The underlying points of reference in the study was to obtain relevant information from modern and professional counselors in view of the societal understanding and interest, using the counseling services in their lifetime along with analysis of the modern counseling system efficacy in the country. The two big institutions employing modern counseling systems were carefully chosen with purposeful selection of study sites. Qualitative study method was conducted, employing descriptive analysis of data. The tools used to gather information were interview, observation and focus group discussions with significant informants of the institutions. Based on the information collected from the informants, the study result disclosed that counseling is the tradition in Ethiopia, even if there was no effort made through higher institutions and the government to incorporate the cultural values of counseling in the education curriculum of the country. The institutions employing modern counseling systems were striving to apply the Westerners method without considering the local community practices that exploit their services. The question of engaging diverse language and multicultural interaction were underemphasized due to the adherent nature of the curriculum. The methods employed, techniques, and procedures used by the existing counseling systems were poorly organized and only functional as to achieve organizational objectives and procedures. It is concluded that locally developed techniques, methods and principles of counseling services could benefit the community greatly.
The concept of psychology, its theories and methods as understood by Westerners, are alien to the thinking of Africans. It would not be difficult to visualize how hard it is for one to learn effectively any irrelevant concept by using unworkable teaching method or research design. Africans in general have not received the need for systematic application of psychology and its principles. For example, traditionally, Africans have their own crude ways of collecting team members for hunting and cattle herding assignments. They have their own wise men with the ability to heal the physic problem of their sick. There are some African countries, currently, whose curriculum is void of the need of psychology. Ethiopia is a case in point where people search for healers than psychologists.
Although traditional psychology has existed, embedded within cultures and the wisdom of people since time immemorial, the western ‘scientific’ discourse of modern psychology started in Ethiopia much more recently.
Taken globally, psychology has thus had a long past but its modern western form has only a short history, and within Ethiopia this is the case (Yemataw, 2014). There are several types of healers – as stated by Ayaya and Aboud (1993) - the zar spirits, wizards, shamans, and others. Cures included drinking holly water, divination of leaves, eating ash without water, beating and burning, animal sacrifices, and the application of animal blood. In all cases, the therapeutical goal was to relieve the person of the effects of the demons and to teach the sufferer how to accommodate the possessing spirit. Macleod (2004) on the other hand explained similar view stating that counseling psychology in South Africa is undergoing significant changes, much like the country itself. The authors examine the state of counseling psychology in South Africa through discussion of both its racial history and present-day positions. The history of psychology cannot be devoid of its politicized past, and remnants of its history are found today, though much has changed.
As Goss and Adebowale (2014) indicated, the practice of counseling and guidance in Africa may not be very comparable with the way these are practiced in the Western world. The reasons range from the nature and experiences of the clients, availabilities of facilities, differences in the facilitating environment and cultural influences to enabling regulations and government policies. Consumers of counseling and guidance services in the continent may not know many of these delimiting factors. Abdul Basit in his study also revealed the cultural perspectives of modern counseling and its application as opposed to Africans allied to the westerners, stating that ‘modern psychotherapy, as it emerged in the west, was deeply influenced by western thinkers who represented the religious-cultural traditions, historical symbols, and narratives of western society. Therefore, it has, been argued that psychotherapy is a white-middle class endeavor from which non-white ethnicity are not likely to profit. Furthermore, it has been argued that ethnic match between client and therapist is essential for counseling to be beneficial (Abdul, 2005).
Hence, the present study mainly focused on descriptive narration that attempts to evaluate status and development of African psychology, specifically Ethiopian context intending to counseling of people with different problems (mental illness, emotional, and social problems), marital and family counseling. This work will hopefully awakening the consciousness of African scholars in identifying and organizing aboriginal counseling principles and therapeutic techniques available in the community for the benefit of Africans by considering individuals and groups who are in need of the service integrating with modern counseling approaches. Accordingly, Okpalaenwe (2017) asserted that some of the western ways that do not help Psychotherapy in African should be refined to suit African setting.
Statement of the problem
As seen in different literatures, Psychology is really in the doldrums now in Africa, specifically in Ethiopia. Sinha (1983) indicated that psychology is fragmented, over-specialized, method centered and dull, same mould in research design and reporting style, inflation of jargon, professional baggage substituted for psychological insight and sensitivity. By furthering this view Okocha et al. (1989) questioned, where does psychology stand in the region now in relation to these allegations? Self-criticism should give rise to hope and invigoration for a better and productive future of the discipline. This should also be seen in the context of the fact that the success of psychology will also account for its weakness. No adequate research has been done in the field of psychology in Africa when compared to other disciplines. Oluwatosin (2004) examined some of the cultural norms and expectations based on consideration of a specifically Nigerian context that interact with – and sometimes directly conflict with – this basic, assumed methods built into the received Western-derived approaches to helping and problem-solving. These downplay, or even ignore, useful sources of help derived from traditional cultural practices and, furthermore, can place an unrealistic expectation of openness and engagement style on clients that can combine to create significant barriers to effective helping. In this view Nigeria has little attempt in localizing the research and attaching to the existing reality of the people under study (Yusuf, 1977). Yusuf further narrated that little is also known about the existence of psychological problems. Questions like, how could mental traits and other psychological characteristics be measured in Africa; what should be given priority in the psychological study? What theoretical support should be accepted with regard to the existing helping relationships in the community, and others has to be answered. Generally, research activities about the role of psychology were handicapped by inadequate theoretical constructs and lack of proper methodological design relevant to the countries. Liranso and Selamu, (2017) discussed similar view stating that ‘in many developing nations, standards for ethical conduct of research and treatment are inadequate or lacking’. Clearly, the implication of this position is that models of counseling, guidance or other forms of help need to demonstrate a level of cultural appropriateness that is not always readily apparent without significant adaptation of both terminology and fundamentals of practice that challenge some very basic assumptions that are built into many Western ways of working in this field (Goss and Adebowale, 2014). Besides, Belinda (2013) indicated that Ethiopia is one of the countries where no evidence could be found to suggest that counseling is available or officially valued in state funded schools.
Hence, it is hoped that this research undertaking generate genuine discussion and debate among concerned scholars. Additionally, having acquaintance to cultural diverse community counseling system is so indispensable to fill the gap found in the field. In a developing country like Ethiopia where the concept of counseling is also unknown to most people, that is, the confusion made between traditional counseling mode and modern /Westerner/ counseling system, there is a need to ponder on some of the following research questions to settle the argument to some extent. The reality to be a beginner in assessing modern counseling system available in the country is not an easy task for young researchers like us. However, any effort made to put what is evident in the country with regard to the existing reality of counseling system may lay a ground and smooth the progress of further study. The study is targeted to answer the following questions.
(i) Who are said to be counselors in Ethiopian context in the modern counseling systems?
(ii) What techniques and procedures of counseling do Ethiopian counselors employ as modern counseling system (approach, time, sitting arrangements, tempo, and place)?
(iii) Is there positive relationship between counseling providing institutions and the professionals?
(iv) What are the challenges and prospects modern counseling faces in Ethiopia?
(v) What are the basic similarities and differences between Ethiopian counseling practice and the Western systems?
Objectives of the study
The study was mainly designed to explore the counseling practices in Ethiopia associated with the modern/Western counseling system prevailing in the country with great emphasis to identify principles and techniques relevant to Africa, specifically Ethiopia. The specific objectives of the study were to:
(i) Identify professional expertise of modern counselors working in different service giving institutions in Ethiopia;
(ii) Discover the techniques, principles and procedures followed by modern counselors in Ethiopia;
(iii) Examine the opportunities and challenges that are pragmatic in the work realm;
(iv) Assess possible relationship vibrant linking job area with teaching Institutions;
(v) Investigate the counseling relationship employed by modern counseling systems apparent in Ethiopia with respect to its counterpart, the Westerners.
Significance of the study
It paves way for African researchers and psychologists review their own traditional counseling customs accessible in their respective community. This signifies that certain forms of customary relationships are mandatory in leading community life if organized, sequenced and systematically arranged. This study also is significant to as a pioneering assessment in the area of psychology, more specifically in counseling employing traditional knowledge and skills of the community in laying base for the subsequent research works. It additionally paves way for institutions to incorporate well-organized localized counseling custom in their curriculum for the advancement of psychological theories and principles significant to the country.
Scope of the study
The scope of this study was geographically delimited to two institutions accessible by the researcher, considering that they can effectively produce relevant data to the prevailing research work. Conceptually, it was delimited to modern counseling system employed in Ethiopia.
Background of the respondents
All informants from modern counseling institutions were BA holders from both institutions. The Orthodox Church counseling department, which is mainly focusing on the HIV/AIDS counseling, initiated on pre and posttest counseling. The interview was held with the informant at workplace in her office and other six involved on FGD. Emanuel Mental Health Hospital as a pioneer and the only well organized mental health hospital in the country has employed professional counselors from Psychology in the recent years. Six counselors from the organization were participated on the focus group discussion held in their office upon permission from the medical director now. It was hot and so was the debate since all the members were young professionals eager to advocate their field of work in the organization and further expand throughout the country. Two others were interviewed.
Modern counseling in Ethiopia
In Ethiopia, most of the HIV/AIDS related counseling employs the modern counseling system relevant to Westerners method. Even though the counseling techniques and principles followed are of varied types, depending on the organizational objectives and directives, the underlying principles are almost the same in all similar institutions. Most of the counselors in these organizations seem to be cumulative of different fields depending on the interest of the institutional objectives rather than relying on the counseling objectives. Only very few organizations employ professional counselors from psychology department, including International organizations working in the areas of HIV counseling. It is obvious that the employment of nurses on the fields of modern counseling to HIV seems essential in the area, deserting fields of psychology, is not recognized.
In almost all institutions, approximately three weeks training was arranged for about 21 days in which these counselors were alleged as competent handlers of emotions of people with high shock, denial, and complicated thoughts of life. What is evident here in Ethiopia according to the writer is that there are sufficient numbers of psychology graduates in the country who were/are able to successfully handle such a case who were given diminutive attention from responsible organizations.
The concept of counseling and role of the counselors
The role of counselor is giving pretest counseling to assist the individual make testing by going to medical centers or Voluntary Counseling and testing centers. Those individuals who went to VCT come to the office for further counseling whether identified positive or negative. However, what matters is how the counselors handle the state of affairs. If the person is found positive, can get continuous counseling based on the emotional shock the person exhibits. The emotions one shows as of the counseling office are categorized into four (shock, denial, revenge, and stress) before accepting their problem. The Western counseling system supports the view of this finding. According to APA (2000), Psychotherapy is used to help people solve problems, achieve goals, and manage their lives by treating a variety of mental health issues. This type of therapy is used to treat conditions like depression, anxiety, eating disorders, phobias, and substance abuse. Depending on the needs of the patient, it may be used alone or in conjunction with other therapies and treatment methods. As of the guideline of MoH (2000), all clients undergoing HIV testing should be provided with post-test counseling in person. The form of the post-test counseling session depends on the test result; this is often brief in provider-initiated testing. For positives, sessions will focus on providing support to cope and referral for care and treatment. Every opportunity has to be given to the client to express his/her feelings about the results and related personal issues. The post-test counseling session should include the development of a risk-reduction plan specific to the client’s results and personal life situation. Actually, to what extent these counselors handle the risk is under inquiry.
The training given to the Home Based Care workers /clergies/ was only for about three weeks, which is assumed as not sufficient for the observation of the researcher. Counseling itself need a background in psychological issues to be treated during HIV counseling since we are dealing with human nature showing different behavioral manifestations. In South Africa, for example as stated in Leach et al (2003), ‘Because of changes in governmental policies, beginning in 2001, there was an effort to train 10,000 counselors (not counseling psychologists) per year for 3 years to help the country cope with the overwhelming social and medical issues mainly stemming from the AIDS pandemic.’ This indicates that at least ‘HIV counselors’ in South Africa attained training for one year that has great difference with that of Ethiopia. Additionally, according to Leach et al. ‘because of this drive, universities scrambled to modify their counselor training programs. Counselor trainees engage in basic counseling interventions, and in the case of HIV/AIDS, counselors offer support for the afflicted and their families and educate communities on the transmission and course of HIV/AIDS (Leach, 2003)’. On the contrary, three weeks training is only given without any refresher courses in Ethiopia. Some universities only add a topic in their courses of study instead of gearing the training towards counseling intervention of HIV/AIDS counseling pandemic. The understanding of professional registration in the field of counseling and acceptance of counseling services in the country was/is also under question.
As of the observation done in the interview room, the researcher identified that the room itself was not appropriate to conduct counseling. However, the counselor handles counseling sessions in the office where the organization uses this class as the storeroom and as counseling office, which is inconvenient to keep privacy of their clients. Similar situation applies in all other counseling centers for HIV in Ethiopia where the rooms for counseling were not so convenient even if they attempt to employ Western form of counseling principles and systems. Counseling in these organizations become
critical after disclosing the result to switch the emotional shock one experiences realizing that he/she is positive in the same room. The approach one employs in this form of counseling could vary depending on the cultural context of the counselor, experience, professional expertise and objective of the counseling underway. A study result indicating the same opinion and served as a guideline by MoH (2000) supports the same finding stating that, ‘Client needs vary widely; therefore counseling and testing approaches and modalities should be flexible to respond appropriately. No single approach or service delivery model is suitable for all populations, or feasible in all settings.’ The study result indicated hence that, choices and approaches would depend on the needs, availability of resources and accessibility.
HIV counseling as mentioned by the respondents was a voluntary dialogue between a counselor and client, couple or a group of clients as of the work guide forwarded by Ministry of Health. It is therefore, a process of enabling clients to understand and make informed decisions on whether to be tested for HIV, to understand the results and facilitate future planning. The common components were pre-test, post-test and ongoing counseling. If the individual is interested to know his status, the counselor welcomes and send the client to Voluntary Counseling and Test (VCT) center of his/her choice. The result is only revealed to the counselor through the referral laboratory and it will be disclosed to the individual for posttest counseling and further support.
The counselor use stereotyped approach in managing the shock an individual experiences after identified positive to HIV/AIDS. Consequently, posttest counseling was a serious issue that involves life and death questions banging brain of their client leaving the individual unable to decide what to do next. This finding is in harmony with the result of the study done by Wilson (1995), stating that in most Western societies, people are expected to receive counseling both before and after an HIV test. The counselor therefore, should be able to absorb all this emotional conflicts and burdens their client bore and be able to calm down him/her either using at least one of the scientific approaches in this regard or being eclectic in use.
Additionally, question of culture-based counseling is crucial in the metropolitan since there are diverse cultures and views that are in use to settle down such distressing situations. A finding by Bolton-Brownlee (1987) supports the same view, stating that ‘a major assumption for culturally effective counseling and psychotherapy is that we can acknowledge our own basic tendencies, the ways we comprehend other cultures, and the limits our culture places on our comprehension.’ On the top, the authors gave special emphasis on the usefulness of knowledge of different languages and ethnic values to assist their clients effectively; since, the counselor would like to tilt herself to the religious aspect of counseling than abiding to the professional ethics of counseling. The origination of counselors focus on own personal culture contrary to giving the impression to clients culture has great waves on the counseling perception in modern societies.
When responding to a question, what type of services they are giving and how they joined this institution the discussants at Emanuel Mental Health Hospital replied the following.
We joined this organization after going through strong competition to get to the work area. The notice was publicized on Ethiopian Herald one of the known English newspaper in Ethiopia. We passed the written examination and successfully did the interview held at the organization. We were hired to give counseling service for the mentally ill patients recovering from the psychiatry ward and others identified by the psychiatrists. The services we render are counseling for those identified somehow able to think and rethink about their life without much influence from relatives or family.
All the workers in the department were professionals from department of psychology even if they have no specialization in the field. They were BA holders from different universities of Ethiopia like Jimma, Finfinne /Addis Ababa/ and Gondar in the field of psychology having a training of 4 years of study and joined the hospital passing through high competition amongst numbers of graduate students in the area. All of them mentioned that they are professionals in the field who in conjunction serve the patients with trained nurses and social workers. The program in South Africa is a little wider than that of ours in its option to produce psychologists in the area where the study done by Leach states the two routes to professional activities. ‘Students can become psychologists through one of two routes. First, they can complete a 3-year bachelor’s degree with a psychology major and then compete for a 1-year psychology honors degree, followed by a 1-year master’s program and 1-year internship training. Second, students can enter a 4- year psychology program that includes more psychological studies than the previous program, including a specialization and a practicum, and then advance to the master’s program (Leach et al, 2003)’. In Ethiopian universities, the second route was operating for years, while currently there is a shift to three years study, which is in progress with no honors degree. However, efforts of the counselors to discharge their duty takes a lead incorporating the experiences they gained from universities and work performance they are assigned on.
The counseling underway by the church seems directive since the counselor gives clients an option that s/he believes better. The result whether positive or negative could not be disclosed until posttest counseling is given. If the individual is found positive for HIV/AIDS, continuous counseling session may be arranged for him/her. Since most of the counselors were/are theologicians (clergies), they also give spiritual counseling as spiritual fathers, except the very few social science graduates serving as counselors. This shows that professionals in the field have negligible input or not serving in counseling HIV patients. However, certain post testing traumas like shock, denial, revenge, stresses, etc. are more of psychological that need intensive counseling and support from professionals’ side than the only attempt of clergies.
On the other hand, when the counselor encountered the distinct values and beliefs of the culturally different client with an addiction, for example, cultural bias may well result in the counselor's perception of denial. Unfortunately, such bias invites misperception and a resulting misdiagnosis that contributes to an ineffective approach to treatment. This area is seen as a major gap, which paves for further research.
The clients and counseling arrangements
The ability and experience of the counselor greatly influences the work of psychotherapy in assisting individuals to make testing or not to do testing. This is because, sometimes people working on none professional areas tend to follow their own personal experience, intuition, feeling, belief, custom, and ways that they assume positive in their approach which, in turn could have negative implication on the client. Literature in other areas goes in line with this study stating that, a pluralistic counselor considers all facets of the client's personal history, family history, and social and cultural orientation. This is always true since some people are sympathetic while others are of apathy type. This finding is in harmony with the study done by Romero et al. (2005) as counselors must view the identity and development of culturally diverse people in terms of multiple, interactive factors, rather than a strictly cultural framework. In the course of communication, some may follow more judgmental and commanding approach than listening to the individual client. This type of counseling has a destructive effect than its assistance, even if the impact of physiological needs overtake the deadly syndrome that gives time to consummate.
Emotional problems may generate long rooted mental distress with the needs for professional assistance that may be mishandled by nonprofessional counselors assigned on the post. Knowledge of absorbing emotional outburst from client and use of different counseling techniques are critical that these counselors lack. Methods of handling emotional transference may also have danger. The finding of La Fromboise (1985) as cited in Bolton-Brownlee, Ann (1987) supports this finding in the sense that, adherence to a specific counseling theory or method may also limit the success of counseling. This shows that modern counseling, specifically, in the field of Pre and posttest counseling for HIV/AIDS needs further consideration since the emotional stresses one develops during posttest result disclosing could be of harmful type leading to more psychological problems on self and vengeance on others.
The 21 days standard training prepared by HAPCO (HIV/AIDS Prevention and Control Office) in integration with FHI (Family Health International) and organized by Ministry of Health on theories and practices done under close supervision of health workers disregarding professional counselors. This showed that professional counselors did not participate on the training, which might have adverse effect, and make the counseling service for HIV/AIDS patients inefficient as to minimize the unforeseen troubles which intricate and make their problems unresolved. If the situation goes as is, the social aspect of human life was/is ignored which makes counseling worthless and tough for the permanent users of the service. Thus, behavioral change that the organizations expects from the individual people with problem relies on integration of human aspect (social), physical and psychological aspect of the client than medical treatment alone. In accordance with the finding of this study, stating the association of counseling with the HIV test, Watney (1987) as cited in Wilson (1995) indicated that, amidst the polemics of what has called ‘AIDS commentary’, there is general agreement on three issues. First, that AIDS is primarily a social phenomenon with urgent and consuming medical issues attached.
Second, that, short of medical breakthrough, the most effective response to HIV infection is via cultural and behavioral change. Third, such change will depend upon communication process that are complicated and little understood. Regarding beneficiaries and services, informants from Emanuel Mental Health Hospital (EMHH) mentioned the following:
Either clients coming to the department are assigned by referral from psychiatrists (in most cases) or through any information, they have about the service. The mentally ill are the target groups who benefit much from counseling service in the hospital. Other clients are individuals who have information about our service even if the number is very few. Most clients who get the service in the hospital are youth/adolescents, young adults, few children and old people. Since the service rendered in the counseling department are mostly in groups, family of the patients (clients) are also the target groups involving in the session. They get training from nurses on the medical treatments and how to use the prescribed medicine. Then the family is educated on how to cope up with the mentally ill people.
Depending on the needs of the patient and referral of the psychiatrists in the hospital, psychotherapy may be used alone or in conjunction with other therapies and treatment methods. Psychotherapy is the treatment of mental and emotional disturbances and disorders using psychological methods. As mentioned here, this type of therapy may last for just a few sessions, or treatment may last for several months, depending on the individual needs of the patient and/or the parents/care givers.
The patients grouped under one therapy session are those identified as having similar problems/cases. In each group, five to ten people/patients were clustered for conducting group counseling. They might have two or three different groups based on the assortment of cases under treatment. Three groups of professionals (counselors, social workers and nurses) participate on the session and each has training and education to be given turn by turn. Counseling session is once per week and is termed ‘open ended’ and one can replace the other if the client is discharged from the hospital. The individual is referred to the counseling department first before grouped. If the problem needs personal treatment, the counselor handles the case on individual basis. However, most counseling sessions were handled in groups since the patients exhibit similar problems and too many people get treatment from this hospital employing the same form of therapy. At certain cases, few patients identified with similar problems might be reluctant participating in the discussion, critics, and comment giving. The parents/family or guardians get training and education session in different classes mostly aided by the nurses to assist these patients.
On the other hand, as of the modern counseling system employed in Ethiopia, clients to Orthodox Church were those individuals who get there for economic support and HIV counseling provision under the church. These people (counselors) give counseling related to HIV based on the pre and posttest results to be revealed by the HIV testing centers. Nevertheless, clients coming to Emanuel Mental Health Hospital were/are those individuals facing certain forms of mental problems or individuals having psychological problems who have information about counseling provisions. The procedures these counselors employing seems by large what they assume better in assisting their clients even if they didn’t follow specific procedures.
The sitting arrangements employed by both organizations were almost the same even if the clients they serve and the counseling under use was different. When individual case is considered, the counselors at the hospital make use of the sitting arrangement to the sides of the table to reduce face-to-face contact as to manage the emotions one could experience during first meeting. Similar case was also used by the church albeit the room observed was not appropriate to conduct counseling to minimum standard. The group counseling sessions were done by different professionals from health, social work and psychology in the way that all the workers were/are sitting between the clients to conduct side-to-side discussion, organized for general discussion sessions.
Counseling tools, procedures and techniques
Counseling procedures and techniques followed by the church was in line with objective of the church. With regard to the discordant case, the counselor had a warning from the head or church leaders on what to do other than telling the woman, in most cases, to take self-care as much as possible during sexual interaction. In the Holy Bible, 1st Corinthians chapter 7 verses 10-11 ‘no one is allowed to make divorce against his wife or her husband’, stating no precondition necessitates the same. However, Luke 19: 9 explains that no one has a right to split-up unless found committing adultery (Onesmos, 1997). Hence, the counselors get in to dilemma of reconciling script and objective of the church establishment in accomplishing its mission by preaching the Holly Bible with the new incoming devastating sexually transmitted epidemic discordant between couple/spouse.
The counseling system itself is in confrontation as to what method to follow whether only relying on the spiritual matter or use the modern counseling system in assisting the clients in problem. Seemingly, laboratory based results revealed by medical workers about the female discordant was denied access of counseling on how to care and keep herself from the attack of HIV if the partner is found positive. This shows that the development of modern counseling in different institutions was/is under question, since the HIV counseling organizations follow unique/alien approaches rather than widely used modern counseling techniques to the Westerners. Gordon clearly forwarded that there exist magic thinking related to counseling from either spirituality or witch doctors or modern counselors. ‘And despite their vast differences in method, the magic, the religious and the scientific approaches to human suffering have something else in common: the remedy is essentially of a psychological nature. The witch doctor practices psychotherapy using his charms and fetishes as the physical vehicles for his cure. The priestly healer achieves the same end through the believer's faith in his ministrations. The modern psychotherapist relies chiefly upon his dynamic understanding - magical or imaginary - of the patient's mental processes and on their purposeful manipulation by purely psychological means (Gordon, 1999).’
It seems better if the counselors build good relationship with the couples and try to give counseling service for the spouse as to bridge efficient communication and discussion method on how to make safe sex without putting life of partner in to risk of this destructive pandemic disorder. The study result of Godbole and Mehendale supports this finding stating that, a study among STD patients in a district hospital in Maharashtra state documented difficulties and deficiencies in communication with regular sexual partners on sexual matters. Specific strategies need to be considered for improving sexual communication and negotiation of safe sex in couple of settings. In the first couples’ cohort study in India, 242 HIV sero-discordant couples were enrolled in 2002-2003 and the incidence of HIV infection was observed to be 1.97% per year, much lower compared to that reported in Africa (Godbole and Mehendale, 2005).’ In this sense, there has to be clear discussion made between couples aided by the counselor on safe sex as one method of reducing the danger or risk factors associated to the HIV dispersal among partners. Therefore, Africa, specifically Ethiopian religious organizations working on HIV counseling, has to learn much from Indian experience and save life of their community by giving different options of safe sex application; leaving the decision to spouse to choose the best for the family survival.
It has been assumed, therefore, either because of the lack of professional competencies each counselor demonstrate or from the hindrance rules and regulations of each organizations that block certain situations not to be applied officially in respect to organizational standards and missions, few clients were missing to receive appropriate counseling services. In support to this finding, Gordon explicated ‘poor treatment outcomes are likely when patients experience the therapeutic relationship as hostile or oppressive. When therapists use intervention without skill or use only weak intervention such as giving advice; when patients are not genuinely engaged in therapeutic tasks or are highly defensive, and when patients routinely experience insecurity, distress or confusion in sessions rather than support, relief or insight (Gordon, 1999).’
The principle followed by the counselors at Emanuel Mental Health Hospital for individual counseling session was similar to that of the Westerners though there were no written document or procedure to follow other than their personal experience and notes in addition to certain references found in the institution. The guidelines available and the ethical issues under use were more of health related ones than focusing on developing professional counseling knowledge of the workers who have good background in the field of psychology. Personal notes and knowledge of each counselor that might vary even in an institution leaving aside the questions of employing standardized procedures based on either different schools of thought or types of modern counseling approaches mostly aided the principles and procedures they use. In the United States, a great number of psychotherapists take an eclectic approach to treatment, combining different methods and techniques. Often, this approach allows therapists to tailor treatment methods to the needs and personalities of their clients (Gordon, 1999)’. The finding of this study is highly supported by the view of this writer even if the approach may show a discrepancy depending on the quality of the therapists, details of training, education and economic standard of the patients in different countries; well established techniques of the westerners, and other relevant factors.
The counselors in Emanuel Mental Health Hospital employ the six counseling principles /techniques/ employed by health workers in the Western community despite the procedures followed vary. They use GATHER as a principle in their work G-greet, A-ask, T-tell, H-help, E-explain, and R-return. Gather is applicable as six counseling principles used as technical guidance /competence/ in the work groups of reproductive health program in family planning. Greet as good connection, tell clients about methods, help clients choose, explain how to use, and returning helps continuing clients treatment assumed as the underlying six principles they employ as adopted from Murphy and Steele (1995). Giving due respect to clients and centering him/her as point of intervention is the foremost intent of the counselors at the hospital that seems of client centered approach. In the client centered approach, unconditional positive regard to the patient is a key to therapy. In the Carl Rogers client centered psychotherapy, there are no as such well-prepared techniques to counseling as of psychoanalysis and Behaviorism. The counselors rather accept the client as he/she is, honor him/her, and try to develop trust in the clients mind. In their work, the counselors also use encouraging the individuals (clients) talk about anything they feel in life and assumes, as it is the center for their problem, associates them to the employability of the psychoanalysis method that made them sometimes of eclectic type. Catharsis as a process of bringing out what are all stored in the unconscious mind of the patient is used in psychoanalysis that these counselors employ as one technique in getting opinion of their clients through asking. Consequently, a counselor at Orthodox Church seems to use transference whether in positive sense or negative form, which could be viewed on individuals, identified as positive during testing. This might have great implication on the counselor if not properly handled. In his paper Raymond explained the following supporting the study result of this work. ‘It is common, and even expected, for the client to experience feelings for the psychotherapist that are called a transference reaction; these feelings are really no different than common “love” or “hate”. And in this transference the client’s intense belief in the psychotherapist can cause some difficult problems that must be resolved within the psychotherapeutic work (Raymond, 2008).’ Hence, counselor’s ability, knowledge and skill to hold the situation are a binding whether to continue the session or terminate. A finding by Raymond asserted the same result affirming that ‘so if transference isn’t handled carefully it will lead to disaster. For example, many clients have had their lives ruined by sexual affairs with their psychotherapists, all because the psychotherapist took the client’s erotic feelings personally and failed to help the client understand their clinical meaning (Raymond, 2008).’
Concerning the spaces used in the counseling session as observed by the researcher, it could not allow free access of talk to the individual and there could be a fear to express secret matters since it is exposed to other counselors who share the same class together. Due to this fact, confidentiality of an individual might face danger and people may not explicitly speak what they feel and want in such a shared office situation. When one observes the counseling service use in Ethiopian context and the effort of the counselors at the hospital, it seems an interesting start in the development of modern counseling system in the country even if they overlooked the cultural components in their endeavor. A study done by LaFromboise (1985) cited in Bolton-Brownlee Ann clearly put the application of different principles and cultural values in counseling, supporting entirely this study result affirming that, ‘adherence to a specific counseling theory or method may limit the success of counseling. Many cultural groups do not share the values implied by the methods and thus do not share the counselor's expectations for the conduct or outcome of the counseling session. To counter these differences, effective counselors must investigate their clients' cultural background and be open to flexible definitions of "appropriate" or "correct" behavior (Bolton-Brownlee Ann, 1987).
Since cultural concepts of counseling system were/are not incorporated in the curriculum of the country’s education, one could not blame counselors of this hospital, why they ignore the relevant part of counseling tradition in their work. Unless universities and government bodies give attention to the development and emancipation of the varied cultural counseling traditions integration in the curriculum, direct application of the Westerners counseling principles and approach may miss its relevance and leads to discontentment. In the same discourse, what is accepted in one culture of our society may be seen as a taboo in the other culture since Ethiopia is one of the countries with diverse culture in the world having more than Eighty ethnic and cultural groups. A writer named Ibrahim (1985) as cited in Bolton explained the following strongly supporting this finding. ‘A major assumption for culturally effective counseling and psychotherapy is that we can acknowledge our own basic tendencies, the ways we comprehend other cultures and the limits our culture places on our comprehension. It is essential to understand our own cultural heritage and worldview before we set about understanding and assisting other people. This understanding includes an awareness of one's own philosophies of life and capabilities, recognition of different structures of reasoning, and an understanding of their effects on one's communication and helping style. Lack of such understanding may hinder effective intervention (Bolton, 1987).
The procedures followed by the counselors at Emanuel mental health hospital is of modern type referring to westerners’ mode of therapy. In fact, there is a certain difference in the applications between this institution and the Westerners. Significantly in the identification/selection of clients grouping to one cluster for counseling purpose, knowledge of the counselors, tools needed in the room or counseling environment, patient’s situation, and other relevant issues like mode of interaction, relationship between the counselors and other professionals like nurses and social workers, and convenience of counseling room (heat, light, voices). Moreover, the counselors in the hospital employ all the techniques they have learnt and what they believed useful for assisting their clients. Additionally, the counselors have no mastery of one technique to use it properly in their service since such professionalism needs further training to acquire the skill. The discussant counselors were in need of further training and education specializing in the same field, giving emphasis to different types of counseling in the area of their career.
In the group therapy sessions, some of the clients were/are reluctant, that might arise from mood disorder or what Sigmund (1953) said ‘negative transference’. If mood disorder is the case, the patient again needs further medical treatments to cultivate appropriate affect towards other and self. Freud used the term negative transference to refer to the resistance engendered in the patient by the threat of the uncovering process of psychoanalysis. It is therefore, in this finding, one can imagine that how people with mental health problem, specifically, the mood disorder can react to the existing psychotherapeutic relations. A finding by Sigmund Freud underlined the same situation supporting this finding involving that, ‘transference can also frighten you into terminating psychotherapy prematurely, rather than working through the feelings, especially the angry feelings – within the treatment. For example, during the therapeutic process you will experience many emotions that are similar to the intense and confusing emotions you felt as a child: disappointment, anger, confusion, feeling misunderstood, feeling devalued, and feeling abandoned. Experiencing these negative reactions to the psychotherapy process itself is called a negative transference. For if you are caught in it, you will feel victimized and will blame the psychotherapist for your pain, and the entire therapeutic process will feel like judgment and criticism. And then, in deep bitterness, you will want to “get away” from the psychotherapy just as you wanted to get away from the original emotions as a child (Freud, 1953).’ Similar accidental attempt of attack faced a counselor in Orthodox Church where her client realized that his spouse victimized him and he negatively transferred his bad feeling to the counselor associating her femininity.
Another area of concern in the mental health hospital is where to start counseling and timing of medical treatment. Any reference to the hospital or new case that appears in the hospital has to be seen by the medical doctor /physician/ before any identification of case was done. After medical treatment is complete, if the psychiatrists believe that the case has to be seen by groups of counselors, social workers and nurses, s/he later sends the client to the department. What has to be clear here is that identification, assessment and the professional counselors leave all intervention for the psychiatrists than exploring problems. However, psychological support has to be given before any medical approach/support to the individual if the problem is found as a less severe type. Once the counselors identify the case at hand employing different counseling techniques, the patient can be referred to the psychiatrists with the information they have gathered from the patient or caregivers for further medical aid. Necessary evidence with regard to the patient has to be compiled by the counselors before any treatment the patients get from the mental health care services to facilitate for the proper assessment of the case at hand. Psychiatrists have to rely on the results obtained from counselors or employ other screening and identification techniques to reach on symptoms suspected. Counseling support may continue also after medical action is functional, if the case has to be seen further.
Similar situation is also applicable to the church counseling in which most of the programs are under the clergies from different discipline. As of the writer’s observation to different HIV/AIDS counseling organizations, all matters with regard to the clients were/ are concluded by the physicians and/or nurses. Most of these counseling service centers are organization driven than directed by counseling principles and theories applicable in the modern world. The flooding destructed Dire Dawa is one best exemplary area mentioned by the counselors of Emanuel Mental Health hospital informants stating that ‘only health workers were assigned to the area for medical and counseling purpose assisting the victims in the post-traumatic stress reduction’. This shows that:
(i) Modern counseling system commences at early age and the knowledge government bodies and NGOs have about the profession is limited;
(ii) Health workers monopolize counseling profession, which is evident in every HIV counseling areas under most or all NGOs in the country.
(iii) Time of start and termination in the mental health hospital is under the decision of one area, specifically health, than sharing roles on the time (when to start and terminate counseling) for the professionals;
(iv) Most government and NGOs rely on counselors attending three weeks training than graduates from department of psychology, which is evident in almost all organizations working in the area except Emanuel hospital that has realized the usefulness in the recent years. What astonishes the writers more was the module and training manuals prepared by different organizations were piloted by nonprofessionals who are alien to psychology/counseling which could restrain development of counseling in particular and psychology in general in the country.
Grouping in the hospital were not based on similarity of problems. This is because, the physician assume that all mentally ill people show similar behavioral problem or need counseling of the same type. However, the root causes of the patients may vary depending on the situation they faced in life. If we consider a patient referred to the hospital because of addiction to alcohol and bipolar cases, categorizing these people with very far psychological problem under one group has deteriorating effect on either of them or both since they benefit incredibly little from the session or may benefit none. This is for the reason that, group therapy has to deal with people having similar problems getting chance of assistance with group of therapists (mostly) discuss on their problem without fear in the interaction sessions by sharing ideas and views among themselves because of the aid received from the counselors.
Counseling sessions
The counseling sessions may vary depending on the type of counseling needed. As of this organization, pretest counseling is very short that is specific to organization-based move to conduct HIV test before any form of support is proposed. This form as in the Ministry of Health intention termed as organization initiated HIV testing. After this organization driven test, posttest counseling continues based on the test results. The posttest counseling may continue for days, weeks and maybe years effected by home based care service giving agents. The study indicated by Wilson forwarded the same result on the session one has to use in counseling that goes in concurrence with this finding. ‘An individual seeking psychotherapy will usually meet with his or her chosen therapist for a period of weeks, months, or years. This type of therapy,’ here the behavior therapy, ‘may require fewer treatment sessions than cognitive therapy. However, the length of therapeutic treatment varies with each individual patient (Wilson, 1995).’ In the course of counseling sessions, there seems to be no significant difference between church counseling in Ethiopia and that of the modern /westerners/ counseling system. However, the difference lies on catching up the behavioral assessment of individual clients need and wants to obtain the counseling as useful or not. Consequently, the method and procedure the counselor employs to attract the clients to the session, ability of handling, approaching the clients, enthusiasm and empathy the counselor shows to the client, and other relevant factors determine the situation.
As indicated by the counselors, they like to address all areas of counseling even if they were confined to entertain circumstances coming to the hospital due to mental illness cases. These people come to the office for identification of personal calming down of stress, neurosis or psychosis. Cases related to conduct disorders that need further assessments and intervention may not come to the hospital. This is because it is handled at the community, level or under, court. Very few cases may get attention and proper intervention by the counselors that may take hours of discussion between the counselor and the patient.
In contrary to the Orthodox Church counseling approach, the mental health hospital counselors prefer to have longer interaction sessions on their first meeting than the subsequent ones. The reason behind is basically unavailability of the clients for further counseling session either due to limited time or afar distance from the counseling center or economic challenges that the clients encountered. The long distance they come across by referral has great impact to determine the sessions even though these people are in need of counseling services.
Other factors like the clients mental preparedness, parents or clients ambition for immediate solution, feelings of discomfort because of cultural and language barriers between the clients and counselors, difference in the social relations and gaps of interaction as expected in clients cultural dimension and the situation in the hospital has great influence on the strangers coming from rural or far areas of the country side. Cultural dissimilarity and communication variation is of paramount importance that made clients develop abhorrence on the services when, in most cases, they want to be silent than giving opinion on the sessions they are involved in. This area needs further study that could be seen as one of the identified research gap.
Integrative advance among counseling service giving institutions
The authors’ personal experience and observation while working as employee of one local NGO as project officer, reveals similar opinion and result as of the counselors. Different organizations try to have large number of clients than giving effective and sufficient counseling to the patients. This arises from unhealthy competition to have a number of clients for statistical report for the supporting national or international donors. This type of competition for no better service has negative impact on the patients and the community, divulging them for duplication and wastage of materials on the organizations. Therefore, thinking positively where all endeavors is to assist the victims in searching for new incidents or cases for better-integrated counseling support seem practical.
The finding clearly put nullity of integration between different counseling service rendering organizations due to the difference in organizational objectives and absence of professional counselors’ assignment on counseling services. Competitively, all organizations run to fulfill organizational objectives pertinent to their institutions than concerned of the counseling procedure, techniques and tools of counseling standardization relevant to the country. Lack of professional association and legal or official recognition to the counseling field has put forth grand knock on the bringing together of professional counselors working on the field, since this is a question of professionalism that emanates mainly from professional knowledge and ethics.
Challenges encountered in the modern counseling program
One can simply imagine that professional workers were not assigned on the counseling and three weeks training is not sufficient to handle such a critical issue that dissects between life and death cases. Availability of appropriate places for counseling is also essential in counseling as to make the clients at ease of confidentiality or not to worry for privacy. Even if the interviewee had no objection on the training, it is believed that adequate training on counseling were not given to the counselors at varied levels as to handle pretest and posttest trauma. On the other hand, the priests’ inclination to play role of spiritual fathers than counseling behavior in leading and guiding psychotherapy was one source of difference. Assignment of professionals in the field of psychology, preferably counseling psychology, in the department was suggested if counseling is a viable work within the organization since counseling has its own procedures, techniques and approaches of work dealing with human beings. It is also advisable if professional counselors replace the existing counselors or assigning those professionals as assistances can add value to the service. Vontress (2001) suggested on the professionalism of counselors strongly supporting this finding revealing that ‘in Western societies, USA in particular, the counselor is anyone, male or female of any age, who has met the academic preparation requirements set by the state or some other jurisdiction. Entry into counseling and other psychotherapeutic professions depends on the individual's ability to obtain the requisite academic preparation and license to practice.’
What one faces in the work atmosphere when directly coming from learning institutions is common to all, the situation counselors at Emanuel Mental Health Hospital faced was different to other organizations. In the first place, the department was new in the hospital. Secondly, health workers that determine the counselor’s initiation to apply and exercise what had been learnt in their respective institutions mainly dominated the work atmosphere in the hospital. Thirdly, the new environment to work exposure delimits how and what to do in their endeavor to apply what they have gained. Fourthly, lack of appropriate work guideline in relation to whom, how, when, and in what manner to accept and support the clients, which made their work atmosphere more complicated. Lastly, the purpose of counseling in the hospital was understood as a support to the health care workers than viewed as one disciplinary area. One could not at any quest did not reach on facilitated setting at the beginning except very few successful individuals in developing country like Ethiopia. Hence, much is expected of the counselors in the hospital to develop self-initiation and capability to work with other coworkers and strive to plant counseling strategies in the hospital.
Possible solutions suggested alleviating problems of counseling in the country
Professionals in the mental health hospital believe that curriculum integration is a relevant issue to be considered by higher institutions who train professionals in the field of psychology as major point of attention. Interdisciplinary approaches planned to incorporate relevant topical issues in counseling courses has to get attention in the department of psychology. This needs further discussion with professionals in the department of psychology since question of specialization and fields of general practitioners production could be an issue that might be raised by others from different specialty ranges. However, the common understanding of all members for insertion of other courses like multicultural issues is mandatory. This finding is highly analogous to a study done in South Africa by Leach showing that ‘for changes to occur, counseling psychology must be perceived as having relevance in the larger community. Counseling psychology will need to consider what it can learn from traditional healing practices as well as better train new psychologists to work from a culturally sensitive perspective. It is hoped that the inclusion of both traditional and Western healing approaches to treatment will eventually become more prominent in training programs (Leach et al, 2003). It seems worthwhile to identify interests of students in the psychology field whether they wish to get specialty in the field of counseling and plan for the area depending on the needs assessment results. It is also better if research work is done on the inclusion of different course. Informants of EMHH opined that ‘it seems better to have wide range of support groups among counselors working on the same field and groundwork of standardized working materials that serves for all counselors in the country to give similar service for the clients.
Since there were/are no standardized counseling procedures and unified systems of counseling employed by bevy counseling offices in the country, the issue of bringing all concerned bodies working on HIV counseling should come from training universities forming joint relationship with different organizations working on the business. Forming support groups in their effort has critical input for the successful improvement in the area of counseling whether at institutional level or hospitals or HIV counseling organizations. The effort made by MoH and HAPCO reveals that in order to have a unified national ART program, tools, systems and reports must be standardized. MoH, as the responsible body, must lay down mechanisms to eliminate uncoordinated individual operations. This is mostly furnished by Health Monitoring Information systems as of the guideline set by MoH (2005).
As the psychology professionals in the hospital mentioned, most of the HIV counselors lack the knowledge and capability to relate disorders related to HIV/AIDS and its impact on the individual identified as positive. Most of the health workers try to associate the problem or relate the disorders to physical condition/ problem as of the researcher suggestion in addition to the professional’s proposition. What so ever a person possesses a shock due to HIV positive cases, those nurses who are peripheral to the profession of psychology, give personal judgment as shock management and might prescribe a medicine or a needle that emanates from modest knowledge to human behavior and its manifestations. In addition to the question of professionalism, questions related to counseling ethics, procedures, privacy and confidentiality, counseling principles, and knowledge in the science and philosophy of the field has to get attention. Subsequently, some patients going for VCT may expire because of the inappropriate advance of disclosing the situation if found positive or may be collapse because of the unbelievable situation they were apathetic to hear.
