Over the last decades, mental health surveys in Afghanistan found very high prevalence figures for mental health problems among the Afghans. These epidemiological data suggest that the majority of the Afghan population suffer from a mental disorder such as depression or post-traumatic stress disorder. Such findings are often met with surprise by the Afghans who doubt that most of the people around them would suffer from a psychiatric illness. This paper explores the discrepancy between the findings from surveys using brief symptom-based questionnaires and the lived reality of the Afghan people. The authors argue that the outcomes of such mental health surveys should be interpreted with caution and can be better seen as indicators of ‘non-disordered’ psychosocial distress rather than as a general mental disorder. To better understand psychosocial wellbeing of the Afghan people, the survey data need to be put into context and have an eye for the cultural and social ecologies in which symptoms are produced. Many symptoms may actually be normal responses to living in difficult circumstances. Moreover, mental health surveys may conflate cultural idioms of distress with mental illness and often do not take into consideration that the Afghan social world is highly gender segregated. Future mental health research in Afghanistan should use contextually appropriate and culturally validated instruments and be complemented by in-depth ethnographic explorations of emotional suffering among Afghans. Key implications for practice

• MHPSS practitioners should critically examine the results of psychiatric epidemiological surveys in humanitarian emergencies.
• Mental health researchers need to go beyond estimating prevalence figures of discrete mental disorders and move towards using dimensional approaches to mental health.
• Qualitative research can provide important insights around cultural idioms of distress that may be gender-specific.

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Little is known about who and what Afghans turn to cope with mental distress precipitated by ongoing socio-political and economic problems. In a cross-sectional survey, the authors examined help-seeking behaviour for mental distress in 306 Afghans residing in Kabul, Afghanistan, and how their choice of what to access for help is influenced by various social and mental health-related factors. Factors predicting the use of six distinct resources for support were examined, including biomedical and behavioural health and community-based resources. Results indicated that Afghans mostly draw on their faith, followed by social support, to cope with mental distress. Higher distress symptoms had a moderate, but statistically significant influence, on seeking help across all resources, whereas demographic factors only predicted encounters with primary care physicians. Female gender predicted social support seeking, and income increased the likelihood of encounters with herbalists. Meeting the psychosocial needs of Afghans through promoting a more integrated mental healthcare system is discussed. Key implications for practice

• Help-seeking for mental distress among Afghans in Kabul is highly pluralistic
• Although religious activities were the most widely used coping resource, those seeking care outside, from biomedical practitioners and traditional healers were, on average, more distressed.
• An integrated mental health system that embraces both modern and traditional healing practices may be more efficacious than medicalised mental health systems in meeting the unmet psychosocial needs of Afghans.

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Mental health disorders are common in low and middle-income countries (LMICs), creating vulnerability to adverse outcomes. Despite this, there is a gap in understanding the perspectives of people with psychosocial disability (PPSD). A mental health project from Afghanistan collected lived experience narratives through semi-structured interviews with PPSD and family members. The interviews focused on individual experiences of barriers and enablers to social inclusion. Four main barrier themes were elicited: symptoms of mental disorders interfering with social inclusion, unhelpful family attitudes and behaviour, unhelpful community attitudes and behaviours and lack of access to quality mental health services. Three prominent enabler themes were also identified: family support and understanding, access to quality mental health services and supportive community attitudes and behaviours. Connection to supportive community and support from family was a critical finding. These results reinforce the importance of hearing from lived experience to help shape both service and community development programmes. Key implications for practice

• Engaging with the lived experience of psychosocial disability is beneficial, necessary and possible in LMICs
• Understanding key, context-specific barriers and enablers for PPSD will improve wellness, recovery and inclusion
• In the Afghan context, working with families and communities to promote supportive environments towards mental health will improve social inclusion and access to services.

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This paper reports on the results of a research study that was conducted by the members of the Departments of Counselling at Kabul University and Herat University in collaboration with their international advisors. The purpose of the study was to determine how Afghans practicing counselling psychology or wishing to employ professional psychological counsellors understand and operationalize the knowledge, skills and values required to be a professional counsellor in Afghanistan. In workshops with 147 male and female participants − including supervisors, professionals and paraprofessionals − from six different sites in five of Afghanistan’s seven regions, the study used the Develop a Curriculum method, which aims to ensure that curricula and standards for new professions introduced in the post-conflict period will be relevant and applicable in the Afghan context as informed by Afghan experts in the field. Findings indicate that participants had markedly different conceptualizations of what the role of a counsellor should be (e.g. focusing on individual methods versus working with families and communities). Furthermore, these differences exist along professional lines (e.g. medical versus protection), as well as region. The findings underscore that a deep knowledge of Afghan cultures, customs, and spiritual beliefs was required, along with detailed professional knowledge of individual, group and family counselling ideas, values and practices. In addition, constant self-awareness and reflection at every level is needed to balance these two essential areas of competence to resolve contradictions and to blend both seamlessly into one set of professional standards. Results of this study will assist Afghan faculty members in adjusting their curricula to align with the realities of providing culturally relevant counselling in Afghanistan today. Key implications for practice

• All Afghan counselors should be highly trained, supervised in practice, and well versed in international standards, as well as Afghan customs, culture and values.
• Assumptions regarding the clients' beliefs, cultural values, experience or ideas can never be assumed and must be explored for counseling to be effective.
• All Afghan counselors, like their international counterparts, require supervised support for self-awareness and reflection to be effective in the Afghan context.

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It is assumed that mental health problems are prevalent among Afghans and that the number professional mental health services are less than is required. An interview with one of the pioneers of the contemporary mental health sector Dr. Rohullah Amin is here presented. Psychological interventions are a relatively new approach for addressing emotional and behavioural problems in Afghanistan. However, providing mental health services for many people with few professionals remains a challenge and requires high levels of knowledge, skills and creativity. Mental health professionals may use different available approaches for addressing mental health issues but incorporating cultural strengths into their service makes their efforts acceptable and may lead to more desired outcomes. Use of television and other media may be one way to destigmatise seeking mental health services, as well as educating people about psychological health. Furthermore, mental health and psychosocial support could be used as tool for enhancing the quality of Afghan lives.

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The main objective of this study was to study the effectiveness of memory specificity training (MEST) on the symptoms of post-traumatic stress disorder (PTSD) of bereaved Afghan adolescents. Participants were bereaved Afghan adolescents with PTSD and depressive symptomatology and were randomly assigned into the MEST, trauma-focused cognitive behavioural therapy (TF-CBT) and a control group. In this study, a quasi-experimental design with pretest–post-test and follow-up with experimental and control groups was used. The instruments used were the Impact of Event Scale-Revised, Persian versions of the Mood and Feelings Questionnaire, clinical interview and demographic questionnaire. Post-intervention, the MEST and TF-CBT groups had significantly lower levels of PTSD symptoms compared with the control group. There was no significant difference between the MEST and TF-CBT groups. These effects were maintained at 12 weeks. Post-intervention, the MEST and TF-CBT groups also had significantly lower levels of depression symptoms compared with the control group.The findings of this small pilot study suggest that MEST is a promising intervention for the treatment of PTSD and a larger randomized controlled trial is warranted.

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Afghanistan has one of the highest rates of substance use in the world, yet existing treatment focuses on detoxification, residential rehabilitation and with very low intensity aftercare. Current available treatment should be changed to more evidence-based modalities, such as structured psychosocial interventions. In addition, the main role of affect in development, maintenance and abstinence of substance use disorders should be also taken into account. Many therapy models can assist in substance use disorders recovery, such as the trans-theoretical model of change, which is a motivational programme that facilitates change by (1) increasing awareness and self re-evaluation; (2) understanding the necessity for change; (3) increasing motivation; and (4) maintaining change and preventing relapse. This field report describes using group therapy for those who are not sufficiently motivated to drug cessation, components of group therapy, as well as results, challenges and suggestions for future studies.

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The psychosocial and mental health support system in Afghanistan has evolved significantly over the last decades. Inge Missmahl, founder and director of the International Psychosocial Organisation gGmbH traces the history of the sector over the last fourteen years and reflects on working towards the long-term integration of biopsychosocial mental health care in the Afghan Public Health System. Health system integration was accomplished through development and training delivery of a value-based counselling approach. The approach is based on six fundamental principles which consider the sociocultural origins and context of the individual’s symptomatology, emphasises personal empowerment over pathologisation and promotes a symmetrical relationship between counsellor and client. Over 300 Afghanis were trained in this approach and qualified as psychosocial counselors and counselled over 10,000 clients in total. The work to date highlights the importance of designing long-term, applied training programmes which include self experience and qualitative supervision in psychosocial support provision.

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Developing sustainable efforts to address the psychosocial consequences of complex emergencies is often a challenge. There is a limit to what humanitarian efforts can achieve, even with the best of intentions. Locally based tertiary education programmes are needed to provide conceptual frameworks and to develop and sustain professional psychosocial support programmes both during and after the emergency. In Afghanistan, over 30 years of armed conflict and its sequelae have placed an extraordinary emotional strain on every member of the population, affecting not only individuals but also families and communities. The Ministry of Higher Education has therefore taken the initiative to develop two new academic programmes in counselling psychology in its public university system. These programmes are designed to prepare a new generation of academics who can come to understand the specific Afghan context of psychosocial suffering and prepare appropriate interventions to support transformation on an individual and communal level. They are also poised to educate a new generation of qualified practitioners to serve individuals, families, communities and the society itself. In this article, the authors describe a partnership programme with the two universities designed to provide external support for their efforts.

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Working with family conflicts can be a challenging task for counsellors. In a collectivist society, such as Afghanistan, where interactions between people of the opposite sex are highly regulated, counselling sessions with an individual involved in a family conflict may not be very effective unless conducted in a culturally sensitive manner. As asking for help from professionals may be considered to be ‘lunatic’, as well as a potential threat to the honour of the family, family counselling is not often easy to carry out and may actually pose risks to the client and to the counsellor. Therefore, family counselling is likely to be more effective if counsellors team up with respected members of the community, such as social workers and religious leaders, to deliver family counselling.

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There are several factors that can lead to social anxiety disorder (fear of being judged or rejected), such as genetics, environmental factors, learned experiences, deficits in social skills, cognitive factors and/or culture. Considering all these factors, there are many people prone to develop social anxiety disorder in Afghanistan. In a recent study conducted at Herat University, it was shown that many students suffer from social anxiety disorder. The case described in this personal reflection concerns a student, who, upon assessment of her symptoms, the author diagnosed as having social anxiety disorder and provided several counselling sessions. After some time, positive results were achieved and the client recovered significantly from her disorder by the conclusion of the sessions.

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In Afghanistan, most families strongly believe that their female members should stay at home concern themselves with housework. In general, women are anything but encouraged to get an education and/or have a professional career. This personal reflection shows that Afghani women, with support, can develop their competences and enjoy life.

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Girls living in juvenile rehabilitation centres, especially as a consequence of escaping from home or sexual contact, can be difficult to engage in counselling sessions. Often, this can be related to the idea that help seeking from a psychologist or counsellor is equivalent to being labelled as ‘crazy’. Added to that is the belief that family secrets must stay at home, so girls feel uncomfortable speaking about their problems. As a result, counsellors’ attempts may lead to failure. This personal reflection shows the author’s first experiences working with clients. It suggests using simple contextual methods (such as handicrafts or storytelling) to begin a therapeutic relationship, using group counselling versus individual counselling and engaging family members to solve honour issues.

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This short case history describes the counselling process with an adolescent girl in Afghanistan. It illustrates the lack of sexual education for children and adolescents in Afghan society and reaffirms that listening is the most important part of counselling. Listening includes showing that you believe the client, being careful with questions and giving the client the feeling that she does not have to justify herself.

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This personal reflection examines the author’s experience while conducting qualitative research on the traumatic life events and coping among the female workers in Kabul University’s dormitory for female students. It also describes the experiences of one of the study’s participants, a woman who suffered from severe domestic violence and enacted various ways of active coping.

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Drug addiction is a problem in many countries, affecting many lives, damaging the addicted individual and affecting their families and communities. In underdeveloped countries, such as Afghanistan, there are often no appropriate systems for rehabilitating drug addicted people. Most hospitals tend to use detoxification as the main treatment programme, and there remains a large gap between demand and treatment services. In this case study, the author discusses the possibilities for dealing with the various causes of substance abuse and recommends solutions.

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This personal reflection on my daily interactions with an Afghan woman, Bibi Hawa, aims to describe how I witnessed her psychological distress, partly manifested as chest pain, and her resilience to this distress in a particular Afghan socio-cultural and political context. My reflections shed light on the importance of finding a space in which resilience can be built. As mutual trust, friendship and a reciprocal guardianship developed with Bibi Hawa, I came to recognise her capabilities as a woman, mother, friend, housekeeper, breadwinner and co-worker as well as the way in which she was able to move forward by fostering resilience through building upon her own abilities and the Afghan cultural values of family unity, perseverance in overcoming challenges and dedication in fulfilling responsibilities. This reflection reiterates the importance of rethinking the ways in which cultural values can enhance resilience and the need to find the means and space to cultivate these cultural values as a source of resilience in daily life.

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This personal reflection shares four vignettes from the author’s field journal while on assignment in Afghanistan. Note 1 shares the thoughts (with permission) of a few of her female Afghan colleagues; Notes 2 and 3 share experiences from field work day-to-day; and Note 4 closes with a reflection about some of the larger socio-political complexities that may tacitly underpin humanitarian intervention in Afghanistan. This reflection piece offers no answers, only musings.

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