**7. South African narratives**

As a result of the global outbreak of COVID-19, most people in South Africa struggled with the "new normal". It is under this "new normal" that citizens were expected to change their ways of life. The adjustment process affected the economies, corporate spaces, education system, religion and families. At the personal level, the

*Volunteer Counseling Services in the Context of COVID-19: Compromises and Challenges DOI: http://dx.doi.org/10.5772/intechopen.101972*

pandemic and the process of adjustment triggered in most people, the onset of mental disorders, such as anxiety and depression [3]. The rise in these disorders suggested that the psychological services were needed, to maintain the mental health for the citizens.

During lockdown, citizens who were presenting with symptoms of mental illnesses became more frustrated because the public health care centres were only accessible for the severe and emergency cases. To help the public, mental health practitioners who run their private practices offered their volunteering services to the citizens who were affected by both COVID-19 and gender based violence. Their counseling services were offered through direct telephone or through *WhatsApp* calls. In the process of executing their volunteering services, these counselors experienced several challenges as cited below:

#### **7.1 Telepsychology**

Most of the mental health practitioners (registered counselors/psychologists) in South Africa were trained to use the traditional methods of counseling such as face-to-face counseling. When COVID-19 hit the shores of South Africa, the first challenge was to find a new counseling mode and platform that would not expose the clients/counselors to COVID-19 since the traditional methods were not safe. It is in this regard that telepsychology was recommended as the safest method in this era. As an unfamiliar method, some of the counselors and psychologists were not confident in using it:

*Honestly, I did not know how to do counseling online. I am used to see the clients face-to face. At first I was afraid that I am gonna do it wrong, but once you pick up the phone, the conversation just flow. I can even pick the emotions on the other side. Practice makes perfect.*

At first, the practitioners were not confident in using this mode since they did not have the formal training in it. Again, the practitioners were concerned that without such training, they are likely to violate HPCSA ethics rules and regulations. As such one counselor countered: *"I feel good when I do something I master. This one was just new. You learn as you go. The problem is that as you learn, you don't want your practicing licence to be revoked".* These concerns were genuine. For instance, according to the HPCSA form 223, the health practitioner is expected to obtain an informed consent before the commencement of the counseling session. Under normal circumstances, a consent form is discussed with the client and signed by both parties. When using telepsychology, the concern was mainly on how the practitioner would obtain such consent. Initially, this uncertainty led most of the practitioners to be uncomfortable in volunteering their health care services. Another counselor affirmed:

*At first it was frustrating because we had no document to sign. A phone just rings and the person start narrating his or her problems. I resorted to verbal informed consent, but I had to read up on HPCSA and the APA guidelines to ensure that I do it right.*

Even though it was frustrating at first, counselors had to navigate their way through, to ensure that they do not deny the public of these vital services, yet at the same time they ensured that they do not violate the HPCSA ethics.

In addition, another issue that was raised concerning telepsychology was confidentiality. According to HPCSA form 223, in offering psychological services, the practitioner is expected to maintain confidentiality. However, it is during this time that the practitioners experienced an ethical dilemma on how to handle confidentiality in telepsychology since the information of the session could still be accessed by the network providers of both users. Most of these practitioners are still uncomfortable with this intervention approach since private information might not necessarily be private. As such one counselor stated:

*You see, one thing that might lead us into trouble when using this method is confidentiality. Do you know that the workers at those networks can still access our recordings? What if the spouse is working in one of the networks, s/he might access the file and listen to the whole conversation. I don't trust phones. The phone can still be hacked and the information can be accessed. I don't think I will do forensic work online. I am still afraid.*

Although there is no total security of information when one uses this mode, in the meantime, to mitigate this risk, most of the practitioners resorted to informing the clients about this limitation before the commencement of the first session. The challenge with this form of mitigation is that it is likely to limit the client from sharing their most private issues with the practitioner.

#### **7.2 Challenges during the intervention process**

When they started with the intervention, some of the practitioners did not anticipate that the cases would be overwhelming. Immediately when their telephone numbers were broadcasted over the local radio stations, the practitioners were overwhelmed by many calls which were outside the scope of the mental health practitioner expertise. For example some counselors expressed:

*One client called me about food parcels. She said that she did not get her food parcels for three months. I encouraged her to go to the local social worker.*

*…this woman called me and asked about the procedures of divorce. She said she does not have enough money to pay the lawyer. Her husband was cheating on her for a long time and now she wants divorce. She received counseling in the hospital in the past. This time she just wanted to start with the process of divorce…*

The influx of calls from the citizens was an indication that most people indeed needed help, not only related to COVID-19 but covering a wide range of issues. To narrow this influx of calls, the public were encouraged to contact the practitioners on matters related to mental health.

As they continued to offer their volunteering services to the public, one other challenge was that there was no uniformity in recording of the statistics. Since this volunteering was unplanned, it was not coordinated. Instead, different templates were used to record the cases. In as much as psychological intervention was provided, statistics is also important for designing future intervention strategies based on the current findings as a baseline. With such gaps, it would be a challenge to improve the services and for future intervention.

Another challenge that was brought forth was the issue of boundaries. Since the practitioners availed their personal contact numbers to the public, it was challenging at first because some individuals would sometimes phone the counselor at odd times even *Volunteer Counseling Services in the Context of COVID-19: Compromises and Challenges DOI: http://dx.doi.org/10.5772/intechopen.101972*

though the public have been informed of the counselor's available times. Giving out personal numbers to the public led to enmeshed boundaries. To resolve this problem, practitioners had to find ways to re-create boundaries. To this effect, one counselor said:

*Once I realised that some called me late at night when I am sleeping, I decided to switch off the phone because it is a business phone. For my family I use the other one.*

Despite all these challenges, it seems practitioners perceived them as a learning curve that contributed to their professional growth.

#### **7.3 Financial implication**

When they started volunteering, it was anticipated that the time spent with the general public might affect the businesses of counselors negatively since most of them are self-employed. However, the counselors reported that they scheduled times for their daily work and for volunteering differently in order to control interference. Even though their businesses were not affected, a concern related to costs was raised. It was reported that some of the members of the public called the practitioner using less credit and during the session, they requested to be called back once their credit is depleted:

*They will call you knowing that they don't have enough airtime. When their airtime is finished, they send you "please call me". You find yourself calling them back with your own money. When you call them back, their conversation becomes lengthy. You end up being frustrated.*

To ensure that their volunteering do not affect their finances, some of the practitioners stated that they informed the clients that they are liable for their phone bill. For instance, it was clarified that if the call breaks, the client would call again when s/he has enough credit. Alternatively, they were sent a message to contact the toll-free numbers for the non-governmental organizations that are providing counseling services too.

Even though their volunteering compromised their time and money in some instances, to some extent the process has enabled them to be innovative in trying to meet the needs of their clients using telepsychology. Despite the compromises and challenges, volunteer counseling appears to have also brought fulfillment as one counselor expressed: *"Even though I was not paid, at least I helped other people".* It appears as if it is this fulfillment and inner peace that made the practitioners to turn a blind eye to these challenges and continue to assist the people. In as much as it was fulfilling, it is recommended that these practitioners should not overwork themselves, to avoid compassion fatigue, which might eventually be registered as another challenge.

### **8. The Ugandan narratives**

On March 21, 2020, Uganda confirmed the first case of COVID-19. This unfortunate information resulted to restrictive measures including country-wide lockdown of sectors except those providing essential goods and services [13]. This has been accompanied with mental problems including stress, depression, anxiety and others. Mental health services were notably on demand during the pandemic owing to the rise in mental health issues, child abuse and gender- based violence [14]. Cognizant of the repercussions of the virus on the mental health, the Ministry of Health (MoH) invited and recruited volunteer health professionals in response to the National fight against COVID-19. Some of these volunteer counselors provide face-to-face counseling services while others have resorted to telepsychology. Volunteer counselors have been surprised at how effective telepsychology can be of help amidst the pandemic. One of the counselors said:

*Previously, we did not think that providing counseling services over the telephone would have much impact. Now, we have learnt that distance should not be a barrier to helping individuals, even if they come from remote communities.*

The use of telepsychology helps connect mental health professionals to undeserved clients. The client and counselor can engage in service while maintaining social and physical distance. People are encouraged to call or send messages to the mental health professionals. However, there are noticeable challenges and compromises on the side of mental health workers who volunteered their services. These challenges and compromises are categorized into three themes as presented below.

### **8.1 Limited skills to use telepsychology and internet connectivity issues**

The term telepsychology refers to using internet and communication technologies. In the context of COVID-19 this means access to internet is access to counseling services. However, counselors and clients had issues related to internet subscription. Some of the telepsychology channels and information platforms leveraged on third party operators including Facebook, WhatsApp and others are costly. The extra charges incurred on Over the Top (OTT) tax affected the use of telepsychology platform and mental health information access for the population [15]. Besides, many counselors did not have adequate training in the use of modern technology. Other counselors complained of poor network connectivity and consistent power blackout. In this context, the counselors believe that there is need for national guideline grounded with respect to local context. One counselor had this to say:

*Telepsychology innovation has the capacity to reduce the mental health costs and enable access to better quality mental healthcare. However, loss of internet connectivity and unreliable power supply impede its application.*

In developing countries like Uganda, many people are offline because either they cannot afford smartphones or costs involved and hence unable to access the service. Internet access plays an important role in providing mental health services. Additionally, internet connection is not always stable. One counselor put it better:

*A dropped connection may not be a big problem between a counselor and a client. It could lead to possible client misunderstanding and mismanagement.*

Counselors are able to offer counseling through modern technology to clients who had psychological and emotional challenges. However, some counselors believe that many other clients are unable to transit to telepsychology despite the fact that they are in need of professional support. One counselor said:

*Clients without the means from the equipment such as lack of smartphones are largely affected by the inability for me to provide face-to-face services. Those with*  *Volunteer Counseling Services in the Context of COVID-19: Compromises and Challenges DOI: http://dx.doi.org/10.5772/intechopen.101972*

*psychological problems are unable to access psychological care at all. Sadly others are reluctant to adapt to the "new normal".*

#### **8.2 Verbal versus nonverbal communication in counseling**

Non-verbal communication is established through gestures, postural positions, eye contact, voice tone and nodding. The volunteer counselors believe that failure to observe the nonverbal communication was a serious challenge to them using telepsychology. The counselor may wish to match the client's posture with verbal communication for congruence or incongruence. The counselors believe that something is lost due to virtual distance between the clients and counselors. One counselor tells her experience with respect to non-verbal cues:

*I volunteered to provide counseling service to a married couple who hit a rough patch in their lives. As counselor I listened attentively to both the wife and husband as they narrated their alternative views of their marital problems. The wife is willing to tell me how unhappy she is, she feels the husband is cheating on her and considering quitting marriage. On the side of the husband everything is okay and the wife is simply paranoid. That's all the husband said through the session that took 60 min. The challenge is that I am unable to assess the nonverbal behaviours of the couple when working remotely which would tell more to the story if all of us were together in the same counseling room. There are things that are much harder to notice and attend to virtually.*

Counselors believe that when sitting with clients, they often use their own body language and positioning to help clients feel more comfortable during moments of silence or when struggling with difficult emotions. However, this strategy is difficult to deploy with telepsychology sessions. One counselor said. The outbreak of COVID-19 therefore has had a deep impact on the way counselors communicate with clients given the need to maintain isolation and social distancing. However, both of these have been compromised in the COVID-19 experiences. A counselor narrative expounded on this challenge:

*…not having cues from the audience makes it difficult for counselors to know if the clients are engaged. As a counselor I rely on non-verbal communication to proffer care to my clients: head nodding, smiling, focussed eye contact. The absence of these elements makes it difficult to help my clients.*

#### **8.3 Privacy and confidentiality**

The rapid emergency of digital technology used by counselors to deliver services during COVID-19 is characterized by issues related with privacy and confidentiality. The counselors acknowledged that there are no national guidelines for secure management of individual's electronic information and services placing personal private data at risk. Other individuals might have access to private and confidential conversation. Even stored data could be accessed by unauthorized companies or people. Therefore there are significant privacy and confidential risks in telepsychology systems that can greatly impact the clients' and counselors' levels of trust and relationship and use of the technology [16]. A client who wants privacy, getting a safe place in crowded house to do a 60 min telepsychology session is quite challenging. A counselor shared his experience:

*Some clients might worry about privacy and there is reluctance among clients to have these modern technologies that affects counseling sessions. Clients may be more confortable having such sessions while face-to-face with the counselors.*

#### Another counselor shared her experience:

*There is a probability for other people to overhear sessions especially because these sessions took place in homes, in our sitting rooms or small compounds hence risking confidentiality.*

#### Another counselor reported:

*Besides malfunctioning internet connection and other technological issues, one of the biggest barriers for social distance counseling in maintaining a client's privacy especially if the clients want to talk about the person is nearby. An emotional husband could not tell the entire story concerning her wife whom he considered a source of the problem.*

Some clients found it difficult to be able to speak in private. Their children, wives or husbands were home and it was difficult to have an hour-long or so conversation without being interrupted. It is a challenge for counselors to address difficult issues when family members are around or nearby. The spread of the virus and social distancing measures are changing the way counselors work across the scope of the field. In the transition from face-to-face to telepsychology, new ethical challenges are emerging. With family members including children, roommates and partners spending more time at home, it can be difficult to maintain the confidential space which is key to therapeutic relationship.

### **9. Recommendations**

In the context of COVID-19, telepsychology has become a reality facilitating the ease of providing online counseling within the challenges of safety protocols. Therefore, this paper recommends that counseling regulatory bodies within African countries (particularly in Nigeria and Uganda) should generate operative policies to guide provision of e-counseling services. Such policies should expand on the training needs of counselors, ethical issues of confidentialities, relationship boundaries, and informed consent among many others as the counselor's narratives presented in the paper emphasized. No doubt such policies will highly offer immensurable support to counselors who otherwise may continue to grope in the dark for want of guiding procedures to follow, except for South Africa where there is seemingly an already existing policy.

It is anticipated that the policy document should influence the higher education training program to appreciate the need to make a paradigm shift towards integrating the canons of e-counseling into its curriculum in order to adequately prepare the student counselors to be effective and efficient e-counselors. This would also mean that concurrent workshops in terms of in-service-training ought to be offered to the already trained professional counselors in order to boost their efficiency of telepsychology skills. Again the onus falls on regulation bodies to ensure that such policies are inaugurated and practiced.

In view of the poor internet connectivity that majority of the counselors raised, the paper recommends that policy makers of counseling bodies liaison with network *Volunteer Counseling Services in the Context of COVID-19: Compromises and Challenges DOI: http://dx.doi.org/10.5772/intechopen.101972*

providers in alliance with government to negotiate a sustainable service provision, which ought to facilitate telepsychology. Such negotiations ought to include confidentiality and the cost of data tariff, bringing it to affordable rate. In this way, counselors will be attracted to integrate traditional counseling approaches with e-counseling in order to continue to be relevant to the populace that needs their services.
