Pakistan is described in the Lonely Planet guide as ‘one of the world’s best-kept secrets’.1 Unknown and unvisited by most people in the West, perceptions are shaped by a steady stream of news stories with little good to report.

In a country renowned for its political instability, where 49 per cent of the population lives in poverty2 and where there is no public health service, you might not expect to find the words ‘counselling’ and ‘Pakistan’ in the same sentence. But increasingly it seems that awareness about therapy is growing and the appetite for self-development among Pakistan’s urban middle class is fuelling the gradual emergence of a counselling profession.

Nearly 30 years ago Professor Farah Ibrahim, specialist in counselling psychology and education, now of the University of Colorado, Denver, reflected on the pattern of other developing nations and envisaged the potential for counselling in Pakistan. She rightly predicted that, as the extended family gave way to the nuclear family and as society became more urban and industrialised, the demand for counselling in Pakistan would increase.3

For the urban middle classes able to afford counselling, the biggest obstacle to receiving it has been the lack of qualified counselling practitioners. Pakistani counselling trainees often access therapy while studying in the UK or US but discover, on returning home, that finding a good therapist is not easy. Meanwhile the most vulnerable members of Pakistan’s society have little in the way of access to counselling support, other than that provided through the charities established by wealthy benefactors to help those in poverty.

A recent article in The Lancet drew attention to the scale of Pakistan’s drug problem as one of the challenges the new government, elected in May this year, must face.4 It’s estimated that there are 6.45 million drug addicts in the country and there is a growing need for treatment centres and hospitals equipped to address the problem and understand its links with poverty and abuse.4

It was this that led Abdul Allana, a businessman from Pakistan, to come to London 12 years ago to attend a residential diploma course on addiction, run by Lynne Kaye, Director of the Centre for Personal and Professional Development (CPPD), an established counselling training school in the UK. This meeting was the start of a relationship that continues to play its part in the development of the counselling profession in Pakistan. Having started Alleviate Addiction Suffering (AAS), a rehabilitation centre for some of Karachi’s male drug addicts, Abdul saw a need to introduce counselling skills to his team of clinical psychologists, doctors and paramedics. He invited Lynne Kaye to visit Pakistan to provide some vital training on the subject of addiction and child abuse.

Counselling training

‘I have never accepted an invitation from any trainee before but this one felt compelling,’ says Lynne, who describes her first training experience in Karachi as ‘utterly profound’. She explains: ‘So many men were open about their own abuse as children; they did not hold back. There was an enormous humility, grace and openness; but the hunger for self-development among the people we met was absolutely overwhelming.’

Responding to this yearning for knowledge, CPPD has been delivering its own independent counselling training in Karachi since 2003, from one of Karachi’s training venues. ‘When we began offering counselling training in Pakistan there was no humanistic relational therapy training available to potential trainees,’ explains Lynne who, along with fellow Director Jenny Sandelson, regularly travels to Pakistan to deliver the same part-time courses that they run in London at certificate, diploma and advanced diploma level. This year, for the first time, CPPD is running the same three-year BACP accredited training programme in Karachi that they have run in London, Malta and Northern Ireland.

‘What has been most striking about trainee groups in Pakistan is their openness and enthusiasm for self-reflection and development,’ Lynne says. ‘There has not been an existing culture of therapeutic counselling training and the trainees have seized the opportunity to express their feelings.’ A female lawyer in her 30s, now in training, believes: ‘There is a huge need for counselling in Pakistan. There is a culture here of not talking about how you feel and constantly covering up what you feel. There is a lot of shame around topics such as sexuality, masturbation, abuse and not conforming to the “norms”.’

Those accessing counselling or signing up for counselling training are predominantly urban professionals from the middle classes. ‘Almost all the trainees have gone through university because education is so important in Pakistan. They come from the legal profession, or multinational companies, or they may be CEOs of charitable organisations, psychologists, teachers, organisational or business trainers, physiotherapists and housewives (who are university educated). We have also had psychiatrists attending our training in Pakistan,’ Lynne reports.

Confidentiality and boundaries

‘In Pakistan our trainees know each other’s families, and their siblings, and may come from the same community. So if confidentiality was breached, it could have profound consequences, and lead to a rift or a break-up in a family,’ Lynne adds. Indeed, in the most extreme circumstances, it could endanger someone’s life. The groups are considered carefully therefore to ensure that siblings, relatives and spouses are not studying together.

As both clients and counsellors tend to come from the same sector of society, this can also pose problems for practising therapists. Atia Naqvi is a counselling psychologist trained with CPPD, with eight years’ experience and a successful private practice. Negotiating boundaries is one of the complexities she must continuously address in her work. ‘It’s a small segment of society who can afford counselling and so the likelihood of knowing someone is very high. Sometimes I work with someone for one or two sessions and then realise that they may be closely connected to someone who I know well. This can become very challenging in terms of how to manage the relationship with the client and I often need to refer clients on. This is a dilemma that happens a lot as a practitioner in Karachi.’

Farah Saeed, a counsellor and supervisor, describes how the cultural context in Pakistan has influenced how she has learnt to negotiate boundaries: ‘I don’t think in Pakistani culture the word “boundary” has a synonym. We have a rather staunch collectivist culture, where saying “It’s my life” is a crime and is mostly punished in the form of social isolation. The way we are raised, we are not taught to be on our own. Implementing boundaries with clients in this culture is a big challenge for me.’

Trauma is never far away and frequently emerges among trainees, who describe their experience of violence, muggings, car-jacking or of their loved ones being held at gunpoint. Says Lynne: ‘There is PTSD everywhere in Karachi. Almost half of the trainees in a recent cohort had been held at gunpoint and some three or four times. That speaks volumes in terms of what the trainees have to carry for themselves and, potentially, for their clients too.’

Counsellor Saira Shaikh reflects on the emotional fallout for her and her family when her father was held at gunpoint by burglars at home. It led to his breakdown and, with a lack of counselling provision in Lahore, he was treated with electric shock therapy and SSRI antidepressants and took several years to recover.

In Karachi, Atia Naqvi recalls a powerful experience when she was a counselling trainee: ‘My first awareness of a “safe space” came on the first day of training. Right before our first class I had been car-jacked. The robbers sat in my car and made me drive around for a while before dropping me and my two-year-old son on a secluded street and then taking off with my car and valuables.

’Throughout this ordeal I was only conscious of being concerned for my baby. When my tutor, Lynne, asked me, “How are you doing?” I found my eyes welling up with tears, something that I wasn’t accustomed to. I realised I had no clue how I was doing!’

Unsurprisingly, with incidents like this being common among trainees, the need for therapy while undergoing training is very real. This has been particularly problematic because there have been so few qualified counsellors in practice. ‘Initially some of the trainees sought therapy with psychiatrists. This may or may not have been that effective but it was better than nothing in the early days,’ explains Lynne. ‘To provide support we would visit Karachi every two months and offer a combination of supervision and therapeutic work. The training is designed to be therapeutic. We allow trainees a lot of space and it is very process-orientated.’

Practicalities

The tutors travel to Pakistan several times each year to teach the courses. The days are long and the training intensive. But the main challenge is highlighted by Jenny Sandelson: ‘It’s the lack of a pre-existing infrastructure around the profession of counselling. This has meant that CPPD has had to build the infrastructure to support the training. It has also had to promote counselling as a profession to the wider community. This has taken time and has meant that the initial trainees had to create placement opportunities and practices.’

Trainees need to gain a placement and accumulate 220 hours of counselling practice. Placements now exist in hospitals, NGOs, prisons and rehabilitation centres willing to make use of the voluntary hours being offered by trainees. Maintaining contact with trainees from the UK and the logistics of running a training long distance requires constant innovation. For example, supervision is offered by Skype. But, as Jenny points out: ‘The local market cannot afford to pay the going rate for supervision in the UK. We need supervisors in the UK who are willing to work at reduced session rates and in an entirely different context and culture’.

It seems that, whether living or working in Pakistan, there is a need for contingency plans. Atia Naqvi describes a typical day in Karachi: ‘It’s a very dynamic city: a great place to be and a scary place too. Today it was raining and there was no power, so it’s not a regular, predictable city where we can work to a planned schedule.’ Adapting to this unpredictability is essential for the trainers, Jenny explains. ‘We are to some extent reliant upon the internet, and in a country where there has been an unreliable electricity supply, this can be stressful. The country is also increasingly politically unstable. The number of sectarian killings and armed robberies has increased significantly over the past few years. This has meant that we have had to put in place alternative forms of reaching trainees if we are prevented from travelling there.’

Colonialism

Mindful of potential criticism that counselling training is being taken to Pakistan by the British to exploit the local market, Jenny points out that, while CPPD is quite naturally ‘pro-therapy’, all its work in the development of counselling overseas has been by invitation. Providing training in Pakistan is not about the financial reward, she explains: ‘At a personal level, it is incredibly rewarding and innovative work. As a tutor, you can’t get stale when you work with difference on this scale.’

Inevitably, as more counsellors become qualified in Pakistan there will be a growing body of potential tutors to contribute to training programmes. ‘This year one of the first students we trained in 2005 is now going to be teaching counselling training on the certificate course,’ says Lynne. It is, she points out, a clear sign of how the training will develop in the future: once local counsellors are trained, they will become the educators in the field.

Elsewhere in Pakistan there are further signs of this. One of CPPD’s former counselling trainees is Tahir Ahmed. Spotting a gap in the provision, he has established his own counselling organisation, Therapy Works, in three major cities: Karachi, Lahore and Islamabad. Established to respond to the growing demand for counselling, Therapy Works has also expanded into training and now offers integrative counselling training courses at certificate and diploma levels, accredited by the Counselling and Psychotherapy Central Awarding Body (CPCAB) in the UK.

Last year Heather Price, CPCAB’s external verifier for Therapy Works, visited all three cities to assess the quality and standard of the courses. ‘What really struck me as I was reading some of their essays is the amazing journey that many people have been on during the lifetime of a course. They may have come from violent or abusive backgrounds and there is a lot of depression, oppression and anxiety. Their work using TA and other theoretical approaches helps them to understand aspects of their “self”, their own life history and patterns of behaviour. Particularly, but not only, the women have often been kept subservient. The big thing that comes out of it in terms of their self-development is that the trainees realise that they now have choices,’ she says.

Showing signs that the profession could be expanding further, the founder of Therapy Works has some ambitious plans to extend the reach of counselling into rural areas. Through a programme known as ‘Barefoot Counselling’, Tahir aims to train 100 trainees to work with clients in their own towns and villages across Pakistan. The idea is to provide basic but much needed emotional support at a grassroots level and the opportunity for trained counsellors to earn a living from their work. If his hopes are realised, counselling will reach a whole new sector of Pakistani society.

Finding work

The familiar issue of finding work post-training for newly qualified counsellors in Pakistan soon emerges, as one trainee explains: ‘The biggest challenge faced by future trainees will be finding a stable income from counselling. While private practice pays well, the public sector does not. Salaries for trainee counsellors and counsellors are low and barely sustainable, which is why, even as a trainee, one has to be on the look-out for private clients to supplement income.’

Many practitioners drawn to counselling training are psychologists and psychiatrists, who are not trained to work relationally but who can adapt their learning to their professional lives, as Jenny Sandelson observes: ‘There are few actual job opportunities in counselling at present and so undertaking training makes sense if trainees can incorporate it into their existing profession. The mental health field in Pakistan is very traditional and medicalised, so the idea of counselling is probably appealing to practitioners who are open to working in different ways.’

There is a growing recognition of the need for counselling within organisations such as hospitals, counselling psychologist Atia Naqvi says. But for now she, like many qualified counsellors, is working in private practice. ‘I am working 18–20 clinical hours a week. I get a lot of referrals from hospitals and referrals of clients with depression. There are lots of relationship issues, teenagers, drugs and abuse. But I and a lot of my colleagues have to send clients away,’ she reports.

Regulation and standards

As the number of counsellors in Pakistan increases, they speak openly about the challenges that lie ahead for their profession. In a country where there is an unsatisfactory legal system, where corruption and abuse are rife and where, as one counsellor pointed out, it’s impossible to get professional indemnity insurance to cover one’s work as a counsellor, there is much for them to be concerned about. The lack of a governing body is a central issue, as one trainee explains: ‘We have no regulator like BACP here. This leaves the profession open to be abused. There are a lot of unqualified counsellors providing their services to clients, which can be extremely dangerous.’

In the absence of a regulatory body, counsellors, trainees and training providers in Pakistan are looking to established overseas professional bodies such as BACP to regulate the profession against unethical or unprofessional practice and to accredit courses. But a simple translation of the membership criteria from the UK to Pakistan appears to pose immediate problems economically, as Jenny Sandelson explains: ‘The cost of trainee membership is very high for the trainees in Pakistan where the average salary of, for example, an accountant is about £4,000.’ Counsellor Farah Saeed believes that future trainees and present practitioners need to organise themselves as a group force and develop an ethical code of conduct that is best suited to this culture. ‘We need to learn to work and live with these ethics and train, educate and support others in ethical practices,’ she says.

Conclusion

Against the odds or perhaps because of them, the seeds of counselling that have been planted are taking hold in Pakistan. Slowly the value of talking therapies is being understood and counselling is travelling from the realms of the privileged few into organisations and out into rural Pakistan.

However, the figures collected by CPPD reflect how far there is still to travel: ‘Since we began in Karachi, we have trained 44 trainees and we now have 14 proficient therapists practising in Pakistan who I would happily recommend,’ reports Lynne Kaye.

With an eye to the future, Jenny Sandelson has a strong sense of CPPD’s aspirations for Pakistan’s counselling community: ‘Our hope is that in the long term the graduates will take on the running of the training and develop it to give access to wider communities. You have hungry trainees in Pakistan. Competition is needed which enriches the whole field.’

This appetite for more counselling training is summed up by clinical psychologist Atia Naqvi: ‘There is a genuine hunger for training, workshops and constant availability of resources in the field of counselling and psychotherapy. I would love to pursue a doctorate in counselling and yet the only doctoral programme available is in clinical or organisational psychology. I hope that soon we may have access to more training, but for now we can only read about it and wish it could be made available to us in Pakistan.’

Nicola Banning is an MBACP accredited counsellor specialising in working with individuals and organisations. She is also editor of the BACP Workplace journal Counselling at work. Nicola has a background in broadcasting with the BBC and is now a freelance writer on counselling, the workplace and professional development.

References

1. Singh S, Brown L, Clammer P, Cocks R, Mock J, O’Neil K. Pakistan and the Karakoram Highway (7th revised edition). Melbourne: Lonely Planet Publications; 2008.
2. AFP/Mussadaq M. UNDP report: nearly half of all Pakistanis are living in poverty. The Express Tribune; 29 March, 2013. http://tribune.com.pk/story/528162/undp-report-nearly-half-of-all-pakistanis-are-living-in-poverty (accessed 31 July 2013).
3. Ibrahim F, Almas I. Guidance and counselling in Pakistan. International Journal for the Advancement of Counselling 1983; 6(2): 93–98.
4. Yaqub F. Pakistan’s drug problem. The Lancet 2013; 381(9884): 2153–2154. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61426-9/fulltext?rss=yes (accessed 22 July 2013).