The engagement in the discussions was not so much on specific questions on topics as on how this program had changed them as professionals, their clinical practice and Caritas-CCAMH. Although one of the participants said, “changes are difficult to explain”, we obtained rich material and found four overarching perspectives during the analysis: participatory learning process, integration of theory and practice with an emphasis on skills, learning in real clinical situations and building self-confidence and job satisfaction.
“All topics were relevant because we chose them”—participatory learning process
Participants described having partnerships or collaborations with different experts from abroad. The experts provided them with new knowledge that had been adapted to the Cambodian context so as to be useful for the staff. Then, the experts had to learn from the staff at Caritas-CCAMH and a mutual learning process was going on. One senior staff member said:
I think experts from abroad learn from other developing countries like us. And we get new experiences that the experts can use in their countries as well. They adapt them to fit with our country.
Another senior participant added:
They [the NT] shared experiences with us, and we had some points to share with them. For example, we helped with cases and those cases were difficult, so they shared with us how to help.
The participants experienced an exchange of knowledge enhanced over time. They emphasized the importance of the discussions of topics for the program beforehand and during the stay. This was the background for statements that all the topics have been relevant for Caritas-CCAMH; that is, the topics were chosen in collaboration with the NT. As one participant said, “Usually, before taking any topics, they asked us to choose and always asked for ideas from our team.”
The Caritas-CCAMH team is multidisciplinary comprised of professionals with various backgrounds concerning knowledge and experiences. The participants stated that essentially the multidisciplinary nature of the NT (i.e., a pediatrician, a child and adolescent psychiatrist and a child psychologist) was an advantage when selecting issues for the teaching blocks to fit the needs of the staff. They reflected that for instance children with autism and intellectual disability may also have emotional problems. However, when the training did not match the everyday work and if there was too much information, it could be difficult for them to follow when they could not apply the knowledge to their own practice.
The participants described the program as a “meeting between experts”. The NT members were experts on different aspects of children’s mental health while the staff members were experts on the Cambodian context; children’s health risks, the availability of resources, etc. Participants emphasized their active participation in developing the teaching block and the flexibility of the program, both before and during the NT’s stay. This required an ability of the NT to modify the teaching process while they were actually doing it, that is, to reflect in action.
“Theory applied with cases and skills is crucial”—integration of theory and practice
The participants characterized their existing knowledge about young people’s MNDD as superficial and said that their education was not “deep enough” and that they to a small extent, had learned the skills needed to manage children’s mental health problems before they started working at CCAMH. They all agreed on the need for new knowledge and that the learning was most effective when the teaching combined theory and practice. To facilitate that, they emphasized the value of applying theory in the analysis of cases from the daily clinic. One senior male participant said:
We brought our own cases for the discussion. We took part in analyzing and assessing the case with them to come up with a plan for how to change the child’s behaviour.. . Therefore, this is different from class teaching.
A novice added:
Theory combined with practice makes us learn faster. .. And without practice, theory never becomes skill.
Participants summarized that knowing how to analyse a case is the first step to applying a skill, and frequently repeated that learning skills was an important aspect of the teaching. A senior staff member reflected:
So, they told that “if we have knowledge, we need skills.” For example, if children threw things, how should we handle this? If we did not have skills, we did not know how to help children. Therefore, we have to have skills to succeed in our work. Some people are good at talking, but not doing. To help children, you should have knowledge and skills.
However, skills can be difficult to learn within the frame of the one/two-week’s courses the NT provided and the participants asked the team to stay longer, which to some extent, can be compensated with repetition over years. Participants recalled, as an example, a workshop on cognitive behaviour therapy (CBT). After three days, the session had to start over from the beginning; the concepts were unfamiliar and the skills were complex. The training in the CBT approach was repeated in later workshops and different situations. For some of the participants, that meant they had got a basic understanding and said it had been useful for them to apply this thinking in their daily practice.
An example of the interactive learning with repetition is a senior female therapist rendering from a workshop on management of children’s behaviour problems:
The teacher made a table and asked us to fill [it] in. .. and then she showed us the proper places. We noted that we put things in the wrong places. Then we knew the right places after the mistake. Later we practiced with clients. At first things did not go smoothly. But after practicing again and again, we felt confident in helping clients and asking questions.
To be able to practice the new skills in clinical work, participants said the training was necessary. Some participants mentioned that some staff lacked commitment and they went on as usual, for example, by continuing their routine without changing to a broader bio-psycho-social-inspired assessment. Participants reflected that maybe a structure for following up the new knowledge was missing.
Participants gave examples of how useful cases from their daily clinic were for them to connect the new knowledge to their everyday clinical work. The learning process shifted between theory and practice with frequent repetitions in the actual session, but also the topics and skills could be an issue in later sessions. They expressed high appreciation for the opportunities for feedback and reflections both on the content and the process.
“It opened my eyes widely”—learning in real clinical situations
Many said they had vivid remembrances of clinical demonstrations, for instance, the pediatrician training them in newborn baby screening. They described how the pediatrician screened newborns in hospital, and then supervised staff at health centres. This awareness in observation was transferred to other situations, for instance, to observe children at all ages when they come to consultations—to assess their appearance, hygiene, drooling, nutritional status, etc. They also mentioned that from the abovementioned demonstrations they learned to pay attention to the parents as well. A senior nurse said:
I learned how to communicate with mothers, for example, when we did newborn screening at health centres; we always asked the mothers “how are you?” Before, I was not aware of this.. . This is what I learned: when the young patients come, do not forget to talk with the parents.
Some elaborated further on this and recalled from other sessions that the therapist has to reach a consensus with the parents on the nature of the problem, how to understand it and what to do about it. They remembered the repetition of the concept of “therapeutic alliance.” After observing the NT’s consultations and having had their supervision on real consultations on video or through the one-way mirror, they said they felt more comfortable starting a consultation. One senior male nurse said, “They have offered us skills on how to sit with clients, how to listen to clients and how to ask [questions]. Those are skills that we do in practice with clients, not [just] theory.”
Participants explained that they had learned these skills, to a large extent, unconsciously, regardless of their professional background, just by being present. The NT’s attitude facilitated their learning; as one novice staff member said, “I want to say about communication.. . for example, she listened to us, asked us questions.”
The NT team was characterized as polite and friendly, almost like friends. Some added that maybe because of this closeness, the NT too often said “yes.” Sometimes the staff actually needed frank feedback, even if it was negative, to learn. A staff member been at CCAMH for six years said “They do not need to please us”.
They remembered this learning in clinical situations as pegs for memory, as one said: “I still remember this as if it was the last lesson.” However, most of the cases for discussion were prepared from the files, and demonstrations were done through role-play. Many stated that they missed learning in real situations.
Regardless of background knowledge and profession, all the participants mentioned observing the NT in consultations and clinical procedures or having gotten supervision in clinical situations. They evaluated this learning highly and talked about transferring knowledge and skills from one situation to another. This modeling and acquiring of tacit knowledge seemed to have been facilitated by what was experienced as the NTs friendly attitude.
“The changes are not only for clients, but ourselves as well”—self-confidence and job satisfaction
This capacity-building program, in their perception, changed their thinking, feelings and behaviour. Concerning thinking, they mentioned empathy for the client and knowing how to analyse them. Concerning feelings, they said they had gained confidence in and enjoyment of their work. As a senior nurse said:
Like others have said, we get knowledge without [conscious] awareness, for example, skills in communication. We have improved a lot now. We have confidence in working with clients. If we had not, we would feel unease, cold hands, cold feet and sweating.
Concerning behaviour, they gained the skills to do their work. Acquiring skills and self-confidence were closely related. They said that when they had skills and knew what to do, they felt self-confident, which made the work more effective. However, there would be cases that were out of their reach and could not be alleviated. One senior therapist recalled once she had presented a case that never improved, she felt bad as a therapist:
She said there must be one or some who are not [getting] better, despite [our] efforts. Therefore, there is no need to feel bad [about this case].. . So after I met her, I felt relieved.. . I never blame myself anymore.
Circumstances outside the therapy room that the therapist could not influence, might have had a negative impact. For that participant, acknowledgement of her helplessness in these situations changed her attitude when seeing clients.
The challenges for professionals in the field of children’s MHDD problems in LMICs are tremendous, and the staff said that they could sometimes feel “anxious, sweating and fearful.” Mastering clinical skills and acknowledging the limits of their mandate supported the participants’ self-confidence. The learning strategy inspired by reflective practice seems to have assisted the participants in integrating the affective aspects of the therapist role.