MD, MS Clinical & Counseling Psychology
This article was first published on the Pennsylvania Psychologist in Dec 2010
Dozens of women, men, and children line both sides of the corridor, waiting for a general practitioner. Some adults complain of fever, lack of appetite, stomachache, high blood pressure, cough, or diarrhea. However, the complaints of others are vague: headache every now and then, back pain without any history of trauma or bone disease, pounding heart, sensitivity to crowds and noise, hot flashes, and so forth. This population appears in most medical clinics run either by the government or non-governmental organizations in Afghanistan. Some even show up in hospital emergency rooms. And what are they prescribed? Usually analgesics such as ibuprofen or acetaminophen, known there as “paracetamol,” for a week or two. And what happens? These patients show up again and again with similar symptoms.
More than 3 decades of war has shattered the infrastructures of Afghanistan, among them the health system. Many health care professionals have left the country; others struggle to get by in inadequate facilities with severely limited resources. War has hobbled the younger generation’s efforts to acquire higher education and improve life. The result: Afghanistan needs thousands of doctors to address the demand of an increasing young population as well as its returning refugees and internally displaced persons.
And when it comes to mental health, the situation is even worse. There are too few psychiatrists and psychologists, and the latter actually have only a bachelor’s degree in psychology and are not trained in clinical work. The majority of public clinics offer basic medical services by one doctor and a couple of nurses during the day, so the workload is high. Beyond their walls, too few health care professionals with too few resources struggle to address the increasing demands. Recent statistics (BBC World Service, Persian, 2010) indicate that more than 60 percent of Afghans suffer from “mental problems” —unsurprising, given all the traumas and challenges the people have been through so far, when even in a post-industrial economy like Japan, the cost of suicides and depression have been estimated at $32 billion in the past year (BBC World Service, 2010).
Afghanistan’s capital, Kabul, is served by only one psychiatric hospital and a few governments, private, and semi-private clinics. Other major cities also lack facilities. This highlights the dire need for facilities and for training as many mental health professionals as possible, a considerable commitment of time and money. However, a less costly intervention may also help.
The more clients, the less the time one has to spend with them individually, which affects quality of treatment. Afghans’ cultural, historical, and individual pride may account for their impatience with learning and expecting others to value them appropriately. This, added to the time pressures on medical personnel, can increase frustration and burnout, further alienating doctors from patients and causing more misunderstanding and misdiagnosis, particularly with patients who suffer from a mental disorder. Is there a way to minimize the mis-communication and streamline the workload? I believe there is: Improve the quality of doctor-patient relationships. Psychologists and physicians in other cultures may understand the benefit of rapport on patients having a medical condition or a mental disorder or both, but Afghan health care professionals lack training in developing arid maintaining professional relationships with patients beyond a brief review of the Hippocratic Oath.
Described by Steward and Gilbert (2005), improving the doctor-patient relationship requires effectively engaging at both the cognitive level (the doctor will learn more about the patient), and the emotional level (the doctor will feel the patient’s pain and suffering). In terms of time spent with each patient, this change would be front-loaded: While it might initially mean spending more time actively listening to each patient, it permits the professional to distinguish those with possible mental disorders from those with a medical condition so the former can be referred to a mental health center for appropriate treatment.
A high percentage of those who seek treatment in medical clinics in other countries have a psychological disorder. Afghanistan is no exception. Because mental disorders are strongly stigmatized there, Afghans may not seek treatment at all, or if they do, medical clinics may be the first place they turn to. As a result, physicians at these clinics are most likely to be the “front line” for mental health patients, and their referral authority may undercut the stigma of going first to a mental health clinic.
Were the doctor-patient relationship to be improved, Afghan physicians could interrupt the cycle of vague somatic complaints obscuring a mental health issue and being treated by an unending round of analgesic prescriptions; treatment would be improved; and physicians would be freer to treat acute and chronic medical diseases.
A nation traumatized by conflict and serious challenges needs comfort and care as a cornerstone for its treatment.
BBC World Service, Persian (2010). Sixty percent of Afghans suffer from “mental problems.” Retrieved October 10, 2010, from Afghan Society Page, http://www.bbc.co.uk/persian/afghanistan//2010/10/101010_k01_afg_depression.shtml
BBC World Service (2010). Suicides cost Japan economy $32bn. Retrieved September 7, 2010, from http:/www.bbc.co.uk/news/world – asia-pacific-11219492
Steward, M., & Gilbert, B. W. (2005). Reflections on the doctor-patient relationship: From evidence and experience. British journal of General Practice, 55, 793-801