Day 2: the hospital and the psychiatrists

The days starts at 7.30 here - meet for a cup of tea before being driven off the hospital for a 8am briefing.

One of our ever-present drivers, always waiting for us

The briefing was for the whole NGO team, and about eight were there for it this morning: surrounded by flipcharts, to-do lists, everybody with at least one laptop on their lap. Tasks for the day, snags, people coming and going, important meetings - and a warm welcome for a newly arrived psychiatrist from Europe who doesn't speak Farsi. But thankfully Nadia the team interpreter was available for most of the day; she is a local young doctor who wants to train in obstetrics - but is doing this job for an NGO while things are so chaotic in Kabul.

Then to the nicely refurbished library - with a large and a small teaching room, and a few small shelves of books (mostly donated from UK, but quite a number in Arabic script too). Bright blue walls, sun playing on the vertical blinds, projector bolted to the ceiling, a familiar-looking circle of about 25 new chairs and people trickling in for the seminar. As good as most postgrad teaching rooms back home, and better than many; the circle soon filled up with psychiatrists (all men) and psychologists (mostly women, all sat together) and anybody more than five minutes late was not allowed in.

The door to learning

The new education centre

The small seminar room

The teaching plans and timetables

The planned session on Kleinian theory was postponed so that I could have a conversation with them all about how things worked in the hospital, and how they thought the training programme might help. I made some complicated comments about using therapeutic relationships to improve understanding and clinical effectiveness - and was surprised how many of them got the point straight away and agreed. I warmed to my theme, and explained how the future visits will be for training events that will give them an intensive experience of being in groups themselves - and why this will help them, and how it can be quite challenging. Again, even more surprisingly, general agreement. Now my guide book says that Afghanis tend to be very polite and would generally try being agreeable rather than upset a guest - so I'll have to wait to see if they know what they are letting themselves in for. And when I later talked Yousuf through the normal format for these 3-day courses, he gave me a list of things that might be different in this culture:

• sensitivity to gender issues - fair enough about having completely separate sleeping quarters, but I'm determined to get those men cooking for each other (and he assures me that none of them will ever have cooked anything before).
• prayer times - which need to be religiously observed (boom-boom) and therefore timetabled - but would expose fascinating dynamics, as he knew the range of religious belief to be very wide - and never openly discussed.
• overwhelming exposure to trauma. Most people here have experienced family and personal loss as a result of the wars, and are generally open about discussing it. But to do so in a therapeutic space where feelings could be overwhelming needs careful thought about containment - especially small group conductors and interpretation.
• humour can sometimes be extreme - but in a defensive way to avoid discussing 'serious' matters. And most Afghanis are long-practiced and expert at it.
• gay relationships are sometimes disapproved of and can be the subject of the jokes - and projected onto various ne'er-do-wells.

The doctors and psychologists at Kabul Mental Health Hospital

We also thought language exercises could be devised - and that it might be very eye-opening for their professionals to experience the power dynamics of having an expert by experience in our staff team. We shall have to see what we can arrange!

The work discussion group was reassuringly familiar - which is enough said for those who know about such things, and probably quite inexplicable for those who don't. I was charmingly invited to lunch by two of the female psychologists, and - being somewhat confused by how this isn't even mentioned as a possibility in my etiquette guide - was rather relieved when I realised that it was against the security rules to go anywhere with any locals without the NGO cars, driver, security person and all. So I gracefully apologised - and later learned that this is exactly the right thing to do anyway - even if I was able and keen to go.

At lunchtime one of the other NGO staff came over to tell us about the murder of the President's brother - a powerful political presence in Kandahar, one of the least safe areas. It was by a trusted bodyguard, so the conversation turned to how it is increasingly difficult to identify who is Taliban - and how sophisticated and long-term their planning is becoming. We also wondered if it would increase the restrictions on us and our movements - which are already close to the maximum without having to stay in our house all day every day. And after that, its just the safe room, then emergency evacuation.

The afternoon tour of the hospital was both better and worse than I had imagined. The bad news is that yes, they do chain people to the beds (in some hospitals they have to raise the cost of their own chains); there are ten patients in a small room (all day - with nowhere else to go), sat on beds which almost touch  each other; nobody is admitted unless their relatives come too to look after them; nurses are almost non-existent; efficient psychiatrists can see sixty patients in little over an hour; the forensic ward is only different because it has more chains.

The hospital kitchen (as seen on YouTube)

Dr Rahimi is very upset with the state of the buildings

Dr Haigh believes ECT should only be a very last resort

BUT the patients do talk together, appear generally well fed and clothed, seem to care about each other, sometimes include spiritual healing in their treatment, receive medication efficiently, and only have a 5 second waiting time for psychological treatment. The last one is not a test to see if you are still awake, but the way the outpatient clinic works: 1-2 minutes with the doctor and nurse (sat at the left and centre tables, below - the doctor interviewing, diagnosing and prescribing and the nurse completing the notes) then along to the next table with a psychologist as soon as you have finished, if the psychiatrist thinks it will help (by the window on the far right). You might not get very long for your session, though, and none of it all is exactly confidential...

The Kabul Mental Hospital Outpatient Clinic

A little later in the day we had a detailed discussion with nearly all the senior doctors in the hospital, plus the head of psychology and a representative from the trainee psychiatrists. Which made seven - not a large number for a psychiatric hospital covering about half the souls of Kabul (pop 3.89m). Interestingly, they are all TV celebrity doctors, too - with about 40 local channels now, they are all signed up to be the 'television psychiatrist' for at least three or four of them. However, they were all committed to learning better ways of running their practice, being more psychologically-minded, and becoming less professionally isolated. Unfortunately, just like many psychiatrists in England who are not now managers, they have no power to make any of it happen: apart from the unimaginable skimpiness of the resources - the management are not very interested in change (which is perhaps different to England where they are interested in change but too much of it and in the wrong directions). So my own prescription is for some heavy-duty reflective consultation exercises. But as the insidious and probably unconscious undermining has already started ('forgetting' meetings, slipping back into old command & control ways, and other things), don't hold your breath that it will happen.

Refurbishment under way

The psychiatrist and his bright green newly painted female ward

My most optimistic thoughts are that such a tabula rasa gives wonderful opportunity for the development of a  truly commnunity-based network of self-help non-residential therapeutic commuities: ideally one for each of the proposed five community teams, in the same buildings as them (rumour has it that many military and other buildings will be vacant soon, as troops move out), and with both mental health programmes and addictions: forming the heart and hubs of all the city's mental health services. And they could be run as cooperatives between the professional staff, service users (always "patients" here), volunteers, families and friends. The psychiatrists would only need to look in once a week, and the rest of the time they could be seeing their private patients who do not like the thought of groups, or are too psychotic or organically ill to be attend them.

The private patients are simply those who actively choose to see one of the psychiatrists, rather than just be taken to the state hospital - they do not get treatment that is much different from the state hospital outpatient clinics (ie very quick mental state assessment, diagnosis and prescription). The working day here for the psychiatrists is mornings at the state hospital then afternoons seeing literally dozens of these private patients (which they also do at weekends).  Now, of course, they are also expected to go to the new psychiatry courses which Yousuf has set up to improve the clinical standards - and I suppose they squeeze the TV appearances in between times.