Training programme for improving Afghanistan's
mental health provision
Commentary from 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
- 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
- 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’
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
- Psychological involves feelings, fantasies,
thoughts, behaviours and any contents of a person’s mental ‘inner
- 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 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
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.
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
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
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
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.