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Cultural Challenges to Psychosocial Counselling in Nepal

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transcultural
psychiatry
June
2005

ARTICLE

Cultural Challenges to Psychosocial Counselling in

Nepal

WIETSE A. TOL & MARK J. D. JORDANS

Centre for Victims of Torture, Nepal (CVICT)/Transcultural
Psychosocial Organization (TPO), Amsterdam

SUSHAMA REGMI & BHOGENDRA SHARMA

Centre for Victims of Torture, Nepal (CVICT)

Abstract This article describes the way in which the practice of psycho-
social counselling was adapted culturally to the context of Nepal within the
Centre for Victims of Torture, Nepal (CVICT). After a brief description of
the Nepali setting and CVICT’s counselling and training approach and the
relationship of its psychosocial counselling intervention with existing
methods of dealing with psychosocial problems, the cultural challenges of
implementing psychosocial counselling and our response to them are
sketched along with concepts deemed important in psychosocial coun-
selling. A discussion follows in which the authors’ stance on the export of
psychosocial counselling to non-western cultures is outlined.
Key words adaptation • cross-cultural • non-western • psychosocial
counselling • training

Since 1996 a violent conflict has surged in the Himalayan kingdom of

Nepal as a result of a Maoist insurgency called ‘the People’s War.’ Both
government forces and Maoists are grossly violating human rights on a

Vol 42(2): 317–333 DOI: 10.1177/1363461505052670 www.sagepublications.com

Copyright © 2005 McGill University

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massive scale (Amnesty International, 2002). As of 13 March 2004, a total

of 9170 deaths had been reported, with most deaths occurring after the
declaration of a state of emergency in November 2001; in addition, 4162
people were reported as having ‘disappeared’ or been abducted and an esti-
mated 31,635 people were displaced (INSEC, 2004).
Torture has been endemic in Nepal since its establishment and through-
out its recent politically unstable history (Sharma & Van Ommeren, 1998).
The Centre for Victims of Torture, Nepal (CVICT) was established in 1990
and has provided services to tortured Bhutanese and Tibetan refugees,
state-sponsored torture survivors, and more recently, to those tortured by
the Nepali security forces and the armed Maoist insurgents. CVICT was
established to rehabilitate torture survivors from the democratic
movement in 1990 that overthrew the ‘Panchayat’ rule, a party-less auto-
cratic government system initiated by the then king Mahendra. CVICT,
however, found that torture continued within the new multiparty democ-
racy after 1990 and is currently on the rise (Stevenson, 2001).
CVICT, like all centres offering psychosocial services in non-western
settings, must face the challenges of adapting ‘western’ practices of
psychosocial counselling to cultures in which these practices are new (e.g.
Tseng, 2001).1 The underlying concepts that have helped build and shape
western practices are not generally shared by cultures that do not have the
same historical and cultural background, which means that the export of
western practices cannot be done without a re-formulation of psychiatric,
psychotherapeutic and psychosocial counselling concepts, or abandoning
them altogether, in the new host country.
A rich literature has followed the emergence and popularity of the post-
traumatic stress disorder (PTSD) construct (Bracken, Giller, & Summer-
field, 1995; Summerfield, 2001; Turner, 2000; Young, 1995), as well as other
concepts of illness (e.g. Kleinman & Good, 1985) that originated in the
West and have now been exported throughout the world. Usually, scien-
tists and practitioners fall somewhere between the extremes of universal-
ist and cultural relativist positions, practicing a basic western talking cure,
but adapting it to the cultural environment of the country in which they
practice. This article aims to describe the ways in which CVICT has had to
adapt the practice of psychosocial counselling in Nepal. This can perhaps
provide a starting point for similar cultural adaptations in other non-
western settings, and adaptations within western settings with non-
western clients.

The Setting
Nepal is a relatively small country, landlocked between China (Tibetan
Autonomous Region) to the north and India to the south. It comprises an

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Tol et al.: Cultural Challenges to Counselling

area of 147,181 square kilometres and had a population of 22.9 million in

2000 (Central Bureau of Statistics His Majesty’s Government of Nepal,
2000). Geographically, it is divided into three regions: a Himalayan moun-
tainous region to the north, a region of foothills in the middle and a
southern plain region, the Terai, in the south.
Although small, the country is very culturally diverse. In 1999, 58
different ethnic groups and 32 languages were recorded (Central Bureau
of Statistics His Majesty’s Government of Nepal, 2000). Since the unifi-
cation of previously separate kingdoms by King Prithvi Narayan Shah in
1768, a unification process has begun, this entailed the adoption of a
national language, Nepali, which is spoken by approximately 60% of the
population. This unification process has, however, proved very difficult
because of the rugged Nepali landscape and the country’s underdeveloped
infrastructure, which hamper national communication.
Writing about a Nepali culture overall thus requires huge generaliza-
tions.2 It has to be kept in mind that many differences exist between
different ethnic groups and subpopulations within Nepal. Although the
cases in this article neatly fit the commonly described Nepali cultural
characteristics, we have encountered many exceptions to these character-
istics. One should be careful in over-simplifying a culturally rich context
such as the Nepali one. We do, however, feel that it is possible to speak of
a pan-Nepali context, for instance, in the case of illness beliefs regarding
spirits.

General Description of CVICT

CVICT has grown into an institute for the training of psychosocial coun-
sellors in Nepal, mostly in the context of the impact of human rights viola-
tions (e.g. child labour, armed conflict). Originally focusing mainly on
torture survivors, the centre has, because of the scarcity in recourses for
mental health, broadened its scope to include other target groups under
the umbrella of organized violence, and systematic violations of human
rights. The target group discussed in this article, the clients seen at CVICT,
thus comprise a range of people whose human rights have been violated,
from internally displaced people and torture survivors to sexually abused
adolescents and women accused of witchcraft. CVICT’s training approach
has been described in more detail elsewhere (Jordans, Sharma, Tol, & Van
Ommeren, 2002; Jordans, Tol, Sharma, & Van Ommeren, 2003; Van
Ommeren, Sharma, Prasain, & Poudyal, 2002). What follows is a short
description.
In the very beginning of implementing training programmes in a
country with extremely few mental health resources, CVICT opted for
short-term training programmes with a training-of-trainers (TOT)

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structure (for a review see Van Ommeren et al., 2002). These training
programmes were deemed ineffective, as psychosocial counselling skills
(which usually only meant basic communication skills) were only super-
ficially learned (and not practiced), and students were required to teach
their barely learned skills to new students. Moreover, training was
performed by expatriates, flown in for the purpose, with a minimal knowl-
edge of cultural issues and who were thus insensitive to important issues
hampering effective implementation in Nepal. In our opinion, 10-day
training programmes in psychosocial counselling taught by someone who
does not know the cultural context of Nepal and which are designed to
train trainers are not effective. ‘Trainers’ resulting from these programmes
do not learn sufficient skills themselves and can thus not impart them to
others. ‘Counsellors’ are confronted with clients’ problems that are too
difficult for them to deal with and there is a significant danger of harm
being done to both the ‘counsellor’ and the help-seeker. We are currently
trying to introduce an awareness of quality control, and raise the issue of
essential elements in training for paraprofessionals in Nepal, but we have
found it difficult when donors are easily swayed towards low-cost training
programmes that can, in their view, reach a large number of people in a
fast and inexpensive way.

Description of the Practiced Psychosocial Counselling

After determining that the short-term training programmes were ineffec-
tive, a different approach was chosen (e.g. Jordans et al., 2002). A longer-
term 5-month training programme was offered, in which students could
practice their skills with real clients, under clinical supervision. Problem-
solving (Egan, 1998), emotional support in a therapeutic relationship
offering trust and hope, and a focus on skills (Ivey & Ivey, 1999) were
chosen as the main components, because these seemed most culturally
compatible and concrete. It is important to note that although we
acknowledge that the words ‘counselling’ and ‘psychotherapy’ are often
used interchangeably, and that there is a continuum rather than two
distinct entities, we feel that a distinction has been useful in our clinical
and training practice. Within ‘psychotherapy,’ as we see it, more emphasis
is placed on reflective activity, analytical processes (e.g. dissecting and
sharing with the client aspects of the relationship between the client and
the psychotherapist) and longer-term training programmes, whereas in
‘counselling’ more stress in placed on working in a problem-focused
manner in a less reflective way, and, in our context, working with shorter-
term trained paraprofessionals. Working with paraprofessionals in Nepal
is essential as there is a lack of mental health resources and complicated
academic psychotherapeutic approaches are difficult to teach to an

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inexperienced audience. It is our opinion that, in Nepal, the client usually

focuses on a problem at hand, rather than wanting to find out how
personal and relational mechanisms contribute to the existence of a
problem, and paraprofessionals are more than adequate at helping clients
with this level of problem. It is also important to note that we have
included the word ‘psychosocial’ in front of ‘counselling.’ We feel, follow-
ing the Psychosocial Working Group (2003), that this helps to put focus
on both the individual aspects brought to counselling as well as the social
aspects, consisting of wider community connections, existing healing
resources, and culture and values.
On a theoretical level, we have borrowed heavily from medical anthropo-
logical concepts as derived by Kleinman (1988), for example, to try to work
in a culturally informed manner, by being knowledgeable about and
encouraging traditional practices, working from clients’ explanatory
models, and using local idioms of distress (Van Ommeren et al., 2002).
Psychosocial counselling starts with the complaints that a client brings
into the session, and is aimed at decreasing disability. The client is assisted
in dealing with problems himself/herself within a counselling process, or
is sometimes referred to traditional healers or other existing resources if
the counsellor feels that to be more appropriate. Specifically, the coun-
selling process consists of: (i) introduction, explanation and rapport
building; (ii) assessment of and understanding of the problem (including
looking for positive assets); (iii) goal setting (asking the client what
outcomes are preferred); (iv) problem management (exploring and identi-
fying solutions, brainstorming, working with existing coping strategies,
using social and cultural resources, and additional techniques such as
relaxation and psycho-education); (v) implementation (making a plan of
action and transition); and, finally, (vi) termination of counselling
(including closing and follow-up) (Egan, 1998; Ivey & Ivey, 1999; Jordans
et al., 2003). Throughout this article we use case vignettes to illustrate the
type of counselling we train people to practice at CVICT.
During training and the supervision of subsequent practice, we have
often encountered salient and less obvious difficulties to implementation
that seemed to arise out of working within the Nepali cultural context.
Here we give a description of a number of these observations described
within a set of categories essential in practicing psychosocial counselling.
These dimensions are not mutually exclusive, and certainly not thought to
be exhaustive.

Relationship with Existing Healing Methods

In our opinion, existing resources that deal with psychosocial problems
in the different Nepali contexts can be divided into two categories;

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(i) non-formal sharing activities within communities; and (ii) more

formal activities, including shamanistic practices and the presentation of
problems in formal health sectors.
With regard to non-formal sharing activities within communities, it is
acknowledged by Nepali people that sharing emotions with others can be
beneficial as seen for instance in the Nepali sayings ‘Dukha pokhyo bhane
dukha kam hunchha’ (after sharing your pain it becomes less), ‘Roe pachhi
man halka hunccha’ (after crying your heart becomes light), and ‘Kasaiko
kumma/kaakhmaa royo bhane manma shanti hunchha’ (the process of
crying on some one’s shoulder/lap to feel peaceful). Sharing of emotions
takes place in the community on two hierarchical levels, namely with peers
in groups such as youth clubs and women’s gatherings and with people of
higher social status as when villagers consult with the village elders includ-
ing teachers, respected religious persons and older people also referred to
as gurus. Help given by people of higher status usually consists of listen-
ing to the problem presented and subsequently giving advice on the best
course of action.
Psychosocial counselling, as practiced by CVICT, has many features in
common with this sharing. However, the relationship in counselling is
more professionalized, through specialization and training practices and
we discourage giving advice (see Locus of Control section). We assume
that it is because of the advice-giving nature of the informal sharing activi-
ties that it has been difficult to explain counselling in Nepal as an inter-
vention in which advice giving is not necessarily beneficial as it can
increase dependency.
The second category of existing methods to deal with psychosocial
distress is comprised of more formal systems in which a distinction
between bodily complaints and psychosocial complaints is generally not
made. Different ‘medical’ traditions coexist in Nepal and people generally
visit several during the course of one illness. These different traditions
include shamanistic practice, Ayurvedic healers, jharpuke vaidyas (healers
that work through ‘blowing’ of mantras and ‘sweeping’ to remove evil
influences) (Subedi, 2001), as well as visiting priests and doing Hindu puja.
Our counselling also has features in common with these interventions,
because we also use symbols of authority and the same phases of symbolic
healing take place (Kleinman, 1988). The more formal interventions have,
however, shaped a treatment expectation for the use of medication and an
active approach by the healer, rather than ‘just’ talking. In particular, allo-
pathic medicine is becoming more common in Nepal. As a result, our
clients in the lower part of the country, for instance, are often very inter-
ested in receiving an ‘injection,’ although this might not be medically
appropriate for their somatic complaints.

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The Therapeutic Relationship

Evaluation of psychotherapeutic services and a focus on common aspects
within the practices of the different psychotherapeutic schools have
repeatedly brought forward the importance of the therapeutic relationship
or therapeutic alliance (e.g. Frank & Frank, 1991; Rössler & Haker, 2003).
We hypothesize that the importance of the therapeutic relationship
remains when practicing psychosocial interventions in Nepal. A Nepali
client, however, relates differently to a counsellor than a western client.
Much of the way of relating to other people in Nepal is guided by issues of
social hierarchy and the avoidance of conflict, perhaps as a consequence of
the collectivist nature of the Nepali setting; the counselling relationship is
no exception. In addition to the pervasive caste system, gender issues and
strong notions of respect for the elder influence the way relationships are
formed and which behaviour is displayed within them. For a young female
counsellor, for example, it is awkward to actively challenge an older male
person on certain beliefs. For a male counsellor, it is practically impossible
to ask a higher caste elder woman about sexuality.

Case 1
When providing psychosocial support in a Bhutanese refugee camp one of
our psychosocial counsellors was a so-called low-caste person, referred to as
Dalit. People from the lowest caste are regarded as ‘untouchable,’ which
means that a higher caste person cannot sit, share food, or drink from the
same tap as them. Also, Dalits are not allowed to participate in certain
religious functions, and cannot enter high-caste people’s premises. One
high-caste Nepali-speaking Bhutanese refugee was experiencing many
problems, among which nightmares, palpitations, headaches, physical
weakness and dizziness played the major part. When these problems were
severe the counsellor was very welcome to come to the client’s hut and they
sat together and discussed the different problems the client had and the
counsellor initiated relaxation techniques. After the psychosocial coun-
selling seemed to have some effect and the client felt better, the client
became more and more reluctant to invite the counsellor into her home, as
she expressed they were so ‘different.’
Because hierarchy plays such an important role in forming relationships
in Nepal, it is necessary to describe how CVICT-trained psychosocial
counsellors are viewed within their societies. Most counsellors trained so
far have been high caste, i.e. Brahmins or Chhetries (the two highest castes
in a caste system of four) men and women aged between 20 and 30 years
old. The respect they receive depends a lot on the setting in which they
practice and possible age and gender differences. For example, younger
people would be considered juniors practicing in their own communities,

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but accepted as experts in outside communities. In general, they are viewed

as respectable people with some authority in their subject, comparable
with nurses and rurally even doctors. They are called Sir or Miss to denote
respect, as well as Nani (a term used to refer to respected younger persons).

View of the Self and Introspection

Geertz (1974) defined the western conception of the person as ‘a bounded,
unique, more or less integrated motivational and cognitive universe, a
dynamic centre of awareness, emotion, judgement, and action organized
into a distinctive whole and set contrastively both against other such wholes
and against its social and natural background.’ (p. 126). Psychotherapeutic
methods differ in the way in which they rely on this conceptualization. On
a generalized spectrum of opposites, one could state that the psycho-
dynamic approaches use this conceptualization as a starting point to
uncover and interpret conflicts and relational difficulties in the earlier-
described self, whereas cognitive-behavioural approaches postulate a self in
which beliefs and behaviour need to change, using the self described earlier
as the autonomous agent of change. The conceptualization of the person in
Nepal is different, more linked with notions of a collectivist identity, in
which social relationships define a person to a far larger extent than indi-
vidual traits, and in which abstraction of the individual from her direct
social surroundings seems somewhat strange. It is in this respect that
digging into personal identity during psychosocial counselling feels less
natural and appropriate to a Nepali person. We have experienced this
directly in the general difficulty of practicing introspection.
Related to this is a lack of focus and monitoring of the self. A Nepali
person generally does not scrutinize herself and her emotional state. No
emphasis is placed upon the goings-on in the deeper levels of personal
identity and emotional life. Deeper experiences are usually articulated in
relation to social hierarchy, function and relationships with others. Linked
with the lesser intensity of introspection, there is a different vocabulary for
emotional words. There are many emotion terms, but these are not
expressed often. Our clients usually describe distress through emotions
strongly anchored to somatic complaints rather than more abstract
feelings. For example, tauko jhanann bhayo is a current-like sensation in
the head, referring to anger; kanparo tatyo is hot temples, referring to
anger; pet bhatbhat polyo is an inflammation of the stomach, referring to
jealousy or anxiousness; and gada laglagkamyo is trembling in the legs,
referring to nervousness or fear. Some emotions are expressed easily
though, especially anger, worry, fear, irritation and sadness.
As these examples suggest, the notion that non-western people often
somatize their complaints is not fully correct. In Nepal, people often

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present somatic complaints, but they do not necessarily represent bodily

versions of emotional complaints. Instead, people simply experience their
inner workings in a different more body-centred way. However, psychoso-
matic mechanisms of symptom production definitely exist, especially in
torture survivors, when it has been very difficult, either because of social
appropriateness or other reasons, for survivors to share their emotions. We
devote a lot of time to such psychosomatic symptoms in our training
programmes.
As it is our view that Nepali people perceive their inner selves in a more
diffuse manner, linked with social notions, we have had to adapt the intro-
spective emphasis of psychosocial counselling by focusing more on
concrete behaviour in the counselling and supervision of counselling. As
mentioned, we rely more on skills, problem management and an emphasis
on emotional support in our training and practice, rather than on more
abstract principles like the stimulation of introspective processes and
analysis of transference. We still do work a lot with notions of resistance,
however.
Furthermore, there is a taboo against expressing strong emotions. If
strong emotions are expressed at all in counselling, they are expressed in
later sessions, after the relationship with and trust in the counsellor have
been strengthened. Psycho-education on the nature of counselling and
affirmation of confidentiality has helped in this respect.

Case 2
A 42-year-old, high-caste married man came to us complaining of back-
aches and whole-body pain, worrying, goda katkat khanchha (sudden
pricking, burning pains in the legs), jiu phatakkai hunchha (weakness), and
nightmares related to being tortured by the army, as he was accused of being
a Maoist supporter. The Maoists came to his house in the night and
demanded food and a place to sleep, and the man felt afraid to refuse them.
Rather than focusing on his complaints, he felt most worried about the
relationship with his family members, as he could not perform the family
role he had taken before. Owing to his physical pain and pre-occupation
with what happened when in army custody, he was not taking the same
responsibility in the household anymore, and his workload at the farm had
become much less. This caused conflict within his extended family. The
client and counsellor focused on the family conflict situation and brain-
stormed about the different possibilities to communicate, explain, and
increase understanding between the family members, as this was the client’s
wish. Also our yoga therapist worked at decreasing physical tension and
introduced relaxation exercises. The client reported improvement in his
bodily pain complaints, and felt he was more able to deal with the conflict
within his family.

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Locus of Control
Tied in with the conceptualization of the self is the conception of where
the locus of control (the appreciation of ones own influence on a situation)
is found, either externally or internally. Although no research on this
specific issue has been done in this area in Nepal, we feel that our clients
generally place the locus of control outside themselves. This happens on a
causal level, in which illness is mostly attributed to outside supernatural
causes, such as karma and/or spirits. This also happens within the coun-
selling setting, in which the client is expected to be leading within the
process of change. Expectations of our clients often agree with a frame-
work of outside causes and an external locus of control, and measures
against distress are expected to comply accordingly. Medication against
physically perceived problems and rituals to drive out distress inflicted by
spirits are examples of expected outside interference. Counselling assumes
an active, autonomous agent of change with an internal locus of control,
for instance in the case of goal setting within a problem-solving approach.
In short, clients are not used to carrying decision power.
Adaptation has focused on working from the client’s perspective, with
referral to traditional healers, and also with psycho-education. As depen-
dency is not desirable in a psychosocial counselling relationship, rather
than working from an external locus of control, we rely on psycho-
education and change through practice, to stimulate an internal locus of
control. Moreover, although we do stress that counselling is not the giving
of personal advice, because we do not want to create dependency and
would like to increase self-efficacy, the Nepali counsellors more often
engage in the giving of suggestions within the psychosocial counselling
sessions, after which they assume a background role again (suggest and
fade-technique).

Abstraction
The Nepali education system, generally, relies on the remembrance of facts
by heart (rote learning) and mostly does not stimulate independent critical
thinking. In social exchanges one relies more on the authority of the social
hierarchically higher placed person concerning the truth of things. In our
supervision of counselling trainees we have often encountered the diffi-
culty of analysing the relationship between the counsellor and the client,
rather than the manifest contents of the words spoken. Moreover, the more
abstract notions of, for instance, transference and the explanatory model
need intensive elaboration and practical examples. We, therefore, strive for
explanations and interpretation of psychosocial interventions that are as
concrete as possible.

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Illness Beliefs
Counselling in Nepal means working in a setting with a rich variety of
cultural practices and beliefs. It thus requires a constant cultural sensitivity
and postulation of cultural hypotheses on behalf of the counsellor and
client, a non-judgemental attitude towards these differences, an openness
to explore, and an awareness of one’s own cultural background. Moreover,
although relief through talking and sharing is generally acknowledged, the
formalization of this in a counselling approach is generally new to most
cultural groups especially in the rural areas, and thus requires a more
extensive introduction.
Although there is a rich variety in cultural illness beliefs, there is
evidence of an underlying belief in spirits causing illness (Peters, 1981;
Subedi, 2001) and spirit possession that can be found across the whole of
Nepal (Hitchcock & Jones, 1976). For instance, the spirit-caused illnesses
among the Tamang in the Kathmandu Valley, the description of spirits
beliefs among Brahmin-Chetri in Newakot district (Peters, 1981), and the
client worldview concerning spirits in Dolakha district (Miller, 1979) share
common features regarding the way spirits are believed to cause illness.
Spirits that are dwelling everywhere from graveyards to houses can inflict
illness because they are ‘hungry.’ If they are not appeased through food
offerings, sometimes regarded as a substitute for the human body, they can
attack humans and cause illness. Furthermore, illness can be caused by
bewitchment (control of spirits by witches), loss of soul (fright can cause
the soul to leave the body) and spirit possession, in which a spirit can take
control of a persons behaviour by ‘riding’ him (Peters, 1981).
The shaman is regarded as the only one who can communicate with the
spirit world, through a process of trance or spirit possession. Thus,
shamanic ritual has also shaped expectations as to what is needed to cure
illness, together with what people have learned to expect from allopathic
medical services. From both one expects a ritualized concrete session in
which the healer actively diagnoses and prescribes. In this respect, we have
found that if our counsellor actively does something, like working with the
eye-movements in EMDR with torture survivors, or doing a relaxation
exercise in general practice, this confirms the expectations of the client and
elicits stronger responses.
We have enriched the counselling approach by working with a tool for
cultural adaptation, the EMIC questionnaire, and through our relation
with traditional healers.

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Case 3
A 36-year-old woman from an ethnic minority group, living in a village in
the hills surrounding our centre, was accused of witchcraft by her villagers,
as the son of her neighbours had suddenly died. When she came to our
centre she was very afraid, visibly trembling, did not speak much to the
counsellor except for repeatedly saying ‘I am afraid,’ and ‘I don’t speak
Nepali.’ Our counsellor found out through family members that she did
speak Nepali very well, and that she had been forced to eat faeces by her
neighbours, which is a common way of dealing with people accused of
witchcraft as the faeces are supposed to weaken the power of the accused
witch’s mantras. The counsellor decided to work on trying to systematically
verbalize the emotions that were visible through somatic expressions, and
used EMDR for this purpose. After several sessions the client began to speak
more, and when her fear subsided she explained that she was accused of
being a witch because she had been a single mother since the beginning of
her marriage and had been able marry off her son, and had always strug-
gled hard to survive, taking on all work she could find.

Discussion
We hypothesize that the collectivist nature of Nepali identity, with its
avoidance of conflict and stress on sameness, on the one hand, has a role
in shaping a taboo on the sharing of strong emotions and, on the other
hand, contributes to the intense stigmatization of mentally ill persons.
Other contributors to this process are fear of the unfamiliar and the
interpretation of illness as caused by spirits, which are considered danger-
ous. Clients who have been sexually abused, for example, in the case of
trafficking for commercial sexual work, are often ostracized and generally
have great trouble re-integrating in their old society after their return from
the brothels. The mentally challenged, people with psychotic disorders or
depression are regarded with suspicion.
Having considered these observations on cultural differences seen when
implementing psychosocial counselling in Nepal, one could ask, ‘Why
practice psychosocial counselling in Nepal at all?’
First, we feel that clinical experience suggests that counselling does help
to deal with distress. We have seen clients improve, and they have expressed
their gratitude. Because no scientific research has yet been done in this area
in Nepal, a cost-effectiveness study is currently under way at CVICT, as
well as in other non-western countries, to assess the practice of psycho-
social interventions, in cooperation with the Transcultural Psychosocial
Organization in Amsterdam, The Netherlands. Currently, the status of
mental health interventions in low-income countries is unclear, with only
a few research studies showing a mixed picture. Three research studies

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showed a positive impact of psychological treatments in Chile, Uganda and

India (respectively Araya et al., 2003; Bolton et al., 2003; Chatterjee, Patel,
Chatterjee, & Weiss, 2003) and two studies showed no difference between
control and treatment groups in Mozambique and India (respectively
Igreja, Kleijn, Schreuder, Van Dijk, & Verschuur, 2004; Patel et al., 2003).
Second, although cultures are not museums, secluded from other
cultures – they can change and are changing – one has to be careful when
introducing new approaches not to undermine pre-existing ways of
dealing with distress. This means working together with local healers and
other available resources to manage distress and collaborate from a non-
judgemental stance. One has to be equally careful, however, in condemn-
ing the importation of approaches just because they are new or western.
We do not condemn westerners tired with over-medicalization in western
countries for looking at alternatives in eastern meditation practices.
However, one also has to be careful not to idealize local resources, such as
traditional healers. We have experienced that traditional healers can do
damage as well as be helpful. In urban centres a globalizing trend is present
and young urbanites are less inclined to go to traditional healers, in whom
they do not ‘believe.’ Rather than falling into extremes we propose working
in an open dialogue, where the local party can make informed choices and
take the best from several contexts to achieve an intervention that is maxi-
mally helpful, instead of maximally Nepali.
Third, our stance lies in the middle of the universalist–cultural relativist
spectrum. We believe that if counselling concepts are appropriately
adapted to the cultural context, different cultural groups have enough in
common and are able to deal with distress through a talking cure, tapping
into universal human helping behaviour, such as empathy, emotional
support and compassion. We feel that the sharing behaviour present in
Nepal justifies this stance, as sharing emotions in a (therapeutic) relation-
ship is not strange to the Nepali context.
In our case, cultural adaptation has meant: (i) working from a coun-
selling approach, with its focus on demystifying academic clinical psychol-
ogy and the use of micro-skills (Ivey & Ivey, 1999), rather than
psychotherapy; (ii) the use of concrete tools, such as relaxation, problem
management, drawing, sentence completion tests and play; (iii) psycho-
education plays a big role in our working with clients unfamiliar with a
psychosocial counselling approach; and (iv) integrating cultural knowl-
edge by incorporating local idioms of distress and explanatory models, and
working with existing resources.
The mode of adaptation of counselling does not necessarily have to be
the same in contexts other than our own and the views and background
of the authors have played a certain role. However, we believe that any
approach in a more collectivist society can benefit from a community

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Transcultural Psychiatry 42(2)

approach in which all folk methods of healing are incorporated. Psycho-

social counselling is just one part of the spectrum of psychosocial care and
dealing with distress in the context of human rights abuses. Tapping into
local resources also means taking care to include basic social units such as
the family, working place, religious associations, and others. Working with
groups and families seems a natural choice in such cases.

Acknowledgements
We are deeply grateful to the counsellors, trainers, Dr Lakshmi and Dr Osti, and
our other staff at CVICT and the School of Applied Human Sciences (SAHAS) in
Kathmandu. Their comments on this article and sharing of clients’ stories related
to the article were much appreciated.

Notes
1. Although we realize that a western–non-western dichotomy is an overgener-
alization, we have used it here for illustrative and convenience purposes.
2. The definition of culture as followed in this article is ‘shared learned
behaviour which is transmitted from one generation to another to promote
individual and group adjustment and adaptation. Culture is represented
externally as artefacts, roles, and institutions, and it is represented internally
as values, beliefs, attitudes, cognitive styles, epistemologies, and consciousness
patterns’ (Marsella, 1988, p. 10).

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WIETSE A. TOL, MA, is currently research coordinator at the Centre for Victims of
Torture, Nepal (CVICT). He has an MA in Clinical Psychology and is currently
pursuing a PhD degree under the supervision of Professor Joop T. V. M. de Jong
of the Transcultural Psychosocial Organization (TPO) in Amsterdam, The Nether-
lands and the Vrije Universiteit in Amsterdam, The Netherlands. His current
projects mainly concern research on measuring the effectiveness of psychosocial
programs for human rights abused in non-western countries, as well as clinical
and training activities. Address: Centre for Victims of Torture, Nepal (CVICT),
Post Box 5839, Bansbari, Kathmandu, Nepal. [E-mail: wietse@cvict.org.np]

MARK J. D. JORDANS holds an MA in Developmental Psychology. He is training

coordinator for the Centre for Victims of Torture, Nepal (CVICT) and is currently
project coordinator for Transcultural Psychosocial Organization (TPO) in
Amsterdam. His experience lies in developing and conducting long-term, skills-
based training programs in psychosocial interventions and implementing projects
that aim to establish psychosocial care systems in a non-western context. Address:
Centre for Victims of Torture, Nepal (CVICT), Post Box 5839, Bansbari,
Kathmandu, Nepal.

SUSHAMA REGMI holds an MA in Clinical Psychology from Tribhuvan University,

Kathmandu, Nepal. She has been a lecturer in psychology at Tribhuvan University
and started working at the Centre for Victims of Torture, Nepal (CVICT) in 1999

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Tol et al.: Cultural Challenges to Counselling

as a psychosocial counsellor for torture victims. She is currently the course coordi-
nator for a post-graduate diploma course on psychosocial interventions at the
School of Applied Human Sciences (SAHAS). This is a college in Kathmandu,
Nepal that has training programs on providing care for survivors of organized
violence. Address: Centre for Victims of Torture, Nepal (CVICT), Post Box 5839,
Bansbari, Kathmandu, Nepal.

BHOGENDRA SHARMA holds a MBBS degree from Nepal and a MSc in epidemiol-
ogy from the Erasmus University in Rotterdam, The Netherlands. After working
as a medical doctor, he co-founded the Centre for Victims of Torture, Nepal
(CVICT) in 1990, of which he is currently the president. He has contributed to
several studies on the psychiatric impact of torture on the Nepali-speaking
Bhutanese refugees in Nepal. In 2004, Dr Sharma was elected president of the
International Rehabilitation Council for Torture Victims (IRCT) located in
Copenhagen, Denmark. Address: Centre for Victims of Torture, Nepal (CVICT),
Post Box 5839, Bansbari, Kathmandu, Nepal.

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