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PSYCHOSOCIAL APPROACH TO COUNSELING WITH

THE CLIENTS INSIDE AND OUTSIDE KATHMANDU


VALLEY
Submitted on: December 20, 2007

Submitted To:

1. PGDPC, PROGRAM
TRICHANADRA MULTIPLE CAMPUS
FACULTY OF HUMANITIES AND SOCIAL SCIENCES
TRIBHUVAN UNIVERSITY

2. TRANSCULTURAL PSYCHOSOCIAL ORGANIZATION


(TPO – NEPAL)
LAZIMPATH, KATHMANDU

3. EDUCATION AND COMMUNITY HEALTH ORGANIZATION


(ECHO)
LAGANKHEL,LALITPUR

Submitted by:
PRAGYA SHRESTHA
ROLL NO: 19

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ACKNOWLEDGEMENT

Trichandra Multiple Campus has been conducting Post Graduate Psychological


Counseling since 2004. For the internship, I chose and requested Education and
Community Health Organization (ECHO) and Transcultural Psychosocial
Organization (TPO-Nepal) for my placement.

I would like to take the opportunity to express my sincere gratitude towards Dr.
Govind Prasad Adhikari (Director of ECHO), who encouraged me to take the
counseling course and supported as the best he could. I would like to thank Mr. Bal
Kumar Thapa (Chairman), Ms. Narayani B.K (Yoga trainer) and all the staffs of
ECHO for allowing me to do internship in ECHO.

It would not be possible to accomplish my internship without the help of TPO-Nepal.


For this, I am obliged to Mr. Nawaraj Upadhya (Office Incharge) and Mr. Mark
Jordans (Technical Advisor) who agreed my request for my placement. I am deeply
grateful towards my supervisor Ms. Jamuna Shrestha (Psychosocial Counselor), who
helps me during my placement. I am also thankful to Psychosocial
Counselors/trainers - Ms. Ambika Balami, Mr. Ken Woods, Mr. Nabin Lamichane,
Ms. Parbati Shrestha and Mr. Prakash Acharya for giving valuable opinions and
views. Deeply thanks to Mr. Raam Katwal (Finance Officer) and Ms. Puspanjali
Dhakal (Administrator assistant) for managing the budgeting part for my placement. I
appreciate the kind understandings from Mr. Nagendra Prasad Luitel and Ms.
Jashmine Bajracharya towards me. I am deeply grateful towards all the cooperative
colleagues of TPO Nepal. Without them my internship would not be successful.

Special thanks go to Dr. Bharati Adhikari, Ms. Kishori Thapa and Mr. Kedar
Raymajhi for their valuable suggestions on dealing with the client’s problem.

It would do injustice to my placement if thanks were not given to community people,


my friends, seen & unseen hands of well-wishers to make my placement successful.
Lastly, I would like to thank CWDC for teaching me the effectiveness of games with
children that were very fruitful while intervention.

Pragya Shrestha
26 July, 2006

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TABLE OF CONTENTS

1 Executive Summary………………………………………………………. 5
2 Background Introduction …..……………………………………………. 6
3 Methodology………………….………………………………………….. 7
4 Definition of Psychosocial……………………………………………….. 8
4.1 Psychosocial Problems outside Kathmandu Valley………………………. 9
4. 2 Psychosocial Problems inside Kathmandu Valley………………………. 10
5 Psychosocial counseling…….……………………………………………. 10
6 Stages in counseling………………………………………………………. 11
7 Conclusion………. ……………………………………………………… 12
8 Recommendation………. ………………………………………………… 12
9.1 Annex 1 – Case Study (1)………………………………………………… 13
9.2 Annex 2 – Case Study (2)………………………………………………… 14
9.3 Annex 3 – Case Study (3)………………………………………………… 15
9.4 Annex 4 – Case Study (4)………………………………………………… 16
9.5 Annex 5 – Case Study (5)………………………………………………… 17
9.6 Annex 6 – Case Study (6)………………………………………………… 18
9.7 Annex 7 – Case Study (7 ~ 10)…….……………………………………… 19

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1. ACRONYMS USED IN THE REPORT:

CHDW - Community Health and Development Worker Training

CMA - Community Medical Assistant

CWDC - Child and Women Development Center

ECHO - Education and Community Health Organization

PGPC – Post Graduate Psychological Counseling

TPO – Transcultural Psychosocial Organization

EKATC - ECHO & KOPION Alternative Therapy Center

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1. EXECUTIVE SUMMARY

1. The short information of PGPC course of Trichandra Multiple Campus, ECHO


and TPO-Nepal are given in this Report.

2. This report gives information, methodology and counseling stages in Psychosocial


Approach used with the clients of inside Kathmandu Valley and Outside
Kathmandu Valley.

3. The Report provides the Case Study of Ten Clients.

4. It is recommended to the Academic Sector, GOs, NGOs and INGOs, if the


Counseling program is conducted in different part of Nepal rather than only inside
Kathmandu Valley. Also, it would be very effective and fruitful to reduce the
psychosocial problems of the community people, only if there are enough
counselors in different parts of Nepal.

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2. BACKGROUND and INTRODUCTION:

As the Theoretical portion of Post Graduate Psychological Counseling (PGPC) finishes,


Trichandra Multiple Campus has been sending its students of Post Graduate
Psychological Counseling (PGPC) in different organizations. The students of PGPC have
to choose the organizations according to their interested areas for the
placement/internship. For this, the students have to counsel and take 10 clients from the
given organizations. Therefore, Ms. Pragya Shrestha, the PGPC student has chosen
ECHO which has been solving most of the public health problems in Nepal by creating
awareness in the grass root level and the next organization TPO-Nepal which has focused
on local public health, psychosocial and mental health.

ECHO has been conducting one of the programs called “ECHO & KOPION Alternative
Therapy Center” (EKATC). In the clinic, few patients who have psychosomatic problems
come for the treatment. Therefore, Ms. Shrestha has chosen those patients. Similarly,
TPO-Nepal has been conducting one of the projects “Emergency Psychosocial Support
for Kapilbastu” for 3 months with the support from UNICEF. Thus, Ms. Shrestha has
chosen to take clients from Kapilbastu.

Focusing on Counseling in Psychosocial Approach, Ms. Shrestha, the interned counselor


has applied the counseling skills with the clients.

GOAL: To counsel ten clients using the counseling skills in Psychosocial approach.

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3. METHODOLOGY:

In Counseling Room:

 By following the stages of counseling; Using Communication skills, Different Tests,


maintaining the session report, brainstorming, by observation

Outside the counseling room (working as part of community outreach programmes):

 By following the stages of counseling; Using Communication skills, conducting


interviewing to the community people, providing psycho-education, maintaining diary,
and sharing with other counselors, using play therapy with children, by observation

Total numbers of clients taken inside Kathmandu Valley (Kapilbastu): 4


Total numbers of clients taken outside Kathmandu Valley (Lalitpur): 12

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4. DEFINITION OF PSYCHOSOCIAL:
We are social human being and we live in the society. Our thoughts, emotions and
behavior (Psychological aspect) towards the social aspect (family, society, culture, norms
and value) or society towards us is different. This interrelation between psychological
aspects and social aspects is called Psychosocial. If the society accepts his/her behavior,
s/he can adjust in the society and shows good daily functioning. But, if the individual
cannot balance them, it impacts his/her thinking, emotions and behavior that lead to
psychosocial problems (lack of concentration, fear, guilt etc) and develop bad daily
functioning.

Individual

Psychological Aspect e.g. Social Aspect e.g. Family,


emotion, feelings, thoughts Culture, Norms & Values
Interaction

Consequences

Positive Negative

No psychosocial problems Psychosocial Counseling Psychosocial problems


eg. Low self-esteem, fear,
Flashbacks and nightmares,
sleep disturbance, Suicidal
Good Daily functioning thoughts
eg. -Go to school/college daily If not solved
- Good performance in
school/college activities and Bad Daily functioning
other daily activities eg. - Mostly or totally absent in
school/college
Need specialized care - Poor performance in
eg. Psychriatic Care school/college activities and
other daily activities

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4.1 PSYCHOSOCIAL PROBLEMS FOUND OUTSIDE KATHMANDU VALLEY

Psychosocial problems found in Kapilbastu during violence


Violence (murder, dacoit, rape, destruction of physical infrastructure) in Kapilbastu, the
Western side of Nepal, has impact in everyone’s life especially children and women from
past four months. During this violence, the houses were burned; assets/property such as
Television, religious books, bookshelf, bed, sofa and many other things were destroyed
and burned. Women became widows, children became orphan, many girls were raped,
and people suffered loss of their family members. When these social network (family,
community), community infrastructures (houses, etc), traditional roles (religious books)
etc are loss or weakened, the hearts and mind of people get impact. As a result, the person
of the community has been affected psychologically. This effect could be physical,
mental and spiritual as well.

Due to these various problems, children left schools due to fear. Physical and mental
problems have increased due to loss of loved one and assets. The resources (land,
domestic animals, etc) were left in the village as they were. Most of the villages, family
and community have feelings of insecurity and do not want to go back to their own
villages where the incidents had happened. They have nothing but the tents in the camps
and have houses without roof in the villages. Thus, people living in camps as well as in
villages are suffering from coldness, which may lead to severe physical problems, as the
winter season has already started. They are in stress which may lead to long-term mental
illness. These various reasons are negatively affecting children, women and other adult
and old as well.

Psychological symptoms are arisen because of social events/processes. Therefore, social


events are agents of psychosocial problems whereas psychological symptoms/processes
are the manifestation of psychosocial problems. For instance, in case of Kapilbastu,
murder, dacoit, rape, destruction of physical infrastructure, poverty, unemployment,
sexual exploitation, displacement, etc. are social events whereas, fear, frighten, stress,
sadness, anxiety, low self-esteem, hopelessness, helplessness, ambivalence, feelings of
insecurity, psychosomatic complaints (such as headache, back pain, do not want to eat,
problem in sleeping etc that cannot be diagnose by medical check up) etc are the
psychological effects of such painful social events.

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Based on: Jordans. M.J.D.(2003). Training handbook: Psychosocial counseling for children in need of
special protection- Trainer’s guide. UNICEF Nepal

4.2 PSYCHOSOCIAL PROBLEMS INSIDE KATHMANDU VALLEY

Psychosocial problems found in Lalitpur


No much interaction and good terms with family members, fighting/quarrelling between
family members, do not receive proper care and respect from the family, sons and
daughters refuse to take care of elderly etc, break-up in affairs among youngsters, no
extra activities in government school, bullying from friends etc. are social events.
Whereas, feelings of inferiority complex, poor concentration in study, look despair,
aggression, fear, feels stress all the time, anxiety about the career, suicidal thoughts,
extreme fear, loneliness, feelings of ambivalence, sleep disturbance, poor appetite and
weight loss, restlessness, hyper active, suspicious nature, feelings of guilt, low self-
esteem, hopelessness, psychosomatic complaints (such as pain in finger, hand, back and
legs, do not want to eat, problem in sleeping etc that cannot be diagnose by medical
check up) etc are the psychological effects of such social events.

5. PSYCHOSOCIAL COUNSELLING
Counselling is a planned intervention between the client and counsellor/helper to assist
the client to alter, improve, or resolve his/her present behaviour, difficulty, or
discomforts. It is a process of helping the client to discover the coping mechanisms that
he/she found useful in the past, how they can be used or modified for the present
situation, and how to develop new coping mechanisms.

Psychosocial approach to counseling places focus on the well-being of the individuals in


relation to their environment. Its focuses not only on individuals but sees them as a part
of bigger social units such as families and communities. It focuses on the understanding
of the relationship between individuals and their environment. Thus, client’s problems are
seen in relation to his/her surroundings. This approach widens holistic understanding of
psychological and social processes.

Psychosocial approach to counseling emphasizes the psychosocial well-being and


empowerment (gaining insight into one’s problem and being actively involved in
addressing one’s sufferings and trying to change it) of client.

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6. STAGES IN COUNSELING:
The six stages of counselling are applied “Identification”, “Beginning”, “Assessment”,
“Formulation” “Implementation” and “Ending”. The arrows on the diagram represent the
movement through the stages.
Stage 1: IDENTIFICATION

Stage 2: BEGINNING

Stage 3: ASSESSMENT
The process of gaining information
about the problem and the client

Information goes Formulation gives unanswered


in to formulation… questions for assessment…
Stage 4: FORMULATION
An understanding of the problem
informed by theory and knowledge
Setting goals in counselling
Agreeing a helping plan
Deciding what to do and
If appropriate… planning how to do it…

Stage 5: IMPLEMENTATION
INTERVENTION
Stage 5: Implementing the counselling goals
REFERRAL Problem management
TO OTHER
SERVICE You may need to
Stage 6: adjust your
ENDING intervention…

EVALUATION
Is the intervention working?
…or you may need to rethink
your formulation
Stage 6: ENDING

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Source: SAHARA’s counseling manual
7. CONCLUSION:
The emotional support, play therapy, muscle relaxation exercise, communication skills,
drawings in counselling in psychosocial approach was very effective for the people
outside the Kathmandu Valley and inside the Kathmandu Valley to reduce psychosocial
problems.

8. RECOMMENDATION:
1. The academic sector has to work with national governments and private sectors. This
networking will provide the government to develop monitoring and evaluating the
program so that government encourages such kinds of program (Post Graduate in
Psychological Counseling) to be strengthen further.

2. It is recommended to the Academic Sector, GOs, NGOs and INGOs, if the Counseling
program is conducted in different part of Nepal rather than only inside Kathmandu Valley.
Also, it would be very effective and fruitful to reduce the psychosocial problems of the
community people, only if there are enough counselors in different parts of Nepal.

3. The referral system should be strong so that the counselor can refer the clients to the
concerned organizations.

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Annex 1:
CASE STUDY
Name: Laxmi Nepal (Name and caste change)
Age: 24 years
Education: B.A
Marital Status: Single
Occupation: Reporter
Problem faced from: 1 year
District: Lalitpur

Beginning and Problem identification: The presenting problems she mentioned were
worry about the career; father talked negative things about her with other people;
boyfriend does not care much now; she has to look after herself and her younger sister.
Identified problems psychosocial problems were anxiety about the career, suicidal
thoughts, extreme fear, loneliness, feelings of ambivalence, sleep disturbance, poor
appetite and weight loss. She has been taking anti-depressant drugs.
Assessments, Formulation and Ending:
Family Information: There are mother, father, she and younger sister. She and her father
earn the bread for the family. The relationship with her aunts and other relatives is not
good as they complain negative things about her with her father. She said her father
thinks that she made his reputation down.
Personal Information: The client is a reporter. At the same time, she is doing graduation
and worry about her career. Many times, she reaches home at night. She thinks this is the
reason that her aunt doubt on her and complains about her with her father. She has an
affair with another reporter. She is in ambivalence that on one hand she thinks he does not
love her anymore and on the other hand she thinks he loves her as he becomes jealous
when he saw any boy with her.
Strength: She has been using Emotional-focus coping strategies such as venting emotions
(Share feelings with closest friend), and Problem- focus coping strategies such as
Instrumental social support (Seeks concrete advice, assistance, information).
Support: Counselling (Uses communication skills, ask about the expectation to the client,
empathy, encouragement of strength)
Implementation- Action and Evaluation:

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Action Plan: After doing brainstorming, for the worry about career, she said she would
finish the graduation her and search for work and study in foreign country. About the
boyfriend problem, she said she would do clear conversation with him.

Annex 2:
CASE STUDY
Name: Maya Dhakwa (Name and caste change)
Age: 61 years
Marital Status: Married but widow. One son and one daughter
Problem faced from: 1 year
District: Lalitpur
Beginning and Problem identification: The presenting problems were pain in finger,
hand, back and legs.
The identified psychosocial problems are poor concentration, suspicious nature,
loneliness, and feelings of guilt and sleep disturbance.
Assessments, Formulation and Ending:
Family Information: There are a son, daughter-in-law and a grandchild. Her son and
daughter-in-law earn the bread for the family.
Personal Information: The client does some household work like cleaning rooms, doing
Puja. She feels alone at home as her son and daughter-in-law go for job and her
grandchild comes home late from school. She has feeling of guilt as she cannot do
household work and she is getting older.
Strength: Participate in socio-cultural activities; spend time in religious activities such as
visiting temples, worshipping, listening and singing religious songs.
Support: Psychosocial Counselling (Uses communication skills) empathy, encourage the
strength

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Annex 3:
CASE STUDY
Name: Sita Nepal (Name and caste change)
Age: 16 years
Class: Class 6
Marital Status: Single
Problem faced from: 1 year
District: Kapilbastu
A 16 years old girl, leaving in Western side of Nepal and studying in school, was raped 4
times by her own father.
Beginning and Problem identification: After 5 sessions, a counsellor has identified the
problem of the client (16 years old girl). The identified psychosocial problems were poor
concentration in study, suspicious nature, feelings of guilt, suicidal thoughts, extreme
fear, feelings of insecurity, ambivalence, loneliness, cannot do eye contact, Humiliation
of feeling, Isolation, Sleep disturbance, poor appetite and hopelessness.
She has been sexually abused from one year. As the father comes in front of her, she
totally becomes numb. To resolve the problem she tried to attempt suicide 3 times.
Except her mother, sisters and brother nobody in the community knows she is raped from
her own family.
Assessments, Formulation and Ending:
Family Information: There are mother, father, brother, sister and sister-in-law. Source of
income is from agriculture. Her brother earns the bread for the family. Client’s relation
with other family members (except father) is good. Family is from Bramhin caste. Father
is drunkard and use very bad/dirty words.
Personal Information: The client does the daily house hold work. She is studying in
school and wants to pass the S.L.C. She is shy kind of girl. Friends tease her in school.
She cannot study because of bad environment at home.
Support: Psychosocial Counselling individually and with family (Talk with mother,
father, brother, sister and sister-in-law). Ask with mother about suicide; ask about the
expectation to the client. A commitment was taken from one of the member of
community to observe the client behaviour and to look after her.
YCL has threatened her father as he uses bad words in the community. Family does not
want the legal action/process as they think when the legal process is done their reputation
will be down in the community because they are from Bramhin caste (major caste).

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Family want to solve the problems within the house. As a result, her mother and her elder
sister have been protecting to her.

Implementation- Action and Evaluation:


Action Plan: After doing brainstorming, the client finally said something to protect
herself. The counsellor has encouraged her strength. Client thinks of escaping to resolve
her problems. She wants to study and pass the S.L.C. She thinks it can be managed when
she does not light off at night. She thinks she has to put light on or keep lighter/torch light
with her. Similarly, she can put weapon with her so that when her father comes in front of
her, she can attack on his private part. She also says that she could stay without sleeping
at night. Her mother and her elder sister did the commitment that they would give the
security or protect her while sleeping and while doing other daily activities.
Evaluation: As the distance is very long from Kathmandu to Western part of Nepal, the
counsellor had taken a commitment from one of the member of community to observe the
client behaviour and to look after her. A follow-up session has to be continued.

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Note: This case is taken/handled by an experienced Psychosocial counsellor Mrs. Jamuna Shrestha
(Supervisor of Ms. Pragya Shrestha) and Ms. Pragya Shrestha assisted her.
Annex 4:
CASE STUDY

Name: Rita Basnet (Name and caste change)


Age: 25 years
Marital Status: Married with one son and one daughter
Problem faced from: Since violence
District: Kapilbastu
A 25 years old woman, leaving in mother’s home, has loss of valuable assets (jewelleries,
clothes, etc) during violence. She said that during incident, she was outside from that
area. Since the incident, she has fever, difficulty to sleep, loss of appetite, weight loss,
hopelessness, helplessness, frustration, worry, flashback of valuable property, and anxiety
on how to survive.
Support: Psychosocial Counselling (Problem identification, empathy, encouragement for
normalization, provide psycho-education).

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Annex 5:
CASE STUDY
Name: Suman Dahal (Name changed)
Age: 14 years
Education: Class 7
District: Lalitpur

Beginning and Problem identification: The presenting problems he mentioned were


poor concentration in study; bullying from friends.
Identified psychosocial problems were feelings of inferiority complex, poor concentration
in one thing, restlessness, and hyper active.
Assessments, Formulation and Ending:
Family Information: There are mother, the client and younger brother. His father died
two or three years ago. His mother earns bread for the family. His mother is seriously
sick. His elder brother is studying in class 9.
Personal Information: The client has poor concentration in anyone particular thing.
Strength: Curious in learning new things
Support: Counselling (Uses communication skills), Play therapy, use I.Q test (Mixed
Type Group Test of Intelligence test).

Need follow-up

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Annex 6:
CASE STUDY
Name: Rupesh Majhi (Name changed)
Age: 14 years
Education: Class 9
District: Lalitpur

Beginning and Problem identification: The presenting problems he mentioned were


headache; bullying from friends.
Identified psychosocial problems were feelings of inferiority complex, poor concentration
in study, look despair, aggression, fear, feels stress all the time.
Assessments, Formulation and Ending:
Family Information: There are mother, father, he and younger sister. His father has gone
to foreign country for job. At present, his mother earns the bread for the family.
Personal Information: The client is very weak in study. He wants to become a computer
engineer. He is good at singing and dancing. He says, “He feels stress in his headache,
when his friends bully him by saying Maghi machha marna gane hoina (Fisherman,
don’t you want to go for fishing?).”
Strength: Shares feelings with best friend; good at singing and dancing
Support: Counselling (Uses communication skills, Play therapy, Progress Relaxation
Exercise, expression through drawing, encouragement of strength)
Implementation- Action and Evaluation:
Action Plan: To reduce stress and aggression, he said he would do the Progress
Relaxation Exercise whenever he had. To stop being bully from friends, he would talk
with friend clearly.
Evaluation: While observation, he looks happy than previous. He said that Progress
Relaxation Exercise has helped him to reduce his aggression and stress. Good
improvement in study as per his exam mark sheet.

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Annex 7:
CASE STUDY

Group intervention
Nos. of children: 10
Age: 6 ~ 12 years.
Male: 4 and Female: 6

Problem Identification: Feeling of insecurity as they go to school in group, sleep


disturbance, hallucination of assets, fright with strangers, loss of appetite, suspicious with
friend as well, nightmare and feelings of revenge.
Problems/ difficulties: These children go to school in group as they have to go through
jungle, very quite place to reach school. It takes 20 ~ 30 minutes on bicycle. Also, they
do not note book, stationeries, school book. At present, they are not able to sleep as they
do not have shelter and clothes. Thus, there are high changes of cold diseases.
Support: Play therapy; tell stories, song and talking.
Strength: Walk in group; whenever stranger come in their place, they immediately convey
message with their parents.
Recommendation: Need follow up

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BIBLIOGRAPHY:
1. FINAL Sahara reader_proofread
2. Handouts prepared by Ms. Jamuna Shrestha and Ms. Pragya Shrestha
3. Jordans, Mark. Powerpoint: Trichandra Lecture Psychosocial counseling.
4. Jordans. M.J.D.(2003). Training handbook: Psychosocial counseling for children in
need of special protection- Trainer’s guide. UNICEF Nepal
5. Mixed Type Group Test of Intelligence test (MGTI).
6. (October/November, 2007) “3-Days Orientation on Psychosoical counseling for
students of St. Xavier’s college”
7. Case study and sharing from Ms. Jamuna Shrestha, a psychosocial counselor.

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