|Year : 2018 | Volume
| Issue : 3 | Page : 231-242
Developing a culturally relevant counselling psychology degree programme in Afghanistan: Results from a DACUM study
Martha Bragin1, Bree Akesson2, Mariam Ahmady3, Sediqa Akbari3, Bezhan Ayubi4, Raihana Faqiri3, Zekrullah Faiq5, Spozhmay Oriya3, Basir Ahmad Karimi6, Basir Ahmad Azizi7, Fareshteh Barakzai6, Hikmatullah Noori8, Kristina Sharifi9, Mohammad Hadi Rasooli10, Sayed Jafar Ahmadi11, Hannah Wolfson9, Sataruddin Seddiqi3
1 PhD, Silberman School of Social Work at Hunter College, CUNY, New York, New York, USA
2 PhD, Wilfrid Laurier University, Brantford, Ontario, Canada
3 MA, Kabul University, Kabul, Afghanistan
4 MSc, Kabul University, Kabul, Afghanistan
5 MS, Kabul University, Kabul, Afghanistan
6 MA, Herat University, Herat, Afghanistan
7 BA, Herat University, Herat, Afghanistan
8 MBA, Silberman School of Social Work at Hunter College, CUNY, New York, New York, USA
9 MPH, Silberman School of Social Work at Hunter College, CUNY, New York, New York, USA
10 MD, Silberman School of Social Work at Hunter College, CUNY, New York, New York, USA
11 PhD, Silberman School of Social Work at Hunter College, CUNY, New York, USA
|Date of Web Publication||30-Nov-2018|
Silberman School of Social Work at Hunter College, City University of New York, 2180 Third Avenue, New York, NY, 10035
Source of Support: None, Conflict of Interest: None
This paper reports on the results of a research study that was conducted by the members of the Departments of Counselling at Kabul University and Herat University in collaboration with their international advisors. The purpose of the study was to determine how Afghans practicing counselling psychology or wishing to employ professional psychological counsellors understand and operationalize the knowledge, skills and values required to be a professional counsellor in Afghanistan. In workshops with 147 male and female participants − including supervisors, professionals and paraprofessionals − from six different sites in five of Afghanistan’s seven regions, the study used the Develop a Curriculum method, which aims to ensure that curricula and standards for new professions introduced in the post-conflict period will be relevant and applicable in the Afghan context as informed by Afghan experts in the field. Findings indicate that participants had markedly different conceptualizations of what the role of a counsellor should be (e.g. focusing on individual methods versus working with families and communities). Furthermore, these differences exist along professional lines (e.g. medical versus protection), as well as region. The findings underscore that a deep knowledge of Afghan cultures, customs, and spiritual beliefs was required, along with detailed professional knowledge of individual, group and family counselling ideas, values and practices. In addition, constant self-awareness and reflection at every level is needed to balance these two essential areas of competence to resolve contradictions and to blend both seamlessly into one set of professional standards. Results of this study will assist Afghan faculty members in adjusting their curricula to align with the realities of providing culturally relevant counselling in Afghanistan today.
Key implications for practice
- All Afghan counselors should be highly trained, supervised in practice, and well versed in international standards, as well as Afghan customs, culture and values.
- Assumptions regarding the clients' beliefs, cultural values, experience or ideas can never be assumed and must be explored for counseling to be effective.
- All Afghan counselors, like their international counterparts, require supervised support for self-awareness and reflection to be effective in the Afghan context.
Keywords: Afghanistan, armed conflict, counselling, culturally relevant approaches, DACUM method, participatory curriculum development
|How to cite this article:|
Bragin M, Akesson B, Ahmady M, Akbari S, Ayubi B, Faqiri R, Faiq Z, Oriya S, Karimi BA, Azizi BA, Barakzai F, Noori H, Sharifi K, Rasooli MH, Ahmadi SJ, Wolfson H, Seddiqi S. Developing a culturally relevant counselling psychology degree programme in Afghanistan: Results from a DACUM study. Intervention 2018;16:231-42
|How to cite this URL:|
Bragin M, Akesson B, Ahmady M, Akbari S, Ayubi B, Faqiri R, Faiq Z, Oriya S, Karimi BA, Azizi BA, Barakzai F, Noori H, Sharifi K, Rasooli MH, Ahmadi SJ, Wolfson H, Seddiqi S. Developing a culturally relevant counselling psychology degree programme in Afghanistan: Results from a DACUM study. Intervention [serial online] 2018 [cited 2019 Feb 19];16:231-42. Available from: http://www.interventionjournal.org/text.asp?2018/16/3/231/246436
| Introduction|| |
By the mid-20th century, Afghanistan had made great strides in developing its education system. With 19 campuses around the country, the free public university system compared favourably to those of neighbouring countries and was well-equipped to educate the professionals and thinkers needed to meet the country’s growing needs. However, the armed conflict that followed this period left the education system in complete disarray, and without either human or material resources (Hayward & Babury, 2015).
Although efforts have been made to rebuild the higher education system, there is still much to be done. There remains a great need to strengthen faculty and institutional capacity, especially in contemporary professional education. Professional development and academic resources are also required to ensure that existing professional needs, such as those in medicine and law, meet contemporary standards. In addition, new professions are needed to prepare Afghanistan for the 21st century.
The University Support and Workforce Development Program, funded by the United States government was designed to meet those contemporary needs, by providing partnerships for academic and educational development to ensure that new academic programmes were developed to meet the country’s growing needs for an effective workforce. Among the programmes proposed for this partnership programme by the Ministry of Higher Education (MoHE) was that of professional counselling.
This paper reports on the results of a research study that was conducted by the members of the Departments of Counselling at Kabul University and Herat University in collaboration with their international advisors. The purpose of the study was to determine how Afghans practicing counselling psychology or wishing to employ professional psychological counsellors understand and operationalize the knowledge, skills and values required to be a professional counsellor in Afghanistan.
Why counselling? The impetus for a bachelor’s counselling degree programme in Afghanistan
The Afghan Government’s National Mental Health Strategy (NMHS) for Afghanistan (Government of Islamic Republic of Afghanistan (GOIRA) & Ministry of Public Health (MoPH), 2009) laid out an ambitious scheme for establishing integrated and comprehensive mental health and psychosocial support services for all Afghans. Impressively, as of the programme’s completion in 2014, the mental health portion of that care is on its way to being well-established. As part of the Basic Package of Health Services and Essential Package of Hospital Services, Afghans with mental, neurological and substance use disorders can receive a continuum of mental health care from the hospital to the community. This includes supportive counselling by paraprofessionals (refer to Missmahl, I. (this issue). Value-based counseling: Reflections on 14 years of psychosocial support in Afghanistan). However, the majority of threats to emotional well-being in Afghanistan is not necessarily defined as a mental disorder. Although mental disorders such as post-traumatic stress disorder (PTSD), anxiety and depression may occur, context-generated distress that is in large part caused by armed conflict, violence, and their economic and social sequelae, place an extraordinary strain on all Afghans (Babury & Hayward, 2013; Government of Islamic Republic of Afghanistan (GOIRA) & Ministry of Higher Education, 2009; Inter-Agency Standing Committee (IASC), 2007; Miller, Omidian, Rasmussen, Yaqubi, & Daudzai, 2008; Scholte et al., 2004; Ventevogel, Jordans, Eggerman, van Mierlo, & Panter-Brick, 2013; Ventevogel, van Huuksloot, & Kortmann, 2006).
University programmes teaching professional counselling skills that prepare graduates to address such issues are well-established throughout Asia and the Middle East. However, in Afghanistan, the establishment of formal education in professional counselling lags. This left an important gap in national capacity (Babury & Hayward, 2013; Bragin et al., 2014; GOIRA & MoHE, 2009).
To address this gap, the NMHS called for the creation of paid counselling positions to address the general need for psychosocial support in addition to four specific populations: (1) children and adolescents in schools; (2) young persons in the juvenile justice system; (3) families at risk of domestic violence; and (4) military veterans and police persons directly affected by the conflict (GOIRA & MoHE, 2009, Strategic Component 1, especially 1.1, p. 14). To address the need for qualified professionals to fill these positions − along with any positions already created in the public hospitals and community health centres − the NMHS called for Afghan universities to educate professional counsellors to provide the mandated services and to supervise the paraprofessionals with limited formal education who currently serve as supports to medical doctors (GOIRA & MoHE, 2009, Strategic Component 6, especially 6.3, p. 20). This task was then given to the MoHE, long a proponent of the creation of professional counselling degree programmes (Babury & Hayward, 2013).
The ministry selected its two flagship universities − Kabul University and Herat University − to develop Afghanistan’s first counselling degree programmes at the bachelor’s level. As counselling is a new academic subject and profession, it was necessary to conduct research on how counselling is understood and should be practiced in the Afghan context. The results of the research are intended to inform the competencies required to establish a new university curriculum.
| Background to the DACUM method|| |
The Develop a Curriculum (DACUM) method is primarily used as an occupational analysis tool to better understand a profession by identifying the knowledge, skills, personal qualities and tools required to be successful in a particular job (Adams, 1975; de Onna, 2002; Engleberg & Wynn, 1995). This in-depth occupational analysis is conducted by resource panel of ‘experts’ who are considered to be highly skilled practitioners in their field or those who require the services of such practitioners (Cran, 1998; ILO CINTERFOR, 2011; Wolford, McGee, & Ritchey, 1996). Under the guidance of a skilled facilitator, the resource panel develops an occupational skill profile − including the knowledge, skills, personal qualities and future trends − that can be used to plan and develop curricula and identify future educational needs (Cran, 1998). To gather the information effectively, the participants share data that are organized into charts (known as ‘DACUM charts’) (Wolford et al., 1996, p. 176).
Although published research using the DACUM method remains limited, the method has been used over the past 5 decades in a variety of settings and contexts ranging from speech communication to food protection professionals (Linton et al., 2011). Relevant to the current study, the DACUM method has been used in educational programmes for helping professions such as nursing and clinical nutrition (de Onna, 2002; Kang et al., 2015; Kosidlak, 1987; Lee, Kim, Shim, Choi, & Yu, 2017). DACUM has also been used in settings where cultural context is especially important. For example, Cran (1998) used the DACUM method to identify the tasks, skills and knowledge required for indigenous police training programmes in British Columbia, Canada.
In the last decade, the DACUM method has been successfully used in volatile contexts such as conflict settings, where a practical and efficient process is often needed to create effective and sustainable programmes. For example, Conway and Jeris (2006) used the DACUM method to develop a training programme for Sri Lankan grassroots leaders. The authors found that the DACUM method ‘provided powerful experiences to the Panel members of democratic, participatory and transparent decision-making’ and a ‘sound frame of reference for ongoing programme design decision-making’ (p. 6).
Bragin et al. (2014) partnered with the National Skills Development Program (NSDP) to develop the National Occupational Skills Standards (NOSS) and culturally relevant social work curricula in Afghanistan. Participants in that study were asked to define social work in Afghanistan, as well as what knowledge, skills, and qualities Afghan social workers needed to perform their jobs well.
| Materials and methods|| |
Rationale for DACUM method
The DACUM method was first introduced in Afghanistan by the World Bank Group and recognized by the Government of Afghanistan to ensure that existing Afghan experts were consulted whenever a new profession was introduced into the country in the post-9/11 period. This requirement originally was applied only to skilled trades requiring a technical school education and then expanded to the professions (Bragin et al., 2014). The DACUM model was chosen for this study because it is well-suited for identifying the competencies required to construct a counselling psychology curriculum that would be used in both universities to prepare students who would then be employed wherever they were needed, throughout the country. The method was chosen for its potential sensitivity to issues of local culture while uncovering rich data. To utilize the method for the counselling profession, it was necessary to make some modifications, while remaining firmly within the competencies framework, to insure that the information gathered reflects the breadth and range of participant experience (Bragin et al., 2014). One such modification was the inclusion of a specific question, asking which specific Afghan cultural traditions or practices the practitioners considered helpful to their clients.
All research took place in Afghanistan, a diverse country divided into 34 provinces and seven regions. The MoHE, the governing body of Afghanistan’s public university, operates campuses in each region of the country including teachers’ colleges and university centres with undergraduate and graduate faculties. Admission to MoHE universities is free of charge to high school graduates who qualify and pass an entrance examination. The research took place at six MoHE university sites in five of the country’s seven regions. The universities were Kabul University, Bamiyan University,1 Herat University, Balkh University (in Mazar-i-Sharif), Kandahar University, and Nangahar University (in Jalalabad city). Security concerns prevented research in the North Eastern and North Western Regions of the country.
The research team
The research team consisted of professors from the two counselling degree programmes, Kabul University and Herat University, with support from the international principal investigator and the Afghan senior advisors employed at each university by the Partner University Hunter College of the City University of New York (CUNY). In each region, five research team members − one Afghan technical advisor, two facilitators, and two note takers − conducted DACUM focus groups. The international Principal Investigator (PI) was present in the provinces.
Recruitment of participants
The first step in the DACUM process is to select a resource panel to identify the knowledge, skills, personal qualities, and future trends associated with being a counselling psychologist in Afghanistan (Curtain, 1990). Normally, this resource panel would consist of job holders and supervisors selected to represent a variety of work situations and a range of responsibilities that are included in the profession of counselling psychology (Cran, 1998; Curtain, 1990). In addition, participants should ‘be good at their job, who are articulate and appreciate what the exercise is trying to achieve’ (Curtain, 1990, p. 115). The two universities’ Technical Advisory Committees (TACs) had been developed prior to the start of the research to advise the counselling psychology programmes at the two universities on curriculum development and other technical issues related to counselling psychology in Afghanistan. The TACs consisted of representatives of the governmental, non-governmental, and private organizations who currently employ counsellors or who planned to hire graduates of the counselling psychology programmes.
The research team asked the TAC members to identify the most knowledgeable and expert Afghan counsellors whom they knew, or those who supervise, train, educate, or plan to employ counsellors in every region of the country where their organizations work. A recruitment letter in the local language (Dari or Pashto) was given to potential participants to invite them to participate in the research, along with an Institutional Review Board (IRB) approved recruitment script.
Samples were largest in urban centres of Kabul and Herat, and smaller in other cities such as Mazar-i-Sharif, Kandahar, Jalalabad, and Bamiyan. Care was taken to insure a balance between male and female participants at the supervisor, professional, and paraprofessional level. [Table 1] details the participant demographics according to gender, work role and location.
Care was also taken to include different kinds of professionals in the sample. Due to significant differences in viewpoints based on professional training and area of work, participants were grouped into the following five profession categories: (1) health and mental health counsellors, including mental health professionals and paraprofessionals; (2) substance abuse counsellors, referred to in Afghanistan as ‘de-addiction counsellors’; (3) child protection, education, and justice counsellors, including supervisors of child protection units, school counsellors, juvenile justice workers, and paraprofessional youth counsellors; (4) women’s rights workers, including medical and psychology professionals who have received specialized training in gender-based violence and related issues, as well as persons with unrelated degrees who receive ongoing service training and supervision from an Afghan women’s organization; and (5) university professors, including psychologists and those with related degrees who teach clinical psychology and counselling at the university level. [Table 2] details the participant demographics according to gender, work role, and practice area.
|Table 2: Participant demographics by gender, work role and practice area|
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So as not to incur costs as a result of their participation in the research and to ensure safety, the project paid for participants’ meals and travel to and from the research site. The DACUM participants received no other compensation for their participation.
Informed consent processes were followed in accordance with approval from the Hunter College, City University of New York, University-Integrated Institutional Review Board (CUNY UI-IRB no. 2016-0805). Focus groups ranged from eight to 18 participants.
The DACUM method, as previously applied in Afghanistan (Bragin et al., 2014), uses a series of charts that group answers to five questions: (1) duties, or the scope of work for a job or profession; (2) the tasks required to perform those duties; (3) the knowledge, skills, values, attitudes, and attributes of an effective practitioner and a supervisor; (4) the necessary tools to do the work, and any technical terms that are common to the field; and finally, (5) future trends or areas where the profession is needed but not now active (Bragin et al., 2014). When piloting the protocol for this study, we made two modifications to the standard charts. First, we removed the question regarding technical terms, because the question was considered too complex to be answered properly in a short discussion. The technical lexicon is not established on a national level and therefore warrants a separate study to be undertaken in the future with the collaboration of universities, governments, and practitioners. Second, we added two additional questions that were important to developing an understanding of the scope of work of professional counsellors in a cultural context. The two additional questions were (1) free list and describe the psychological and social concerns that present at your agency/programme and require counselling intervention, and (2) free list and describe any traditional Afghan practices that have promoted resilience or well-being among people who come to your agency/programme after facing severe adversity.
To effectively move through this process, the facilitator gave each participant a copy of the DACUM chart in the local language. The facilitator explained the DACUM process and asked the participants to review and think about each of the items. The facilitator installed a flip chart at a central point in the room, and one of the note takers filled in each page of the flipchart, so that all could see and discuss each page. The facilitator then invited the participants to form groups of three or four to discuss their responses and make notes if they wished to remember their thoughts. Each group was then invited to list the responses to each question with the responses recorded on the flip chart. The subsequent groups were invited to add new ideas and to agree or disagree with what was recorded. Note takers tracked agreements, as well as disagreements. Note takers were also careful to note whether certain professions had different concepts or whether there were differences by gender or by qualification level. For all focus groups, this procedure was repeated for all of the items on the charts, as well as for the two questions noted above. After the close of each focus group, the research team recorded any thoughts or reflections about the process, including what they learned and how they reacted to it. At the conclusion of the study, the research team also met to share and reflect upon their thinking on the findings and the process.
Data and notes from the focus groups were transcribed into English and Dari language Word documents. DACUM charts were coded with the goal of developing and clarifying themes and subthemes. The competencies sections of the DACUM charts were coded by subject, frequency and emphasis of mention (Conway & Jeris, 2006). They were also analysed by region, gender, and general area of professional work. The coded data were then analysed for frequency and consistency of issues raised by the participants. Most important for the analysis was checking for convergence and divergence between different areas of the country, different areas of work within the field of counselling psychology, and the different levels of responsibility for professionals. Throughout the coding process, consultation took place with the translator, the local PIs, and the research team members to ensure agreement as to the meaning of terms, answers, and ideas.
| Findings|| |
General findings: Duties, tasks, knowledge, skills and values2
Study participants agreed that counselling constitutes a distinct professional activity that takes place between specially trained persons and people in need of support. Their work includes some form of intake, assessment, treatment planning, and treatment. Record keeping was considered a must.
The participants broadly agreed that counselling must be distinct from merely ‘advice giving’ and should focus on helping clients come to their own decisions. They also considered it important that absolute confidentiality be observed except in cases when family members or other outsiders may be informed should there be potential for harm to the client or someone else. According to the participants, counsellors must be knowledgeable about psychological principles and the care of their clients and be trained in the specialized skills needed to conduct their sessions.
The data indicated that the way that counsellors did their work was extremely important. All counsellors should listen carefully and without judgement. They should be self-reflective and self-critical in their stance. They should show kindness, consistency and be able to manage their own emotions, so as to better manage those of the clients. They should always do so within the confines of accepted Afghan cultural norms of behaviour.
The role of supervisors
We asked all participants to fill in the charts separately for workers and for their supervisors. We report here on only the most salient findings. Supervisors were to be knowledgeable about all of these areas and able to serve as managers, organizing the work and providing evaluation, encouragement, and guidance towards improvement. They should also be role models in the work. Their fairness and impartiality are considered essential. The self-reflectivity and capacity to manage emotions–both their own and those of others–was considered vital to the supervisory process. Supervisors of paraprofessionals should also assist in solving the day-to-day problems of the people they supervise, including financial ones if necessary.
The importance of Afghan culture
Almost all participants agreed that counsellors and supervisors had the duty to be aware of their cultural context. Whether participants considered these positive or negative, counsellors should be cognizant of the moral, customary, and religious underpinnings of Afghan society. Kabul-based women’s rights counsellors went so far as to state that beyond awareness of cultural ‘constraints’, professional counsellors should remind clients of these when needed and help them to adapt. According to the participants, counsellors require detailed knowledge of the customs and cultures of Afghanistan and should be careful to behave in such a way as to remain effective within those cultural contexts. However, the nature of these elements was almost never explained in detail, which will be discussed in the limitations below. Furthermore, the data were not clear as to whether the participants considered these ‘constraints’ positive or negative for clients or for the profession. What was clear is that the participants and Afghan researchers agreed that all Afghan counsellors knew what they meant by these references and that any counsellor trained in Afghanistan would have to know these implicit and explicit rules of customs and cultures intimately. One participant suggested that to be effective, a counsellor would have to be an Afghan.
The participants saw Afghan culture and customs as key to successful and effective counselling, and yet they did not speak about them with the same detail that they provided for the part of professional activity that was specifically derived from Western practice as taught in counselling textbooks and handbooks available from European and North American sources or documents made available by the World Health Organization. Some of these issues were mentioned in more detail when the issue of therapy arose. Forced marriage and the custom of paying debts by exchanging children, especially girls, were mentioned specifically. The gender-based problems that boys face were not mentioned as related to gender but rather as related to poverty.3
Rather than suggesting that counselling sessions should be gender-aligned (e.g. male counsellors should counsel male clients and female counsellors should counsel female clients), participants were concerned that modest dress be observed by both men and women. They also warned that kind behaviour by female counsellors towards male clients could potentially be misinterpreted as inappropriate behaviour. But for the most part, the participants made repeated and frequent references to culture, customs, or ‘to being Afghan’ without further detail.
Tools and materials
Participants dedicated much discussion to the importance of private and comfortable spaces, with chairs, couches, and desk, in which to work and see clients. However, these spaces are in short supply. They described the need for paper, pens, and charts for record keeping, in addition to locked cabinets to maintain records. Computers were noted as an important tool, particularly as a source of teaching and learning; however, unreliable electricity and internet access can limit their usefulness.
Participants noted specific tools and materials aligned with their own areas of practice. For example, women’s rights counsellors noted the need for exercise equipment in their practice, as many Afghan women are confined to the home and cannot leave except for specific occasions such as religious festivals, weddings, and funerals. Those working with children in Herat, Kabul and Mazar-i-Sharif suggested the importance of having toys and drawing materials available for child-centered therapies. Professors of psychology and all participants engaged in educational counselling suggested assessment and testing tools, although few are validated for Afghanistan. Paraprofessional counsellors and substance abuse counsellors noted specific materials that made up part of their protocols and were supplied to them for that purpose. And Kabul and Mazar-i-Sharif participants recommended access to an up-to-date library for professional learning and development.
The data indicate that there is greater public awareness of the counselling profession and its role, as well as greater opportunities to positively intervene in diverse areas of public and private life. With that awareness came hope for greater professional opportunities. For example, participants suggested a broadening of their own role in public education. The participants wanted to increase the opportunities for counselling in all areas of life, including career, family and marital counselling, child development and parental counselling. There was broad interest in increasing knowledge of contemporary evidence-based practice, such as positive psychology and cognitive behavioural interventions. The participants wanted to see counselling extended to military, police, medical services, disabilities, and other areas where only medical and pharmacological interventions are used at the present time.
There were findings that aligned specifically with the participants’ areas of practice. For example, child protection specialists and women’s rights specialists suggested Islamic approaches to counselling and tailored counselling approaches to meet the needs of diverse cultural groups. The university and child specialists wanted to see more support for research and publication, as well as better access to seminars and advanced training for counsellors on the national and international levels.
Answers to special questions
Reasons that people seek counselling in Afghanistan today
Study participants discussed how people come to mental health clinics for serious and persistent mental illness and to de-addiction clinics for the treatment of substance abuse disorders. Such treatment is always referred to or coordinated with medical personnel. However, the majority of clients do not come with these complaints but rather with a broad range of problems rooted in life’s adversities ranging from poverty, joblessness, family difficulties, marital difficulties, exposure to family violence and the violence of war. Participants specified some of the sequelae of conflict-related violence, including situations of insecurity, the frequency of conflict-related deaths, forced migration and the specific cultural stressors of widowhood. Participants spoke of the special problems facing women and girls in a society described by those in Herat as being ‘patriarchal’. Some noted that ‘family problems’ − although cultural in nature − may be related to the stressors of poverty and armed conflict, which can undermine normal family functioning.
Afghan cultural practices that promote resilience
All participants mentioned the role of religious faith and a connection to the community as the main positive cultural forces for the maintenance of well-being and promotion of resilience for Afghans, which is aligned with previous work by Eggerman and Panter-Brick (2010, p. 71) who found that hope arose from Afghans’ expressions of key cultural values (such as faith), which ‘form the bedrock of resilience, drive social aspirations, and underpin self-respect and dignity’. The participants identified several common specific actions that can promote resilience.
Participants oftentimes mentioned consultation with mullahs (local clergy), a practice that is so widespread as to be universal in Afghanistan. Among less-educated families, the wearing of tawiz (talismans) containing words from the Quran are often included in these treatments as well. According to the participants, this religious engagement can be very helpful in relieving anxiety among their patients. However, participants expressed concern that the quality of religious advice was dependent upon the mullah (clergyman) and his capacity and beneficence. They emphasized that counsellors should be aware of this potential difficulty. Visiting shrines was another cultural practice that was widely mentioned and agreed upon by the participants as a means of promoting resilience. These shrines are typically outdoor green spaces where one can picnic and pray in well-tended surroundings. Participants noted that women are permitted to walk around to pray and contemplate freely. Similarly, participants noted the importance of giving to charity − a long-time Afghan custom as well as a religious requirement − as a way for those who are suffering to feel better.
The data indicate that some cultural practices were regionally specific. For example, in Herat, professors noted that poetry reading and writing had the potential to promote resilience. Professors in Bamiyan mentioned Afghan zeal, defined as the energy to persist in finding solutions against all odds. Mental health paraprofessionals in Kabul described mutual respect as an Afghan practice they believed promoted resilience. Mental health professionals in Mazar-i-Sharif highlighted engaging in leisure activities with children as a cultural practice that contributes to well-being and encourages resilience.
Divergences among sectors
Although there were some differences in the findings between men and women, and there were some regional differences that occurred from time to time, the main distinctions were between the health and mental health counsellors and the other sectors, especially the child protection, education and justice, counsellors and the women’s rights workers.
The findings indicate that participants who were categorized as health and mental health counsellors and substance abuse counsellors considered one-on-one counselling the key activity of the counselling profession. Furthermore, they believed that the counselling function should be distinct from − rather than integrated with − the provision of social services and other supports. Professional counsellors had some difficulty defining duties and tasks and distinguishing them from skills, attitudes, attributes and values. Paraprofessional mental health counsellors use one protocol validated in randomized trial and therefore confined their responses to those within the protocol. Substance abuse counsellors also described having specific protocols to follow.
In contrast to the view of participants who were health, mental health, and substance abuse counsellors, the data indicate that the child protection, education, and juvenile justice counsellors as well as women’s rights counsellors see community engagement as a part of the counsellor’s role. These two sectors had clearer conceptions of their duties and the concomitant tasks required to complete them. Participants in these sectors considered community engagement as an essential part of the solution to any individual and family problem, regardless of whether they were medical doctors, supervisors, professionals, or paraprofessionals. Furthermore, they considered it important to utilize interventions that combine counselling and social or other services as needed. More specifically, counsellors based in schools are obliged to call community meetings, engage with parents on school committees, provide psychoeducation to teachers on best practices in caring for children with difficulties, and advise teachers and school administrators on plans for individual children who are identified as being in need. Counsellors working in child protection or with women’s rights organizations work with shura, or traditional local councils, to gain their help in identifying instances of abuse, so that they can intervene to protect the vulnerable, provide counselling if needed, and also find local solutions to the problems that may be causing the abuse. In contrast to participants from the health and mental health sectors, these participants noted that the counsellor should not confine their knowledge to psychology, although they considered that important. They also emphasized the need for both a broad fund of ‘general knowledge’, so that they could be respected in the community. Women’s rights counsellors thought that Knowledge of Islamic Law, as well as its local customary application was also critical for them.
There were also regional differences among participants who were women’s rights workers. Three different focus groups in three different regions provided different points of view on women’s empowerment. Herat-based counsellors who face chronic problems of self-immolation among abused young married women, identified the root cause of these problems as ‘the patriarchy’ and defined this as a comprehensive system that subjugated women. Kandahar-based paraprofessional counsellors who worked with abused women − as no women’s counselling organizations operate in this region − stated that ‘interventions should empower women to find their own solutions to life’s problems’. Kabul-based counsellors in the same organization emphasized the need to ‘inform women about limitations imposed by the culture and customs of Afghanistan’.
| Discussion|| |
The findings underscore three important points. First, Afghan counsellors agree that it is important to have knowledgeable professionals to care for people suffering from both mental illness and psychosocial distress in the context of Afghanistan. The study participants conveyed a strong belief that professional care can be extremely helpful in addressing the psychosocial sequelae of the many challenges facing the Afghan population. Participants also reinforced the understanding that because counselling can serve as a protective barrier against suffering in difficult environments, these services should be available to all people, whether rich or poor.
The rising number of individuals seeking professional care poses a challenge within the under-resourced setting of Afghanistan. As Ventevogel et al. (2012, p. 4) note, ‘This carries the risk of creating a relatively large coverage of services with low quality and limited sustainability’. As has been found in other conflict-affected settings (van de Put & van der Veer, 2005), to provide counselling to the entire Afghan population would require the training of massive numbers of professionals. Furthermore, this pressure on counselling professionals makes it difficult for them to use psychosocial interventions that might take more time than other interventions such as the prescription of drugs (Ventevogel et al., 2012). In light of these realities, there is a need for community-based psychosocial approaches (refer to van Mierlo, 2012) as well as the training of a new cadre of community-based psychosocial counsellors (Bragin & Akesson, this issue).
Second, the relevance and importance of culture was a main finding from this study. Participants emphasized how professional standards should be interpreted and modified with a deep knowledge of Afghan culture and customs that should be effectively integrated into the counselling process. As Firling (1988, p. 32) writes, ‘it is the underlying thread that runs through an otherwise independent system of close-knit families and clans’ in Afghanistan. Culture should therefore be a defining element of any psychosocial intervention in Afghanistan. The importance of culture has been underscored in other research on mental health and psychosocial care for Afghans (Omidian, 2012; van Mierlo, 2012). For example, Omidian’s (2012) psychosocial wellness project for Afghan teachers found programmes that are rooted in the local culture are effective at promoting positive coping strategies and preventing psychosocial problems. The Afghan teachers reported that they were exploring their own ‘cultural strengths’ rather than just learning concepts that were not relevant (p. 245). Omidian concluded that
’… psychosocial programmes that meet the needs of a population work best when they reflect those parts of the culture that the participants recognize as important and positive. Participants take ownership of their own healing process when able to use locally significant metaphors, images, and texts’ (p. 246).
By exploring their own values and attitudes regarding well-being and healing, participants were more prepared to solve challenges. As another example, van Mierlo (2012, pp. 142-143) described the importance of culture in developing a community-based psychosocial project to fortify women’s agency and reduce domestic violence:
’… the extensive and structural attention to community preconditions, in order to adapt the programme design to the local context, seems to reinforce the sustainability of interventions in a country where family, religion, traditions and informal relationships play an important role.’
In this way, the support of psychosocial well-being must also be a flexible process, responsive to social and cultural needs and changes.
It is important to also note that, as Eggerman and Panter-Brick (2010, p. 81) explain, ‘culture is not just an anchor of resilience, but also an anvil of pain’, or as Wessells and Strang (2006, p. 200) identify culture as ‘the double-edged sword’. Culture is vital for the maintenance of social identity, social order and hope, especially in the face of adversity. According to Firling (1988, p. 32), ‘Afghans have a well-instituted cultural system …. Clear predictable mechanisms for handling life events give the Afghans security and a sense of purpose and meaning in their lives’. But at the same time, culture can contribute to psychosocial distress. For some, restrictive cultural practices can serve as a source of violence and inequality. For example, previous research in Afghanistan found that young people felt that they were unable to meet the high standards of ‘what makes an honourable Afghan’ and felt oppressed under these cultural dictates (Panter-Brick & Eggerman, 2012, p. 383). The counseling profession is therefore in a position to exacerbate or mitigate the dual nature of culture.
Finally, there were interesting differences in conceptualizations of counselling among the different sectors. Although professional and paraprofessional counsellors in the health, mental health and substance abuse sectors consider that counselling should be performed exclusively one-on-one between a counsellor and a client, counsellors working in child protection, education, juvenile justice, and women’s rights believed that working with family and community − in addition to individual counselling − was essential to positively alter aspects of the environment that create challenges to psychosocial well-being. However, research in Afghanistan has found that both individual-focused and community-focused approaches outside the formal healthcare sector are effective to address psychosocial challenges within the population and can strengthen mechanisms of self-help and foster resilience (Ventevogel et al., 2012).
Limitations of the sample
The study aimed for a diverse sample of counselling professionals in Afghanistan. Sampling resulted in 147 male and female participants − including supervisors, professionals and paraprofessionals − from six sites in five of Afghanistan’s seven regions. Security concerns prevented the research team from travelling to Badakhshan in the Northeast and Fariyab in the Northwest, two distinct regions that may have contributed a different perspective to the data. Furthermore, such as other research using focus groups (Ayrton, 2018), the diverse nature of the participants included in each of the focus groups discussions may have contributed to power asymmetries along the lines of class, ethnicity, and education. Power-reduction strategies − such as same gender groups − aimed to reduce these asymmetries as much as possible. However, this and the small sample size certainly limited the scope of the findings.
Limitations and challenges of ‘charting’ a new profession
When in the past, the DACUM method was used to define new occupations in Afghanistan, those occupations included practicing members of relatively well-known professions or occupations, including engineers, auto mechanics, kindergarten teachers, and social workers in child protection (Bragin et al., 2014). However, in this case, the counselling profession is currently being developed by different programmes, supported by different practitioners serving different populations. For this reason, it was often difficult for the participants to categorize their answers according to the chart headings. Often the same idea was represented in different parts of the charts by different groups in different locations. This was particularly true for the duties and tasks. For instance, in Herat, no duties were defined, but rather characteristics and values of the counsellor were understood as duties. In another example, the idea of maintaining confidentiality was mentioned in every focus group and in every location. But it was sometimes identified as a duty, a task, a value or even a skill. In some cases, participants placed a factor they considered essential in every category. This could mean there was confusion in terms of defining the terms: duty, task, skill, value. However, in the view of the authors, the failure of these distinctions seemed more related to the challenge of creating a completely new profession ‘from the ground up’.
Limitations of the translation
A significant limitation of the study was the ad hoc nature of the translation. The relevant government ministries have not yet validated a lexicon of universally recognized technical terminology in psychology. Without such a lexicon, the same Dari or Pashto words were translated in different ways at different times by the note takers. Sometimes the same word was translated by one person in very formal professional English and by another note taker or translator with a more informal word. To address this limitation, the research team conducted translation checks with the note takers and translators to confirm the original Dari language was translated correctly and ensure the fidelity of the translation. But this was far from an exact science and therefore represents a limitation of the study.
Related to this limitation is how certain terms were defined by the facilitators, participants, and interpreters. All members of the research team were adequately knowledgeable about counselling to probe participants’ comments during the focus group discussions. However, their understandings of these terms may have differed from person to person. For example, this is especially true for words that describe feelings, which poses a challenge as to how feelings are acknowledged, understood, and respected within the counselling profession and within the Afghan culture.
Challenges following up on cultural ideas
The study was also limited by cultural assumptions shared by the Afghan research team. For example, the Afghan researchers aligned with the participants in assuming certain phrases meant the same thing to all Afghans, when in fact there may have been cultural differences among or between groups. For example, the phrases ‘behave like an Afghan’ and ‘our culture and traditions’ were assumed by the research team and participants to have the same interpretation for everyone, and therefore, no follow-up questions were asked to clarify. However, when the non-Afghan research team members coded the responses, it was unclear what was meant by these phrases. In checking with the Afghan researchers, different responses ensued.
The belief that all Afghans have the same definition of what it means ‘to be Afghan’ represents a significant (and likely erroneous) assumption that considers culture as a homogenous concept. To clarify this issue, future research could explore the practice areas that practitioners find conflict with cultural norms, expectations and practices. Furthermore, universities play an important role not only in facilitating research to answer such questions, but also in engaging in such discussions with their students. In this way, the conflict between practice and perceived cultural generalizations becomes an important part of reflective practice that should be included in the Afghan counselling psychology curricula.
This limitation is less related to language and says more about the complexities of integrating Afghan culture, customs and oral traditions with Western concepts, as discussed earlier in this paper. It is aligned with previous work that acknowledges the challenges of translating Western concepts in non-Western contexts (van der Veer, 2008, p. 133):
’Knowledge and know-how should not be seen as goods that can be packed, exported and distributed. Knowledge and know-how are like living organisms that develop in a particular habitat and only survive by adapting to local conditions.’
Based on this research, it would be important to further explore Afghan cultures, customs, and oral traditions and indeed religious values and their relation to any Afghan way of counselling that is developed going forward. It would be helpful if Afghan professors, students and counsellors were provided with formal space to ‘interrogate’ their own culture, not as a means of pointing out deficiencies, but as a means of furthering enlightenment. Nevertheless, neither the Afghan researchers or participants’ elaborated definitions of Afghan culture and its relationship with counselling psychology, requiring both further research and careful inclusion of space for this discussion and its implications in any curriculum proposed as a result of this study.
| Conclusions and recommendations|| |
As the first comprehensive study of the counselling profession in Afghanistan, the findings highlight potential areas that could support the development of the profession via higher education and through future research. For the counselling curriculum to be effective in Afghanistan, it must integrate the commonly used Western training and specialized concepts and methods drawn from and developed in the Afghan context. To accomplish this, the inclusion of learning about the specific context of Afghan cultures, customs, and religious requirements within the higher education counselling curriculum is essential. Coping and healing among the Afghan population will only be effective if, as Firling (1988, p. 34) notes, Afghans ‘do so from a position of strength and security gained from the conviction that their Afghan heritage is valuable and one of which to be proud’. To move forward with developing an Afghan way of counselling that integrates Western and culturally relevant approaches there should be a specialized lexicon of psychological terminology in both Dari and Pashto to promote a common language for discussion and development of the profession in Afghanistan. The findings suggest other topics that should be implemented into higher education including universal professional preparation of students and faculty in the contextual nature of biopsychosocial assessment and treatment planning. Specific courses and studies in Afghan cultures and customs, as well as Islamic psychology are essential.
This research represents not only an initial discussion of what important elements are needed when developing an Afghan counselling psychology curriculum, but also what makes for effective culturally contextualized counselling practice. The findings evoke the question of whether counselling must be valued and fostered for its emancipatory potential in the face of cultural practices that may promote inequality and oppression, or whether counselling should integrate and promote cultural norms. Furthermore, as Omidian (2012, p. 246) notes, ‘If people feel their norms and values are under attack, they will refuse to listen to something they might actually want to learn’, which can contribute to different forms of inequality and oppression. Culture is not static, but it is in a state of constant flux, adapting to the contextual realities. Acknowledging the role of culture in the counselling profession is also a dynamic process that this study has merely touched upon. There is no easy solution to this complicated issue. Aligned with the work of Eggerman and Panter-Brick (2010), future explorations could examine the opportunities and boundaries of cultural constructions, as they affect psychosocial healing and well-being (Haans, 2008).
The findings represent a beginning by which to better understand the counselling profession in Afghanistan. In this way, this study also serves as a platform for future research projects exploring counselling and related topics in Afghanistan. There has been one important clinical trial studying the effectiveness of the ‘values-based counselling’ method used by the mental health paraprofessionals included in this study (Ayoughi, Missmahl, Weierstall, & Elbert, 2012). The trial indicated that counselling is more effective than pharmacological interventions for the treatment of psychosocial problems among Afghans in Mazar-i-Sharif. This study suggests that it would be important to explore the effectiveness of other interventions at both the individual and community level within each of the different sectors. The different views regarding individual and community interventions were a finding from the current study that warrants further exploration and evidence. For these and other studies, it would be vital to encourage Afghan professionals and practitioners to contribute to theory and practice through research projects. Future research should also explore concepts and meanings within the Afghan context that have relevance for healing. For example, this research team is currently involved in a phenomenological study to develop Afghan-specific indicators of psychosocial well-being. The research will elaborate and operationalize definitions of psychosocial well-being as understood by persons working in education, counselling, health, community development, and related professions. This could represent an important beginning in the understanding of how Afghan professionals understand psychosocial well-being in their own contexts and point a way to further studies that would join the others cited here in elaborating a contemporary Afghan psychological counselling, curriculum and practice.
- Both Kabul University and Bamiyan University are located in the Central region. Bamiyan University represents the rural areas, whereas Kabul University represents the urban areas.
- As will be explained in the ‘Discussion’ section, the same ideas were often mentioned as ‘duties’ in one focus group, ‘tasks’ in another, and ‘values’ in still another. Therefore, we highlight the main points here without excessive attention to category.
- The terms ‘poverty’, ‘joblessness’, ‘effects of emigration’ and ‘drug addiction’ were frequently listed as a reasons that families or children come to counselling. What was not mentioned are two conditions of potential importance. The first is the custom in conservative families of designating the oldest son as breadwinner when his father dies. Even if the child is very young, he will be asked to support his family, and he is often sent abroad to increase his wages. These boys often fall prey to the drug trade and addiction if they are two small and young to earn much money. The second condition is the custom of giving a boy to a commander or local landowner as a kind of tax or bond for help in time of future need. The commander may use the boy as a member of his elite guard or for sexual purposes. This is illegal but still practiced in the countryside and in conflict zones among destitute families (Babak, 2017; Sultaniet al., 2009).
The content is solely the responsibility of the authors. We would like to thank Ceci Sturman, Stefanie Alleyne, and Sediqa Jawadi for their support on the research. We would also like to thank the anonymous peer reviewers for their insightful and helpful feedback. The manuscript has been read and approved by all authors, and all requirements for authorship have been met. Each author believes that the manuscript represents honest work.
Financial support and sponsorship
Funding for this project comes from United States Agency for International Development’s (USAID) University Support and Workforce Development Program.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]