Provision of mental health services in resource-poor settings: a randomised trial comparing counselling with routine medical treatment in North Afghanistan (Mazar-e-Sharif)

<p>Abstract</p> <p>Background</p> <p>Psychosocial stress caused by war, ongoing conflict, lack of security, and restricted access to resources promotes mental suffering and diseases in many resource-poor countries. In an exemplary setting, the present study compares the efficacy of psychosocial counselling with routine pharmacological treatment in a randomised trial in Mazar-e-Sharif (Afghanistan).</p> <p>Methods</p> <p>Help seeking Afghan women (N = 61), who were diagnosed with mental health symptoms by local physicians either received routine medical treatment<b/>(treatment as usual) or psychosocial counselling (5-8 sessions) following a specifically developed manualised treatment protocol. Primary outcome measures were symptoms of depression and anxiety assessed before treatment and at follow-up using the Hopkins Symptom Checklist and the Mini-International Neuropsychiatric Interview. Secondary outcome measures were psychosocial stressors and coping mechanisms.</p> <p>Results</p> <p>At 3-month follow-up, psychosocial counselling patients showed high improvements with respect to the severity of symptoms of depression and anxiety. In addition, they reported a reduction of psychosocial stressors and showed an enhancement of coping strategies. At the same time, the severity of symptoms, the quantity of psychosocial stressors and coping mechanisms did not improve in patients receiving routine medical treatment.</p> <p>Conclusion</p> <p>These results indicate that psychosocial counselling can be an effective treatment for mental illnesses even for those living in ongoing unsafe environments.</p> <p>Trial registration</p> <p><a href="http://www.clinicaltrials.gov/ct2/show/NCT01155687">NCT01155687</a></p

Afghan mental health and psychosocial well-being: Thematic review of four decades of research and interventions

Background Four decades of war, political upheaval, economic deprivation and forced displacement have profoundly affected both in-country and refugee Afghan populations. Aims We reviewed literature on mental health and psychosocial well-being, to assess the current evidence and describe mental healthcare systems, including government programmes and community-based interventions. Method In 2022, we conducted a systematic search in Google Scholar, PTSDpubs, PubMed and PsycINFO, and a hand search of grey literature (N = 214 papers). We identified the main factors driving the epidemiology of mental health problems, culturally salient understandings of psychological distress, coping strategies and help-seeking behaviours, and interventions for mental health and psychosocial support. Results Mental health problems and psychological distress show higher risks for women, ethnic minorities, people with disabilities and youth. Issues of suicidality and drug use are emerging problems that are understudied. Afghans use specific vocabulary to convey psychological distress, drawing on culturally relevant concepts of body–mind relationships. Coping strategies are largely embedded in one's faith and family. Over the past two decades, concerted efforts were made to integrate mental health into the nation's healthcare system, train cadres of psychosocial counsellors, and develop community-based psychosocial initiatives with the help of non-governmental organisations. A small but growing body of research is emerging around psychological interventions adapted to Afghan contexts and culture. Conclusions We make four recommendations to promote health equity and sustainable systems of care. Interventions must build cultural relevance, invest in community-based psychosocial support and evidence-based psychological interventions, maintain core mental health services at logical points of access and foster integrated systems of care.publishedVersio

Aide psychosociale et travail de deuil en tant que contribution à la paix et à la réconciliation – l’exemple de l’Afghanistan

In diesem Artikel werden die Erfahrungen von drei Jahren psychosozialer Arbeit in Kabul reflektiert. Individuelles Leiden und kollektives Eingebundensein in die traditionelle afghanische Gesellschaft, der Anstieg der Gewalt im privaten und öffentlichen Raum sind Spannungsfelder, die deutlich machen, dass eine erfolgreiche Friedens- und Versöhnungsarbeit beim Individuum ansetzen muss und dass psychosoziale Hilfe dazu einen wichtigen Beitrag leisten kann.Schlüsselwörter Afghanistan; Unbehandeltes Trauma; Langzeitsymptomatik traumatischer Erfahrungen; Soziale Identität;Häusliche Gewalt; Viktimisierung; Psychosoziale Arbeit; Kultursensitive Psychologie; Humanitäre ArbeitThe experience of three years of psychosocial work in Kabul is the background of this article. Individual suffering within the traditional Afghan society, the postwar situation, the increase of public and domestic violence are themes which demonstrate clearly that a peace building and reconciliation process must start within the individual. Psychosocial aid is a necessary first step.Keywords Afghanistan; Untreated trauma; Long-term symptoms of old trauma; Social identity; Domestic violence; Victimisation; Culture-sensitive psychology; Humanitarian workOn présente dans cet article une réflexion sur les expériences acquises durant trois ans de travail psychosocial et psychologique à Kaboul. La souffrance individuelle, un ancrage collectif dans une société traditionnelle, ainsi que les ruptures subies par les Afghans au niveau de leur identité culturelle et sociale en cette période (d'après)-guerre - tous ces facteurs étant accompagnés d'une augmentation de la violence dans la sphère privée et publique - sont champs de tension qui montrent clairement que pour réussir, une démarche de paix et de conciliation doit commencer au niveau individuel et qu'un soutien psychosocial peut apporter une contribution essentielle à ce niveau.Au cours des deux dernières années, 32 conseillers psychosociaux ont été formés à Kaboul. L'équipe offre actuellement jusqu'à 1600 consultations par mois. Elle a enregistré une nette corrélation entre les symptômes à long terme issus de traumatismes anciens et les conflits ainsi que la violence trouvés dans le cadre familial. Il s'est également avéré qu'un soutien psychosocial peut être utile à ce niveau et qu'il permet d'éviter en partie de nouvelles souffrances.Nous traitons également de la question de savoir jusqu'à quel point notre psychologie individualiste, développée dans une société occidentale, peut être utilisée lorsqu'il s'agit de personnes vivant dans une société collective comme la société afghane. Le critère prioritaire doit être que l'approche se fasse dans un cadre sensible à la culture, tenant compte des conditions sociétales et individuelles, tout en se centrant sur l'individu, avec son vécu personnel, et en jouant le rôle de témoin de ses expériences et de sa souffrance

Value Based Counseling: Un intervento psicosociale a breve termine di portata variabile per contesti in cui le risorse scarseggiano

Während die psychische Grundversorgung von Menschen in einkommensschwachen Ländern und Krisengebieten staatliche und nichtstaatliche Organisationen grundsätzlich vor enorme Herausforderungen stellt, stehen einkommensstarke Länder, die Geflüchtete aufnehmen, vor der Aufgabe, ihre Gesundheitsdienste auf die besonderen Bedürfnisse dieser Menschen einzustellen. Die WHO empfiehlt als ein Vorgehen für die Förderung psychischer Gesundheit in ressourcenarmen Settings die Skalierung kurzer und vereinfachter Versionen evidenzbasierter Interventionen, die kompatibel mit dem soziokulturellen Wertesystem der Anbieter:innen oder Anwender:innen vor Ort sind. Die von der Ipso gGmbH angewandte psychosoziale Kurzzeitintervention Value Based Counseling (VBC) entstand 2004 in Afghanistan aus der Praxis heraus. VBC hat eine Reihe von Eigenschaften, die die Kurzzeitintervention zu einer skalierbaren Adaption machen. Der salutogenetische Ansatz und der daraus folgende Verzicht auf eine Diagnose ersparen die Notwendigkeit, Diagnosen anzupassen oder als Konzept vor Ort einzuführen. Die Kürze der Intervention eignet sich für ressourcenarme Settings und die strukturierte Gesprächsführung zudem für eine Umsetzung in eine digitale Anwendung, die Klient:innen unabhängiger von Counselor:innen macht (guided self-help).The provision of basic mental health care is particularly challenging in low-income countries and when communities are affected by adversity such as natural disasters or wars. Mental health services in high-income countries may also be challenged if they need to adapt their health services with the aim of serving refugees effectively. The WHO recommends the scaling up of brief, basic, non-specialist-delivered versions of existing evidence-based psychological interventions which are compatible with the socio-cultural value system of the local provider or user in resource-poor settings. The psychosocial short-term intervention Value Based Counseling (VBC) employed by the NGO International Psychosocial Organisation (Ipso) is based on a theoretical approach that is strongly influenced by field experience with communities affected by adversity first gained in Afghanistan in 2004. Various aspects of the counseling approach make it suitable for upscaling. The salutogenetic approach saves the need to adapt diagnoses or to introduce them locally as a concept in mental health care. The brevity of the intervention is an advantage in resource-poor settings, and the basic structure can be used in a digital guided-self-help application that reduces the need for counselors.Se da un lato l’assistenza psicologica di base nei Paesi a basso reddito e nelle aree di crisi pone enormi sfide alle organizzazioni governative e non governative, i Paesi ad alto reddito che accolgono i rifugiati si trovano davanti al compito di adattare i loro servizi sanitari alle esigenze specifiche di queste persone. L’OMS raccomanda di applicare, su scala variabile a seconda delle esigenze, versioni brevi e semplificate di interventi basati sulle evidenze scientifiche, compatibili con il sistema di valori socioculturali degli operatori o degli utenti locali, per promuovere la salute mentale in contesti in cui le risorse scarseggiano. L’intervento psicosociale a breve termine Value Based Counseling (VBC), applicato da Ipso GmbH, è nato da un’esperienza sul campo in Afghanistan nel 2004. Il VBC presenta una serie di caratteristiche che consentono di regolare l’intervento a breve termine nella portata in base alle esigenze. L’approccio salutogenetico e la conseguente rinuncia a una diagnosi permettono di evitare la necessità di adattare le diagnosi o di introdurle come concetto a livello locale. La brevità dell’intervento si presta a contesti in cui le risorse sono scarse e la conversazione strutturata è adatta anche all’implementazione in un’applicazione digitale, che rende i clienti più indipendenti dai consulenti (guided self-help)

Value-based counseling (consulenza basata sul valore). Cultura e religione come elemento significativo di un intervento psicodinamico a breve termine

Value-based Counseling (VBC) ist aus der Praxiserfahrung der jungianischen Psychoanalytikerin Inge Missmahl entstanden, die sie vor allem in Afghanistan, aber auch in Sri Lanka, China, Haiti und der Ukraine machte. Die psychodynamische Kurzzeitintervention hat einen salutogenetischen Ansatz, der darauf abzielt, das Kohärenzgefühl und die Selbstwirksamkeit von Menschen wiederherzustellen. Dies geschieht im Rahmen eines nicht-direktiven, aber sorgfältig strukturierten Gesprächs. VBC beruht auf einem Menschenbild, das von einem inhärenten Bedürfnis des Menschen nach einem sinnerfüllten Leben ausgeht. Das Potenzial des Menschen zur Selbstentfaltung und sein Streben, dieses Potenzial zu nutzen, bildet die Grundlage für die Förderung menschlicher Selbstheilung. Der Beratungsansatz vermeidet eine Pathologisierung klinischer Symptome, denen intrapsychische oder interpersonelle Konflikte, traumatische Erlebnisse, ein disruptives soziales Umfeld oder schwierige Lebensübergänge wie Migration oder der Verlust von Lebensgrundlagen zugrunde liegen, und bemüht sich stattdessen um ein Verstehen der Bedeutung dieser Symptome als Ausdruck unbewältigten sozialen Stresses. VBC geht davon aus, dass sich einem Menschen, der sich seiner Situation, der damit verbundenen eigenen und fremden Wertehierarchie sowie der damit ausgelösten Gefühle bewusst wird, Handlungsspielräume für Veränderungen eröffnen. Als Ausgangspunkt für die Wahrnehmung der Welt und der damit verbundenen Gefühle wird Kultur und in diesem Zusammenhang auch Religion als eine sinnstiftende Ressource betrachtet, die gezielt im Counseling eingesetzt werden kann.Value-based Counseling (VBC) evolved from the work experience of the Jungian psychoanalyst Inge Missmahl gained mainly in Afghanistan, but also in Sri Lanka, China, Haiti and Ukraine. The short-term psychodynamic intervention has a salutogenic approach that aims to improve the sense of coherence and self-efficacy of clients in the course of a non-directive but carefully structured conversation. VBC is based on the idea of man/woman as a human being that has an inherent need for leading a meaningful life. Our human potential for self-development and our pursuit of harnessing this potential can be used to facilitate human self-healing. The counseling approach avoids pathologising clinical symptoms underlying intrapsychic or interpersonal conflicts, traumatic experiences, a disruptive social environment, or difficult life transitions such as migration or loss of livelihoods, instead seeking to understand the significance of these symptoms as an expression of unresolved social stress. VBC is based on the experience that we can discover scope for change if we understand our emotional reaction to a situation experienced as an impasse by becoming conscious of the hierarchy of our own values that triggers this emotional reaction as well as of the values of concerned parties. Culture, and in this context religion, shape our perception of the world and of our feelings associated with this perception. Culture and religion are therefore regarded as a resource that can provide meaning and that counselors can refer to and use with deliberate care in their interactions with clients.Il Value-based Counseling (VBC) è nato dall’esperienza pratica della psicoanalista junghiana Inge Missmahl, acquisita principalmente in Afghanistan, ma anche in Sri Lanka, Cina, Haiti e Ucraina. L’intervento psicodinamico a breve termine ha un approccio salutogenico volto a ripristinare il senso di coerenza e di auto-efficacia delle persone. Ciò avviene nel quadro di una discussione non direttiva ma attentamente strutturata. Il VBC si basa su un’immagine dell’uomo che parte da un bisogno umano intrinseco di avere una vita piena di senso. Il potenziale di autosviluppo dell’uomo e il suo sforzo di utilizzare questo potenziale costituisce la base per sostenere l’autoguarigione umana. L’approccio di consulenza evita di patologizzare i sintomi clinici basati su conflitti intrapsichici o interpersonali, esperienze traumatiche, un ambiente sociale dirompente o transizioni di vita difficili come la migrazione o la perdita di mezzi di sussistenza, e cerca invece di comprendere il significato di questi sintomi come espressione di stress sociale irrisolto. Il VBC parte dal presupposto che una persona che viene a conoscenza della sua situazione, della gerarchia dei valori ad essa associati e di quelli altrui, nonché dei sentimenti che ne derivano, avrà un margine di manovra per il cambiamento. Come punto di partenza per la percezione del mondo e dei sentimenti ad esso associati, la cultura e, in questo contesto, la religione sono considerate una risorsa significativa che può essere utilizzata specificamente nella consulenza

Rethinking mental health care provided to migrants and refugees; a randomized controlled trial on the effectiveness of Value Based Counseling, a culturally sensitive, strength-based psychological intervention.

BackgroundDespite traumatic experiences and persistent psychosocial stressors, many refugees and migrants display resilience and strength in the midst and aftermath of hardships. 'Value Based Counseling' (VBC), a low-threshold, short-term and culturally sensitive psychological intervention avoids the stigmatization and pathologization of mental health problems, and, in line with latest research calling for a rethink of mental health care for migrants and refugees, focusses on the resilience and resources of clients.MethodThis pragmatic, assessor-blinded randomized controlled trial employed a pre-post control group design to assess the effectiveness of VBC in the development of psychological assets. Refugees and migrants aged 18 or above were randomly assigned to either VBC sessions delivered by counselors matched with their clients according to gender and native language, or to a waiting list.ResultsPer protocol and intention-to-treat (ITT) analyses revealed that compared with participants in the waiting-list group (n = 50), the VBC group (n = 53) experienced a greater improvement in resilience (adjusted difference 11.59, 95% CI 8.35 to 14.84, effect size .49, p ConclusionVBC with a focus on personal resources in the Here and Now, and with a culturally sensitive approach, helps clients exposed to persistent psychosocial stressors to develop strength and to increase agency over their lives

Value Based Counseling training course.

BackgroundDespite traumatic experiences and persistent psychosocial stressors, many refugees and migrants display resilience and strength in the midst and aftermath of hardships. ‘Value Based Counseling’ (VBC), a low-threshold, short-term and culturally sensitive psychological intervention avoids the stigmatization and pathologization of mental health problems, and, in line with latest research calling for a rethink of mental health care for migrants and refugees, focusses on the resilience and resources of clients.MethodThis pragmatic, assessor-blinded randomized controlled trial employed a pre-post control group design to assess the effectiveness of VBC in the development of psychological assets. Refugees and migrants aged 18 or above were randomly assigned to either VBC sessions delivered by counselors matched with their clients according to gender and native language, or to a waiting list.ResultsPer protocol and intention-to-treat (ITT) analyses revealed that compared with participants in the waiting-list group (n = 50), the VBC group (n = 53) experienced a greater improvement in resilience (adjusted difference 11.59, 95% CI 8.35 to 14.84, effect size .49, p .001) and perspective taking (adjusted difference 3.98, 95% CI 2.12 to 5.84, effect size .39, p .001) after four sessions on average. These positive results remained consistent until a 3-month follow-up assessment within the VBC group.ConclusionVBC with a focus on personal resources in the Here and Now, and with a culturally sensitive approach, helps clients exposed to persistent psychosocial stressors to develop strength and to increase agency over their lives.</div