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Attacking mental health problems in Afghanistan

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KHAMZARGAR, Afghanistan – As one of only five female therapists in the northeastern Afghan province of Kapisa, Farkhunda Shahab struggles to soothe the anguished.

With her baby daughter perched on her lap, Shahab, 26, listened to the problems of women facing abusive husbands and economic hardship, or of young girls mourning a father long after his death.

With little formal training, women like Shahab have nonetheless become the front line in trying to improve mental health care in this part of Kapisa, a rural area marked by war, first between Afghan insurgents and Soviet occupiers, and later between the Taliban and the government they toppled.

Shahab cares for dozens of patients, many of whom must endure long journeys to see her. She does not dispense medication; instead, she listens to their complaints, asks questions, leads them in meditation exercises and offers advice on ways to change their habits in life to feel better.

But at night, back at a home set deep in a lush valley, past spiraling roads and wild olive trees, it is her own pain she struggles with.

Her husband is an opium addict who has relapsed six times. Her three children – the oldest is 12 – are malnourished, their childhood shaped by bitterness toward their father.

In Afghanistan, it is only fitting that the therapist herself is overwhelmed.

The mental burden of the violence continues to weigh down every sector of Afghan society as the war and Western presence here continue into their 14th year, and the country’s nearly perpetual conflicts move into a fourth decade. Beyond that, the stress of upheaval and economic desperation has exacerbated already rampant problems with domestic abuse and drug addiction, with women often bearing the brunt.

"For us, it has become a vicious cycle of repeated traumatic experiences over years and years," says Dr. Suraya Dalil, a former Afghan minister of health. "It’s been too much, not only on individuals, but also on the society, which is just waiting for a spark to let out the anger."

No recent figures are available, but surveys conducted nearly 10 years ago found that symptoms of depression, anxiety, and post-traumatic stress disorder were widespread, and officials say the situation has probably gotten worse. One study published with the National Institutes of Health in the United States found that 62 percent of Afghan respondents had experienced at least four traumatic events in the preceding 10 years, with women reporting an even higher rate.

"If you are in a continued environment of violence, without empathy, it is difficult to survive psychologically," said Inge Missmahl, the director of the International Psychosocial Organization, which trains therapists across Afghanistan. "You have to protect yourself somehow, to survive in everyday life."

Shahab said her village, in the Khamzargar district of Kapisa, was rife with abuse, poverty and addiction.

"In my village alone, I know of 50 addicts," she said. "When my husband goes out of the house, they are across the street calling for him. Some villagers taunt me sometimes: ‘You are a psychological counselor. How come your husband is an addict?’"

Though it is hard for many women in Afghanistan to travel, and overcome a cultural stigma against seeking help, nearly 70 percent of patients who seek counseling in facilities like the one where Shahab works are women.

At the small Kapisa hospital, Shahab saw about 90 patients in March, many of them referred by medical doctors who could not find a physical illness to account for their symptoms. When she is overwhelmed by visitors, Shahab sends some to a male colleague, who shares an office with a dermatologist.

One morning, a middle-age woman covered in a blue burqa came to Shahab with complaints about a debilitating headache. Shahab listened with patience and asked simple questions. No, the patient could not remember when the headaches had begun. Yes, it is worse in certain situations. Her unemployed husband has a heart condition, and they cannot afford the surgery he needs. He screams at the children and beats them. When he screams, her hands begin to tremble and her headache grows worse.

Shahab picked up a visit card for her. She wanted the woman to come back for frequent sessions.

"Are you not giving me any medicine?" she asked.

Shahab was silent for a moment, and then said with a sympathetic gaze, "Medicine for you will not cure your husband."

The Afghan government has made mental health care a priority only for the last four years. To make care more affordable, and decrease the stigma attached to it, the Health Ministry incorporated counseling into the primary health care service it provides across the country, placing "psychosocial counselors" like Shahab in some local clinics.

One ministry official said mental health care could still be a hard sell for international donors and senior Afghan leaders. There are only about 260 of the counselors across the country, for a population of nearly 35 million.

Still, offering nonmedical services in local clinics has proved to be a big step forward, said Missmahl, whose organization trains the counselors.

"This is certainly not enough, but it is already a wonderful achievement," she said. "It helps people to cope better with their everyday life."

Shahab became a counselor almost accidentally. She just needed a job. Her husband was increasingly becoming a burden, and she had to feed him and the children. She heard from a friend that the ministry was looking for people to train as counselors.

Yet Shahab believes the best training for her has been the resilience she gained in the face of problems she has faced from a young age.

She was born in the village she still lives in, in 1987 or 1988 – she is not sure. Her father was shot and killed at his mosque shortly before she was born. The reasons for the killing remain unclear, but it shattered their family and forever changed life for Shahab and her two siblings.

A marriage was arranged to a man almost 20 years her senior when she was only 13. But the marriage did not stop her from completing her education. She took two of her youngest children with her to school, placing them at the kindergarten as she attended classes.

While she draws on her own struggles to lend insight that helps others cope with their pain, she said, her patience is running out with her husband, who relies on her for money. She pays him a stipend, and he washes the dishes, cleans the house and takes care of the children. He is not physically abusive, she said, but is threatening and suspicious.

"My training has helped me put up with my husband’s situation. When he doubts me, when he is difficult, I understand," she said. "Now when he curses at me, I just smile."

Life became so difficult that, when she was pregnant with her youngest child, she told one colleague that she did not want to have the baby, that it was unfair for the child to be born into a life like its mother’s. Her youngest son was already growing tired of the situation, refusing to go see his father while he was in drug treatment.

"When my husband came home from the hospital, the boy said, ‘If you get hospitalized again, I will put a gun to your chest,’" Shahab recalled.

The new baby could be the spark of luck she needed to turn her life around, her colleague told her. Not convinced, Shahab called her trainers in Kabul, the capital of Afghanistan, and spent hours with them on the phone seeking counseling. It had taken her awhile to establish that relationship with her superiors. Initially, she had been reluctant to share her struggles with them, thinking if the organization knew of her life she would never be hired.

By now, two years on the job, Shahab has learned to leave her pain at home when she goes to work – so much so that her calm presence has become the subject of envy for many of her patients.

Once she overheard chatter between a patient and her friend as they were leaving a session.

"She is so calm and quiet. I wonder how rich, how nice her husband must be," one of the women said to the other.

"If only they knew my life," Shahab said.

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