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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],
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