Back to work after the weekend – on Saturday-which-feels-like-Monday : it’s going to be a long week as I’m going to have another Monday, starting as soon as I’m back. A very upbeat team meeting – starting just after 0800. The CD (=NGO's country director) is coming every day to hold the reins until a new CoP (=Chief of Party, what an odd expression) arrives to lead and manage the whole mental health project here. There has been a lot of chatter and worry about whether the project is up to scratch, or at least there is for the visible bits of it like whether walls have been painted or electric switches fitted or getting the water turned on when somebody turned it off. The less tangible products – like better staff attitudes and less grumpy patients at Jangalar – for which I think I have seen and heard convincing evidence, seem to be to nebulous to be registered clearly on the project tick boxes, though I know we have to try to do just that before we finish.
I don’t have any other experience to compare it with, so I have no idea whether it is a realistic worry or not, but I would think it was quite a morale problem if everybody in the team thought they weren’t doing good enough. With the pervasive paranoia that must be inevitable for anybody living in a war zone, this could surely be enough to break the camel’s back. But what was noticeable was the energetic and infectious enthusiasm of the new CD: she was on top of everything that needed doing, and even willing to start an addictions therapy group herself to get the idea of ‘self-counselling’ off the ground (using expertise from a previous life). So although it lasted till well after 0900, it felt like time together well spent. And with a bit of gentle prompting from Yousuf and I, they even warmed to the idea of possible team awaydays, and relational skills training.
I went straight from this into being an observer in the ‘day hospital’. Now if ‘day hospital’ conjures up images of people sitting around and gently convalescing, in spacious therapeutic surroundings, forget it! This was a slightly shabby room about 15 feet square, with a circle of about 12 chairs. People came into the group once weekly (there were different ones each day) either when they were still in-patients, or in the 12 weeks since they left; there were different groups taking place on each weekday. There were six women and two men in it today, which is less than usual as some of the hospital beds are shut for the refurbishment. Although I had good interpretation of what was being said in Farsi, for most of what was happening, I didn’t need to know the content. To a strictly trained group analyst, here are the less-than-perfect things that were observable without the language:
- · The conductor (a psychologist) spoke to one person at a time, nobody else spoke until it was the next person’s turn.
- · Nearly all the conversation seemed to be questions (from him) and answers (from the group member)
- · People wandered in and out
- · There were several interruptions for administrative matters
- · A referral was made and accepted while another patient was speaking - a man was brought in with a referral note and sat down
- · During his turn to be asked questions, the man who was admitted to the group during it became rather animated with what he was saying, and hitting his head. Others looked worried and looked to the conductor, and he seemed to indicate that he shouldn’t have been there. In fact he quite soon walked out.
- · Each person was given just over five minutes.
- · When one of them started getting upset, the subject seemed to change and he moved onto the next person.
- · I don’t know if there was a starting time, but there wasn’t a set finishing time and most of them just drifted away when everybody had ‘had their turn’.
- · The two who seemed most troubled by the new man came over to Yousuf and seemed to be imploring him to do something.
- · After that, somebody else from the group came in and had a long, and what looked like quite intense, conversation.
But, oddly enough for somebody who is even obsessional about how far away his group therapy chairs are from each other, and how perfect the circle is, I was strangely encouraged by it. So I wondered why, and came up with this list:
- · It was a group, and a therapy group, and it was happening here in Kabul
- · They were all sat on chairs, in a circle, and talking.
- · There were empty chairs for absent members (though this may have been accidental).
- · It seemed to be valued by the organisation, and its members
- · Not counting myself and yousuf, it had the ‘perfect number’ for an analytic small group – eight members plus the conductor
- · The mix of members’ problems seemed to be very reasonable: one woman talking of domestic violence, another with difficult family rivalries, a man with crippling self-doubt, an agoraphobic woman who was now managing to come in from some distance away after being an inpatient, a woman who appeared very resistant to speaking and would only utter single syllables when questioned by the conductor, and two who had had their turns before we came in. Even the man who was hitting his head appeared more angry and upset than psychotic, so may well have been a suitable member for a longer-term group.
- · It was a mixed group – gender, age and socioeconomic status (one member implied being quite wealthy).
- · It had a clear slow-open format, with members staying for (I think) twelve sessions after discharge from hospital.
- · There was at least a level of trust that enabled the four women wearing bhurkas to show their faces and express emotion in them.
- · The conductor is one of the psychologists who was in the Tuesday morning psychotherapy teaching sessions, and wants to learn more.
- · The room, although not in any way comfortable or well-furnished by our UK standards, was still good enough for conducting group therapy.
- · It happens every week.
- · There are different groups on the other mornings, conducted by different psychologists.
- · It felt like the basic structure for establishing a group therapy culture is in place.
- · I always enjoy groups!
Next, a brief discussion with Yousuf about the training course plans, which had been quietly germinating for a few days. With a couple of rough old diagrams, they sprouted into two courses delivered in six 3-day events. One course will be for 80 people and be called ‘Biopsychosocial Medicine: Awareness Level’, and the other will be a more intensive course, hopefully for training 20 future trainers, called ‘Biopsychosocial Medicine: Foundation Level’. As the 14 psychologists were all assembled in the library for something unrelated, we thought we would try out the idea on them when they finished their meeting. And they liked it, a fact probably not unrelated to the expectation that they will all be expected to do the ‘Foundation’ level, and form the backbone of the new way of doing things. So germination led to sprouting, which seemed to get the warm sunshine it needed – let’s just hope that everything blossoms by next spring!
Bolstered with enthusiasm at this, I resolved to do a quick report for the NGO to gather all this together straight after lunch. I started about 1.30pm, expecting to finish by about 2.30. In the way of these things, it was finished and emailed off almost exactly 12 hours after I started it: 1.30am. But it is an evidence-based analysis of what needs I have unearthed during the week, and a detailed plan for setting up these two levels of ‘biopsychosocial’ training in the three future visits (late September, late January and April). The details are too much for this blog, but they are uploaded as a pdf resource.
But it wasn’t all work and no play, as a certain downtown trip happened, and what a trip it was. In order to not compromise security, I can only portray it by photographs in which the location is not discernable, and the captions are somewhat cryptic…
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| Just what we need in Slough |
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| $50,000? |
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