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The Royal College of Psychiatrists Improving the lives of people with mental illness

Biopsychosocial Medicine, Greencare and Therapeutic Community Treatment

Training programme for improving Afghanistan's mental health provision 

Commentary from Rex Haigh, FRCPsych

Biopsychosocial Medicine, Greencare and Therapeutic Community Treatment by Rex Haigh FRCPsych

The two major public health problems facing Afghanistan are the mental health and conditions resulting from life in a war zone, and opiate addiction. These are both biopsychosocial conditions, requiring evidence-based psychosocial approaches in addition to psychotropic medicines. 


As Afghanistan is predominantly an agricultural country, it is suggested that a combination of therapeutic approaches delivered in a ‘greencare’ format of therapeutic community, with recently developed experiential training for staff (in Kabul Mental Health Hospital), would provide an effective, economical and culturally acceptable programme for development of innovative and high quality services.


The European Union ‘Cooperation in the field of Scientific and Technical Research Action 866’[i] published a ‘conceptual framework’ for greencare, which reviewed a wide range of evidence and concluded that:


  • “Greencare” is a useful phrase summarising a wide range of both self-help and therapy programmes.
  • Research to date has demonstrated correlations of well-being in greencare settings .
  • Research that would demonstrate cause-and-effect relationships between greencare interventions and improvements in health and well being has not yet been carried out.


It also drew up a value base:


  • Contact with nature is important to human beings.
  • The importance of this is often overlooked in modern living conditions.
  • People can find solace from being in natural places, being in contact with nature and from looking after plants and animals.
  • In addition to this solace, contact with nature has positive effects on well-being, with physical, psychological and spiritual benefits.
  • Existing or new therapeutic programmes could be improved by incorporating these ‘green’ elements.
  • The planning, commissioning and delivery of all health services would be enhanced by consideration of potential ‘green’ factors.

Greencare also works to principles of sustainability, environmentalism and ‘low-tech’. Together with the proven therapeutic benefits of ‘connecting with the land’, these principles would ensure that unnecessary or expensive equipment or technological processes would not be necessary; it is also likely to have a very low carbon footprint and make use of locally sourced materials and labour. It would not have the quality of ‘experts coming to tell the locals how to do it’ – but rather helping the local people to learn universal human psychosocial techniques (such as sharing distress in a group therapy format) and adapt to their own local circumstances and cultural requirements.


This model integrates fragmented understanding of individual distress and inability to function by using a biopsychosocial model[ii]. This sees biological, psychological and social factors all as important determinants in the formation, development and maintenance of ill health and disorder. 


  • Biological includes genetic, neurological, hormonal, pharmacological and any other physical or physiological factors.
  • Psychological involves feelings, fantasies, thoughts, behaviours and any contents of a person’s mental ‘inner world’.
  • Social influences include any aspects of a person’s life amongst others, and includes friendships, intimate relationships, past and present family relationships, poverty, education, living conditions and many other factors.


The advantage of using biopsychocialism to understand mental health problems is that it can embrace complexity and uncertainty, and lead to helpful understanding of multifactorial systems – from prevention through to society-wide consequences. This has particular relevance in an area of high uncertainty and risk, rapid change of circumstances, and general lack of stable societal structures.

Therapeutic communities

Biopsychosocial Medicine, Greencare and Therapeutic Community Treatment by Rex Haigh FRCPsychTherapeutic communities are not a single mode of treatment, but a service-user partnership format within which formal therapy is one of many things that take place[iii]. The therapy may tackle particular difficulties, or examine particular relationships in great depth, but the ordinary time together is just as much part of the programme – and ‘therapeutic ordinariness’ can be a remarkably transformative experience for people who have only ever experienced discord, chaos or brutality in their day-to-day relationships.


Similarly, in a society-wide environment of war, constant disruption, fear for one’s own safety, and high risk of loss of loved ones, ‘normal’ interpersonal relationships can have a very healing effect. Therapeutic communities for the residential treatment of and recovery from opiate addictions have a very substantial positive evidence base, and they have been established worldwide for this purpose, in considerable numbers.


An important part of this ‘ordinariness’ is making decisions together in a way that emphasises members of these programmes taking responsibility for themselves and for each other. When responsibility for ‘real’ arrangements is included, such as growing food or tending animals, the power to train people to take this responsibility is greatly increased, as is the scope for creativity and spontaneity in doing so.


A clear parallel between greencare and therapeutic communities is the expectation of change, growth and transformation. Apart from the direct analogy between botanical and human emotional development, the metaphorical meaning of ‘growth’ is true for both. Clients and staff often experience and report any greencare project (not necessarily those set up as therapeutic communities) as a transformational process, and one whose value is much beyond the simple function of, for example, growing food or rearing animals.

Training considerations

A specific experiential training for this type of work was established by the UK Association of Therapeutic Communities in the 1980s, and has been running continuously since 1995.


More recently, these residential (three day) training events have been incorporated into a module of a government-sponsored mental health ‘Knowledge and Understanding Framework’. This is validated by the Open University (40 level 4 credits) and delivered by the Institute of Mental Health at Nottingham[iv].


Two draft modifications of this module have been written to meet the specific requirements of trainees in Kabul Mental Health Hospital. For psychiatrists, psychologists, social workers and nurses, a programme of three separate three day workshops is planned – which will be very similar scope and scale to the UK students in Nottingham; these trainees could then be expected to participate in developing and delivering psychological treatment programmes based on these principles.


A single 3-day workshop ‘foundation level’ course has also been planned for a wider range of staff, to include other branches of health care, medical students and all others who might benefit from a deeper understanding of biopsychosocial principles.    


These experiential training programmes are gaining international recognition: they have been successfully delivered in several Italian settings, and for an addiction workers in Australia. They are being planned in Bangalore and Taiwan for 2012-13, and have submitted abstracts for inclusion in the WPA conference in Prague in October 2012.




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