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© 2012 Elsevier Masson SAS. All rights reserved. European Psychiatry 27 (2012) / supplement n°2 / S76-S80 Teaching psychiatry and establishing psychosocial services – lessons from Afghanistan I. Missmahl a , U. Kluge b , Z. Bromand c , A. Heinz b, * a International psychosocial organization (IPSO). b Department of Psychiatry and Psychotherapy, Charité – Berlin, Germany c Department of Psychiatry and Psychotherapy at St Hedwig Hospital, Charité - University Medicine Berlin, Germany Keywords: Afghanistan Mental health Training of psychosocial counsellors 1. Introduction ABSTRACT Countries suffering from long term civil war, such as Afghanistan, are characterized by high rates of traumatization [14]. Quite often, such prolonged confl icts also impair the education of medical students, particularly in topics that –in spite of evidence to the country– are widely not recognized as urgent or life saving such as mental health. In spite of a population in which more than 50% have been reported to suffer from symptoms of posttraumatic stress disorder and other symptoms of affective disorders [9], Kabul, a city with more than 5 Million inhabitants, hosts only two public psychiatric inpatient services besides newly developed addiction centers. Such sparse medical resources for the treatment of mental disorders are rather normal in large parts of the world: the average number of psychiatrists in high income countries is 200 times greater than that in low income countries [11]. In the academic teaching hospital of Kabul’s Medical Faculty, training of medical students in psychiatry and psychotherapy is limited to a two week internship during the last year of medical * Corresponding Author. E-mail address: andreas.heinz@charite.de (A. Heinz) Proofs 68767 EUROPEAN PSYCHIATRY THE JOURNAL OF THE EUROPEAN PSYCHIATRIC ASSOCIATION ISSN 0924-9338 June 2012 Vol. 27 - Supplement n°2 pp. S1-S81 Migration and Mental Health S1 Editorial A. Heinz, U. Kluge S4 The willingness to participate in health research studies of individuals with Turkish migration backgrounds: barriers and resources. A qualitative analysis of focus groups D. Dingoyan, H. Schulz, M. Mösko S10 Socio-economic status and emotional distress of female Turkish immigrants and native German women living in Berlin MC. Aichberger, Z. Bromand, A. Heredia Montesinos, S. Temur-Erman, A. Mundt, A. Heinz, MA. Rapp, M. Schouler-Ocak S17 Mental health of Turkish woman in Germany: resilience and risk factors Z. Bromand, S. Temur-Erman, R. Yesil, A. Heredia Montesinos, MC. Aichberger, D. Kleiber, M. Schouler-Ocak, A. Heinz, MC. Kastrup, MA. Rapp S22 The infl uence of stigma on depression, overall psychological distress, and somatization among female Turkish migrants A. Heredia Montesinos, MA. Rapp, S. Temur- Erman, A. Heinz, U. Hegerl, M. Schouler-Ocak S27 Translation and adaptation of the Zung Self-Rating Depression Scale for application in the bilingual Azerbaijani population F. Mammadova, M. Sultanov, A. Hajiyeva, M. Aichberger, A. Heinz S32 Construction and interpretation of self-related function and dysfunction in Intercultural Psychiatry A. Heinz, F. Bermpohl, M. Frank S44 Explanatory models and concepts of West African Malian patients with psychotic Symptoms F. Napo, A. Heinz, A. Auckenthaler S50 How to express mental health problems: turkish immigrants in Berlin compared to native Germans in Berlin and Turks in Istanbul A. Vardar, U. Kluge, S. Penka S56 Health services and the treatment of immigrants: data on service use, interpreting services and immigrant staff members in services across Europe U. Kluge, M. Bogic, W. Devillé, T. Greacen, M. Dauvrin, S. Dias, A. Gaddini, NK. Jensen, E. Ioannidi-Kapolou, R. Mertaniemi, R. Puipcinós i Riera, S. Sandhu, A. Sarvary, JFF. Soares, M. Stankunas, C. Straßmayr, M. Welbel, A. Heinz, S. Priebe S63 The German concept of “intercultural opening” as an answer to challenges of migration - the development of an assessment tool for the appraisal of its current implementation in the mental health care system S. Penka, U. Kluge, A. Vardar, T. Borde, D. Ingleby S 70 Cross-cultural training in mental health care – challenges and experiences from Sweden and Germany S. Bäärnhielm, M. Mösko S75 Teaching psychiatry and establishing psychosocial services – lessons from Afghanistan I. Missmahl, U. Kluge, Z. Bromand, A. Heinz S80 Afterword A. Kleinman We describe the extremely limited psychiatric resources of war- torn countries like Afghanistan. In such countries, we suggest to apply experience from training medical students in industrialized countries to teach a very basic and simplifi ed understanding of psychiatric classifi cations and core diagnostic symptoms to medical students (who will later serve in various medical disciplines in regional and district hospitals) and to medical staff including nurses and psychosocial counsellors working in health posts and district hospitals. We describe such a brief but clinically relevant list of symptoms and classifi cations based on experiences with medical student and practitioner training. © 2012 Elsevier Masson SAS. All rights reserved. education. Psychiatric services including outpatient facilities are extremely rare both in Kabul and the countryside. Doctors dealing with mental disorders often tend to prescribe neuroleptics, antidepressant medication and antiepileptic medication at the same time in varying doses, and there are hardly any organized meetings to ensure quality control of medical care for the mentally ill [6]. Lack of treatment resources for mental disorders contributes to the persistence of widespread psychosocial problems in Afghanistan: subjects suffering from posttraumatic stress disorder and other affective disorders often also display further problems such as high rates of opiate abuse and dependence and high frequencies of impulsive violence, particularly in domestic contexts [5,10,15]. Therefore, there is a spiralling continuation of violence within families and thus within society. Here we report our experiences with establishing basic mental health care by training psychosocial counsellors (often with medical background such as nurses) and by establishing a road map for psychiatric care within the Afghan Medical System, report on teaching efforts within the Mental Health Hospital, a psychiatric clinic owned by the Ministry of Public Health, and the Ali Abad Teaching Hospital of Kabul’s Medical Faculty. We focus on aspects of mental health care and training that can easily be generalized and applied to other countries and contexts, in which medical infrastructure is impaired by long lasting civil and military confl icts. 13_Heinz.indd S76 14/06/2012 14:45:44
2. Psychosocial care as a necessary foundation for psychiatric medical care The very low number of doctors focusing on mental health care in Kabul (about 30 medical doctors mainly trained in internal medicine with varying degrees of exposure to psychiatric patients) compared to the number of inhabitants of Kabul (about 5 million) shows that even with the highest efforts, training of medical specialists for mental health care cannot match the need for psychosocial care in a highly traumatized and large population. Therefore, medical care should only be secondary to primary psychosocial interventions addressing domestic, family and social confl icts that often result from traumatization and suffering from mental disorders. Within a so called Basic Package of Health Care Services, the Afghan government supports the establishment of positions for psychosocial counsellors (PSCs) in comprehensive health care centers (CHCs), which care for a population about 100 000 inhabitants [11]. The PSC trainees are selected according to selection criteria set by the Mental Health Department of the Ministry of Public Health, e.g. preferably a medical background (medical doctors, nurses, midwifes), or a degree in social sciences or social work, over 25 years of age, not overburdened by own psychological problems, and with high motivation, i.e. interest for a deeper understanding of social relations within defi ned cultural contexts. After the selection process, they enter one year training. After the fi rst three months intensive training, they take their fi rst examination and after 9 months practical work under supervision their second examination. Only then can they work as PSCs in the Comprehensive Health Care Centers. Counsellors can address family confl icts and violence e.g. resulting from drug (particularly opiate) abuse and from affective disorders in traumatized family members [15]. Psychosocial counselling can help to strengthen women’s rights by increasing contact between the women’s original family and the extended family into which a woman married, and by identifying family members that can help mediate confl icts and protect women and children. Psychosocial counselling can also help to deal with milder forms of depression and traumatization that do not require medication. Furthermore, a well- established network of psychosocial counsellors can help to distinguish between patients with major psychiatric disorders such as schizophrenia, who can live within a family and are treated rather well, and those who urgently need more specialized medical care in order to facilitate their life within a family context. Given the average prevalence of schizophrenia is at least one percent of the population [8], in a city like Kabul, at least 50.000 subjects will suffer from schizophrenia, clearly indicating that any outpatient hospitalized care delivered by medical departments and clinics is currently illusionary. Therefore, medical facilities have to focus on those few subjects who, due to the severity of their symptoms, can currently not be integrated and supported by their families. Therefore, medical staff in health posts, district and regional hospitals needs basic knowledge in order to transfer those few patients who need more intensive therapy towards specialized psychiatric units and to help stabilize the vast majority of psychiatric patients with the help of psychosocial counsellors and some basic medication skills. Foreseen were two psychosocial counsellors (PSCs) in each Comprehensive Health Care Center I. Missmahl et al. / European Psychiatry 27 (2012) / supplement n°2 / S76-S80 S77 (CHC), one female and one male. At the time being, the Basic Package of Health Care Services foresees only one, which would mean that half of the population would be excluded, since men cannot treat women and vice versa. This is supported by the European Union and USAID. Offi cially only one counsellor per CHC is found in Basic Package of Health Care Services guidelines. The Ministry oad Public Health is aware of this unbalanced situation and currently plans to amend it. 3. Training of psychosocial counsellors Besides basic knowledge in the classifi cation of mental disorders (which is required e.g. to decide when referral is necessary), it is of main importance for psychosocial counsellors to be able to understand and interpret social confl icts from different perspectives and the meaning of the symptom in the given cultural context. The key to successful treatment is to help the patient feel again that she/he can actively infl uence their lives again. Furthermore, counsellors need to have the skills to explore together with the client solutions based on the patient’s values and his resources, and they need to refrain from giving advice. For example, without proper training, one drug counsellor was rather proud of convincing a drug addicted woman to marry the man that her family had selected for her, feeling that this helps social integration of her client. However, she did not consider the case from the perspective of the individual, neither did she compare family values with overall traditional values or with perspective of “true love” as experienced by the client. Well trained counsellors, on the other hand, are able to consider the values and intervene in a culturally appropriate way. For instance, a desperate father felt forced by traditional values to kill his daughter because she was raped by a family member. The empathetic counsellor helped the father to accept and reconnect with his feelings of love for his daughter. The client was thus able to take a stand to defend his daughter and to develop a confl ict resolution strategy within the family. In order to avoid that psychosocial counsellors just intervene on the side of tradition without discussing different perspectives and behavioural and social options with the client, counsellors have to experience themselves how social interactions can be interpreted within diverse contexts and to understand their own biases and prejudices. Therefore the training plan foresees that all training contents are fi rst refl ected through self experience - no “cold knowledge”. During the fi rst three months of intensive training, all afternoons are fi lled with self experience in different groups, supported by single talks. In the mornings, case- centered intervention skills are taught. There are now well- trained Afghan counsellors in place; the team of the core trainers is working together since 2004. The fi rst curriculum has been developed by Inge Missmahl based on experiences within a pilot phase. This fi rst curriculum was taught to 30 Afghan men and women, who then worked in 15 centers in Kabul from 2005- 2008, where they treated more than 11.000 patients, 70% with good results according to symptom- based pre- post evaluations. After this phase, the training was evaluated and improved and the second training period started in 2008. The trained counsellors then worked in 9 CHCs in Herat, Mazar- e- Sharif and Bamyan. After the second evaluation of the training’s content and methodology [4], Proofs 13_Heinz.indd S77 14/06/2012 14:45:44
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Vol. 27, Supplement n°2, June 2012
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Editorial © 2012 Elsevier Masson S
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health of Turkish woman in Germany:
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studies [8,6,27]. Commonly suggeste
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lack of desire to obtain an educati
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the study should be emphasised [4,1
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clear is the picture regarding depr
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SD=15.9; t(183)= - 2.575; p=.011).
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as caring for children and taking c
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were then scrutinized independently
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[6] Berry J, Kim U. Acculturation a
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