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.

Day 1 in Kabul

A long way from the yurt in Slough, though further in miles than it is in ideas...

Hindokosh Mountains - West of the Himalayas

The plane from Bahrain looked to be fairly empty when I did the online check-in , but when I was the last one to board it (being a bit other-worldly at what should have been 5am) I found it was completely full - and most of the occupants seemed to be lively and inquisitive children. A whole family of them were occupying the seat 

I had chosen, and I had lesson one in 'go with the flow': when I showed the resigned-looking air stewardess the seat number on my boarding card, she gave a big shrug and an even bigger smile. However, one of the bigger boys, who spoke good English, took the situation in hand - and moved some younger members of his extended family out of their seats and offered me a very good place next to the window just behind the wing - hence some spectacular views of the just-snow-tipped mountains in the last half hour of the flight, and then a city emerging on the plateau.

Northern Kabul

My phone leapt into life while I was in the immigration queue, and Yousuf was was telling me that he couldn't quite believe I had arrived. But I still had to get past the rather sinister-looking passport and visa inspection cabins - almost quaint-looking in dark wood, but with large mirror windows and inscrutable immigration officers. But it took less than 30 seconds for him to wave me through, and the baggage reclaim just like you'd expect anywhere (except for several colourful soft random-looking items ties up with layers of knotted string).

And who is he under the arch?

Walking out of the exit was a little wierd, as I was expecting people there at a barrier meeting the passengers with signs scrawled on pieces of paper - and when I stopped to look around for them, I was very quickly ushered towards the outside door by a polite uniformed official. And just in the other side of that door was Yousuf - with the driver and security man. Apparently, they shouldn't have been allowed out of the car park (some way away) to meet me - and I should have been bundled on the bus to he-didn't-know-where. But a small offering to the airport staff unofficial benevolent fund had ensured that he was able to wait for me by the door...

A quick phone call home was prevented by the UN vehicle in front, which had a large thick ariel on its roof - this, the security man explained, being a mobile signal jammer, effective up to 50m, to prevent mobile phone activation of roadside bombs. He thought it was probably for somebody for the American Embassy.

The slow lane

The roads and driving were amazing. And I thought it was exciting when I was last in Rome! This made even the most random and chaotic of Italian driving seem like a quiet Sunday in a genteel English town. But we soon arrived at the Kabul Headquarters of the NGO running the project. 

As we drove through Kabul, my hosts pointed out the high walls and razor-wire fences round all the ex-pat buildings, as they would be easy AOF (Afghan Opposition Forces) targets otherwise - for suicide bombs, kidnappings, ordinary theft and burglary, and so on. The IMH was similarly in a concrete enclosure, and Yousuf exlpained that new 3+m high concrete blocks with wide bases have been appearing everywhere recently - and there is probably a concrete trader somewhere who is doing very well out of it all. But as we went past the ones outside the Parliament building, we said it not that different to Westminster - except the ones there are shiny, a bit smoother, and painted black. Inside IMH, antique tables with modern PCs , and an elegant sweeping wooden staircase with a huge satellite dish on the roof gave a hectic workaday feel in a setting of well-faded grandeur.

An excellent opportunity for concrete block manufacturers

The basement bunker was my first appointment, with the recently-arrived head of country security plus our own house's security guard. I was expecting a simple powerpoint presentation, a few dos and don'ts, and good night. But after a few warm-up slides with lists of facts and figures about the country, it was down to the hard stuff. The polite chit-chat was over, and it was like the moment that you decide it's probably better not to make a joke when they ask at the airport if you packed all your own bags. First 'this might happen to you' followed by several things you never even think about as even being possible to somebody like you, then 'this is where it's happening at the moment' with extraordinary detailed maps with arrows showing which directions they're moving in, and coloured in to represent the threat level (we're currently just shy of the one where nobody is allowed to move anywhere, which is one below the 'lock yourselves in the windowless room on the left of the front door with the steel plate door firmly bolted'). 

Following that, we had 'this is when it last happened and to whom' (a couple of days ago, to several people) and cheerfully supplemented with 'there's less than a quarter of all this that you every get to hear on the news', and finally 'this is what you can do to minimise the risk'. That involves keeping the car windows up, doors locked, seatbelt on and never getting out of it until you're at you destination with the gates shut behind you - including the 100 yard trip from the house to the hospital. Also, we have codewords for each of us and each building, and they phone round everybody twice a day to check that we are safe, and that we are where we are meant to be - but only using the codewords. From the news, it's probably not surprising that Kandahar is considered the worst at the moment - and an absolute no-no for the likes of us - but as I'll only be doing the 100 yards to and back from the hospital, I won't need to worry about that one. 

Now I'm not usually much of one to worry - and indeed I felt sensible about this, but a few minutes ago as I sat at my desk to write this I noticed that the thick net over the window was tucked back, so I could see into the street below. Normally, I would have thought 'what an interesting view' (which it is), 

Interesting view - with a hole in the head

but I unthinkingly pulled the net right across and then consciously thought ' with my head visible from the road, eyes glued to the laptop, and this obviously being an ex-pat house, I'd be a sitting duck for a bullet if anybody nasty and armed walks past. And there's a lot of nasty and armed people in this town'.

The living room in our 8 bedroomed house with air conditioning, wifi, resident drivers, security guards, and cook. 

Because one of the others in the house was leaving and because I had just arrived, the four of us decided to go out to a restaurant to celebrate. It had to be one on the 'safe' list, and we had to be back by the 7pm curfew - which was a problem as by the time we assembled to go out it was 6.30pm, and we had to do all the faffing about with the cars and gates business. But the duty security officer was surprisingly helpful: he checked with the security chief, and allowed us to extend the curfew to 7.30, as it was in an area which was thought to be very secure (just by the bus stop where Yousuf used to wait for his school bus 40 years ago, in fact). Now the security men at Grendon wouldn't have been like that, I thought. Thank goodness that people are allowed to exercise a bit of discretion!

Lift-off

After far too long, at last I write again. Amidst the desolate and ransacked landscape of the NHS, a few shoots of new and fresh green life are starting to emerge. Today was one of them.

After a morning of heavy rain, a week-long teapot crisis, a month-long effort to turn an almost bare patch of soil into an vibrant, nurturant and tranquil space, and a three-year long effort to get greencare off the ground - it all came together this afternoon.

Thanks to dozens of people who have been working tirelessly, energetically, creatively and because they feel an absolute passion for 'doing mental health differently'. And thanks of course to the BIG Lottery which has awarded us (as ExclusionLink) a grant to set it all up at Wexham Nursery, through its EcoMinds programme with Mind.

I'm too tired to try to put the atmosphere into words, but here's a few photos to try saying it...

The 'cake of the yurt' which was cut at 5pm

Somebody said 'it looks like Baby Jesus is missing' - so we found one!

Come this way, to the willow circle...

Where the wishes grow on trees

Like this one, which has a certain appeal for us...

And a lot of information ended up in the programme - so it's uploaded here for you can see more of what went on...

More later. Goodnight - and thank you all!

Yurt's Up!

David and I arrived about half an our before anybody else, and we made ourselves a cup of coffee and did some of the domestic stuff: washed up two months' coffee cups, cleaned out the water urn (which was pretty scanky when we boiled the kettle from it last week) and tidied up a bit.

We were just discussing how much we might manage to do if nobody else turned up when he first wave of the cavalry arrived: one of our members with four energetic teenage girls in tow. Then came the second wave, and the third and fourth battalions of willing eco-warriors. For each parent, there were three or four next-generation recruits. Well before lunchtime, there were twenty three people helping us to put up the yurt as its makers intended. Although a few were sometimes to be found in conditions of immediate mental exclusion, transfixed and immobile in that unique state of close communion with their electronic networks of relationships, they helped enormously when it came to vital tasks like 'spreading out the liner to see how it fits', and 'holding up the sides while we work out where the strings go'.

There were also the trolley races - with the big ones pushing the little ones up and down the concrete paths in garden centre trolleys - at increasingly breakneck speeds and with a rising decibel count.

But the main job of the day was happening - the yurt had never before been clothed in more than one and a half layers of its three layer covering, but by the lunch break at about 1pm, the inner liner was in place, as were the three felt panels around the walls.

Lunch was a very jolly affair: three loaves and seven bananas went a long way (although there was a cooked chicken, some lumps of cheese and a few other items too). We resurrected the garden furniture we had been given last Autumn, and it was like a huge multicultural family picnic in the middle of a recently ploughed field.

Before much longer, the felt roof was in place - followed by the canvas walls, canvas roof covering and top transparent window. The most exacting procedure was ensuring that the canvas folds on each side of the door were 'straight, crisp and symmetrical' - but, with a few minutes concentration and effort, they were!

A few cords and strings were probably subject to a little over-zealousness, but everything was stable and looking good well before the allotted finishing time of 3.30pm. At last, the deed was done.

All that remains is to:

• clean the two muddy girth belts (that go all the way round to hold the walls in place) and tie them on to the door frame
• put skewers into the ground to hold down the roof, in case of hurricanes
• plane and adjust the door slightly as it seems to have swollen in the wet, and does not fit its frame any more, and cannot be properly closed

Time for nesting

We've had a few snags since we last did much with the yurt (which you can read about in earlier postings to this blog) - but now that spring is coming, and the EcoMinds lottery money is about to start - we're picking it all up again.

Next Saturday, 26 March we are going to 

• finish putting the yurt up
• furnish and decorate it
• see what needs doing to our teepee
• (if we have time) decide what sort of site we need to ask the council about for the City Farm project

Here’s the rough plan for staffing and running the project now we have the Lottery money. It is NOT written in stone – this is only a first draft, and we’re open to anything at this stage.

But we need to make sure we spend the money as allocated each quarter, or it gets complicated asking for variations (or we risk losing what we haven’t spent).

So we need to hit the ground running, and fortunately – it’s the right season for getting going now.

• Stay at Wexham nursery for this year, and do most of what we grow in pots etc.
• Finish putting the yurt up, furnishing and decorating it
• Ditto for the teepee
• Change the Wexham programme so people are free to come every lunch & afternoon if they want
• David continues his Thursday and Monday afternoons with the project, and Sheena Mondays
• We add six three hour XBX sessions over the week (six is my estimate – we need to get figures for what the costs are to make sure it is accurate for using the grant at the right rates. 
• Plan to start doing all this in April 
• Connect with Linsdey and the funding she is raising for the City Farm (which will only partly be for us to use) 
• Get back to John Rice with details of what we need
• Have three non-horticultural task groups of staff + XBXs + volunteers: 

1. Planning and organising the launch event (which we have good funding for)
2. Recruiting volunteers and participants
3. Publicity and website (with help from the EcoMinds publicity office)

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