|Year : 2018 | Volume
| Issue : 3 | Page : 197-201
From the editors… An introduction to a Special Issue: A focus on mental health and psychosocial support in Afghanistan
Martha Bragin1, Bree Akesson2, Bezhan Ayubi3, Marian Tankink4
1 PhD, Silberman School of Social Work at Hunter College, CUNY, New York, New York, USA
2 PhD, Wilfrid Laurier University, Waterloo, Ontario, Canada
3 Assistant Professor and mental health counsellor at the Faculty of Psychology and Educational Science of Kabul University, Afghanistan
4 PhD, Editor in Chief of Intervention
|Date of Web Publication||30-Nov-2018|
Editor in Chief of Intervention
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bragin M, Akesson B, Ayubi B, Tankink M. From the editors… An introduction to a Special Issue: A focus on mental health and psychosocial support in Afghanistan. Intervention 2018;16:197-201
|How to cite this URL:|
Bragin M, Akesson B, Ayubi B, Tankink M. From the editors… An introduction to a Special Issue: A focus on mental health and psychosocial support in Afghanistan. Intervention [serial online] 2018 [cited 2019 Apr 21];16:197-201. Available from: http://www.interventionjournal.org/text.asp?2018/16/3/197/246440
| Introduction|| |
Mental health in Afghanistan
Afghanistan continues to face extraordinary challenges after almost 40 years of continuous armed conflict. Despite these difficulties, many Afghans have been working tirelessly to protect, rebuild, develop and maintain their national institutions. One such effort was the National Strategy for a Mentally Healthy Afghanistan (Government of Islamic Republic of Afghanistan (GOIRA), & Ministry of Public Health (MoPH), 2009), which recognised the impact of conflict on mental health and psychosocial wellbeing. The National Strategy laid out an ambitious scheme for establishing integrated and comprehensive mental health and psychosocial support (MHPSS) in the country. Under the leadership of the Ministry of Public Health, professional psychiatric care is now part of the Basic Package of Health Services and Essential Package of Hospital Services. Furthermore, primary care doctors, assisted by paraprofessionals, are available to diagnose and treat people with mental health, neurological and substance use disorders, working in settings ranging from the hospital to the community.
However, the National Strategy also noted that nearly four decades of armed conflict has overstressed many of the protective factors that were inherent in Afghan society. Many Afghans experience psychological sequelae directly related to the conflict, such as injury, loss and exile. However, many more experience the indirect effects of conflict, such as the ossification of family structures, erosion of communal protections, uncertainty about the future and stressors affecting familial and communal relations. In addition, economic deprivation caused by ongoing violence, severe drought and low levels of growth also take their toll on psychosocial wellbeing (Babury & Hayward, 2013; Government of Islamic Republic of Afghanistan (GOIRA) & Ministry of Public Health (MoPH), 2009; Miller, Omidian, Rasmussen, Yaqubi, & Daudzai, 2008; Ventevogel, Jordans, Eggerman, van Mierlo, & Panter-Brick, 2013). In fact, approximately 80% of Afghans who seek MHPSS services are experiencing non-psychotic disorders and adversity-related distress, requiring professional counselling and psychosocial supports rather than medical psychiatric care (Government of Islamic Republic of Afghanistan (GOIRA) & Ministry of Public Health (MoPH), 2009). However, until just two years ago, there was no university-level programme to educate Afghan counsellors, leaving a significant gap in the country’s capacity to respond to the large number of Afghans who enter mental health clinics in need of a broad range of professional responses to the adversity-related psychological and social problems.
Background to this Special Issue
The idea for this Special Issue was conceived out of a United States Agency for International Development (USAID)-funded project to develop and support higher education in Afghanistan to prepare the next generation of mental health professionals. Hunter College City University of New York was contracted to partner with Kabul University and Herat University to create strong, effective, 21st-century counselling departments that are equipped to lead the nation in the intellectual and practical development of effective counselling services, by and for people from Afghanistan’s diverse cultures. The goal of the project was to ensure that graduates of the two programmes were equipped to provide clinically sound and culturally appropriate counselling services to Afghans around the country. Graduates have already begun to work in diverse MHPSS contexts, such as schools, juvenile justice facilities, child protection agencies, women’s support facilities and non-governmental organisations.
Throughout the course of this project, the faculty members charged with teaching these subjects at university level have discovered a dearth of literature on relevant issues relating to Afghan families and communities. They identified gaps specifically relating to concepts of psychosocial wellbeing within an Afghan context and a lack of Afghan literature elaborating on the cultural and spiritual aspects of daily life in Afghanistan. The Afghan faculty members also noted a lack of accessible information on the Afghan-specific programmes that include culturally specific ideas and concepts to support wellbeing among the ordinary Afghans.
Therefore, in this Special Issue, we present a diverse range of texts, including one interview, four research articles, four field reports and nine personal reflections. Fifteen contributions have been authored or co-authored by Afghans with direct experience in MHPSS. The following pages will give the reader a timely and rare glimpse into the work and lives of these Afghan professionals who are committed to the wellbeing of their communities and their country.
The special issue begins with guest editor Bezhan Ayubi and Hikmatullah Noori’s interview with Rohullah Amin, the host of weekly TV programme on psychosocial wellbeing. Amin is an Afghan-trained psychiatrist who began his career working with the Afghanistan National Security Forces to care for the psychiatric needs of veterans and wounded service members. After studying Counselling and Applied Psychology in the United States, Amin returned to Afghanistan with his family in 2013. With an expanded knowledge of MHPSS, he found that the Afghanistan war and its sequelae had affected him and his family in ways that he had not previously understood. He and his wife, university lecturer Sajia Begham, founded and supervised a small programme to provide psychosocial support to families who were living in shelters for women who had experienced family violence. In this position, Amin quickly learned that people from the neighbourhood were seeking his advice on issues ranging from child development and marital problems, to managing intergenerational culture and value differences among extended families. To meet this need, he established a popular weekly radio and television programme to help families deal with the stressors of war, especially as they related to family matters. Ayubi and Noori’s interview explores Amin’s ideas and experiences providing public psychoeducation in contemporary Afghanistan.
In their article titled, ‘Mental disorder or emotional distress? How mental health surveys in Afghanistan ignore the role of gender, culture and context’, Peter Ventevogel and Hafiz Faiz address the discrepancy between the epidemiological data that show high prevalence figures for mental health problems in Afghanistan versus the realities of the Afghan people living in difficult circumstances. Many symptoms that surveys considered to be mental health problems are actually normal responses to living in extremely difficult circumstances. Ventevogel and Faiz critique these surveys, noting that there is not enough attention to idioms of distress and gender segregation in the Afghan society. According to the authors, increasing the understanding of what is ‘at stake’ requires not only better validated surveys, but ethnographic approaches to learning about the everyday experiences of the Afghans. This echoes messages from earlier scholars (e.g. Becker, 1995) about the need for international researchers to move beyond cross-sectional, epidemiological approaches to understand the cultural and emotional experience of populations affected by community and state violence.
In their quantitative research article titled, ‘Examining help-seeking patterns within modern and traditional resources for support in Afghanistan’, Qais Alemi, Susanne Montgomery, Valerie Smith, Carl Stempel, Patrick Marius Koga, Brianna Taylor and Catherine Fisher examined help-seeking behaviour for mental distress among residents of Kabul. They found that health-seeking behaviour is highly pluralistic and differs between men and women. Afghans tend to draw on their faith before using social supports to cope with mental distress. A significant number of people reported encounters with religious leaders and scholars such as mullahs (local clergy) and tawiz (talismans) in their quest for psychosocial care, a message previous highlighted by Honwana (1998, 2005). The authors end the article by promoting an integrated mental health system that embraces the best of both modern and traditional healing practices.
Emily B. Allan, Abdul Fattah Najm, Helen Fernandes and Becca Allchin describe obstacles and supports for people who experience psychosocial disability in their article titled, ‘Participatory lived experience research: Barriers and enablers for social inclusion for people with psychosocial disability in Afghanistan’. Using qualitative research methods to collect data from individuals and families who experience ‘psychosocial disability’, the authors identified main barriers and enabling mechanisms. They found that the absence of good mental health services in Afghanistan represents a significant barrier, whereas a supportive family and community is a critical support element for their research participants. The authors conclude that organisations should place more emphasis on enhancing the support of families and communities.
In the final research article titled, ‘Developing a culturally-relevant counselling psychology degree program in Afghanistan: Results from a DACUM Study’, Martha Bragin, Bree Akesson, Mariam Ahmadi, Sediqa Akbari and others draw upon local knowledge and practices in provinces throughout Afghanistan to develop an Afghan-specific counselling curriculum from the ground up. The authors used the Develop a Curriculum method to elicit standards for new counsellors in the Afghan context. Their findings show that Afghan counsellors at the supervisory, professional and paraprofessional levels agree that effective counselling practices and the curriculum used to teach such practices must infuse the commonly used Western training with a deep knowledge of the Afghan cultures, customs and spiritual beliefs. They noted that this information had been excluded in the formal curriculum and required this addition to promote a rigorous and ongoing study that could contribute to best practice. Furthermore, this study represents a baseline by which to better understand the counselling profession in Afghanistan. The authors suggest that the effectiveness of interventions at the individual and community level should be further explored, which will ultimately contribute to supporting and improving theory and practice in Afghanistan. Several of the authors from this article also contributed field reports and personal reflections in this Special Issue.
This Special Issue includes four field reports on critical issues regarding MHPSS in Afghanistan. The first field report, written by Sayed Jafar Ahmadi, Mohammad Bagher Kajbaf, Hamid Taher Neshat Doost, Tim Dalgleish, Laura Jobson and Zeinab Mosavi, is titled, ‘The efficacy of memory specificity training in improving symptoms of posttraumatic stress disorder in bereaved Afghan adolescents’. The authors outline the challenges facing adolescents in Afghanistan. As a result of living in a war affected context, with its many dangers, adolescents may face chronic school closures and limited access to health care. This field report describes a small study focusing on bereaved adolescents with symptoms of post-traumatic stress disorder. The study introduced a MHPSS programme called the Memory Specificity Training (MEST), as compared to trauma-focused cognitive behavioural therapy (TF-CBT) and a control group without specific therapy. The authors found that adolescents who participated in the MEST and TF-CBT groups had significantly lower levels of depression symptoms compared to the control group.
In the second field report titled, ‘Studying the effectiveness of motivational group therapy in heroin addicts in Kabul’, authors Sediqa Akbari, Changiz Rahimi, Nourollah Mohamadi and Sayyed Hussain Hussaini focus on the pressing issue of addiction in Afghanistan. The field report describes how detoxification is the main response to addiction, with very little attention paid to aftercare. This approach means that those who are addicted, face extremely powerful desires to re-use, which leads to high recidivism rates. The authors describe their experience of a group-therapy programme based on the Trans-Theoretical Model of Change to help people increase motivation to change and decrease cravings. The authors’ small study sheds light on an underutilised, yet promising, approach to address this major social issue.
Inge Missmahl, the founder and director of the International Psychosocial Organisation, reflects on the developmental journey of MHPSS in Afghanistan in the final field report titled ‘Value-based counselling: Reflections on fourteen years of psychosocial support in Afghanistan’. Missmahl describes the long-term integration of biopsychosocial mental health care within the Afghan public health system through the training of psychosocial counsellors using a value-based approach. The reflection highlights the importance of long-term, applied training including reflexivity and quality supervision in psychosocial support provision. It also emphasises, as does Bragin and Akesson’s field report, that the distress experienced by the majority of those seeking mental health treatment is the result of very real problems of daily living rather than any biologically based mental illness. In Missmahl’s experience, this distress is best addressed using six fundamental principles, as well as a context that allows for meaning making and a programme of treatment that enables the sufferer to seek effective solutions.
In the field report titled, ‘Towards an Afghan counselling psychology: A partnership to integrate psychological counselling into the university curriculum at Afghanistan’s flagship public universities’, guest editors Martha Bragin and Bree Akesson detail a project to support two new academic programmes in counselling psychology at Afghan universities. The programme was developed to contribute to the development of qualified MHPSS practitioners who will be working with individuals, families and communities. Bragin and Akesson describe the role of culture, the strengths and limitations of the project, and the future of MHPSS in higher education.
Personal reflections: A colourful bouquet
We know that Afghan counsellors have very interesting stories to tell, but they often don’t have the time or resources to put their stories onto paper. To support Afghan counsellors to write, we invited Guus van der Veer, the very first editor-in-chief of Intervention, to visit a group of academics who are professors at two universities in Afghanistan and to support them in writing short papers about their clinical work. During the few days they collaborated, they focused on writing personal reflections. This kind of writing about experience in the field was an interactional process in which the participants were stimulated to discuss their work with at least one or two colleagues. After five days they produced, according to van der Veer, a ‘colourful bunch of flowers; a collection of personal reflections that may give the reader an impression of how much can be learned from reflecting on personal experience in the field, and how creative, evidence-informed clinicians can be when they also trust their common sense’ (personal email communication, MT).
These personal reflections written by the Afghan counsellors and psychologists shows us how culture and religion are interwoven into psychological approaches and concepts. By integrating Western concepts into the Afghan culture and religion, psychosocial challenges and healing became locally understood and accepted. At the same time, the personal reflections show that, as a counsellor, one is a part of a culture that may limit your possibilities due to social rules and cultural or religious customs.
Bezhan Ayubi describes, ‘Reflecting the potential role of family counselling in addressing emotional issues in Afghan youth’. He describes the case of a young woman who fell in love with a man that was not selected by her family. Ayubi explains how in Afghanistan − where interactions between people of the opposite sex are highly regulated − individual counselling is not effective as they do not address family conflicts. As an Afghan counsellor, this particular family conflict was problematic for him. He also suggests that family counselling would be more effective if the counsellor works in concert with social workers and religious leaders.
In his personal reflection, Basir Ahmad Karimi presents a story of social anxiety in ‘The girl who wanted to stand-up in class and speak to her classmates’. He first explains how many students suffer from social anxiety, as it can be seen as rude, bad behaviour in which young people − especially females − speak in the classroom. Then, Karimi presents the case study of a female student who − as the title describes − wanted to participate in class but was paralysed by anxiety. The issue was resolved when the female student received several counselling sessions to address her social anxiety with positive results. This personal reflection presents an interesting commentary about the interaction between cultural systems and the individual, when cultural rules and habits influence one’s wellbeing.
In her personal reflection titled, ‘An Afghan woman’s story: Fighting for a better life’, Raihana Faqiri describes the belief in many conservative Afghan families that their female members should stay at home. However, these restrictions generally prevent women from either studying or having a professional career. In her case study, Faqiri illustrates how women, and to a certain extent husbands, can be squeezed among Afghan culture, power relations and their own personal ambitions. The author merges a systems approach with the Afghan culture in her work counselling a young woman in this challenging situation. Through this insightful reflection, Faqiri describes how counselling support can enable Afghan women, even those from traditional families, to develop their competence, contribute to society and enjoy life.
Sediqa Akbari wrote a personal reflection on her experiences ‘Starting as a counsellor’, when she first began working with young girls living in a juvenile rehabilitation centre. The author describes how these girls were often sent to this centre by their families after they were caught with a boyfriend that was not selected by the parents. Akbari paints a bleak picture of isolation and sadness at this centre, where the girls were often left alone in the centre and eventually stopped communicating with others. She describes how she used very simple methods, such as handicrafts, to build a trusting therapeutic relationship with the girls. Like many of the articles in this Special Issue, Akbari’s reflection emphasises that engaging family members is necessary to solve these culturally grounded issues.
In his personal reflection, ‘Trauma at home: The importance of listening’, Basir Ahmad Azizi presents the case study of a young Afghan girl who was the victim of incest. Azizi shows that there is a lack of both sexual education and listening to children who have suffered from these experiences. According to the author, listening and empathy is the most important part of counselling in these situations. He illustrates how a counsellor can help create a safe place within the girl’s home, while not putting the girl in further danger by disclosing the abuse.
Not all personal reflections address counselling. In her reflection ‘Active coping with trauma and domestic violence: How Afghan women survive’, Spozhmay Oriya discusses her experiences working on a qualitative research project with female workers in Kabul. She presents one case study of various ways that women engage in active coping in the face of traumatic everyday experiences such as domestic violence. Oriya concludes her reflection by emphasising that enhanced psychosocial functioning and strengthened social networks might be more useful than clinical interventions adopted from Western countries.
Although the effects of gender restriction on the development of girls is the subject of many personal reflections, Sataruddin Sediqi’s ‘The impact of addiction on Afghan youths’ presents a case study of one adolescent boy who faces intersecting psychological, developmental and social stressors when his father dies. The journey from those past stressors to the boy’s current battle with drug addiction illustrates Sediqi’s recommendations for the use of community-based psychosocial support to both boys and their families to prevent and treat the growing problem of addition among Afghan adolescents from poor families.
Next to this range of small pearls showing the work of the Afghans psychologists and counsellors, two non-Afghan scholars describe their experiences of working in Afghanistan.
Sakiko Yamaguchi, describes her daily interactions with an Afghan woman, Bibi Hawa, in her personal reflection titled, ‘Witnessing the vulnerabilities and capabilities of one Afghan woman: Cultural values as a source of resilience in daily life’. Yamaguchi captures the psychosocial and somatic stress experienced by Bibi Hawa and connects this to the Afghan sociocultural and political context. Yamaguchi’s description of her friendship with Bibi Hawa highlights how resilience can be forged by emphasising one’s own capacities, as well as one’s sense of the importance of Afghan culture and values.
The final personal reflection entitled, ‘Thoughts from Afghanistan: Rebuilding community in complexity’, describes Athena Madan’s experience conducting research in Afghanistan, in the wake of a series of simultaneous violent attacks that occurred throughout Afghanistan over the course of 1 day in 2012. On that day, Madan engaged in informal conversations with her female colleagues about their experiences as women in Afghanistan. The personal reflection captures the challenges that these women experience in their daily lives and in the face of extreme political violence. These stories of trauma and loss also underscore the women’s commitment to fostering resilience and creating community as a means to ameliorate negative psychosocial consequences.
| Conclusion|| |
The powerful articles in this Special Issue of Intervention clearly represents a diverse and multi-faceted approach to learning more about the psychosocial issues facing contemporary Afghanistan. Taken together, this collection of articles aims to make a modest, yet important, attempt to address these gaps and contribute to the growing knowledge base about MHPSS in Afghanistan. This Special Issue can be also used for teaching and capacity building at the university level in Afghanistan. At the same time, those who are working in MHPSS-related fields in conflict affected countries around the world will have the opportunity to learn from the Afghan experience. Finally, we hope that these papers will spark further conversations and idea sharing between Afghan mental health workers and those professionals working in other areas.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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