therapy.</p> <hd id="AN0096711173-16">Engaging stakeholders</hd> <p>PCOs found the local council leaders to be a valuable community resource, stating them to be sympathetic to both modern and traditional healing, to possess local authority and have a good knowledge of individuals. PCOs also thought that primary care staff were ideally suited to infiltrate communities and assist with culturally appropriate messages and discourse. They said this is because, although not trained in mental health, most primary care staff speak local languages and understand their communities well. PCOs recognised that introducing something as radical as psychological therapy means having them on board as stakeholders.</p> <hd id="AN0096711173-17">Personal beliefs</hd> <p>The PCOs spoke about their own, now positive, personal beliefs about psychological therapy, 'I believe in psychological therapy more than before'. They noted that clients relapse less when they talk to them, and the clients really appreciated this. The CG spoke about their personal beliefs in terms of which type of therapeutic tools they use, with them being more willing to use therapeutic tools in which they are trained, which they believe work and which they feel more confident using.</p> <hd id="AN0096711173-18">Cultural adaptations of psychological therapy for Ugandan setting</hd> <p>Ways in which PCOs and CG overcame the barriers to psychological therapy provision in Uganda were divided into five subthemes:</p> <p></p> <ulist> <item> language,</item> <p></p> <item> use of others,</item> <p></p> <item> traditional beliefs,</item> <p></p> <item> socialise client to psychological therapy and</item> <p></p> <item> becoming more flexible.</item> </ulist> <hd id="AN0096711173-19">Language</hd> <p>PCOs offered interpretation by allocating clients to local staff who could speak their language, whereas the CG used trained interpreters. Both groups said they used local languages to describe psychological terms. When there was no linguistic equivalent, they used proverbs, local metaphors or approximate words. Specifically, the CG discussed the lack of distinction between thoughts and feelings in the local language, and gave an example of how to overcome this, 'we had come up with the idea of asking for "ideas" not thoughts because they can appreciate "ideas"', and 'when I'm looking for feelings I tend to ask "how are you feeling in your heart" because we tend to feel with our hearts and we tend to think with our minds'.</p> <hd id="AN0096711173-20">Use of others</hd> <p>PCOs stated that they worked with other members of the community to help with the large client workload, by 'sensitising' (educating) local leaders to encourage treatment adherence, and using community members to make a plan for when clients cannot be seen immediately. A recent change in the clinical psychology training programme meant that students were being offered clinical placements for the first time, and had been introduced to the wards at Butabika Hospital. The CG stated that these students helped to lessen their large caseloads.</p> <hd id="AN0096711173-21">Traditional beliefs</hd> <p>The PCOs stated that they overcame difficulties related to traditional beliefs of mental illness by working closely with the traditional and spiritual healers. Examples given were using the traditional healers as advocates to encourage drug compliance and counselling, and giving spiritual leaders skills and knowledge about Western practice. The PCOs expressed the hope of adapting psychological therapies for local use, but had not yet had the time to do so. They believed that clinical psychologists and psychiatrists in Uganda would help them with this in the future. They said, for example, that Motivational Interviewing was a useful technique for helping them with substance and alcohol abuse, but the refinement of that skill within a Ugandan context remains to be completed.</p> <p>The CG concluded that it is not helpful to challenge traditional beliefs:</p> <p>They think witchcraft is the cause of their problem ... I try not to challenge their beliefs ... we are living in an environment which embraces our religious beliefs, our cultural beliefs ... the minute you start challenging their beliefs then it's like you're telling them to get out but I walk along with whatever they believe in, that is OK.</p> <p>With one participant speaking about using the Western model like a behavioural experiment: 'we can't afford to challenge people's beliefs, it's better we try out our ... Western way of working ... and then eventually when they realise that what you have introduced has worked much better'.</p> <hd id="AN0096711173-22">Socialising the client to psychological therapy</hd> <p>To overcome difficulties related to the lack of knowledge about psychological therapy, the CG stated, 'I explain to them what I am, "I am a psychologist" and then I explain ... what a psychologist does'. Examples of this included using a written contract at the beginning of therapy to help the client know what is expected of each party, and explaining the difference between thoughts and feelings when using CBT, '"that sounds like a thought", or "that sounds like a feeling"'. Decreasing the 'doctor–client' power difference was done through discussion with the client, 'I tell them, personally I am a traveller with you ... it is for you to solve your problem so that you take on the responsibility'; 'I tell them point blank at the beginning I don't have the answers but we are going to find out together ... I'm just facilitating'. To overcome irregular attendance, the CG stated that they motivated the client for the next session by explaining the importance and content of it. The CG socialised the client to strict appointment times as they had realised that working overtime by seeing clients who turned up unexpectedly had led to 'burn out'.</p> <hd id="AN0096711173-23">Becoming more flexible</hd> <p>There was agreement between the CG that it was useful to be flexible with their therapeutic boundaries. This was in relation to both the overall treatment structure, 'we normally give people at least three months. [of non-attendance]' before discharging, and with individual sessions: 'I don't use time limited to one hour on the dot, I try to give much longer time'.</p> <hd id="AN0096711173-24">Voice of service users</hd> <p>Both groups discussed having positive feedback from service users. They said they had received gifts as 'thank you' presents, and the PCOs said clients had recommended the service to other people in their communities with similar problems. Both groups were able to give examples of appreciative comments such as 'you are very special because of the way you talk to us'. More specifically, the PCOs gave two examples where service users (one carer and one couple who were having marital problems) said that solution focussed therapy had helped them to overcome their problems, and the CG gave an example where a service user had said that behavioural experiments had helped them to overcome their anxiety.</p> <p>The CG gave an example of negative feedback, when a client had not wanted to try relaxation.</p> <hd id="AN0096711173-25">Training</hd> <p>Both groups wanted more training for specific mental health problems. The PCOs asked for Motivational Interviewing for alcohol problems, and the CG wanted training for clients presenting with psychosis and conversion disorder. The CG wanted help with creating a video library to help them train others, and the PCOs requested 'psychologists to give us support, supervision and new learning'.</p> <hd id="AN0096711173-26">Discussion</hd> <p>The aims of this study were (i) to understand how different groups of mental health practitioners were applying and adapting psychological therapies to the Ugandan setting and (ii) to gain ideas to inform future training.</p> <p>It appeared that both groups had experienced difficulties applying the Western psychological therapies to the Ugandan context, due to a number of issues at cultural (lack of knowledge and belief in psychological therapy, speaking different languages, inability to conduct regular therapy), community (overwhelming workload, difficulties engaging stakeholders) and personal (personal beliefs and level of psychological therapy training) levels. Both groups made attempts to overcome these difficulties through adapting the following: the structure of psychological therapy (being flexible with length and regularity of sessions); the professionals who were giving psychological interventions (through using community resources and students); the way they communicated with the clients (using interpreters and local metaphors); the psycho-education component of therapy (introducing the idea of 'therapy' from the beginning); and through being non-judgemental of traditional beliefs.</p> <p>There were differences between the two groups. The PCOs had started to engage with the idea of providing psychological therapies. They spoke about beginning to now believe in psychological therapies as individuals and had begun to experiment with whether it is feasible, as a profession, to routinely offer psychological treatment. They had started to incorporate psychological ways of working at a systemic level, by working psychologically with the local leaders and the traditional and spiritual healers. This appeared to be a great strength for the profession, allowing for them to be fully integrated into their communities. The CG, on the other hand, had been able to practise the Western psychological techniques they had learnt. They had begun to critically analyse and evaluate what was effective, and how to adapt these techniques for the Ugandan setting. This process had allowed them to realise their knowledge gaps, and ask for specific further training. The CG did not mention community-based work. This could be due to all of the CG being based in institutions rather than communities, and the number of people in these professions being very small, meaning that resources for community-based work were lacking.</p> <p>These findings were consistent with the authors' expectations that the PCOs would discuss psychological therapies at a systemic level and the CG at an individual level. However, both groups appeared to rely on medical diagnoses, which was not consistent with the authors' expectations, with the CG asking for psychological therapies for conversion disorder. This may be due to the medical model being prevalent in the Ugandan mental health settings. The differences between the groups suggest the PCOs and CG to have complimentary roles. The PCOs asked for CG to adapt and offer training and supervision in psychological therapies. The CG are already partly filling this role through teaching modules in the PCO training course, but thought they needed more resources for training. It is possible that the PCOs have a role of helping the CG to work at a community level.</p> <p>Introducing Western ideas of mental health and psychological therapies to other cultures has been met with mixed responses in the literature. It has been blamed with introducing eating disorders to Hong Kong and increasing the prevalence of PTSD in Sri Lanka (Watters, [<reflink idref="bib33" id="ref34">33</reflink>]). Other research has suggested that Western psychological therapies can be successful when treating mental health problems in different cultural contexts, with a number of studies suggesting this to be the case for Uganda (e.g. Bass et al., [<reflink idref="bib2" id="ref35">2</reflink>]; Onyut et al., [<reflink idref="bib20" id="ref36">20</reflink>]; Sonderegger, Rombouts, Ocen, & McKeever, [<reflink idref="bib25" id="ref37">25</reflink>]). However it is important to note that this research has all been conducted outside of the realms of government-funded hospitals and health centres, hence the therapists did not have the limits set on them that the participants in this study had. The mental health professionals in this study spoke positively of their experiences using psychological therapies. Further research is required to ascertain whether these psychological therapies are effective in this setting.</p> <hd id="AN0096711173-27">Future: psychological therapies and training</hd> <p>The need for psychological therapies in Uganda has been recognised, with previous research (e.g. Bass et al., [<reflink idref="bib2" id="ref38">2</reflink>]), professionals and clients stating they are useful. Despite this growing support for psychological therapies, the Ugandan Ministry of Health ([<reflink idref="bib15" id="ref39">15</reflink>]) does not adequately recognise this treatment. They acknowledge that mental health services are lacking in the country, but state that this is due to the inaccessibility to medication, ignoring the influence of psychological therapies. Furthermore, psychological therapies are not mentioned as a recommended treatment option for mental health problems (Ministry of Health, [<reflink idref="bib16" id="ref40">16</reflink>]). Hence it is recommended that the government provide support for psychological interventions through including them in their policies, creating more paid clinical psychology posts and more spaces on the training course, which will allow them to grow as a profession in their own right. Future development priorities for clinical psychologists are learning and adapting more therapeutic techniques, and gaining skills in consultation, training and supervision to train more clinical psychologists. Once these goals have been achieved, they can then begin to focus on supervising and training other professionals in psychological therapies such as the PCOs. Development priorities for the PCOs appear to be gathering the resources and organising service structures to make psychological therapy a possibility, as well as increasing their knowledge in psychological therapies.</p> <p>With regard to external agencies, it appears that they can help by continuing to provide training and consultation on service structure and to offer regular supervision and training in psychological therapies.</p> <hd id="AN0096711173-28">Limitations of study</hd> <p>One limitation was that Butabika-East London Link members were present at both of the focus groups. This means that the participants may have felt the need to be more positive about the training in order to please these members. Another limitation is that the group facilitators were new to this role and may not have pursued enough ideas with follow-up questions. All of the authors involved in this paper understood the Ugandan mental health system, with experience working in these contexts. Whilst this allowed for them to make interpretations of the data based on the context, it also meant that they may have had pre-determined ideas, based on their own experiences and ideas about how psychological therapies could be adapted to this setting, which may have caused biases within all stages of data analysis and write-up. Future qualitative analysis would attempt to address these biases and limitations.</p> <hd id="AN0096711173-29">Conclusion</hd> <p>The results from this study have provided insights into how mental health practitioners were applying and adapting Western psychological therapies to the Ugandan context, and recommendations for future training have been discussed. More qualitative and quantitative research is required to explore how psychological therapy provision can be optimised in Uganda. Qualitative research could use experienced facilitators and observers from Uganda to reduce power imbalances and can look into how best links can collaborate to ensure Uganda's mental health systems improve on a sustainable basis.</p> <hd id="AN0096711173-30">Acknowledgements</hd> <p>The authors would like to thank Mr Cerdic Hall, Chair, Butabika-East London Link; Dr David Basangwa, Director, Butabika Hospital; Mr Mathias Nampogo, Chair, Uganda National Psychiatric Clinical Officers Association; and Dr Dorothy Kizza, Clinical Psychologist, Butabika Hospital.</p> <hd id="AN0096711173-31">Notes on contributors</hd> <p>Jennifer Hall has worked as a clinical psychologist and lecturer in the state-run hospital and university in Uganda since 2011. It is here that she got involved with the Butabika-East London NHS Link. She has a strong interest in cross-cultural psychology and the development of these services abroad.</p> <p>Patricia d'Ardenne has been involved in the Butabika-East London link since 2006 and has already published outcomes from psychological training in Uganda. She has a particular interest in the use of interpreters in cross-cultural psychological therapy.</p> <p>Rosco Kasujja is a lecturer on the Masters of Clinical Psychology at Makerere University. He has research and work experience with trauma in post-conflict Northern Uganda and has a particular interest in systemic therapies.</p> <p>James Nsereko is a clinical psychologist currently working at Butabika Hospital, Kampala. He is trained at Makerere University and lectures into the Masters Programme in Clinical Psychology.</p> <p>Dave Baillie is a Consultant Psychiatrist who has been an integral part of the Butabika-East London Link since 2005. He has previously published research papers into the Butabika-East London Link.</p> <p>Richard Mpango is a clinical psychologist who works at Butabika Hospital in Kampala. He has strong links with the Makerere Clinical Psychology Masters' Programme.</p> <p>Harriet Birabwa is a Consultant Psychiatrist who works at Butabika Hospital in Kampala. She has a strong interest in psychological therapies.</p> <p>Elaine Hunter spent six months based at Butabika through the Link during which time she delivered CBT training to clinical staff in Kampala. She is interested in cross-cultural approaches to working with mental health.</p> <ref id="AN0096711173-32"> <title> References </title> <blist> <bibl id="bib1" idref="ref28" type="bt">1</bibl> <bibtext> Baillie, D., Boardman, J., Onen, T., Hall, C., Gedde, M., & Parry, E. (2009). NHS links: Achievements of a scheme between one London mental health trust and Uganda. The Psychiatrist, 33, 265–269.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref35" type="bt">2</bibl> <bibtext> Bass, J., Neugebauer, R., Clougherty, K., Verdeli, H., Wickramaratne, P., Ndogoni, L. ... Bolton, P. (2006). Group interpersonal psychotherapy for depression in rural Uganda: 6-month outcomes: Randomised controlled trial. The British Journal of Psychiatry, 188, 567–573. doi:10.1192/bjp.188.6.567</bibtext> </blist> <blist> <bibl id="bib3" idref="ref32" type="bt">3</bibl> <bibtext> Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. doi:10.1191/1478088706qp063oa</bibtext> </blist> <blist> <bibl id="bib4" idref="ref29" type="bt">4</bibl> <bibtext> Butabika-East London Link. (2013b). Psychiatric clinical officer psychological training and projects. 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  Data: Mental Health Practitioners' Reflections on Psychological Work in Uganda: Exploring Perspectives from Different Professions
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  Data: <searchLink fieldCode="AR" term="%22Hall%2C+Jennifer%22">Hall, Jennifer</searchLink><br /><searchLink fieldCode="AR" term="%22d'Ardenne%2C+Patricia%22">d'Ardenne, Patricia</searchLink><br /><searchLink fieldCode="AR" term="%22Nsereko%2C+James%22">Nsereko, James</searchLink><br /><searchLink fieldCode="AR" term="%22Kasujja%2C+Rosco%22">Kasujja, Rosco</searchLink><br /><searchLink fieldCode="AR" term="%22Baillie%2C+Dave%22">Baillie, Dave</searchLink><br /><searchLink fieldCode="AR" term="%22Mpango%2C+Richard%22">Mpango, Richard</searchLink><br /><searchLink fieldCode="AR" term="%22Birabwa%2C+Harriet%22">Birabwa, Harriet</searchLink><br /><searchLink fieldCode="AR" term="%22Hunter%2C+Elaine%22">Hunter, Elaine</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22British+Journal+of+Guidance+%26+Counselling%22"><i>British Journal of Guidance & Counselling</i></searchLink>. 2014 42(4):423-435.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
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  Data: 13
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  Data: Journal Articles<br />Reports - Research
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Reflection%22">Reflection</searchLink><br /><searchLink fieldCode="DE" term="%22Psychological+Services%22">Psychological Services</searchLink><br /><searchLink fieldCode="DE" term="%22Psychotherapy%22">Psychotherapy</searchLink><br /><searchLink fieldCode="DE" term="%22Focus+Groups%22">Focus Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Psychologists%22">Psychologists</searchLink><br /><searchLink fieldCode="DE" term="%22Psychiatry%22">Psychiatry</searchLink><br /><searchLink fieldCode="DE" term="%22Counselor+Attitudes%22">Counselor Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Qualitative+Research%22">Qualitative Research</searchLink><br /><searchLink fieldCode="DE" term="%22Professional+Education%22">Professional Education</searchLink><br /><searchLink fieldCode="DE" term="%22Delivery+Systems%22">Delivery Systems</searchLink><br /><searchLink fieldCode="DE" term="%22Media+Adaptation%22">Media Adaptation</searchLink><br /><searchLink fieldCode="DE" term="%22Cultural+Relevance%22">Cultural Relevance</searchLink><br /><searchLink fieldCode="DE" term="%22Work+Environment%22">Work Environment</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Communication%22">Interpersonal Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Stakeholders%22">Stakeholders</searchLink><br /><searchLink fieldCode="DE" term="%22Partnerships+in+Education%22">Partnerships in Education</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Needs%22">Educational Needs</searchLink><br /><searchLink fieldCode="DE" term="%22Client+Characteristics+%28Human+Services%29%22">Client Characteristics (Human Services)</searchLink><br /><searchLink fieldCode="DE" term="%22Access+to+Health+Care%22">Access to Health Care</searchLink><br /><searchLink fieldCode="DE" term="%22Counselor+Training%22">Counselor Training</searchLink><br /><searchLink fieldCode="DE" term="%22Cultural+Influences%22">Cultural Influences</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
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  Data: <searchLink fieldCode="DE" term="%22Uganda%22">Uganda</searchLink>
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  Data: 10.1080/03069885.2014.886672
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  Data: 0306-9885
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The Butabika-East London Link collaborated with Ugandan mental health services to train mental health professionals (psychiatric clinical officers, "PCOs", and clinical psychologists and psychiatrists, "Core Group") in psychological therapies. The aims of this research were to investigate how professionals were applying and adapting psychological therapies to the Ugandan setting and to gain ideas to inform future training. Focus groups were used to explore the PCO's (N = 13) and Core Group's (N = 8) thoughts. Recordings were transcribed and thematically analysed. Themes identified were: issues affecting psychological therapy provision; cultural adaptations; voices of service users; and training. Different professional groups share similar concerns about implementing psychological therapies in a country where psychological services are just emerging. Future directions are suggested.
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  Data: 2014
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  Data: EJ1031600
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        Value: 10.1080/03069885.2014.886672
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 13
        StartPage: 423
    Subjects:
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Reflection
        Type: general
      – SubjectFull: Psychological Services
        Type: general
      – SubjectFull: Psychotherapy
        Type: general
      – SubjectFull: Focus Groups
        Type: general
      – SubjectFull: Psychologists
        Type: general
      – SubjectFull: Psychiatry
        Type: general
      – SubjectFull: Counselor Attitudes
        Type: general
      – SubjectFull: Qualitative Research
        Type: general
      – SubjectFull: Professional Education
        Type: general
      – SubjectFull: Delivery Systems
        Type: general
      – SubjectFull: Media Adaptation
        Type: general
      – SubjectFull: Cultural Relevance
        Type: general
      – SubjectFull: Work Environment
        Type: general
      – SubjectFull: Interpersonal Communication
        Type: general
      – SubjectFull: Stakeholders
        Type: general
      – SubjectFull: Partnerships in Education
        Type: general
      – SubjectFull: Educational Needs
        Type: general
      – SubjectFull: Client Characteristics (Human Services)
        Type: general
      – SubjectFull: Access to Health Care
        Type: general
      – SubjectFull: Counselor Training
        Type: general
      – SubjectFull: Cultural Influences
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Uganda
        Type: general
    Titles:
      – TitleFull: Mental Health Practitioners' Reflections on Psychological Work in Uganda: Exploring Perspectives from Different Professions
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Hall, Jennifer
      – PersonEntity:
          Name:
            NameFull: d'Ardenne, Patricia
      – PersonEntity:
          Name:
            NameFull: Nsereko, James
      – PersonEntity:
          Name:
            NameFull: Kasujja, Rosco
      – PersonEntity:
          Name:
            NameFull: Baillie, Dave
      – PersonEntity:
          Name:
            NameFull: Mpango, Richard
      – PersonEntity:
          Name:
            NameFull: Birabwa, Harriet
      – PersonEntity:
          Name:
            NameFull: Hunter, Elaine
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          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2014
          Identifiers:
            – Type: issn-print
              Value: 0306-9885
          Numbering:
            – Type: volume
              Value: 42
            – Type: issue
              Value: 4
          Titles:
            – TitleFull: British Journal of Guidance & Counselling
              Type: main
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