Psychology

Class Notes @Sarita Sapkota
Unit 1
Humanistic Psychology
1.1 Introduction, major assumptions, strengths, and weaknesses of humanistic psychology

1.2 Abraham Maslow: Hierarchy of needs
1.3 Carl Rogers: Self: real and perceived; unconditional positive regard; the fully functioning
person, empathy
1.1 Introduction, major assumptions, strengths, and weaknesses of humanistic psychology

Humanistic approach is also known as Third force of Psychology and the humanistic approach in
psychology developed criticizing the limitations of the behaviorist (2nd force) and psychodynamic
(1st force) psychology.
The humanistic approach in psychology developed in the 1960s and 70s.
Humanistic psychology rejected the psychodynamic approach as it focuses on unconscious
irrational and instinctive forces to determine human thought and behavior and also rejected the
assumptions of the behaviorist perspective which focuses on reinforcement of stimulus-response
behavior and is heavily dependent on animal research.
Humanistic psychology is a perspective that emphasizes looking at the whole person, and the
uniqueness of each individual.
Humanistic psychology believes that people are good and focuses on helping people reach
their potential by exploring their uniqueness.
Humanistic psychology begins with the existential assumptions that people have free will and
are motivated to achieve their potential and self-actualize.
Humanistic psychologists believe that:
• An individual's behavior is primarily determined by his perception of the world around
him.
• Individuals are not solely the product of their environment.
• Individuals are internally directed and motivated to fulfill their potential.
Major Assumptions
• Humans have free will; not all behavior is determined.
→ Human are free to choose what to do in life, what path to follow and the consequences of
following the path.
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• All individuals are unique and are motivated to achieve their potential or for self-
actualization
→ Self-actualization concerns psychological growth, fulfillment and satisfaction in life.
• People are basically good, and have an innate need to make themselves and the world
better.
→ The humanistic approach emphasizes the personal worth of the individual. People can be good
with the right set of conditions, especially during childhood. The approach is optimistic and
focuses on the noble human capacity to overcome hardship, pain and despair.
• A proper understanding of human behavior can only be achieved by studying humans - not
animals.
→ Humanism views human beings as fundamentally different from other animals, mainly because
humans are conscious beings capable of thought, reason and language. For humanistic
psychologists’ research on animals, such as rats, pigeons, or monkeys held little value.
• Psychology should study the individual case (idiographic) rather than the average
performance of groups (nomothetic).
→ The subjective, conscious experiences of the individual is most important. A psychologist
should treat each case individually as each person is different with unique experiences. As the
approach views the individual as unique it does not believe that scientific measurements of their
behavior are appropriate.
Strengths and weaknesses of humanistic psychology
Strengths
• Shifted the focus of behavior to the individual / whole person rather than the unconscious
mind, genes, observable behavior etc.
• Real life applications (e.g., therapy)
• Humanistic psychology satisfies most people's idea of what being human means because it
values personal ideals and self-fulfillment.
• Can’t compare animals to humans
• It focuses on Qualitative data, which gives genuine insight and more holistic information
into behavior.
• Highlights the value of more individualistic and idiographic methods of study.
Weakness
• Ignores biology
• Unscientific – subjective concepts, which are difficult to test.
• Humanistic psychologists reject a rigorous scientific approach to psychology because they
saw it as dehumanizing and unable to capture the richness of conscious experience.
• Their belief in free will is in opposition to the deterministic laws of science.
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• Humanistic approach is ethnocentric. Many of the ideas that are central to humanistic
psychology, such as individual freedom, autonomy and personal growth, would be more
readily associated with individualistic cultures in the Western world such as the US.
Collectivist cultures such as India, which emphasize the needs of the group and
interdependence, may not identify so easily with the ideals and values of humanistic
psychology.
• It proposes a positive view of human nature, however, it could be argued that this might
not be very realistic when considering the everyday reality such as domestic violence and
genocides.
1.2 Abraham Maslow: Hierarchy of needs
Abraham Maslow was born on April 1, 1908-1970, in Brooklyn, New York.
Abraham Maslow was an American psychologist who developed a hierarchy of needs to
explain human motivation. His theory suggested that people have a number of basic needs that
must be met before people move up the hierarchy to pursue more social, emotional, and self-
actualizing needs.
Maslow’s hierarchy of needs (Need hierarchy theory) The theory is based on: Human beings have
needs that are hierarchically ranked. Maslow first introduced his concept of a hierarchy of needs
in his 1943 paper "A Theory of Human Motivation" and his subsequent book Motivation and
Personality.
This hierarchy suggests that people are motivated to fulfill basic needs before moving on to other,
more advanced needs.
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The basic idea of Maslow's Hierarchy of Needs is that our needs are constantly changing. As one
need is met, we desire other needs.
The Hierarchy of Needs is as follows:
1. Physiological Needs (basic issues of survival such as salary and stable employment)
2. Security Needs (stable physical and emotional environment issues such as benefits, pension,
safe work environment, and fair work practices)
3. "Belongingness" Needs (social acceptance issues such as friendship or cooperation on the job)
4. Esteem Needs: (attention, respect, autonomy, attention, status) (positive self-image and respect
and recognition issues such as job titles, nice work spaces, and prestigious job assignments.)
5. Self-Actualization Needs: (becoming all you are capable of becoming. E.g. subject matter
expert status on the job)
The psychologist Abraham Maslow developed a theory that suggests we, humans, are motivated
to satisfy five basic needs. These needs are arranged in a hierarchy. Maslow suggests that we seek
first to satisfy the lowest level of needs. Once this is done, we seek to satisfy each higher level of
need until we have satisfied all five needs.
Maslow proposed that needs are satisfied in a certain order and that higher-level needs can only
be satisfied once lower-level needs are met.
The needs are, from bottom to top of the hierarchy: physiological (the need for food and water),
safety and security, social, esteem and status, and the need for self-actualization, or living up to
one's full potential.
Physiological and safety needs are lower-level needs that are satisfied externally through salary,
job security etc.
Social, Esteem and Self-actualization needs are higher order needs that are satisfied internally
through responsibilities, autonomy, authority etc.
Five needs are classified in two categories:
1. Deprivation/Deficiency Needs
The first four levels are considered deficiency or deprivation needs (“D-needs”) in that their lack
of satisfaction causes a deficiency that motivates people to meet these needs.
Physiological needs, the lowest level on the hierarchy, include necessities such as air, food, and
water. These tend to be satisfied for most people, but they become predominant when unmet.
During emergencies, safety needs such as health and security rise to the forefront.
Once these two levels are met, belongingness needs, such as obtaining love and intimate
relationships or close friendships, become important.
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The next level, esteem needs, include the need for recognition from others, confidence,
achievement, and self-esteem.
2. Growth Needs
The highest level is self-actualization, or the self-fulfillment. Behavior in this case is not driven or
motivated by deficiencies but rather one’s desire for personal growth and the need to become all
the things that a person is capable of becoming.
1.3 Carl Rogers: Self: real and perceived; unconditional positive regard; the fully functioning
person, empathy
Carl Rogers (1902-1987)
Carl Rogers agreed with the main assumptions of Abraham Maslow.
Rogers (1959) added that for a person to "grow", they need an environment that provides them
with genuineness (openness and self-disclosure), acceptance (being seen with unconditional
positive regard), and empathy (being listened to and understood).
Self: Real and Perceived
Simply, Self-concept is what is your concept about yourselves.
For example, you perceive yourself as “Friendly person”, “Bad person”. Etc.
Self-concept develops through interaction with people in society. It is the perception of our
abilities, behavior, and characteristics.
For example, if someone says you are a good dancer, the dancing ability enhances your self-
concept. This ability goes on developing through interaction with others, receiving positive
remarks.
Rogers further explained that a positive self-thought helps to be optimistic and build healthy
ways of life whereas, a negative one leads to pessimism and unhappiness with depressive and
frustrating signs.
Rogers divided the self into two categories; ideal and real self.
The ideal self is the person you would like to be. It consists of our goals and ambitions in life, and
is dynamic – i.e., forever changing. The ideal self in childhood is not the ideal self in our teens or
late twenties etc.
The real self is what you really are.
Rogers remarked that both self-concepts are essential. A broad gap between these two may
generate difficulties of adjustment. If the ideal self is unrealistically out of reach, the person may
feel frustrated and an inferiority complex may erupt. However, a slight difference may lead to the
positive feeling enhancing it.
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Roger believed that a person’s behavior is a factor motivated by self-actualization tendencies to

work and achieve the highest level of their potential and achievement. During this process, a person
forms a structure of self or self-concept.
A positive self-concept is associated with feeling good and safe. If they have a negative self-
concept, they may feel unhappy with who they are.
A person’s ideal self may not be consistent with what actually happens in life and experiences
of the person. Hence, a difference may exist between a person’s ideal self and actual experience.
This is called incongruence i.e., incongruence is the difference between the ideal self and real self.
Congruence is when our thoughts about our real self and ideal self are very similar; i.e., our self-
concept is very strong and accurate. High congruence leads to a greater sense of self-worth and a
healthy, productive life.
Unconditional Positive Regard
According to Rogers, unconditional positive regard involves showing complete support and
acceptance of a person no matter what that person says or does. The therapist accepts and supports
the client, no matter what they say or do, placing no conditions on this acceptance. That means the
therapist supports the client, whether they are expressing "good" behaviors and emotions or "bad"
ones.
Unconditional positive regard is where parents, significant others (and the humanist therapist)
accepts and loves the person for what he or she is. Positive regard is not withdrawn if the person
does something wrong or makes a mistake.
Rogers elevated the importance of unconditional positive regard or unconditional love when
developing self-concept. To fully actualise, people are raised in conditions of unconditional
positive regard where no conditions of worth are present. When people are raised in an
environment of conditional positive regard in which worth and love are only given under certain
conditions they must match those conditions to receive positive regard. The ideal self is determined
based on these conditions; this contributes to incongruence and gap between real and ideal self.
The consequences of unconditional positive regard are that the person feels free to try things out
and make mistakes, even though this may lead to getting it worse at times.
People who are able to self-actualize are more likely to have received unconditional positive regard
from others, especially their parents in childhood.
Conditional positive regard is where positive regard, praise, and approval, depend upon the child,
for example, behaving in ways that the parents think correct.
Hence the child is not loved for the person he or she is, but on condition that he or she behaves
only in ways approved by the parent(s).
At the extreme, a person who constantly seeks approval from other people is likely only to have
experienced conditional positive regard as a child.
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The fully functioning person

A fully functioning person is one who is continually working toward becoming self-actualized.
A fully functioning person is one who is in touch with their deepest and innermost feelings and
desires. These individuals understand their own emotions and place deep trust in their own
instincts. Unconditional positive regard plays an essential role in becoming a fully functioning
person.
Rogers believed that every person could achieve their goal. This means that the person is in
touch with the here and now, his or her subjective experiences and feelings, continually growing
and changing.
Not only is the fully functioning individual open to new experiences, but they are also capable of
changing in response to what they learn from those experiences. These individuals are also in touch
with their emotions and make a conscious effort to grow as a person and achieve their fullest
potential.
In many ways, Rogers regarded the fully functioning person as an ideal and one that people do not
ultimately achieve. It is wrong to think of this as an end or completion of life’s journey; rather it
is a process of always becoming and changing.
For Rogers, fully functioning people are well adjusted, well balanced and interesting to know.
Often such people are high achievers in society.
Rogers identified five characteristics of the fully functioning person:
1. Open to experience: both positive and negative emotions accepted. Negative feelings are not
denied, but worked through (rather than resorting to ego defense mechanisms).
2. Existential living: in touch with different experiences as they occur in life, avoiding prejudging
and preconceptions. Being able to live and fully appreciate the present, not always looking back
to the past or forward to the future (i.e., living for the moment).
3. Trust feelings: feeling, instincts, and gut-reactions are paid attention to and trusted. People’s
own decisions are the right ones, and we should trust ourselves to make the right choices.
4. Creativity: creative thinking and risk-taking are features of a person’s life. A person does not
play safe all the time. This involves the ability to adjust and change and seek new experiences.
5. Fulfilled life: a person is happy and satisfied with life, and always looking for new challenges
and experiences.
Empathy
Empathy is the ability to emotionally understand what other people feel, see things from their
point of view, and imagine yourself in their place. Essentially, it is putting yourself in someone
else's position and feeling what they are feeling.
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Empathy means that when you see another person suffering, such as after they've lost a loved one,
you are able to instantly envision yourself going through that same experience and feel what they
are going through.
'Empathy is the listener's effort to hear the other person deeply, accurately, and non-
judgmentally.
Empathy is defined by Carl Rogers as a core condition for successful counselling.
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Class Notes@SaritaSapkota Unit_2 Mental Health
Unit 2: Mental Health

2.1 Definition of health, definition of mental health (WHO)
2.2 Basic concepts: Mental health, mental illness, mental disorders, psychosocial wellbeing,
psychosocial problems, and psychosocial disabilities
2.3 Determinants of mental health: Biological, psychological and social
2.4 Promoting mental health: Prevention through community awareness on mental health, peer
group support
2.1 Definition of health, definition of mental health (WHO)
According to WHO, Health is a state of complete physical, mental and social well-being and not
merely the absence of disease.
According to the World Health Organization (WHO), Mental health is “a state of well-being in
which the individual realizes his or her own abilities, can cope with the normal stresses of life, can
work productively and fruitfully, and is able to make a contribution to his or her community”.
2.2 Basic concepts: Mental health, mental illness, mental disorders, psychosocial wellbeing,
psychosocial problems, and psychosocial disabilities
The state of mental health implies that the individual has the ability to form and maintain
affectionate relation-ships with others, to perform in the social roles usually played in their culture
and to manage change, recognize, acknowledge and communicate positive actions and thoughts as
well as to manage emotions such as sadness.
Mental health gives an individual the feeling of worth, control and understanding of internal and
external functioning.
Mental health includes our emotional, psychological, and social well-being. It affects how we
think, feel, and act.
It also helps determine how we handle stress, relate to others, and make choices. Mental health is
important at every stage of life, from childhood and adolescence through adulthood.
Positive mental health allows people to:
• Realize their full potential
• Cope with the stresses of life
• Work productively
• Make meaningful contributions to their communities
• Maintain healthy relationships.
• Ability to adapt to change and cope with adversity.
Many factors contribute to mental health problems, including Biological, psychological and social.
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Mental Illness
Mental illness is health condition involving changes in emotion, thinking or behavior (or a
combination of these). Mental illnesses are associated with distress and/or problems
functioning in social, work or family activities.
Many people who have a mental illness do not want to talk about it. But mental illness is
nothing to be ashamed of! It is a medical condition, just like heart disease or diabetes. And
mental health conditions are treatable. Many people with mental health conditions return to full
functioning.
Mental Illness refers collectively to all diagnosable mental disorders — health conditions
involving:
• Significant changes in thinking, emotion and/or behavior.
• Distress and/or problems functioning in social, work or family activities.
Mental illness can affect anyone regardless of your age, gender, geography, income, social status,
race/ethnicity, religion/spirituality, sexual orientation, background or other aspect of cultural
identity. While mental illness can occur at any age, three-fourths of all mental illness begins by
age 24.
There is no single cause for mental illness. A number of factors can contribute to risk for mental
illness, such as:
• Biological factors or chemical imbalances in the brain
• Early adverse life experiences, such as trauma or a history of abuse (for example, child
abuse, sexual assault, witnessing violence, etc.)
• Experiences related to other ongoing (chronic) medical conditions, such as cancer or
diabetes
• Use of alcohol or drugs etc.
Mental disorders
A mental disorder is characterized by a clinically significant disturbance in an individual’s
cognition, emotional regulation, or behavior. It is usually associated with distress or impairment
in important areas of functioning. There are many different types of mental disorders.
There is no simple definition of mental disorder that is universally satisfactory. This is partly
because mental states or behavior that are viewed as abnormal in one culture may be regarded as
normal or acceptable in another, and in any case, it is difficult to draw a line clearly demarcating
healthy from abnormal mental functioning.
Mental disorders may also be referred to as mental health conditions. Professionals
interchangeably using terms such as mental illness, mental disorder, and mental health.
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Mental disorders, in particular their consequences and their treatment, are of more concern and
receive more attention now than in the past.
Psychopathology is the systematic study of the significant causes, processes, and
symptomatic manifestations of mental disorders.
Psychosocial wellbeing
The term “psychosocial” refers to the dynamic relationship between psychological and social
elements affecting human development.
Psychosocial well-being includes emotional or psychological well-being, as well as social and
collective well-being.
Psychosocial well-being is a multidimensional construct consisting of psychological, social, and
subjective components which influence the overall functionality of individuals in achieving their
true potentials as members of the society.
Psychosocial well-being incorporates the physical, economic, social, mental, emotional, cultural,
and spiritual determinants of health. Well-being of an individual includes coping with the various
stresses of everyday living and realization of the full potential of an individual as a productive
member of the society.
The concept of psychosocial is closely linked to the concepts of “well-being” or “wellness”. Most
definitions of psychosocial are based on the assumption that psychological and social factors are
responsible for the well-being of people.
The term psychosocial implies a very close relationship between psychological and social factors.
Psychosocial well-being is a multidimensional construct consisting of psychological, social, and
subjective components which influence the overall functionality of individuals in achieving their
true potentials as members of the society. Psychosocial well-being incorporates the physical,
economic, social, mental, emotional, cultural, and spiritual determinants of health. Well-being of
an individual includes coping with the various stresses of everyday living and realization of the
full potential of an individual as a productive member of the society.
Psychological well-being is a key part of feeling happy and being able to function day-to-day. It's
easier than you may think to develop healthy habits that can foster your emotional health.
Start small and try practicing one or two strategies to maximize your psychological well-being,
such as writing down a few of your strengths or happy memories. Over time, you will see the
effects that these practices have on your positivity and overall mental health.
Types of psychological wellbeing
1. The term “Hedonic” wellbeing is normally used to refer to the subjective feelings
of happiness. It comprises of two components, an affective component (high
positive affect and low negative affect) and a cognitive component (satisfaction
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with life). It is proposed that an individual experiences happiness when positive

affect and satisfaction with life are both high (Carruthers & Hood, 2004).
2. The less well-known term, “Eudaimonic” wellbeing is used to refer to the
purposeful aspect of PWB. The psychologist Carol Ryff has developed a very clear
model that breaks down Eudaimonic wellbeing into six key types of psychological
wellbeing.
Self-acceptance: It reflects positive attitude about self. An example statement for this criterion is
“I like most aspects of my personality”
Environmental mastery: It indicates effective use of opportunities and a sense of mastery in
managing environmental factors and activities, including managing everyday affairs and creating
situations to benefit personal needs. An example statement for this criterion is “In general, I feel I
am in charge of the situation in which I live”.
Positive relationships: It indicates engagement in meaningful relationships with others that
include reciprocal empathy, intimacy, and affection. An example statement for this criterion is
“People would describe me as a giving person, willing to share my time with others”.
Personal growth: It indicates an individual’s willingness to develop who is welcoming to new
experiences, and recognizes improvement in behavior and self over time. An example statement
for this criterion is “I think it is important to have new experiences that challenge how you think
about yourself and the world”.
Purpose in life: Strong goal orientation and conviction that life holds meaning. An example
statement for this criterion is “Some people wander aimlessly through life, but I am not one of
them”.
Autonomy: indicates independence and regulation of behavior independent of social pressures.
An example statement for this criterion is “I have confidence in my opinions, even if they are
contrary to the general consensus”.
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Psychosocial Problems:
Psychosocial problems refer to the difficulties faced by in different areas of personal and social
functioning.
Psychosocial problems have been described as the maladaptive, negative or unhealthy
intrapersonal emotional and behavioral states, and they often lead to maladaptive, negative and
unhealthy interpersonal networks, human relationships, social connections and social
malfunctioning.
Adolescents are vulnerable to psychosocial problems because of physical and physiological
changes that occur in their body during this developmental stage.
Psychosocial problems have been described as the maladaptive, negative or unhealthy
intrapersonal emotional and behavioral states, and they often lead to maladaptive, negative and
unhealthy interpersonal networks, human relationships, social connections and social
malfunctioning.
Major psychosocial issues included family problems, sexual abuse, violence, psychological
disorder etc. Women were more likely to have suffered violence while many of the men had
problems dealing with their own aggression toward others. Psychosocial problems can be grouped
in following ways:
• Problems with primary support group - e.g., death of a family member; health problems
in family; disruption of family by separation, divorce, or estrangement; removal from the
home; remarriage of parent; sexual or physical abuse; parental overprotection; neglect of
child; inadequate discipline; discord with siblings; birth of a sibling
• Problems related to the social environment- e.g., death or loss of friend; inadequate
social support; living alone; difficulty with acculturation; discrimination; adjustment to
life-cycle transition (such as retirement)
• Educational problems - e.g., illiteracy; academic problems; discord with teachers or
classmates; inadequate school environment
• Occupational problems - e.g., unemployment; threat of job loss; stressful work schedule;
difficult work conditions; job dissatisfaction; job change; discord with boss or co-workers
• Housing problems - e.g., homelessness; inadequate housing; unsafe neighborhood;
discord with neighbors or landlord
• Economic problems - e.g., extreme poverty; inadequate finances; insufficient welfare
support
• Problems with access to health care services - e.g., inadequate health care services;
transportation to health care facilities unavailable; inadequate health insurance
• Problems related to interaction with the legal system/crime - e.g., arrest; incarceration;
litigation; victim of crime
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• Other psychosocial and environmental problems - e.g., exposure to disasters, war, other
hostilities; discord with nonfamily caregivers such as counselor, social worker, or
physician; unavailability of social service agencies.
Psychosocial disabilities
“Psychosocial disability is a term used to describe a disability that may arise from a mental health
issue.”
A clinically recognized condition or illness that affects a person's thought processes, judgement or
emotions.
Psychosocial disability refers to a psychological and social condition that may arise from a severe
mental health issue.
Psychosocial disability is not about a diagnosis, it is about the functional impact and barriers
which may be faced by someone living with a mental health condition.
A psychosocial disability arises when someone with a mental health condition interacts with a
social environment that presents barriers to their equality with others. Someone with a
psychosocial disability may require support to overcome the barriers to social inclusion they face.
Psychosocial disability may restrict a person’s ability to:
• interact with others
• concentrate
• have enough stamina to complete tasks
• cope with time pressures and multiple tasks
• understand constructive feedback
• manage stress
2.3 Determinants of mental health: Biological, psychological and social
1.Biological Determinants
According to the medical model, once the biological causes are identified, appropriate medical
treatment can be developed.
From biological viewpoint, many factors are considered to be the potential causes of abnormal behavior
ranging from head injury, neurotransmitters, hormones etc.
a. Structural brain abnormality
Occurs when areas of brain haven’t developed optimally or have undergone pathological changes.
b. Damage in brain parts
Disorders first recognized as having biological components were those associated with destruction in
brain tissue.
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Example: Damage to certain areas in the brain can cause memory loss, and damage to left hemisphere
that occurs during a stroke can cause depression.
However most mental disorder is not caused by neurological damage. Specific brain lesion with
observable defects in brain tissue are rarely a primary cause of psychiatric disorders. For example:
abnormalities in neurotransmitter systems in the brain can cause psychopathology without causing
damage to the brain.
c. Brain Dysfunction
Advances in understanding how subtle deficiencies of brain structure or function are implicated
(involved) in many mental disorders have been increasing at a rapid pace in past few decades.
d. Infections
Certain infections have been linked to brain damage and the development of mental illness or the
worsening of its symptoms.
e. Prenatal damage
Some evidence suggests that a disruption of early fetal brain development or trauma that occurs at the
time of birth -- for example, loss of oxygen to the brain -- may be a factor in the development of certain
conditions, such as autism spectrum disorder.
f. Substance abuse
Long-term substance abuse, in particular, has been linked to anxiety, depression, and paranoia.
g. Neuro-chemical (neurotransmitter & hormone)
1. Neurotransmitter
In order for brain to function adequately neurons or the nerve cells need to be able to communicate
effectively with one another.
The belief that imbalances in neurotransmitters in the brain can result in abnormal behavior is one
of the basic belief of biological perspective today.
Imbalances can be created in various ways:
1. excess production and release of neurotransmitter substance into the synapses, causing a functional
excess in level of that neurotransmitter
2. Deactivation after being released through reuptake or degradation by certain enzymes
3. Problem with the receptor in the post synaptic neuron, which may be either abnormally sensitive or
abnormally insensitive.
Different disorders are thought to stem from different pattern of neurotransmitter imbalances in various
brain areas. Different medications used to treat various disorders are often believed to operate by
correcting these imbalances.
2. Hormones
Hormones are chemical messengers secreted by endocrine glands in our body.
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Hormonal abnormalities contribute to the development of mental disorder because of the effect
they exert on different brain and body areas for different disorder.
h. Genetics
Each normal human cell has 46 chromosomes arranged in 23 pairs. One chromosome in each pair comes
from mother and one from father. Each chromosome contains thousands of genes that influences physical
and psychological development.
It is the genes you inherit from your parents and from your ancestors. Except for identical twins, every
person has a unique set of genes unlike those of anyone else in the world.
Research in developmental genetics has shown that abnormalities in the structure or number of the
chromosomes can be associated with major defects or disorders. Genetically vulnerable person has
usually inherited a large no. of genes that operates to increase vulnerability.
Although neither behavior nor mental disorder are ever determined exclusively by genes, there are
substantial evidence that most mental disorder show at least some genetic influence ranging from small to
large.
For psychological disorders, the evidence indicate that genetic factor make some contribution to all
disorders but accounts for less than half of the explanation. If one of a pair of identical twins has
schizophrenia, there is less than 50% likelihood that the other twin also has the disorder (Gottesman,
1991). Similar or lower rates exist for other psychological disorders (Plomin et al., 1997), with the
possible exception of alcoholism (klender et al., 1995)
Other factors: Poor nutrition and exposure to toxins, such as lead, may play a role in the development of
mental illnesses.
2. Psychological Determinants
Psychological factors that may contribute to mental illness include:
• Severe psychological trauma suffered as a child, such as emotional, physical, or sexual abuse
• An important early loss, such as the loss of a parent
• Neglect
• Poor ability to relate to others
Various perspectives have shown various reasons for psychological disorder:
Psychodynamic perspective:
Much as biological perspective replaced superstition with the biological cause of abnormal behavior, the
psychoanalytic perspective showed that, intrapsychic conflict, fixation and exaggerated ego defense
mechanism as the suspected cause of mental disorder.
Behavioral perspective:
Behaviorism is concerned with how environmental factors (called stimuli) affect observable behavior
(called the response).
Maladaptive behavior is viewed as essentially the result of:
• Failure to learn necessary adaptive behaviors, and/or
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• The learning of ineffective or maladaptive response

For behavior therapist, the focus of therapy is on changing specific behaviors and emotional responses-
eliminating undesirable reactions and learning desirable ones.
Example: Fears and phobias can be successfully treated by prolonged exposure to the feared situation or
objects- an extinction procedure derived from the principle of extinction of classical conditioning.
Classic work using the principles of instrumental conditioning also showed that chronically mentally ill
people in institutions can be retaught basic living skills such as feeding and clothing themselves through
the use of tokens that are earned for appropriate behavior and that can be turned in for desirable results.
Cognitive approach
Cognitive means mental processes. It is focused on how our metal processes affect behavior.
Cognitive approach assumes that all mental disorder occurs due to error in thinking.
Humanistic approach
This approach is concerned with hope, values, personal growth, self-actualization.
Human beings are always directed towards self-growth and happiness.
Each of us must develop values and sense of our own identity based on our own experience rather than
blindly accepting values of others & then only we will achieve our full potential.
According to this view, psychopathology results from:
• Blockage or distortion of personal growth and natural tendency toward physical and mental
health
• Over dependence on others for gratification of self-esteem.
• Conditioned positive regards
• Difference between real and ideal self
3. Social Determinants:
Certain stressors can trigger an illness in a person who is susceptible to mental illness. These stressors
include:
• Death or divorce
• A dysfunctional family life
• Feelings of inadequacy, low self-esteem, anxiety, anger, or loneliness
• Changing jobs or schools
• Social or cultural expectations (For example, a society that associates beauty with thinness can be
a factor in the development of eating disorders.)
• Substance abuse by the person or the person's parents
Sociocultural approach is concerned with the contribution of sociocultural variable to mental disorder.
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Studies have made clear relationship between various sociocultural conditions and mental disorder
(example: the relationship between the particular stressors in a given society and the types of mental
disorders that typically occurs in it).
Studies also have shown that the pattern of both physical and mental disorders within a given society
could change over time as sociocultural conditions change.
Sociocultural causal factors for psychopathology
1. Low socioeconomic status and unemployment
2. Prejudice and discrimination
3. Social change and uncertainty
4. Urban stressors: Violence and homelessness
1. Low socioeconomic status and unemployment
Lower SES => higher incidence of physical and mental disorder
Example:
Antisocial personality disorder is strongly related to SES, occurring about 3 times more in lower income
category.
People who live in poverty encounter more and more severe stressors in their lives than do affluent people
& have fewer resources for dealing with them. Thus, lower SES group may show increased prevalence of
mental and physical disorder due at least partly to increases stress.
Rates of depression, marital problems & somatic complaints increase during period of unemployment but
usually normalize when employed. Unemployed father is more likely to engage in child abuse. Wives of
unemployed men also exhibit higher level of anxiety, depression and hostility.
2. Prejudice and discrimination:
Vast number of people in our society have been subjected to stereotypes as well to both overt and covert
discrimination in areas such as education, employment etc.
Prejudice (preconceived opinion that is not based on reason or actual experience) among minority groups
may also explain why these groups sometimes show increased prevalence of certain mental disorder such
as depression. One possible reason for this is that discrimination may serve as a stressor that threatens
self-esteem, which in turn increases psychological distress.
Many more women than men suffer from certain emotional disorders, most notably depression and
anxiety disorders. This may be at least partly a consequence of vulnerabilities (such as passivity and
dependence) intrinsic to traditional roles assigned to women and of the sexual discrimination that still
occurs in the workplace.
3. Social change and uncertainty
Due to changing world all aspects of life- education, jobs, families, health, finances, our values and
beliefs are affected. Constantly trying to keep up with the numerous adjustments demanded by these
changes is a source of considerable stress.
10
Simultaneously, we also confront inevitable natural and manmade crisis which increases despair and
helplessness.
4. Urban stressors: violence and homelessness
Rapid urban growth is occurring worldwide- especially in less developed countries. Unfortunately, it is
frequently unregulated and chaotic & growing number of people are unemployed and homeless.
Urban violence: Vast numbers of people in the big cities are direct or second-hand victim of urban
violence. It was estimated that at least 3.5 million people worldwide lose their lives to violence each year
(WHO, 1999). Domestic violence against women and children is especially widespread. Such violence
also results in increased rate of anxiety, PTSD, depression and suicidality.
Homelessness: estimates are that approximately one-third of homeless people are affected by severe
mental illness. Major stressors experienced by being homeless create mental distress including anxiety,
depression, suicidality, and physical illness, even in those who started out healthy.
Impact of sociocultural viewpoint
Sociocultural viewpoint includes concerns with societal, communal, familial, and other group setting as
factors in mental disorders.
2.4 Promoting mental health: Prevention through community awareness on mental health, peer
group support
Mental health heavily influences our quality of life. So, it makes sense that mental health, just like
physical health, needs to be taken care of and maintained. And one way that it can be maintained
is through finding a sense of community.
Community can be defined in many ways, but when simplified down to its most important element,
community is all about connection. Community is not just an entity or a group of people, it’s a
feeling. It’s feeling connected to others, feeling accepted for who you are and feeling supported.
Having connection can help us feel wanted and loved.
We’re social beings, and we are not meant to live in isolation. Community is critical for us to
thrive, especially for someone with mental illness who is already experiencing the common
symptoms of loneliness and isolation.
Community provides many elements that are critical to mental health, but here are three of the
most beneficial aspects which are Belonging, Support and Purpose.
Community Awareness is generally defined as knowledge created through interaction between
community people and its environment.
In the same way we educate communities about physical health concerns such as heart disease,
it’s critical that we start conversations about what mental illness is, how to recognize it and the
fact that it is a treatable illness. Here are some simple steps you can take to help raise the collective
consciousness about mental health:
1. Talk with everyone you know: Ask family, friends and coworkers how they’re doing and
really listen to the answers. If they give any indication that they are depressed or stressed
11
out, let them know that there are resources available to help them. - If you sense that they
might be considering self-harm or suicide, encourage them to seek help immediately and
assist them as appropriate.
2. Open up about your experience: If you’ve struggled or are struggling with mental illness,
share your story. Hearing another person is going through the same thing you are can be a
relief. And, it can be the nudge a person needs to get help and look into treatment.
3. Encourage kind language: When you hear people around you talk about mental illness in
disparaging terms, politely ask them to consider the impact of their words. Any language
that reinforces the stigma of mental illness is harmful and might keep someone from getting
help.
4. Educate yourself about mental illness: It’s not uncommon for people to misunderstand
mental illness. Learn more about it and share what you learn. This includes talking with
children about mental health in age-appropriate terms. Children are not immune to mental
illness and can experience conditions like depression and anxiety as early as elementary
school.
5. Coordinate a mental health screening event: Promoting an event or asking that mental
health screening be part of a community health fair can encourage people to take action
regarding their mental health.
6. Leverage social media: Platforms like Facebook and Twitter can be great forums for
inspiring people to be open-minded and inquisitive when it comes to mental illness.
7. Encourage physical health that supports mental health: Help people understand that
physical health can have a direct impact on mental health. Eating healthy and getting plenty
of exercise and sleep all play a part in a person’s mental and emotional state.
Peer group support
There are different types of peer support, but they all involve both giving and receiving support.
This could be sharing knowledge or providing emotional support, social interaction or
practical help. Everyone's experiences are treated as equally important, and no one is more of an
expert than anyone else.
Importantly, peer-to-peer support is built on common trust among individuals, enabling them to
express issues that are difficult to express in classical mentorship. Support consists of sharing
knowledge or experience, providing emotional and social support, or giving practical advice. "Peer
support helps people to normalize emotions, feelings and mental health and to find self-
compassion."
However, it's important for peer support to be carried out carefully. Those who want to offer peer
support need to be non-judgmental and empathetic, and ensure people feel heard and respected. In
a group setting, it's also key for everyone to be given a chance to speak.
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Unit 3: Status of Mental health on Nepal
3.1 History of mental health services in Nepal: OPD service, mental hospital(s), psychological
services
3.2 Major service providers: Government agencies: government hospitals; private hospitals with
mental health service; non-governmental organizations working in the field of mental health
3.3 Types of professionals in mental health: Clinical psychologists, psychiatrists, psychologists,
social workers
3.4 Para-professionals: Trained psychosocial counselors, community psychosocial workers
(CPSW)
3.5 Mental health policy: Current status
3.6 Referral mechanism: The existing referral chain for mental health problems in Nepal
3.1 History of mental health services in Nepal: OPD service, mental hospital(s), psychological
services
Hospital-based mental health services
Psychiatric services remained virtually unknown in Nepal till 1961. Unlike other countries where
the mental asylum first marked its presence in the care of mentally ill, mental health services
started in a general hospital setting in Nepal.
The first psychiatric OPD service was started in 1961 at Bir Hospital (General Hospital),
Kathmandu. A 5-bedded inpatient unit was established in the same hospital in 1965, which was
further strengthened to 12 beds in 1971. In 1972, a 10-bedded neuro-psychiatric unit was
established in the Royal Army Hospital, Kathmandu.
In 1976, Father Thomas Gaffney started a rehabilitation center for Nepali drug abusers. During
1983-84 a number of non-governmental organizations were started in the field of mental
retardation and drug abuse.
In 1984, the 12-beded Psychiatry department at Bir Hospital was separated and a separate mental
hospital was created, which was then shifted in 1985 to the current site at Lagankhel, Patan. It
then had 25 beds, which were later increased to 39 beds. It is the only mental hospital of Nepal.
Four hundred and one bedded T. U. Teaching Hospital was established in 1983 and Psychiatric
OPD services started in February 1986 followed by the addition of a 12-bedded psychiatric
inpatient unit in December 1987, which was later, increased to 22 since 2000. Since 1997 clinical
psychological services were also started in T.U. Teaching Hospital.
Community mental health service
Nepal's own community mental health service came into existence following Shrestha et al's
(1983) report. Following this survey, training was arranged in mental health for health assistants
and health-post staff in and around Bhaktapur. This led to the setting up of a satellite mental
health clinic in Bhaktapur, staffed by Mental Hospital doctors, for the referrals from these health
post workers.
United Mission to Nepal's Mental Health Program was started in 1984. In Nepal health-posts are
staffed by paramedical, and these were the people who were trained. The aims of the program
were:
· To provide mental health services integrated into existing physical health delivery systems,
rather than setting up specialist structures.
· To increase knowledge and awareness of mental health issues in Nepal.
· To support the existing mental health services of HMG.
In 1989, the Department of Psychiatry of T.U. Teaching Hospital started the Mental Health
Project by launching a Community Mental Health Program in Morang (one of the eastern
districts of Nepal) where there was already a psychiatrist. This program was successful and soon
attracted new staff and a good deal of professional interest. Mental Health Project further started
two programs, one in the western region and another in Banke district with the help of a
psychiatrist in each place.
At present, UMN and Mental health project has been phased out and this work is being
continued from a NGO and has expanded to cover 26 districts. This model involving ‘task
shifting’ has been incorporated into the mental Health Policy.
Private and NGO sector
A few NGOs, with the help of local psychiatrists, are running rehabilitation programs. Apart
from this, private psychiatrists are also contributing to the treatment of mentally ill patients
through regular OPD, in-patient, and satellite clinics.
Other important milestones
1990: Establishment of Psychiatrists' Association of Nepal.
1997: National Mental Health Policy was adopted by the His Majesty’s Government of Nepal.
1997: Three-year residency program started in IOM.
1998: Two-year residency program in Clinical Psychology at IOM.
1999: Establishment of Bachelor in Psychiatric Nursing at IOM.
Mental Health Act has been drafted and ready for adoption at the senate.
3.2 Major service providers: Government agencies: government hospitals; private hospitals
with mental health service; non-governmental organizations working in the field of mental
health
A government agency is a permanent or semi-permanent organization within a national or state
government. These agencies are responsible for oversight or administration of a specific sector,
field, or area of study.
A public hospital, or government hospital, is a hospital which is government owned and is
fully funded by the government and operates solely off the money that is collected from
taxpayers to fund healthcare initiatives.
Mental hospital located in Patan is only standalone government mental hospital in Nepal which
provides 50 beds services. Besides Patan mental hospital, various government hospitals provide
OPD (Out Patient Department) Services and IPD (In Patient Department). Few of the
government hospital providing OPD and IPD services are listed below:
• Bir Hospital
• T.U. Teaching Hospital, Kathmandu (12 psychiatric beds)
• Birendra Army Hospital, Kathmandu (25)
• Dependra Police Hospital, Kathmandu (6)
• Western Regional Hospital, Pokhara (3)
• BPKIHS, Dharan (4)
• Koshi Zonal Hospital (2)
Private hospitals with mental health service
A private hospital means any hospital or institution not directly supported by public funds, or a
part thereof, which is equipped and staffed to provide inpatient care to persons with mental
illness.
Private hospital providing both inpatient and out patients care for mentally ill people include:
• Rhythm Neuropsychiatric hospital and research Centre (Private mental hospital)
• National Hospital
• Medicare
• Kathmandu Model Hospital
• Om Nursing Home
Privately Run Satellite Clinics
** Satellite clinic means a scheduled program of outpatient services for patients requiring
psychiatric or substance abuse treatment following discharge from an inpatient program
conducted at a site remote from the facility in which the inpatient services are provided which
allows patients to obtain needed outpatient services for their psychiatric illness and/or substance
abuse closer to their city or county of residence.
Once or twice a month clinical services through private health centers provided by
qualified psychiatrists
• Bharatpur
• Bhairahawa
• Butawal
• Pokhara
• Hetauda
Non-governmental organizations working in the field of mental health
A non-profit organization operates independently of any government, typically one whose
purpose is to address a social or political issue.
A non-governmental organization (NGO) is a group that functions independently of any
government. It is usually non-profit. NGOs, sometimes called civil society organizations, are
established on community, national, and international levels to serve a social or political goal
such as a humanitarian cause or the protection of the environment.
Non-Governmental Organizations providing mental health service include:
1. Transcultural Psychosocial Organization (TPO) Nepal is a non-governmental
organization established in 2005 with the aim of promoting mental health and
psychosocial wellbeing through development of sustainable, culturally appropriate
and community based psychosocial and mental health support systems. Transcultural
Psychosocial Organization (TPO) Nepal is one of Nepal’s leading psychosocial
organizations. TPO Nepal ‘s primary aim is to promote psychosocial well-being and
mental health of children and families in conflict-affected and other vulnerable
communities, through development of sustainable, culturally-appropriate,
community-based psychosocial support systems.
2. Center for Mental Health and Counseling – Nepal (CMC-Nepal) is a national level
non-governmental organization, registered on 1st May 2003 in Kathmandu District
Administration Office and affiliated to the Social Development Council. It is working
on various levels with preventive, promotive and curative aspects of mental health,
aiming to provide mental health services in the community. It is also supporting other
organizations in their psychosocial programs. The initiator of CMC-Nepal is United
Mission to Nepal, Mental Health Program, established in 1984. CMC aims to work
through other organizations (governmental, NGOs/INGOs and institutions) to promote
awareness and good quality mental health care by capacity building and support. The
aim of CMC – Nepal is towards mainly indirect impact, which would make the
organizations empowered and having the sense of ownership of work in order to carry
out mental health activities in their working area.
3. Autism Care Nepal was founded on 2 April 2008 on the auspicious occasion of the
World Autism Awareness Day. It is the only active autism organisation in Nepal that
is run by passionate parents that care for autistic children. We provide support and
information services to persons with autism and people who work with autistic children
in Nepal. We would like to work with organizations worldwide to share information,
resources and assist families and children at a national level, and look forward to
continuing our contact with families and professionals worldwide. We intend to
educate, aware and act for the rights of autistic children throughout Nepal.
4. Maryknoll Nepal: Maryknoll Nepal, established in 1991, is a non-profit, non-
governmental voluntary social organization, duly registered with His Majesty’s
Government and Social Welfare Council of Nepal. It was established with the main
aim of releasing all the chronically mentally ill patients locked in different jails like
Central Jail in Kathmandu and Dhulikhel jail in Kavre. Those patients were imprisoned
for many years, solely for being mentally ill. There were no hospital facilities to
accommodate them and the families did not want them back due to the chronic and
relapsing nature of their illness. Psychiatric treatment within the jail does not exist. The
other two aims are to provide treatment and then, to rehabilitate the mentally ill within
their own families and communities.
5. The Centre for Victims of Torture, Nepal (CVICT) is a non-profit, non-
governmental organization that rehabilitates victims of torture, advocates the
eradication of torture and promotes human rights within Nepal. CVICT provides
professional medical, psychosocial and legal services to Nepalese men, women and
children who are victims of torture, trauma associated with torture or inhuman
treatment. CVICT believes that a comprehensive, holistic and multi-disciplinary
approach is required to adequately assist victims of torture and their families overcome
the physical, mental and emotional consequences of torture. CVICT has been providing
comprehensive rehabilitation services for victims of torture and other human rights
abuses to restore their human dignity since 1990.
6. Koshish Nepal: Koshish is a non-profitable, national non-governmental organization
(NGO) working to improve the quality of mental health policies and programs, and at
the same time challenge existing discriminating attitudes towards people affected by
mental illness. Koshish is functioning as a “self-help” organization where the mentally
ill persons and their families are themselves given a voice – instead of just other people
“speaking on their behalf”. In fact, the very existence of Koshish evolved from the first-
hand experiences of people with mental health problems, along with the support and
solidarity of their families and related professionals at strategic levels. Koshish has
been working informally and voluntarily on mental health issues since 2004. During
these first years Koshish became involved in the rehabilitation of dozens of people
affected by mental illness. This encouraged us to get officially registered in 2008, at
the District Administrative Office in Kathmandu, with the approval of Nepal Social
Welfare Council.
3.3 Types of professionals in mental health: Clinical psychologists, psychiatrists,
psychologists, social workers
Profession is a paid occupation, especially one that involves prolonged training and a formal
qualification.
Professional a person engaged or qualified in a profession.
There are various professional in mental health:
Psychiatrist:
A medical practitioner specializing in the diagnosis and treatment of mental illness.
A psychiatrist is a medical doctor (an M.D. or D.O.) who specializes in mental health.
Clinical Psychologist:
Clinical Psychologist refers to an expert or specialist in the branch of psychology concerned with
the assessment and treatment of mental illness and psychological problems.
Psychologist:
A person who specializes in the study of mind and behavior or in the treatment of mental,
emotional, and behavioral disorders
Social workers:
Social workers are professionals who aim to enhance overall well-being and help meet basic
and complex needs of communities and people.
Number of mental health professionals in Nepal:
Psychiatrist: 200
Clinical Psychologist: 35
Psychologist: 200
Psychiatric nurse: 85
3.4 Para-professionals: Trained psychosocial counselors, community psychosocial workers
(CPSW)
Para-professional is a trained aide who assists a professional person.
Trained psychosocial counselors:
Psychosocial counselor is a skilled para-professional who provides help to an individual, family,
or group to improve well-being, alleviate distress, and enhancing coping skills.
There are about 800 trained psychosocial counselors in Nepal.
Community psychosocial workers (CPSW):
Community psychosocial workers support people with mental health conditions and their families
in their communities.
3.5 Mental health policy: Current status
Mental Health Policy
A comprehensive National Mental Health Policy was first formulated in 1996 and incorporated
in the Ninth Five Year National Plan by the Government of Nepal. However, the implementation
of the policy was ineffective, and the Mental Health Act never came into existence. Several
attempts were made to revise the policy and ensure effective implementation.
This policy is totally based on medical model of disability. It only talks about providing
treatment and curing the mentally ill people. In the entire policy there is only one strategy, which
mentions about community-based rehabilitation.
Nepal had planned on the following policies concerning mental health in Mental Health Policy
1996.
1. To ensure the availability and accessibility of minimum mental health services for all the
population of Nepal by the year 2000: in particular for the most vulnerable and under-
privileged groups of the population, by integrating mental health services into the general
health service system of the country, and by adopting other appropriate measures suitable
to the community and the people.
2. To prepare Human Resources in the area of Mental Health in order to provide for the above-
mentioned Mental Health Services. This will include Mental Health training of all health
workers, preparation of specialist Mental Health manpower, and training of groups as per
need.
3. To protect the fundamental human rights of the mentally ill in Nepal.
4. To improve awareness about mental health, mental disorders, and the promotion of
mentally healthy lifestyles, in the community by participation of community structures,
and amongst health workers
Comprehensive Mental Health Action Plan for 2013-2020
In 2013, the World Health Assembly approved a "Comprehensive Mental Health Action Plan for
2013-2020". The Plan is a commitment by all WHO’s Member States to take specific actions to
improve mental health and to contribute to the attainment of a set of global targets.
The Action Plan’s overall goal is to promote mental well-being, prevent mental disorders, provide
care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability
for persons with mental disorders. It focuses on 4 key objectives to:
• strengthen effective leadership and governance for mental health;
• provide comprehensive, integrated and responsive mental health and social care services
in community-based settings;
• implement strategies for promotion and prevention in mental health; and
• strengthen information systems, evidence and research for mental health.
The EDCD (Epidemiology and Disease Control Division) prepared a draft in 2018, which has
undergone rigorous consultations with federal, provincial and local government representatives in
mental health and is planned to be endorsed through the MoHP.
The draft policy aims to create an environment in which mental health is valued and promoted,
mental disorders are prevented, and persons affected by these disorders are able to exercise full
range of human rights and access high-quality, culturally-appropriate health and social care in a
timely way.
According to a statement issued by the MoHP, the policy also provides for a provision of allocating
budget to the federal and provincial level on the basis of the burden of mental illness.
The budget so allocated will be used for promotional, preventive, remedial and rehabilitation
sectors. Similarly, the government will gradually establish a separate mental health unit in each
government-run hospital, besides setting up mental health division under the ministry. Mental
health care facilities will be developed not as passive recipients of mentally ill patients for
treatment, but as dynamic institutions actively engaged in interaction with the communities they
serve. This interaction will include assessment of the communities’ mental health needs, the
provision of intervention measures, and action as a coordinating agency for promoting mental
health.
The five key strategies are:
1. to ensure the availability and accessibility of optimal mental health services for all the
population of Nepal
2. to ensure management of essential human and other resources to deliver mental health and
psychosocial services
3. to raise awareness of mental health to demystify mental illness and reduce associated
stigma and promote mental health
4. to protect the fundamental rights of people with psychosocial disability and mental illness
5. to promote and manage health information systems and research in mental health
programmes.
The MoHP developed the Community Mental Health Care Package Nepal, 2074 in 2017 to
facilitate implementation of the 1996 National Mental Health Policy. This package is guided by
the principles of integration of mental health into primary care and the WHO Mental Health Gap
Action Programme (mhGAP).
The MoHP has been scaling up nationwide community mental health programmes based on this
package. Similarly, the National Health Training Centre of the MoHP has developed four different
training modules for building the capacity of non-specialist service providers.
The government of Nepal has gradually increased its political commitment to mental health
services in recent years, culminating with the establishment of a specific mental health desk
within the Ministry of Health and Population’s Department of Health Services.
Mental health care has been included in the list of basic health services in Sub-Section 4 (e) of
Section 3 of the Public Health Services Act, 2075. Furthermore, the Public Health Service
Regulations have expanded the type of mental health services to be included in the Basic Health
Service and Emergency Health Service Packages. In addition, the National Health Policy, 2019,
section 6.17.5, (Mental health, oral, eye, ENT health services shall be developed and expanded)
has a strategy to expand mental health services integrated into overall health systems. The
public funds allocation for mental health is approximately 0.05 USD (Rs. 6.57) per capita (per
individual), with an estimated USD$1.5m (Rs.197,083,500.00) annual budget for mental health
interventions. Notably, this budget does not include costs for human resources or hospital
operations
Mental Health Policy and Mental Health Plan 2020
Nepal has a single, over-arching health policy, with sub-sections related to particular conditions.
Mental health is mentioned in section 6.17.5. There is no standalone mental health policy in
Nepal.
The National Mental Health Strategy and Action Plan (2020) provides a more comprehensive
description of Nepal’s plans for mental health care. This strategic Action Plan describes the
provision of free primary care mental health services for all parts of the country. Described below
are key components incorporated within the National Mental Health Strategy and Action Plan
2020.
National Mental Health Strategy and Action Plan, 2077 (Mangshir 14—November 29th 2020)
The 2020 Mental Health Strategy and Action Plan
As mental health-related policy, plans and strategy were incorporated in the 2019 National Health
Policy, the 1996 Mental Health Policy was automatically cancelled. There was therefore a need
for a detailed strategy and action plan to address the challenges and problems in the mental health
sector, so the 2020 National Mental Health Strategy and Action Plan was prepared. Its vision is to
improve the mental and psychosocial health of Nepalese, enabling them to live productive and
quality lives. The guiding principles of the plan are to ensure easy and equal access to high-quality
mental health services; integrate mental health services into primary healthcare; maintain
participation, cooperation and partnership between government, non-government and private
sectors; and provide an evidence-based and comprehensive mental health service that is rights-
based, participatory and inclusive. Its strategies include managing the necessary resources,
workforce and delivery of mental and psychosocial services; conducting awareness campaigns to
remove superstitions and myths related to mental illness and promote mental health; protecting
human rights of people with mental illness and psychosocial disability; and promoting research by
integration of mental health service-related information into the current information system. It also
mentions monitoring and evaluation of programme implementation at all three government tiers –
central, provincial and local.
The components of this plan seem to be propitious but the existence of only one psychiatric
hospital in Nepal hinders accomplishing its goals. Although there are other referral hospitals
providing psychiatric services, most are located in urban areas and lack adequate human resources.
The idea of integrating mental healthcare into the primary healthcare system has already been
promoted by the 1996 Mental Health Policy and Nepal Health Sector Programme-II. But the lack
of mental health governance mechanisms at the national and district level has not allowed the
policy provisions to be put into practice. Moreover, healthcare workers are already overstretched
and this integration of services could further burden them. Despite these various barriers,
integration can be achievable based on different enabling factors, such as constitutional provision
for health as a human right, inclusion of mental health in the national five-year health plan, and
inclusion of mental healthcare in the Multisectoral Action Plan for the Prevention and Control of
Non-Communicable Diseases.
3.6 Referral mechanism: The existing referral chain for mental health problems in Nepal
Referral is the act of officially sending someone to a person or authority that is qualified to deal
with them.
In context of Nepal client's guardian and clients themselves indirectly refer themselves.
Doctors/Physicians send referral to Psychiatrist etc.
Chapter 4
Psychosocial issues
Psychologic and social (psychosocial) problems, particularly

involving behavioral and school issues, are more common during
adolescence than at any other time during childhood. Adolescents are
much more independent and mobile and are often out of the direct
control of adults. When misbehavior becomes severe and frequent,
adolescents should be evaluated for a psychosocial disorder by a
mental health professional. In particular, depression, anxiety, and
eating disorders are common during adolescence. Adolescents who
have anxiety or mood disorders may have physical symptoms such
as fatigue or chronic fatigue, dizziness, headache, and abdominal or
chest pain.
Depression is common among adolescents, and doctors actively

screen for it during examinations.
Suicide is uncommon, but thoughts about suicide (called suicidal

ideation) are common. Adolescents with suicidal ideation require an
immediate mental health evaluation, and parents should not try to
determine how serious the problem is on their own.
Anxiety often manifests during adolescence, as do mood

disorders and disruptive behavioral disorders such as oppositional
defiant disorder and conduct disorder.
The COVID-19 pandemic and the global response to it, including

changes in daily routines and school schedules, have impacted the
rates of depression and anxiety among many adolescents.
Thought disorders, in which a person has difficulty distinguishing

between fantasy and reality (also called psychosis), most commonly
begin during adolescence or early adulthood. The first episode of
psychosis is called a psychotic break. Schizophrenia
and schizoaffective disorder are examples of thought disorders.
Periods of psychosis may be related to drug use. In these cases,
psychosis may resolve after a period of time.
Psychotic episodes may occur with cannabis (marijuana) use,

particularly edible products. Some adolescents who have a psychotic
episode caused by cannabis use go on to develop a chronic psychotic
disorder.
Eating disorders, especially in girls, are common and can be life

threatening. Some adolescents go to extraordinary lengths to hide
symptoms of an eating disorder, which may include substantial
reductions in food intake, purging after eating, use of laxatives, or
extensive, vigorous exercise.
Characterisitcs and other factors

The psychosocial approach looks at individuals in the context of the
combined influence that psychological factors and the surrounding
social environment have on their physical and mental wellness and
their ability to function. This approach is used in a broad range
of helping professions in health and social care settings as well as by
medical and social science researchers.
Background
Adolf Meyer in the late 19th century stated that; "We cannot
understand the individual presentation of mental illness, [and
perpetuating factors] without knowing how that person functions in
the environment." Psychosocial assessment stems from this idea. The
relationship between mental and emotional wellbeing and the
environment was first commonly applied by Erik Erikson in his
description of the stages of psychosocial development. Mary
Richmond considered there to be a strict relationship between cause
and effect, in a diagnostic process. In 1941 Gordon Hamilton renamed
the existing (1917) concept of "social diagnosis" as "psychosocial
study".
Psychosocial study was further developed by Hollis in 1964 with
emphasis on treatment model. It is in tension with diverse social
psychology, which attempts to explain social patterns within the
individual. Problems that occur in one's psychosocial functioning can
be referred to as "psychosocial dysfunction" or "psychosocial
morbidity." That refers to the lack of development or diverse atrophy
of the psychosocial self, often occurring alongside other dysfunctions
that may be physical, emotional, or cognitive in nature. There is now
a cross-disciplinary field of study, and organisations such as the
Transcultural Psychosocial Organization (United Nations High
Commissioner for Refugees), and Association for Psychosocial
Studies.
Psychosocial assessment and intervention
Psychosocial assessment considers several key areas related to
psychological, biological, and social functioning and the availability
of supports. It is a systematic inquiry that arises from the introduction
of dynamic interaction; it is an ongoing process that continues
throughout a treatment, and is characterized by the circularity of
cause-effect/effect-cause.
In assessment, the clinician/health care professional identifies the
problem with the client, takes stock of the resources that are available
for dealing with it, and considers the ways in which it might be solved
from an educated hypothesis formed by data collection. This
hypothesis is tentative in nature and goes through a process of
elimination, refinement, or reconstruction in the light of newly
obtained data.
There are five internal steps in assessment:
1. Data collection (relevant and current) of the problem presented.

2. Integrating collected facts with relevant theories.
3. Formulating a hypothesis (case theory) that gives the presented
problem more clarity.
4. Hypothesis substantiation through exploration of the problem:
life history of the client, etiology, personality, environment,
stigmas, etc.
5. Further integration of newer facts identified in the treatment
period and preparing a psychosocial report for psychosocial
intervention.
Assessment includes psychiatric, psychological and social
functioning, risks posed to the individual and others, problems
required to address from any co-morbidity, personal circumstances
including family or other carers. Other factors are the person's
housing, financial and occupational status, and physical
needs. Assessments when categorized, it particularly includes Life
history of the client that include data collection of living situation and
finances, social history and supports, family history, coping skills,
religious/cultural factors, trauma from systemic issues or abuse and
medico-legal factors (assessment of the client’s awareness of legal
documents, surrogate decision-making, power of attorney and
consent). Components include: the resource assessment of psycho-
spiritual strengths; substance abuse; coping mechanisms, styles and
patterns (individual, family level, workplace, and use of social
support systems); sleeping pattern; needs and impacts of the problem
etc. Advanced clinicians incorporate individual scales, batteries and
testing instruments in their assessments. In the late 1980s Hans
Eysenck, in an issue of Psychological Inquiry, raised controversies on
then assessment methods and it gave way to comprehensive Bio-
Psycho-Social assessment. This theoretical model sees behavior as a
function of biological factors, psychological issues and the social
context. Qualified healthcare professionals conduct the physiological
part of these assessments. This thrust on biology expands the field of
approach for the client, with the client, through the interaction of
these disciplines in a domain where mental illnesses are physical, just
as physical conditions have mental components. Likewise, the
emotional is both psychological and physical.
The clinician’s comprehension and set of judgments about the client's
situation, the assessment through a theory of each case, predicts the
intervention. Hence a good psychosocial assessment leads to a
good psychosocial intervention that aims to reduce complaints and
improve functioning related to mental disorders and/or social
problems (e.g., problems with personal relationships, work, or school)
by addressing the different psychological and social factors
influencing the individual. For example, a psychosocial intervention
for an older adult client with a mental disorder might
include psychotherapy and a referral to a psychiatrist while also
addressing the caregiver's needs in an effort to reduce stress for the
entire family system as a method of improving the client's quality of
life.Treatment for psychosocial disorders in a medical model usually
only involve using drugs and talk therapy.
Unit. 5: Psychosocial issues
5.1 Meaning and definition of psychosocial counseling
Psychosocial - relating to both the psychological and the social aspects of something.
Counseling - is a process in which clients learn how to make decisions and formulate new ways of
behaving, feeling, and thinking.
Psychosocial counseling - is an interaction in which the counselor (helper) offers another person the
time, attention, respect which is necessary to explore, discover, and clarify ways of living more
resourcefully.
TYPES OF COUNSELING
INDIVIDUAL COUNSELING
Individual counseling is a personal opportunity to receive support and experience growth during
challenging times in life. Individual counseling can help one deal with many personal topics in life such
as anger, depression, anxiety, substance abuse, marriage and relationship challenges, parenting problems,
school difficulties, career changes etc.
COUPLES COUNSELING
Every couple experience ups and downs in their levels of closeness and harmony over time. This can
range from basic concerns of stagnation to serious expressions of aggressive behavior. Marriage
counseling or couples counseling can help resolve conflicts and heal wounds. Overall, couples counseling
can help couples slow down their spiral and reestablish realistic expectations and goals.
FAMILY COUNSELING
Family counseling is often sought due to a life change or stress negatively affecting one or all areas of
family closeness, family structure (rules and roles) or communication style. This mode of counseling can
take a variety of forms. Sometimes it is best to see an entire family together for several
sessions. Common issues addressed in family counseling are concerns around parenting, sibling conflict,
loss of family members, new members entering the family, dealing with a major move or a general
change affecting the family system.
GROUP COUNSELING
Group counseling allows one to find out that they are not alone in their type of life challenge. To be
involved in a group of peers who are in a similar place not only increases one’s understanding of the
struggles around the topic but also the variety in the possible solutions available. Typically, groups have
up to eight participants, one or two group leaders, and revolve around a common topic like: anger
management, self-esteem, divorce, domestic violence, recovery from abuse and trauma, and substance
abuse and recovery.
5.2 History, the emergence of psychosocial counseling in Nepal
During 1947, Psychology was introduced in Tri-Chandra Multiple Campus affiliated to Indian University
as an intermediate level as a part of philosophy. Tribhuvan University was established in 1959 and other
college came into existence. Four more colleges introduced psychology in the academic subject in
intermediate and bachelor level in 1966. During the 1960s, Psychology grew slowly and outside
Kathmandu Valley, introduced in two colleges.
In 1980, Master's level course was introduced.At present, psychology is taught in eight campuses.
Psychosocial Counselling is in the infancy stage in Nepal.Due to many problems related to social issues,
it has impacted in mental health so to deal with this issues psychosocial counseling is a major component
of that care.
Psychosocial Counselling was introduced by Training of Trainee (TOT) to help victims. Nowadays, many
organizations are involved in it. Even The School of Psychology (TSOP) is part of it. In 1991, Training in
psychosocial Counselling was started in CVICT as a TOT. Later it was introduced as 4-5 months course.
After that one-year postgraduate course was affiliated with Purbhanchal University which was initiated by
CVICT.
To compensate, a practice-oriented and skill-based training approach was developed to increase the
number of well-trained counsellors in Nepal. These courses were run jointly by the Center for Victims of
Torture (CVICT—a non-governmental organisation providing rehabilitation services to victims of torture
and other human rights abuses) and the Transcultural Psychosocial Organization (TPO—an international
organization working on developing and researching psychosocial care systems in [post-] conflict
settings). Two courses were developed—(1) a paraprofessional five month course for students with
minimal educational backgrounds and (2) a 1 year post-graduate diploma course in counselling affiliated
with Purbhanchal University, the country’s second largest university. At the time of the study no other
extensive counselling courses were offered in Nepal. Each course has been separately financed by the
donor agency that commissioned the course in order to integrate psychosocial intervention capacity
within ongoing programs of that donor agency.
In Nepal, Counselling is practiced in two ways, one is Advice Oriented Counseling and other is
Informative Counselling.
Sahara Paramarsha Kendra also started a short-term course on psychosocial counseling and many other
organizations has initiated this course like PPR Nepal, CVICT, TPO, CPSSC.The integration of
psychosocial counseling has been made in psychiatry model.It is able to create awareness in society for
the welfare of each individual and society.
5.3 Similarities and differences between psychosocial counseling, counseling, and psychotherapy
Similarities
• Effective for a wide range of people, both adults and children
• Understanding a person's feelings and behaviors, and addressing issues with the goal of
improving a person's life
• Development of a healing, safe, and therapeutic relationship between a therapist and an individual
Differences
Counseling/Psychosocial counseling Psychotherapy

• Focus on present problems and situations • Focus on chronic or recurrent problems
• Specific situations or behaviors • Overall patterns, big picture oriented
• Short term therapy (for a period of weeks • Long term therapy, either continuous or
and up to 6 months) intermittent over many years
• Action and behavior focused • Feeling and experience focused
• Talk therapy • May include testing (such as personality,
• Guidance, support, and education to help intelligence), talk therapy, other therapies
people identify and find their own such as cognitive behavioral therapy
solutions to current problems • In-depth focus on internal
• Secondary process thoughts/feelings (core issues) leading to
personal growth
• Primary process
Counseling may be a better option than psychotherapy if:

• You have specific issues or short-term problems you wish to address
• You wish to learn coping skills to help better manage stress and improve relationships
• You are coping with life transitions and adjustments, such as divorce or grief
• You are coping with addiction issues
• You are looking for someone who is essentially a "coach" who can guide and support you as you
learn to recognize problems and formulate healthy solutions yourself
A psychotherapist may be a better option if:
• You have problems that are significantly impacting your life and relationships
• You are coping with past trauma, or if you believe situations in the past may be playing a role in
your current issues
• Your present issues are chronic or recurring concerns
• You have a chronic medical condition (such as autoimmune disease, cancer, etc.) that is affecting
your emotional well-being
• You have a diagnosed mental health condition such bipolar disorder or a major anxiety disorder
• You have seen a counselor and your issues aren't improving even though you've been actively
working on solutions
5.4 Stages of psychosocial counseling
Stage one: (Initial disclosure) Relationship building
The counseling process begins with relationship building. This stage focuses on the counselor engaging
with the client to explore the issues that directly affect them.
The vital first interview can set the scene for what is to come, with the client reading the counselor’s
verbal and nonverbal signals to draw inferences about the counselor and the process. The counselor
focuses on using good listening skills and building a positive relationship.
When successful, it ensures a strong foundation for future dialogue and the continuing counseling
process.
Stage two: (In-depth exploration) Problem assessment
While the counselor and client continue to build a beneficial, collaborative relationship, another process is
underway: problem assessment.
The counselor carefully listens and draws out information regarding the client’s situation (life, work,
home, education, etc.) and the reason they have engaged in counseling.
Information crucial to subsequent stages of counseling includes identifying triggers, timing,
environmental factors, stress levels, and other contributing factors.
Stage three: (Commitment to action) Goal setting
Effective counseling relies on setting appropriate and realistic goals, building on the previous stages. The
goals must be identified and developed collaboratively, with the client committing to a set of steps
leading to a particular outcome.
Stage four: Counseling intervention
This stage varies depending on the counselor and the theories they are familiar with, as well as the
situation the client faces.
For example, a behavioral approach may suggest engaging in activities designed to help the client alter
their behavior. In comparison, a person-centered approach seeks to engage the client’s self-actualizing
tendency.
Stage five: Evaluation, termination, or referral
Termination may not seem like a stage, but the art of ending the counseling is critical.
Drawing counseling to a close must be planned well in advance to ensure a positive conclusion is reached
while avoiding anger, sadness, or anxiety.
Part of the process is to reach an early agreement on how the therapy will end and what success looks
like. This may lead to a referral if required.
While there are clear stages to the typical counseling process, other than termination, each may be
ongoing. For example, while setting goals, new information or understanding may surface that requires
additional assessment of the problem.
5.5 Scope: Humanitarian crisis, disaster, social conflict, family problems, career counseling,
educational issues, crisis, community problems, day to day life
Humanitarian crisis:
A humanitarian crisis is considered to be an event or events that threaten the health, safety or wellbeing of
a large group of people. Humanitarian crises can be caused by war, natural disasters, famine and/or
disease outbreak.
A humanitarian crisis is defined as a singular event or a series of events that are threatening in terms
of health, safety or well-being of a community or large group of people. It may be an internal or
external conflict and usually occurs throughout a large land area.
A humanitarian emergency is an event or series of events that represents a critical threat to the health,
safety, security or wellbeing of a community or other large group of people, usually over a wide area.
Disaster:
An event resulting in great loss and misfortune. Disasters, however, are the catastrophic events resulting
in heavy losses in terms of human, animal and plant lives, injuries and disabilities and damage to property
and environment.
The World Health Organization (WHO) defines a disaster as “a sudden ecological phenomenon of
sufficient magnitude to require external assistance”.
Social conflict:
Conflict is the confrontation of powers.
Conflict between people.
Social conflict occurs when two or more people oppose each other in social interaction, and each exerts
social power with reciprocity in an effort to achieve incompatible goals but prevent the other from
attaining their own.
Family problems:
Family problems means a kind of troubled relationship between family members which in turn leads to
tensions, whether these problems result from the misconduct of a family member or the two main parties,
and the frequent quarrels and differences between parents, or between children or between children and
parents Make the family in turmoil, and lose the children's prestige, respect and belonging to the family
Family issues are when conflict between or related to family members becomes especially intense or
frequent, to the point that it interrupts your day-to-day life. Some degree of conflict within families is
normal (and even, to a point, healthy) and the family dynamic for each person may be different.
Career counseling:
Career counseling is a service that helps people begin, change, or advance their careers. It can include
one-on-one conversations between a counselor and a career seeker, as well as assessments, activities, and
projects designed to help career seekers make the most of their strengths.
Career Counseling is a process that will help you to know and understand yourself and the world of work
in order to make career, educational, and life decisions.
Educational issues:
Academic concerns, which might include issues such as learning difficulties or disabilities,
underachievement, lack of attention from teachers, and bullying, affect a number of students
throughout their academic careers, from elementary school to college.
Crisis:
A time of intense difficulty or danger.
A crisis is a situation in which something or someone is affected by one or more very serious
problems.
Community problems:
Community Issues are problems or concerns that a arises from a community (town, neighborhood,
or other community group).
Day to day life:
Day-to-day things or activities exist or happen every day as part of ordinary life.
5.6 Related fields: Traditional healing: good practices and ill practices
Traditional healing: good practices and ill practices:
Traditional medicine consists of health knowledge, skills and practices based on indigenous beliefs
and experiences, which use animal, herbal or mineral-based medicines and/or spiritual therapies for the
prevention, diagnosis and treatment of physical and mental illnesses and for the general maintenance of
well-being.
Good practices:
Cures organic and spiritually-based diseases by means of prayers, herbal medicine, and incantation.
Ill practices:
• Chaining of peoples
• Harming peoples
• Human sacrifices
5.7 Culture and counseling: Issues of diversity
Culture is a group's way of life.
Counseling profession deals with diversity and multiculturalism.
It is obvious that culture influences counseling in many ways. The most important thing to keep in
mind when counseling clients from cultures different from own’s own is that they are similar to you and
different from you at the same time. In cross-cultural counseling, it is best to initiate the relationship with
the recognition of the common humanity that you share with clients.
Counselors mut broaden the context for clients, helping them realize that the counseling relationship
involves more than just the counselor and client; it’s about the counselor’s and client’s lived experiences,
which are embedded in their families’ lived experiences, as well as privileges and marginalized
experiences, she says.
5.8 Current trends in Nepal: Pros and cons of integrating mental health services in the primary
health care system and relying upon para-professionals
Integrating mental health services into primary health care services is the most viable way of closing the
treatment gap and ensuring that people get the mental health care they need.
Pros:
• integration ensures that the population as a whole has access to the mental healthcare that they
need early in the course of disorders and without disruption (better access to care)
• Improved case detection,
• Improved wellbeing of mental health patients
• when people receive treatment in primary healthcare facilities the likelihood of better health
outcomes, and even full recovery, as well as maintained social integration is increased. (Better
health outcomes)
Cons:
• shortage of psychotropic medicines,

• lack of private space for counseling,
• workload and health workers’ grievances regarding incentives, and
• perceived stigma causing dropouts.
5.9 Ethical issues in psychosocial counseling
Remley and Herlihy (2016) suggest six principles for counselors to consider:
1. Beneficence: Do good, promote well-being and health.
2. Nonmaleficence: Do no harm, prevent harmful actions and affects.
3. Autonomy: Recognize and respect independence and self-determination.
4. Justice: Promote fairness and equality in dealings.
5. Fidelity: Be responsible to clients and honor agreements.
6. Veracity: Be truthful and honest in dealings.
The APA Ethical Principles (2010) incorporated these principles into its ethical code: Principle A:
Beneficence and Nonmaleficence; Principle B: Fidelity and Responsibility; Principle C: Integrity;
Principle D: Justice; and Principle E: Respect for People’s Rights and Dignity
Autonomy
Autonomy constitutes the individual freedom of choice and action (Kitchener, 1984). An autonomous
person has the liberty to act as long as he or she does not infringe on the rights of others. In a counselor-
client relationship, this means that the client has a right to make decisions about his or her treatment
without undue influence from the counselor. The counselor must fully inform the client to the best of his
or her ability, and as long as the client has been given as much information as possible, he or she has the
right to choose his or her own course of action. Additionally, the client has this right even though the
counselor may think he or she is not acting in his or her own best interest. Kitchener stated that there are
two restrictions on autonomy: when the client’s actions infringe on another’s freedom and when the
client’s level of competence is in question.
Non-Maleficence
The next moral principle addressed by Kitchener (1984) is the concept of non-maleficence. Non-
maleficence is the well-known decree of “do no harm.” Counselors, above all else, should not engage in
behaviors that will knowingly cause harm to clients. Kitchener reported that not doing harm to a client is
more important than benefitting them. In other words, it is more detrimental to clients to inflict harm on
them than to provide services that do not benefit them. At least the client is left unchanged instead of in a
state of further deterioration. The concern with non-maleficence is what exactly constitutes harm? Clients
often experience some discomfort during counseling. This discomfort, however, is qualitatively different
than the discomfort a client might have as a result of engaging in a trauma-based flooding experience, for
example. There are two issues relevant here. First, the clinician and the client should evaluate whether the
benefits outweigh the potential harm. Second, the matter of adequate informed consent, which will be
addressed later in this chapter, is crucial.
Beneficence
Beneficence implies that we are charged to contribute to the welfare and well-being of our client(s).
Kitchener (1984) posited that because a profession labels itself as a “helping profession,” it has agreed to
not only avoid doing harm to its client(s), but it has publicly stated that its responsibility is to act for the
betterment of the client. What constitutes the betterment of the client is a gray area that can be challenged,
yet incompetence on the part of the counselor is another matter
Justice
Simply put, justice constitutes fairness and equal treatment for all clients. The basis of the premise of
justice is that all people are equal. For example, clients may not be treated differently because of sex,
sexual orientation, race, religion, or ability to pay for services. If a counselor has standard treatment
protocols and procedures, he or she must offer those services and procedures to all of his or her clients
without discrimination.
Fidelity
The final moral principle that Kitchener (1984) provided is that of fidelity, which “involves questions of
faithfulness, promise keeping, and loyalty”. Counselors are expected to be honest with their clients and to
fulfill obligations promised to them.
Int J Adv Counselling (2007) 29:57–68
DOI 10.1007/s10447-006-9028-z
ORIGINAL ARTICLE
Psychosocial Counselling in Nepal: Perspectives

of Counsellors and Beneficiaries
Mark J. Jordans & Annalise S. Keen & Hima Pradhan &

Wietse A. Tol
Published online: 9 February 2007

# Springer Science + Business Media, LLC 2007
Abstract The aims of this qualitative study were (1) to add to the understanding of the
growing field of psychosocial counselling in Nepal, and (2) gather concrete points for
improvement of services. Semi-structured interviews were conducted with clients (n=34),
para-professional counsellors (n=26) and managers (n=23) of organizations in which
psychosocial counselling was taking place. The main findings were that stakeholders
generally presented a positive view of the significance and supportive function of
psychosocial counselling, while providing useful suggestions for improvement. Matters of
ongoing training and supervision, confidentiality and integration of counselling within
mainstream care provision need to be addressed and potentially adapted. Implications for
other non-Western countries with little mental health resources are discussed.
Keywords Psychosocial counselling . Nepal . Counsellor training . Counselling services
Introduction
This article concerns the emerging field of psychosocial counselling within Nepali society,
as part of rehabilitation services for children and adults who have been affected by human
rights abuses and community violence. The study aimed at exploring the perceptions of
counsellors, clients (direct beneficiaries) and managers of child care institutions (indirect
beneficiaries) on issues of relevance and applicability of counselling within non-
governmental organizations working for these target groups.
Nepal is a South-Asian Hindu Kingdom, landlocked between India and China and is home
to many ethnic groups. The majority of its 23 million population resides in the countryside. The
M. J. Jordans (*) : W. A. Tol

Public Health and Research Department, HealthNet-TPO, Tolstraat 127,
Amsterdam 1074 VJ, Netherlands
e-mail: mjordans@healthnettpo.org
A. S. Keen : H. Pradhan
Center for Victims of Torture, Nepal,
Bansbari 3, Kathmandu, Nepal
58 Int J Adv Counselling (2007) 29:57–68
main economic activity is agriculture and the majority (82%) survives on less then two dollars a
day (Singh, Dahal, & Mills, 2005). Serious human rights violations have escalated since the
Communist Party of Nepal (Maoists) launched a “people’s war” against the Government
forces in 1996, leading to a climate of intense fear (Human Rights Watch, 2004; Singh et al.,
2005). This is taking place against a background of other people-made disasters afflicting
Nepal, such as trafficking for sexual exploitation and other forms of child labour.
Mental health receives little attention in Nepal. Of the 3% of the national budget that the
Government has allocated for health, approximately 1% is spent on mental health.
Traditional and religious healing methods are commonly practiced. There is no mental
health act and the National Mental Health Policy formulated in 1997 is yet to become fully
operational (Regmi, Pokharel, Ojha, Pradhan, & Chapagain, 2004). Western mental health
practices have started to get increasing attention, most notably through psychiatric services
(there are currently around two dozen psychiatrists) and psychosocial counselling.
Still, the state of counselling in Nepal is largely meagre. Training courses are typically
short, do not include clinical practice and more often than not are given by expatriate
trainers new to the cultural setting. Counselling is habitually misunderstood, resulting often
in judgmental and uninformed implementation, and sometimes in incorrect practices. The
state of counselling is further complicated because of the random application of the word
‘counsellor’ to anyone doing ‘social work’ within an NGO setting (Kohrt, 2006).
To compensate, a practice-oriented and skill-based training approach was developed to
increase the number of well trained counsellors in Nepal. These courses were run jointly by
the Center for Victims of Torture (CVICT—a non-governmental organisation providing
rehabilitation services to victims of torture and other human rights abuses) and the
Transcultural Psychosocial Organization (TPO—an international organization working on
developing and researching psychosocial care systems in [post-] conflict settings). Two
courses were developed—(1) a paraprofessional five month course for students with minimal
educational backgrounds and (2) a 1 year post-graduate diploma course in counselling
affiliated with Purbhanchal University, the country’s second largest university. At the time of
the study no other extensive counselling courses were offered in Nepal. Each course has been
separately financed by the donor agency that commissioned the course in order to integrate
psychosocial intervention capacity within ongoing programs of that donor agency.
The paraprofessional course, involving five months duration, starts with a 3-week core
training period followed by several cycles of alternated supervised practical placements and
further training sessions for increasingly advanced skills and topics. The distribution of training
hours is approximately 400 h of classroom learning, 150 h of clinical supervision, 350 h of
practice within a real-life setting and 10 h of personal therapy. The last component refers to
participants going through counseling sessions themselves, aiming to provide a model for
intervention as well as to create personal awareness and self reflection (Jordans, Sharma, Tol, &
van Ommeren, 2002). Details of the training program have been published elsewhere (Jordans
et al., 2002; Jordans, Tol, Sharma, & van Ommeren, 2003). With this approach, more then 130
counsellors have been trained over the past five years. Except for two batches of psychologists
(n=12), all trained counsellors have minimal educational background (i.e., mainly high school
level, with a few college-level participants), hence the indication paraprofessional.
There are five core-defining features of the training approach, which are widely accepted
in Western programs but are still largely ignored in training programs in most of South Asia
(Frederick, 2002). First, courses are medium to long term, recognizing that learning about
complex and intricate helping processes requires more than just a brief period. Second, a
training of trainers model is not used. This is seen as not appropriate at this point as it
Int J Adv Counselling (2007) 29:57–68 59
requires advanced clinical experience in order to effectively train others. Third, the
approach is skills-based, emphasizing micro counselling skills (A. E. Ivey & M. Ivey,
1999), extensive role plays and practical placements. Fourth, there is a stress on clinical
supervision and practical personal therapy as tools to connect newly acquired skills to an
actual service-provision setting. Fifth, cultural sensitivity is emphasised. Working with
Western-oriented therapeutic assumptions in a non-Western setting requires adaptations to
increase cultural relevance. In this case, adaptation started with a reflection on existing
healing methods, the nature of therapeutic relationships, and the use of therapeutic concepts
such as locus of control, introspection and abstraction (Tol, Jordans, Regmi, & Sharma,
2005). This has yielded changes in intervention strategies including (a) a shift of focus from
intra-psychic or cognitive processes to concrete problem-solving, (b) application of micro-
skills and concrete counselling techniques (e.g., relaxation exercises), and (c) the inclusion
of a thorough psycho-education component.
The training programs use manuals that have been translated and pre-tested in the Nepali
language (de Jong & Clarke, 1996; Jordans, 2002; Jordans, 2003) and are conducted by
experienced Nepali trainers—psychologists who received the first of the intensive training
courses by CVICT and TPO and subsequently gained clinical experience and further
training. The training courses are seen as compatible with international guidelines (Weine et
al., 2002) and include topics such as understanding counselling concepts and process, the
understanding of mental health problems, and the application of counselling skills and
specific intervention strategies. Through role-plays, lectures, experiential learning and
group work, the trainees learn skills specific for targeted beneficiaries as well as generic
concepts such as working with coping strategies, symptom management techniques (e.g.,
relaxation), psycho-education and strengthening of existing resources.
Counselling practiced as a result of the above-mentioned training approach (Jordans et al.,
2003) combines client-centered and problem-solving approaches. It includes non-specific
therapeutic elements, such as empathy, intercultural sensitivity and basic communication skills,
with structured steps that aim to reduce both stressor-induced symptoms of distress as well as,
whenever possible, problem situations (Egan, 1998; A. E. Ivey & M. Ivey, 1999). For
application within a non-Western setting, basic concepts from medical anthropology (e.g.,
Kleinman, Eisenberg, & Good, 1978), such as working with clients’ illness experiences,
explanatory models and idioms of distress, have been included (van Ommeren, Sharma, Prasain,
& Poudyal, 2002) and the level of the intervention has been adapted for paraprofessional use,
following a public mental health approach. The latter involves a shift of focus from providing
specialized psychiatric mental health care with a biomedical focus, to providing an easy-access
level of care targeting common distress that links with existing formal and informal care
structures. It is argued that psychosocial counselling has a place in a spectrum of psychosocial
services for those more severely affected by organized violence and human rights abuse. We
follow the Psychosocial Working Group (2002) in their description of ‘psychosocial’, which
encompasses psychological well-being and/or mental health (emotional, cognitive and
behavioral stability of the individual); it emphasizes social ecology (consisting of the wider
community connections, social support networks and other existing healing resources) and; it
entails working from the significance and appropriateness given by existing culture and values.
Although the implementation of this approach has been positively evaluated through
independent programmatic assessments (Frederick, 2002; Slugget, 2003) as well as
empirical effectiveness research (de Jong, Komproe, & O’Connell, 2004; Tol, Komproe,
Jordans, Thapa, de Jong, & Sharma, submitted), little is known about the opinions and
perspectives of direct and indirect beneficiaries and counsellors.
This study focused on the applicability and relevance of counselling as perceived by local
actors. A qualitative study design, using semi-structured interviews, was chosen, aiming to gather
perspectives on needs for, satisfaction with, understanding of, and attitude towards counselling.
Methodology
Respondents
The study focused on a group of 30 counsellors, who were selected because they had been
trained with funding from the donor that commissioned this study (International Labour
Organization, ILO) as a means to better understand the application of actual services after
completion of the training course. The counsellors had received training one to two years
previous to the study; 26 (87%) were contacted and agreed to participate. Of the
interviewed counsellors, 77% were female and 23% male with ages ranging from 21 to 42.
Clients were sampled through a snowball procedure; counsellors were asked to identify
former clients and approach them for possible participation in the study. The counsellors
were also asked to help arrange contact between their managers and the researchers. The
target client population were children and youth in, or rescued from, high-risk situations
(e.g., child trafficking; child porters; street children; domestic child labourers; orphans).
The interviewed clients (n=34) had received psychosocial care from the counsellors as a
result of expressed and/or observed psychosocial problems. Twenty-six (76%) were female,
eight (24%) male. The average age was 18.6 (SD=7.81) with 24 (71%) respondents
18 years or less and 85% still in school. See Table I for demographic characteristics.
Twenty-three managers (70% female; 30% male) of 17 rehabilitation and care institutions for
victims of human rights abuses and violence were interviewed. The functions of the interviewed
management staff ranged from directors (n=6), to coordinator of programs and residential
centers (“shelters”) (n=11), to administrative officers (n=5). These 17 organizations, within
which counselling was integrated, represent a set of non-governmental organizations
providing institutional or community based care to the above mentioned client population,
both within Kathmandu and other (some remotely located) districts (Jumla, Jhapa, Kaski,
Danusha). Ten (38%) out of the 23 interviews were conducted outside Kathmandu.
Procedure
Interviews with the managers and counsellors were conducted mainly in English with
Nepali translation, while interviews with clients were conducted entirely in Nepali. Most
interviews were conducted by a team consisting of an experienced Nepali psychologist/
counsellor (HP) familiar with the training approach and a medical student from Harvard
Table I Demographic Information of Clients
Gender Mean age Religion Education
Clients (n=34) Female 76% 18.6 (SD=7.81) Hindu 73% Attending school 85%
Male 24% Buddhist 9% Not attending school 15%
Christian 6%
Muslim 6%
None or Other 6%
University joining the team for the purpose of the study (AK). Interviews in the more
remote districts were conducted by a Dutch clinical psychologist (WT—living and working
in Nepal for several years) together with another Nepali psychologist/counsellor. Interviews
lasted from one to one and a half hours.
Informed written consent was obtained from all participants and confidentiality was
assured and maintained throughout. The objectives of the research and its methodology were
explained to potential study participants, and they were assured that non participation would
not in any way result in negative consequences regarding treatment or otherwise. Any
questions or concerns about the study were addressed during the interview and participants
were given contact information and advised to contact the researchers with any concerns.
Instruments
All interviews were done with the use of semi-structured interview formats. Care was taken
to avoid socially desirable response tendencies, through avoiding leading questions and
emphasizing the need for honest answers to be able to improve services. Most questions
were open-ended, but some questions were asked in a closed format to obtain specific
information – on levels of perceived cultural relevance and satisfaction with received services.
The interview format for clients consisted of two parts: (a) demographics and (b)
questions related to the intervention (problems experienced, client’s understanding of the
process of counselling, opinion on counselling received, satisfaction with counselling and
cultural relevance of counselling). The interviews with counsellors and managers were less
structured and consisted of themes. For the counsellors these themes were (a) evaluation of
and perspectives on training received, (b) questions focusing on psychosocial counselling
(felt competence as a counsellor, skills used, type of services delivered), and (c)
organizational aspects (role of management, integration with other services and role in
the organization). The themes for manager interviews were (a) attitude/opinions towards
counselling, (b) opinion on needs for counselling, (c) implementation issues (integration
with other services, difficulties experienced in implementation).
Analysis
The researchers followed steps for qualitative data analysis as described in Varkevisser,
Pathmanthan, and Brownlee (2004). Content analysis was done on the notes taken during
interviews. As is common in analysis of qualitative data collected for small respondent
groups, the analysis consisted firstly of categorizing answers of respondents together. These
categorized responses were subsequently inspected for common themes in the content on
which the description of results was based. Quantitative data were entered and analyzed
with the help of SPSS (version 10 for PC), while word processing software (Microsoft
Word 2000 for PC) was used for the categorization of (translated) qualitative responses.
Results
Clients’ perspectives
Expressed problems and received care
The 34 clients who were interviewed seemed to have presented for counselling with mild to
severe psychosocial problems, based on the clinical impression of the treating counsellor. No
diagnostic interview was conducted as part of the study. Clients stated that their problems
included, in order of frequency: anxiety, aggression, fear, difficulties with reintegration into
society and family life and stigmatization, other family issues, loneliness, trauma, suicidality,
insomnia, domination by others, guilt, and inability to concentrate.
The average number of counselling sessions that clients received was 4.8 (SD=4.6), with the
least being one session and the most being three sessions monthly for one year. It is important to
note that some clients were still in the process of receiving counselling at the time of interview.
Opinion of counselling
Most of the clients interviewed seemed to have a good understanding of psychosocial

counselling. They described it as a process of providing relief by working with a counsellor
with whom they were able to share and/or solve their personal problems. Most of the clients
interviewed stated that psychosocial counselling was a worthwhile service that was culturally
appropriate, with 91% of the clients explaining that counselling fitted perfectly or well within
their cultural setting (“the term is new but this sort of counselling in essence has been
happening for a long time in Nepal”), see Table II. Overall, clients reported to be satisfied
with counselling services offered, with 91% responding that they were very satisfied or
mostly satisfied with services received. As open expressions of emotion are not always
appropriate in Nepali culture, several clients expressed that counselling fulfilled their need
to have someone listen and understand their problems and feelings, with people they saw
overall as trustworthy, understanding and considerate. Many clients also declared that they
appreciated that counselling seemed effective at helping them solve their problems; for
example, by raising their self-confidence, helping them to become less worried or
improving relationships. Some clients discussed how they enjoyed problem-solving with
counsellors (“We discussed the advantages and disadvantages of each decision. When you
are alone, you don’t think about those things. In counselling you can”).
Though clients were generally very satisfied with the service overall, a significant
proportion (27%) expressed a lack of attention to specific needs (see Table II—notably for
medication, entertainment, material support, home visits, vocational training courses,
educational support or a healthy family environment (“It’s good to share my feelings and
problems; but in the end I got nothing; I had wanted to get training”)—reflecting some
discrepancy between service provision and experienced needs.
Table II Overview of Clients’ Responses on Cultural Appropriateness, Satisfaction of Needs and

Satisfaction about the Services (In%)
Fits perfectly Fits well Fits OK Fits a little Does not fit at all
Cultural 82 9 3 6 0
appropriateness
Very satisfied Mostly satisfied Indifferent/ Quite

mildly satisfied dissatisfied
Satisfaction with 71 20 6 3
services
All needs met Most need met Only few needs met No needs met
Satisfaction of needs 38 35 21 6
Confidentiality
Confidentiality came forward as an issue of some contention and confusion. The majority
of the clients stated that confidentiality was maintained throughout the counselling process.
However, some mentioned that confidentiality was not maintained, resulting in reduced
satisfaction and willingness to share. Others simply were worried that confidentiality might
not be maintained. Some specific suggestions were presented, for example that counselling
should take place in quieter areas where confidentiality was more likely to be maintained.
Counsellors’ perspectives
A new profession
For most of the counsellors, the training was their first exposure to psychosocial care in
general, providing a radical new way of thinking about assisting people. Several
counsellors stated that the course not only helped them learn new counselling skills but
led to profound personal development, including being able to communicate more
effectively and feeling more confident. One counsellor mentioned that this sort of training
lends legitimacy to her work. Practical placements were found to be valuable, primarily if
specifically attuned to the training needs. Overwhelmingly, almost all counsellors expressed
a need for more advanced training as well as regular supervision by trained counsellors and
opportunities to share and network with other counsellors.
The majority of trained counsellors were working as counsellors, albeit in addition to
performing other duties within their organizations. For some these multiple responsibilities
were compatible with the counselling activities (e.g., conducting training courses or
awareness programs), but for others they were distracting (e.g., maintaining office logistics
or administrative work) or even incompatible (e.g., management functions). For those who
saw them as distracting or incompatible, the dual functions were perceived as limiting due
to time restraints or confusing due to conflicts of interest, and generally reflective of a lack
of management’s prioritization of psychosocial services.
Service provision
Only slightly more than half of the counsellors interviewed felt competent as counsellors,
many of them expressing that organizational difficulties, uncooperative clients and
insufficient (follow-up) training limited their abilities. Counsellors stated overwhelmingly
that micro counselling skills were the most essential means to provide effective support. In
addition, empathy, relaxation, challenging and brainstorming were mentioned more often
than other skills as being used by the counsellors.
The counsellors saw a wide variety of clients, including, in order of decreasing number
of responses, trafficking survivors, domestic violence survivors, rape survivors, conflict-
affected people, street children, people with HIV/AIDS, (domestic) child labourers,
sexually abused children, community child labourers and destitute people (see Table III).
Integration within the existing care system
The majority of counsellors reported that management at their organizations were

supportive and counselling was integrated into the overall program of their organization.
Table III Summary of Responses
Respondents Responses
(number)
Clients ▪ Clients interviewed were predominantly Hindu women/girls who had attended school
(n=34) ▪ Clients had many different problem presentations including anxiety, fear, aggression,
suicidality, social reintegration issues and family related concerns
▪ Clients were satisfied with counselling services, while a majority expressed specific unmet
expectations
▪ Clients thought counselling services were culturally appropriate
▪ Clients received on average 4.8 counselling sessions (SD=4.6) at the time of study
Counsellors ▪ The training program provided a new perspective of care and lead to profound personal
(n=26) development, but was deemed too short
▪ Maintaining confidentiality was found to be an issue of contention
▪ About half of the counsellors felt competent while the other half did not
▪ The vast majority of counsellors trained were currently working as counsellors, sometimes
limited by multiple responsibilities
▪ Counsellors worked with a variety of clients including trafficking survivors, domestic
violence survivors, rape survivors, conflict-affected children, and street children
▪ There is a need for ongoing training and regular supervision and networking with colleagues
Managers ▪ All managers stated that counselling was implemented in their organizations and most
(n=23) explained that it was well integrated into the organization and indicated for most clients
▪ Difficulties in implementation included the mobile, uncooperative nature of clients, lack
of money and time, need for more counsellors, need for more training, supervision and
follow up for counsellors, need for more awareness and a more systematic approach
▪ Recommendations included: more networking opportunities for counsellors, selection
of counsellors of same ethnicity/gender, and awareness raising for other non-counselling
staff
Of those counsellors who were having difficulties, the most frequent problems mentioned
were that the management wanted counselling to provide immediate results, staff and
managers did not really understand counselling and that managers were not providing
needed resources. Not all had clear job descriptions that specifically included, or made
reference to, providing counselling services.
Managers’ perspectives
Understanding of counselling
Most of the managers seemed to have a good general understanding of psychosocial

counselling, (“counsellors don’t give suggestions or advice—clients find these out
themselves. The counsellor simply facilitates and shows them the way”) and reported
positive changes in clients as a result of it. Some expressed criticism (“counselling takes too
long to be useful; clients are not always cooperative and sometimes even lie; counselling is
too easy on clients”), giving the impression that there remains confusion about the exact
meaning of the work among managers (perhaps unsurprisingly, as psychosocial care is a
new approach for many). However, others expressed criticism that revealed some important
challenges; for example that some counsellors were “too aloof, serious, and isolated ”, and
that “in psychosocial counselling the focus is too much on the psychological component
and not enough on the social ”.
Integration and implementation within organization
All managers interviewed stated that psychosocial counselling as taught by the described
training approach fitted well with the mandate of their organizations. Most stated it was a
crucial part of the services they provide, and was indicated for their target client groups. A
few explained that counselling was only indicated for some of their clients, and only one
manager stated it was rarely indicated.
While a few managers stated that there were no difficulties in implementing counselling
within their organizations, the vast majority explained that they faced obstacles. Not having
enough time to allocate to do counselling well, not having enough money, and the
uncooperative, mobile, diverse or reluctant nature of clients were very frequently mentioned
concerns. It was also mentioned that there simply were not enough counsellors to do all the
counselling that is needed. Although less frequently mentioned, it is important to note that
some managers described obstacles that were reflective of their own role in the service
integration process; for example, the many roles counsellors must play in their
organizations, not being able to provide a proper environment for them, one counsellor
being threatened when trying to intervene in domestic disputes, resistance by other staff and
managers, the stigma related to counselling, employing male counsellors where female
counsellors would be more appropriate for their target populations and the isolated nature of
counsellors within the organization.
Recommendations
The managers had recommendations regarding the improvement of counselling. First and
foremost, most of the managers mentioned that counsellors needed more advanced target
population-specific training. Many managers stated that the counsellors needed more
clinical supervision, more follow-up from expert/senior counsellors in general, and more
opportunities to network with other counsellors. Moreover, many mentioned that they would
like more awareness training for their staff. In particular, several managers expressed that
more counsellors were needed, especially those from the same backgrounds as their clients.
Conclusion
From the interviews a number of positive and negative features emerged. Almost all
counsellors, direct and indirect beneficiaries expressed their support for psychosocial
counselling as it had yielded positive changes in both clients’ perceived well-being as well
as attitudes and empowerment of psychosocial service delivery at large. Moreover,
counselling, as an intervention, was deemed culturally relevant and acceptable.
Clients who underwent counselling sessions generally presented with mild to severe
psychosocial problems (mostly issues of stigmatization, anxiety reactions, aggression, and
depressive moods), and were of the opinion that the supportive and understanding role of
the counsellor was helpful for them to feel reassured or assisted in problem management.
On the other hand, counselling did not always match clients’ expectations and needs (e.g.,
for material support) and several obstacles and criticisms were reported that hindered
effective counselling.
For Nepal, where first steps are being made for the integration of counselling within the
service provision spectrum for vulnerable populations, this study gives indications on how
to continue this development. The conclusions should be seen from the perspective of a
country where mental health has been chiefly represented by an overly medical-psychiatric
model and counselling by short-term training courses without thorough clinical practice and
often provided by culturally alien expatriate professionals. (1) Despite the fact that the
training program was the only intensive psychosocial training program in Nepal, it was still
felt to be too short and not covering some topics in enough depth, or at all. In fact, about
half of the counsellors interviewed did not feel competent enough mainly because they felt
they needed more training. (2) It was perceived by both the counsellors and the managers
that there was a lack of needed follow-up and especially supervision, ongoing training and
networking after completion of the training program. (3) More attention needs to be given
to the integration of psychosocial counselling within the existing care spectrum, with this
including formalizing the role of counsellors within organizations as well as further
sensitization of staff to the exact meaning of counselling. This also needs to take into
account that counsellors need to be selected who better represent the target populations (i.e.,
gender, ethnicity, etc.). While most counsellors found their managers supportive and most
managers described their staff as mostly supportive of counselling, future initiatives are
likely to benefit from more awareness raising in organizations where counselling takes
place. (4) The issue of confidentiality came forward as an important and sensitive point,
from all three perspectives. This might be explained by the collectivist nature of most
ethnicities in Nepal, where privacy is regarded as less essential or less customary.
Future programming, therefore, needs to discuss the function and integration of
confidentiality.
Though findings from this study cannot be simply generalized to other settings, some of
the implications, however, could serve as points of reflection for other countries that go
through similar processes of counselling and psychosocial system development. The
significance of these findings for other non-Western countries that have little psychosocial
resources can be summarized as follows: (1) Counselling should ideally not be practiced as
an isolated intervention, but rather within a system of care provision. The finding that
psychosocial counselling does not address some important client needs indicates that
linkage with other resources, including traditional and religious healing strategies, should
be emphasized. This implies a need for a high level of coordination between both
governmental and non-governmental services that so far has proved difficult to realize in
the Nepali setting. (2) Though adaptations to the local cultural settings are central to our
approach (as mentioned above) we choose not to exaggerate the cultural divide in terms of
helping responses, effectively taking a middle position within the cultural relativism versus
cultural universalism debate. On the question about the cultural acceptability of a new
service like psychosocial counselling in Nepal, clients’ answers were more affirmative than
were expected. (3) Quality control and sustainability of newly trained counsellors, can only
be achieved through parallel development of clinical supervision and case-management
systems. (4) Rather than following a specific theoretical school of psychotherapy, it appears
that a focus on micro counselling skills, concrete intervention techniques and generic
therapeutic elements can make psychosocial interventions in a non-Western context like
Nepal both applicable and feasible.
Though the qualitative study has yielded interesting information and valuable practical
insights, some obvious limitations must be noted: (1) the sample size was small, for the
client, counsellor and manager groups; (2) the design was cross-sectional in nature; (3) the
sample was not selected at random but through purposive sampling, it is, therefore, not
possible to generalize to wider populations in Nepal; (4) the effectiveness of counselling
services was not systematically addressed; (5) as the research was undertaken by
interviewers representing the organization that provided the training program, a socially
desirable response bias might be present in clients’ and managers’ responses, although
specific care was taken to avoid this as mentioned above.
In conclusion, this study provides an overview of the main stakeholders’ perspectives of
psychosocial counselling in Nepal, which has implications especially for the development
and integration process of counselling. The study shows that counselling was mostly well-
received by clients, acceptable and applicable within the Nepali setting and responsive to
needs of this clientele for an understanding, empathic and good listener assisting them with
a variety of psychosocial problems. At the same time it provides worthwhile suggestions on
how to improve and adapt counselling and counselling training programs. Keeping in mind
the limitations, this study indicates that a culturally sensitive implementation of counselling
in a multi-cultural setting like Nepal is perceived by local service providers and
beneficiaries as a viable way to deal with problems presented by such target groups.
Acknowledgments The researchers would like to thank those who assisted in the study and, in particular,
Ram Prasad Sapkota, for assisting with conducting interviews in the more remote areas. The International
Labour Organization (ILO), Nepal funded this study.
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Unit 7
Psychosocial Care and Support
7.1. Mental Health Care: Primary care for mental health within a pyramid of health care (IASC
pyramid)
Mental health care is the treatment and support provided to people who are experiencing mental health
problems. It includes a range of services, such as counseling, psychotherapy, and medication management,
as well as support and care provided by family, friends, and community resources.
The goal of mental health care is to help people improve their mental health and well-being, and to cope
with the challenges of mental health problems. It can involve helping people to understand their thoughts,
feelings, and behaviors, and to find ways to manage them effectively.
Mental health care can be provided by a variety of professionals, including psychiatrists, psychologists,
social workers, and mental health counselors. It can be delivered in a variety of settings, including hospitals,
clinics, private practices, and community-based organizations.
Mental health care is important because mental health problems can have a significant impact on a person's
quality of life and overall well-being.
Primary care for mental health refers to the first level of care that individuals receive for mental health
problems and concerns. It is often provided by primary care providers such as family doctors, nurses, and
other healthcare professionals who are responsible for the general healthcare needs of individuals.
Within a pyramid of healthcare, primary care for mental health would typically be located at the base of the
pyramid, as it is the first point of contact for individuals seeking mental health care. It is followed by
secondary and tertiary levels of care, which may include specialized mental health services such as
counseling, psychotherapy, and medication management.
The role of primary care in mental health is to provide initial assessment and treatment for mental health
problems, and to refer individuals to specialized care if necessary. Primary care providers may also provide
ongoing support and follow-up care to individuals with mental health problems, and may work closely with
other members of the healthcare team to coordinate care.
Overall, primary care for mental health plays an important role in the healthcare system, as it provides the
first point of contact for individuals seeking mental health care and helps to ensure that they receive the
support and treatment they need to manage their mental health concerns.
The IASC pyramid of health care stands for the "Inter-Agency Standing Committee" pyramid of
health care. The IASC is a United Nations body that promotes the coordination of humanitarian assistance
and the development of effective and coherent policies in response to emergencies.
The IASC pyramid of health care is a framework for organizing different levels of mental health care, with
the goal of providing the most appropriate level of care to individuals based on their needs. It is divided
into four levels, with primary care being the first level and quaternary care being the fourth and highest
level.
The IASC pyramid emphasizes the importance of providing primary care for mental health, as it can prevent
or reduce the impact of mental health problems and help people get the care they need at the appropriate
level. It also acknowledges the need for specialized and expert care for people with severe and complex
mental health problems.
The IASC pyramid is a framework for organizing different levels of mental health care, with the goal of
providing the most appropriate level of care to individuals based on their needs. The pyramid is divided
into four levels, with primary care being the first level:
1. Primary care: This level includes interventions that are low-intensity and delivered by non-
specialists. It includes activities such as community-based support, self-help groups, and general
health care services. The goal of primary care is to prevent or reduce the impact of mental health
problems.
2. Secondary care: This level includes interventions that are more specialized and delivered by trained
professionals. It includes activities such as counseling, psychotherapy, and medication
management. The goal of secondary care is to provide treatment for people with moderate to severe
mental health problems.
3. Tertiary care: This level includes interventions that are highly specialized and delivered by expert
professionals. It includes activities such as inpatient hospitalization and intensive outpatient
treatment. The goal of tertiary care is to provide intensive treatment for people with severe and
complex mental health problems.
4. Quaternary care: This level includes interventions that are highly specialized and delivered by
expert professionals in specialized settings. It includes activities such as brain surgery and
experimental treatments. The goal of quaternary care is to provide the most advanced and
specialized treatment for people with severe and complex mental health problems.
The IASC pyramid emphasizes the importance of providing primary care for mental health, as it can prevent
or reduce the impact of mental health problems and help people get the care they need at the appropriate
level.
Psychosocial Care: Concepts and principles
Psychosocial care refers to the integration of psychological and social support in the treatment and
management of mental health problems. It is a holistic approach to mental health care that recognizes the
interplay between an individual's psychological and social factors, and the impact that these factors have
on their mental health and well-being.
Psychosocial care can involve a range of activities, such as counseling, psychotherapy, and social support,
as well as interventions that focus on improving social connections and addressing social and environmental
factors that may contribute to mental health problems. It can be provided by a variety of professionals, such
as psychiatrists, psychologists, social workers, and mental health counselors.
The goal of psychosocial care is to help people understand and manage the psychological and social factors
that influence their mental health, and to provide support and resources to help them cope with and recover
from mental health problems. It is an important aspect of mental health care because it recognizes that
mental health is not just about an individual's internal thoughts and feelings, but also about the social context
in which they live.
Principles of Psychosocial Care
1. Human rights and equity
• Promote the human rights of all affected persons and protect individuals and groups who are at
heightened risk of human rights violation, especially vulnerable groups such as women and girls.
• Promote equity and non-discrimination, ensuring that mental health and psychosocial support
services are available to all affected people regardless of gender, age religion, ethnicity etc.
The main aim is to maximize fairness in the availability and accessibility of mental health and psychosocial
supports among affected populations, across gender, age groups, language groups, ethnic groups and
localities, according to identified needs.
2. Participation
• Maximize the participation of local affected populations in the humanitarian response i.e., involve
local communities and local stakeholders (including vulnerable populations and NGOs
representing the LGBTI community, women with disabilities, etc., as much as possible) in all steps
of programming, including the assessment, design, implementation, and monitoring and evaluation
stages.
In most emergency situations, significant numbers of people exhibit sufficient resilience to participate in
relief and reconstruction efforts. Many key mental health and psychosocial supports come from affected
communities themselves rather than from outside agencies. Affected communities include both displaced
and host populations and typically consist of multiple groups, which may compete with one another.
Participation should enable different sub-groups of local people to retain or resume control over decisions
that affect their lives, and to build the sense of local ownership that is important for achieving program
quality, equity and sustainability. From the earliest phase of an emergency, local people should be involved
to the greatest extent possible in the assessment, design, implementation, monitoring and evaluation of
assistance.
3. Do no harm
Humanitarian aid is an important means of helping people affected by emergencies, but aid can also cause
unintentional harm (Anderson, 1999). Work on mental health and psychosocial support has the potential to
cause harm because it deals with highly sensitive issues.
Remain alert to possible adverse effects during program planning. In addition, measure and record
unintended negative consequences through program monitoring and evaluation. Such unintended
consequences might include: cultural, economic, political, psychological, security and social issues
(adapted from WHO, 2012).
Also, this work lacks the extensive scientific evidence that is available for some other disciplines.
Humanitarian actors may reduce the risk of harm in various ways, such as:
• Participating in coordination groups to learn from others and to minimize duplication and gaps in response;
• Designing interventions on the basis of sufficient information
• Committing to evaluation, openness to scrutiny and external review;
• Developing cultural sensitivity and competence in the areas in which they intervene/work;
• Staying updated on the evidence base regarding effective practices; and
• Developing an understanding of, and consistently reflecting on, universal human rights, power relations
between outsiders and emergency-affected people, and the value of participatory approaches.
4. Building on available resources and capacities
Build local capacities, supporting self-help and strengthening the resources already present. Externally
driven and implemented programmes often lead to inappropriate mental health and psychosocial support
and often the sustainability is limited.
All affected groups have assets or resources that support mental health and psychosocial well-being. A key
principle – even in the early stages of an emergency – is building local capacities, supporting self-help
and strengthening the resources already present. Externally driven and implemented programmes often
lead to inappropriate MHPSS and frequently have limited sustainability. Where possible, it is important to
build both government and civil society capacities. At each layer of the pyramid (see Figure ), key tasks are
to identify, mobilize and strengthen the skills and capacities of individuals, families, communities and
society.
5. Integrated support systems
Activities and programming should be integrated as far as possible.
• Focusing on stand-alone services, for example those dealing only with people with specific
diagnoses, such as post-traumatic stress disorder, can create a highly fragmented care system. In
order to avoid this, ensure that interventions and programming are as integrated as possible.
• Integrate psychosocial support programs and activities into wider systems such as: existing
community support mechanisms, formal/non-formal school systems, general health services,
general mental health services, social services, etc., as well as well as other services and
community support which address violence against women and girls, such as: reproductive health,
antenatal care, infant and young child nutrition, child protection, microfinance initiatives, and
existing community-support mechanisms, such as women’s support groups (adapted from WHO,
2012). This will ensure that psychosocial support programs reach a wider population and carry less
stigma. Experience has also shown that integration often increases program sustainability.
6. Multi-layered supports
In emergencies, people are affected in different ways and require different kinds of supports. A key to
organizing mental health and psychosocial support is to develop a layered system of complementary
supports that meets the needs of different groups. All layers of the pyramid are important and should ideally
be implemented concurrently.
• In conflict and post-conflict humanitarian settings, people are often affected in different ways and
as such require different kinds of support.
• Organize mental health and psychosocial support response programs by developing a layered
system of complementary services (e.g., basic amenities for women and children, such as food) that
meet the specific needs of different groups.
Case management and referral: Importance, processes, and steps
Case management is a process that involves coordinating, planning, and overseeing the provision of
services to individuals who are in need of assistance. It is typically used in the context of healthcare, social
services, and other fields where individuals may require support in order to manage their health or social
needs.
A referral is a recommendation or a request for someone to receive services from another person or
organization. In the context of case management, a referral may be made by a case manager to a specialist
or other provider in order to receive more specialized or specific care or services.
Case management and referral are important tools for ensuring that individuals receive the support and
services they need in an organized and coordinated manner. They can help to ensure that individuals receive
the right care at the right time, and that they are connected to the resources and support they need to manage
their health or social needs effectively.
Importance of case management
Case management is important for a number of reasons:
1. Coordination of care: Case management helps to coordinate the care and services that an individual
receives from multiple providers, ensuring that all of their needs are being met in a coordinated and
efficient manner.
2. Continuity of care: Case management helps to ensure that an individual's care is consistent and
continuous, even if they are receiving services from multiple providers or organizations.
3. Improved outcomes: Research has shown that individuals who receive case management services
tend to have better health outcomes, as they are more likely to receive the care and support they
need to manage their health conditions effectively.
4. Cost savings: Case management can also help to reduce healthcare costs, as it can help to prevent
unnecessary hospitalizations and other costly interventions.
Overall, case management is an important tool for ensuring that individuals receive the care and support
they need to manage their health or social needs effectively.
Referrals are important for a number of reasons:
1. Access to specialized care: Referrals allow individuals to receive specialized care or services from
providers who have expertise in a particular area. This can be particularly important for individuals
who have complex or rare medical conditions, as they may require care from specialists who have
experience in managing these conditions.
2. Continuity of care: Referrals can help to ensure that an individual's care is continuous, even if they
need to see multiple providers or specialists.
3. Improved outcomes: Research has shown that individuals who receive referrals for specialized care
tend to have better health outcomes, as they are more likely to receive the care and support they
need to manage their health conditions effectively.
4. Efficiency: Referrals can also help to ensure that individuals receive the most appropriate care in a
timely manner, as they are directed to providers who have the necessary expertise to manage their
specific needs.
Overall, referrals are an important tool for ensuring that individuals receive the specialized care and support
they need to manage their health or social needs effectively.
Process of Case management
The process of case management typically involves several steps:
1. Assessment: The first step in the case management process is to assess the individual's needs and
determine what type of care and services they require. This may involve collecting information
about the individual's health status, social situation, and support network, as well as identifying any
barriers to care they may be facing.
2. Planning: Based on the assessment, the case manager will develop a plan of care that outlines the
specific services and supports that the individual will need to manage their health or social needs.
This plan may include recommendations for medical treatment, social services, community
resources, and other types of support.
3. Coordination: The case manager will then coordinate the delivery of these services and supports,
working closely with the individual and their healthcare team to ensure that all of their needs are
being met in a coordinated and efficient manner.
4. Monitoring and evaluation: The case manager will also monitor the individual's progress and
regularly evaluate their plan of care to ensure that it is meeting their needs and achieving the desired
outcomes. Any necessary adjustments to the plan will be made based on this evaluation.
Overall, the process of case management involves working closely with the individual to assess their needs,
develop a plan of care, coordinate the delivery of services and supports, and monitor and evaluate their
progress.
Process of Referral
In the context of counseling, a referral refers to the process of recommending or directing an individual to
receive services from another provider or organization. This may be necessary if the individual's needs
exceed the scope of the referring provider's expertise, or if the individual would benefit from specialized
care that the referring provider is unable to provide.
Steps of Referral
The referral typically involves several steps:
1. Identification of need: The first step in the referral process is to identify the need for specialized
care or services. This may involve conducting an assessment to determine the individual's specific
needs and determine what type of care or services they require.
2. Selection of provider: Based on the identified need, the referring provider will select a specialist or
other provider who has the necessary expertise to meet the individual's needs. The referring
provider may consider factors such as the individual's preferences, insurance coverage, and the
provider's location and availability.
3. Request for referral: The referring provider will then send a referral request to the selected provider,
outlining the individual's needs and the recommended course of care. The referral request may
include the individual's medical history, diagnostic test results, and other relevant information.
4. Acceptance of referral: The specialist or other provider will review the referral request and decide
whether they are able to accept the referral. If they are unable to accept the referral, they may
provide the referring provider with suggestions for alternative providers who may be able to meet
the individual's needs.
5. Follow-up: The referring provider will follow up with the specialist or other provider to ensure that
the individual has received the necessary care and services, and to address any issues or concerns
that may arise.
Unit 8
Psychological First-Aid
Introduction to PFA (WHO, 2011)
Psychological First Aid (PFA) is a mental health and psychosocial support intervention that aims to help
individuals affected by crisis or trauma to reduce distress and enhance their coping and recovery. PFA was
developed by the World Health Organization (WHO) in 2011 as a way to provide immediate and
appropriate support to individuals who are experiencing psychological distress following a crisis or
traumatic event.
Overall, the goal of PFA is to provide immediate and appropriate support to individuals who are
experiencing psychological distress following a crisis or traumatic event, and to help them cope with their
distress and begin the process of recovery. It is important to approach PFA with sensitivity, empathy, and
a focus on the individual's needs and preferences.
The key principles of PFA are:
1. Safety: Ensuring the physical safety of the individual and providing a safe and supportive
environment.
2. Stabilization: Helping the individual to stabilize emotionally and cope with their distress.
3. Comfort: Providing emotional support and comfort to the individual.
4. Information: Providing accurate and up-to-date information about the crisis or event and its impact.
5. Connecting: Helping the individual to connect with social support networks and other resources.
6. Protecting: Protecting the individual from further harm and promoting their resilience.
Overall, the goal of PFA is to provide immediate and appropriate support to individuals who are
experiencing psychological distress following a crisis or traumatic event, and to help them cope with their
distress and begin the process of recovery.
Action principle: 3Ls- Look, Listen, Link
The 3Ls (Look, Listen, Link) are principles of action that are used in Psychological First Aid (PFA) to
guide the initial response to individuals who are experiencing distress following a crisis or traumatic event.
1. Look: Observing the individual's physical and emotional state, and looking for signs of distress or
distress behaviors.
2. Listen: Listening to the individual's concerns and fears, and responding with empathy and
understanding.
3. Link: Linking the individual to appropriate resources and support services, such as social support
networks, mental health services, and other relevant organizations.
The 3Ls are intended to help responders provide immediate and appropriate support to individuals who are
in distress, and to help them cope with their distress and begin the process of recovery. They are part of the
larger framework of Psychological First Aid (PFA), which is a mental health and psychosocial support
intervention developed by the World Health Organization (WHO).
The principle of "Do no harm"
The principle of "Do no harm" is a fundamental ethical principle that is based on the idea that actions or
interventions should not cause harm or suffering to the individual or group being served. This principle is
often applied in the healthcare and social service sectors, where the goal is to provide support and assistance
to individuals in a way that promotes their well-being and does not cause further harm or distress.
In practice, the principle of "Do no harm" may involve taking steps to minimize any potential negative
consequences of an intervention, and considering the potential risks and benefits of different actions or
approaches. It may also involve being sensitive to cultural and individual differences, and taking steps to
ensure that interventions are culturally appropriate and respectful of the individual's autonomy and dignity.
Overall, the principle of "Do no harm" is an important ethical consideration that helps to ensure that
interventions and actions are undertaken in a way that promotes the well-being and dignity of the individuals
being served.
Dos and Don’ts in PFA
DO:
• Provide a safe and supportive environment for the individual.
• Listen to the individual's concerns and fears, and respond with empathy and understanding.
• Help the individual to stabilize emotionally and cope with their distress.
• Provide accurate and up-to-date information about the crisis or event and its impact.
• Help the individual to connect with social support networks and other resources.
• Protect the individual from further harm and promote their resilience.
DON'T:
• Try to force the individual to talk about their experiences if they are not ready or willing to do so.
• Push the individual to confront their feelings or emotions before they are ready.
• Provide false hope or make promises that you may not be able to keep.
• Disregard the individual's cultural and individual differences, or impose your own beliefs or values
on them.
• Overwhelm the individual with too much information or support.
Unit 9
Intervention Pyramid for MHPSS in emergency
The intervention pyramid for Mental Health and Psychosocial Support (MHPSS) in emergencies is a tool
that is used to guide the provision of MHPSS services in the context of crises and disasters. It is based on
the idea that there are different levels of intervention that may be required depending on the needs and
resources of the affected population.
i. Basic services and security.

The well-being of all people should be protected through the (re)establishment of security, adequate
governance and services that address basic physical needs (food, shelter, water, basic health care, control
of communicable diseases). In most emergencies, specialists in sectors such as food, health and shelter
provide basic services. An MHPSS response to the need for basic services and security may include:
advocating that these services are put in place with responsible actors; documenting their impact on mental
health and psychosocial well-being; and influencing humanitarian actors to deliver them in a way that
promotes mental health and psychosocial well-being. These basic services should be established in
participatory, safe and socially appropriate ways that protect local people’s dignity, strengthen local social
supports and mobilise community networks.
Basic services and security are important considerations in the provision of Mental Health and Psychosocial
Support (MHPSS) in emergency and humanitarian settings. They are typically considered as part of the
broader context in which MHPSS interventions take place, and may influence the effectiveness and
sustainability of MHPSS interventions.
In the context of the intervention pyramid for MHPSS in emergencies, basic services and security may be
considered at various levels of the pyramid. At the primary prevention level, basic services such as clean
water, sanitation, and healthcare may be necessary for promoting mental health and preventing mental
health problems. At the secondary prevention level, a secure environment may be necessary for the
provision of screening and referral services. And at the tertiary and quaternary prevention levels, access to
basic services such as transportation and communication may be necessary for the delivery of specialized
treatment and long-term support.
Overall, the provision of basic services and security is an important consideration in the provision of
MHPSS in emergency and humanitarian settings, as it can influence the effectiveness and sustainability of
MHPSS interventions.
ii. Community and family supports.

The second layer represents the emergency response for a smaller number of people who are able to
maintain their mental health and psychosocial well-being if they receive help in accessing key community
and family supports. In most emergencies, there are significant disruptions of family and community
networks due to loss, displacement, family separation, community fears and distrust. Moreover, even when
family and community networks remain intact, people in emergencies will benefit from help in accessing
greater community and family supports. Useful responses in this layer include family tracing and
reunification, assisted mourning and communal healing ceremonies, mass communication on constructive
coping methods, supportive parenting programmes, formal and non-formal educational activities,
livelihood activities and the activation of social networks, such as through women’s groups and youth clubs.
Community and social support are important components of Mental Health and Psychosocial Support
(MHPSS) in emergency and humanitarian settings, and are typically considered at the primary prevention
level of the intervention pyramid for MHPSS in emergencies.
At the primary prevention level, interventions may focus on promoting mental health and preventing mental
health problems through activities such as community education and social support. These interventions
may involve building the capacity of community members to provide support to one another, and fostering
social connections and a sense of community. They may also involve providing access to resources and
services that support mental health and well-being, such as recreational facilities, social support groups,
and other types of community resources.
Overall, community and social support play a critical role in the provision of MHPSS in emergency and
humanitarian settings, as they help to promote mental health and prevent mental health problems, and
contribute to the resilience and well-being of affected populations.
iii. Focused, non-specialised supports.
The third layer represents the supports necessary for the still smaller number of people who additionally
require more focused individual, family or group interventions by trained and supervised workers (but who
may not have had years of training in specialised care). For example, survivors of gender-based violence
might need a mixture of emotional and livelihood support from community workers. This layer also
includes psychological first aid (PFA) and basic mental health care by primary health care workers.
Focused, non-specialized supports refer to interventions that are targeted at specific groups or issues, but
that are not necessarily specialized mental health services. They may be provided at the secondary
prevention level of the intervention pyramid for Mental Health and Psychosocial Support (MHPSS) in
emergencies.
At the secondary prevention level, interventions may focus on early detection and intervention for
individuals who are at risk of developing mental health problems. This may involve providing focused,
non-specialized supports such as group counseling, peer support, and social skills training. These
interventions may be targeted at specific groups or issues, such as children, adolescents, or survivors of
trauma, and may be designed to address specific mental health concerns or risk factors.
Overall, focused, non-specialized supports play an important role in the provision of MHPSS in emergency
and humanitarian settings, as they help to identify and intervene with individuals who are at risk of
developing mental health problems, and provide targeted support to address specific needs and concerns.
iv. Specialised services.

The top layer of the pyramid represents the additional support required for the small percentage of the
population whose suffering, despite the supports already mentioned, is intolerable and who may have
significant difficulties in basic daily functioning. This assistance should include psychological or
psychiatric supports for people with severe mental disorders whenever their needs exceed the capacities of
existing primary/general health services. Such problems require either (a) referral to specialised services if
they exist, or (b) initiation of longer-term training and supervision of primary/general health care providers.
Although specialised services are needed only for a small percentage of the population, in most large
emergencies this group amounts to thousands of individuals.
Specialized services refer to interventions that are provided by trained professionals and that are tailored to
the specific needs of individuals who are experiencing mental health problems. They may be provided at
the tertiary prevention level of the intervention pyramid for Mental Health and Psychosocial Support
(MHPSS) in emergencies.
At the tertiary prevention level, interventions may focus on providing specialized treatment and support for
individuals who are experiencing mental health problems. This may involve providing services such as
individual counseling, psychotherapy, and medication management, which are provided by trained mental
health professionals and are designed to address specific mental health concerns.
Overall, specialized services play an important role in the provision of MHPSS in emergency and
humanitarian settings, as they provide targeted support to individuals who are experiencing mental health
problems, and help to ensure that they receive the specialized care and treatment they need to manage their
mental health concerns.

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Class Notes @Sarita Sapkota

1.1 Introduction, major assumptions, strengths, and weaknesses of humanistic psychology

1.1 Introduction, major assumptions, strengths, and weaknesses of humanistic psychology

Roger believed that a person’s behavior is a factor motivated by self-actualization tendencies to

The fully functioning person

Unit 2: Mental Health

with life). It is proposed that an individual experiences happiness when positive

• The learning of ineffective or maladaptive response

Psychologic and social (psychosocial) problems, particularly

Depression is common among adolescents, and doctors actively

Suicide is uncommon, but thoughts about suicide (called suicidal

Anxiety often manifests during adolescence, as do mood

The COVID-19 pandemic and the global response to it, including

Thought disorders, in which a person has difficulty distinguishing

Psychotic episodes may occur with cannabis (marijuana) use,

Eating disorders, especially in girls, are common and can be life

Characterisitcs and other factors

1. Data collection (relevant and current) of the problem presented.

• Effective for a wide range of people, both adults and children

Counseling/Psychosocial counseling Psychotherapy

Counseling may be a better option than psychotherapy if:

• shortage of psychotropic medicines,

Psychosocial Counselling in Nepal: Perspectives

Mark J. Jordans & Annalise S. Keen & Hima Pradhan &

Published online: 9 February 2007

Keywords Psychosocial counselling . Nepal . Counsellor training . Counselling services

M. J. Jordans (*) : W. A. Tol

Table I Demographic Information of Clients

Gender Mean age Religion Education

Expressed problems and received care

Most of the clients interviewed seemed to have a good understanding of psychosocial

Table II Overview of Clients’ Responses on Cultural Appropriateness, Satisfaction of Needs and

Very satisfied Mostly satisfied Indifferent/ Quite

Integration within the existing care system

The majority of counsellors reported that management at their organizations were

Table III Summary of Responses

Most of the managers seemed to have a good general understanding of psychosocial

Integration and implementation within organization

i. Basic services and security.

ii. Community and family supports.

iv. Specialised services.

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