31.01.2007Psychotherapy in KabulCounseling for Traumatized AfghansAfter 20 years of war, many Afghans are desperately in need of psychotherapy. A new approach aims to address the needs of a deeply traumatized nation, as Martin Gerner reports
Kabul's Mental Health Clinic, the only state-run psychiatric clinic in Afghanistan Psychological therapy is virtually unknown in Afghanistan. Until recently there were only 28 psychologists and psychiatrists in the country for roughly 30 million people. The main focus is on treating patients with drugs.
Therapeutic models based on psychological counseling are gradually starting to make inroads, but major international aid organizations tend to overlook these issues and still have not changed their general approach. Yet their involvement is urgently needed.
Karte Seh is a residential area in southwestern Kabul. War-ravaged houses with scarred facades line the streets. During the civil war, from 1992 to 1996, up to 1,000 shells a day rained down on this district. Many people are still traumatized.
Dark and dirty hallways
Two institutions are located on a main street in Karte Seh, roughly 600 meters apart. They both attempt – each in its own way – to help victims.
Man sitting on a bed next to a wood stove in Kabul's Mental Health Clinic - conditions in Afghanistan's hospitals often are bleak and unsanitary One building houses the Mental Health Clinic of Kabul, the only state-run psychiatric clinic in Afghanistan. Housed in one wing of the building is a ward with roughly 30 patients who suffer from depression and schizophrenia. In another wing there are two rooms for drug addicts who are undergoing withdrawal. The hallways are dirty and dark. A corner is used to cook food; the rooms smell dank and musty.
The head of the clinic, Dr. Korechi, says: "We cure the drug addicts in ten days. The cases of depression and schizophrenia are treated, following an initial examination, with injections or medication."
Most people in Afghanistan firmly believe in the healing power of prescription drugs. Patients take up to 30 different tablets every day. At the bazaar, street hawkers push a panoply of pills, yet have no medical knowledge. It often takes a great deal of patience and determination to convince people to try and get through the day without their meds.
Healing body and mind
This is exactly what therapists are trying to do at the Windows for Life project, located at the other end of the street. There is a fundamental difference between this project and the approach used at the neighboring clinic: "We attempt to heal the body and the mind, but not with drugs, as is commonly the case in Afghanistan," says Farhad Habib, a counselor for Windows for Life.
Inge Missmahl manages the counseling centers. "The idea is to lend people a hand without making them an outsider," she says The project in Karte Seh is one of twelve counseling centers in Kabul that offer free therapy sessions. All the centers are operated by Caritas International based in Freiburg, Germany, with funding from the German Ministry for Economic Cooperation and Development. The staff at the twelve clinics includes 32 Afghans, women as well as men. A strong emphasis is placed in gender equality. There are doctors, pharmacists, nurses and teachers who have received specialized training here.
Every month, the counselors provide over 1,800 hours of counseling sessions. "The goal is to help the people we treat at the clinics emerge from their social isolation," is how Inge Missmahl describes the initial therapeutic approach.
Two years ago, the psychologist from southern Germany came up with the idea of creating counseling centers – and now she manages them. Previously, she worked with the organization Medica Mondiale in Afghanistan, where she gained experience with trauma victims.
Help in accordance with the local value system
Inge Missmahl describes the scope of therapeutic treatment:
"In many respects, the patients are limited by their economic and social situation. We can only help them in accordance with their own value system. The idea is to lend people a hand without making them an outsider. For example, if a woman is suffering under the conditions of a forced marriage, you can't just say 'run away!' or 'get a divorce!' Where is the woman supposed to go, and what about the children? That's just not an option. They have to find a way to shape the relationship so that it's livable."
Men in a counseling room in one of Kabul's counseling clinics This could entail that both husband and wife reflect together on how they can help defuse the conflict.
Over two decades of war and the combination of traditions, violence and religion have left precious little room for personal needs. Domestic violence is in many ways legitimated and accepted by local customs. In one therapy group, nine out of ten women reveal that they are beaten every week, even dealt blows to the head with hard objects like sticks and Kalashnikovs. In some families, children have even been beaten to death.
"Sixty to seventy percent of the psychosocial cases that we deal with here are caused by war, and twenty to thirty percent from the period following the retreat of the Taliban," is the assessment of Abdul Fatlah, a counselor.
The family as a final bastion
The sudden arrival of modern views in Kabul, an increasingly confusing situation, and the presence of foreigners with different cultural ideals has left many Afghans deeply shaken. It is primarily men who seek refuge in the family, as a final bastion where they can still exert their influence.
"However, it is not always just the men who are at the root of family conflicts," admits Mariam Zurmaty. The counselor says:
"Sometimes it's the mothers. Often the mother-daughter relationship is the worst in the family and laden with mistrust. There are many taboos. The daughter's choice of a partner is only addressed in perhaps five percent of the families in Kabul. And when a woman talks about menstruating problems, it can cause the entire family to feel embarrassed and ashamed."
Psychosocial roots of the country's problems
Over two years after the launch of the Windows for Life program, there are already success stories. Domestic violence among the patients' families has declined. The counselors at the clinics also feel that the training has been an important learning experience. "I used to beat my children. Now I go outside and take a walk around the block when I get angry, but I don't hit my children anymore," says Sunita Kohestani.
Despite this progress, a project like often fails to attract the attention of major international aid agencies. Inge Missmahl explains: "The problem is that financial backers can't see the success of the project as readily as, for example, the construction of a new road. A road is something very concrete. What we convey to people is something that touches them deep inside and helps them carry on with life."
She concludes: "Roughly eighty percent of the problems in this country have psychosocial roots, but less than 0.1 percent of the funds available are spent to address these issues."
© Qantara.de 2007
Translated from the German by Paul Cohen