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TEDGlobal 2010

Inge Missmahl: Bringing peace to the minds of Afghanistan

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When Jungian analyst Inge Missmahl visited Afghanistan, she saw the inner wounds of war -- widespread despair, trauma and depression. And yet, in this county of 30 million people, there were only two dozen psychiatrists. Missmahl talks about her work helping to build the country's system of psychosocial counseling, promoting both individual and, perhaps, national healing.

- Analytical psychologist
By building psychosocial care into the primary health care system in Afghanistan, Inge Missmahl offers hope to a society traumatized by decades of conflict and insecurity. Full bio

So I want to tell you a story -- an encouraging story --
00:16
about addressing
00:19
desperation, depression and despair in Afghanistan,
00:21
and what we have learned from it,
00:24
and how to help people
00:26
to overcome traumatic experiences
00:28
and how to help them to regain some confidence
00:32
in the time ahead -- in the future --
00:35
and how to participate again in everyday life.
00:37
So, I am a Jungian psychoanalyst,
00:41
and I went to Afghanistan in January 2004, by chance,
00:43
on an assignment for Medica Mondiale.
00:47
Jung in Afghanistan --
00:50
you get the picture.
00:52
Afghanistan is one of the poorest countries in the world,
00:55
and 70 percent of the people are illiterate.
00:58
War and malnutrition kills people
01:01
together with hope.
01:03
You may know this from the media,
01:05
but what you may not know
01:07
is that the average age of the Afghan people is 17 years old,
01:09
which means they grow up in such an environment
01:12
and -- I repeat myself --
01:15
in 30 years of war.
01:17
So this translates
01:19
into ongoing violence,
01:21
foreign interests, bribery,
01:23
drugs, ethnic conflicts,
01:25
bad health, shame, fear
01:28
and cumulative traumatic experiences.
01:31
Local and foreign military
01:34
are supposed to build peace together with the donors
01:36
and the governmental and non-governmental organizations.
01:39
And people had hope, yes,
01:42
but until they realized
01:44
their situation worsens every day --
01:46
either because they are being killed
01:48
or because, somehow,
01:50
they are poorer than eight years ago.
01:53
One figure for that:
01:56
54 percent of the children under the age of five years
01:58
suffer from malnutrition.
02:01
Yet, there is hope.
02:03
One day a man told me,
02:06
"My future does not look brilliant,
02:08
but I want to have a brilliant future for my son."
02:10
This is a picture I took in 2005,
02:14
walking on Fridays over the hills in Kabul,
02:16
and for me it's a symbolic picture
02:19
of an open future for a young generation.
02:21
So, doctors prescribe medication.
02:27
And donors
02:31
are supposed to bring peace
02:33
by building schools and roads.
02:35
Military collect weapons,
02:40
and depression stays intact.
02:42
Why?
02:45
Because people don't have tools
02:47
to cope with it, to get over it.
02:49
So, soon after my arrival,
02:54
I had confirmed something which I had already known;
02:56
that my instruments come from the heart of modern Europe, yes.
02:59
However, what can wound us
03:02
and our reaction to those wounds --
03:04
they are universal.
03:06
And the big challenge
03:08
was how to understand the meaning of the symptom
03:10
in this specific cultural context.
03:13
After a counseling session, a woman said to me,
03:16
"Because you have felt me, I can feel myself again,
03:19
and I want to participate again
03:22
in my family life."
03:24
This was very important,
03:27
because the family is central
03:29
in Afghans' social system.
03:31
No one can survive alone.
03:34
And if people feel used, worthless and ashamed,
03:37
because something horrible has happened to them,
03:40
then they retreat, and they fall into social isolation,
03:43
and they do not dare to tell this evil
03:46
to other people or to their loved ones,
03:49
because they do not want to burden them.
03:52
And very often violence is a way to cope with it.
03:54
Traumatized people also easily lose control --
03:58
symptoms are hyper-arousal and memory flashbacks --
04:01
so people are in a constant fear
04:03
that those horrible feelings of that traumatic event
04:05
might come back unexpectedly,
04:08
suddenly,
04:10
and they cannot control it.
04:12
To compensate this loss of inner control,
04:15
they try to control the outside,
04:18
very understandably -- mostly the family --
04:21
and unfortunately,
04:23
this fits very well
04:25
into the traditional side,
04:27
regressive side, repressive side,
04:30
restrictive side of the cultural context.
04:32
So, husbands start beating wives,
04:36
mothers and fathers beat their children,
04:39
and afterward, they feel awful.
04:41
They did not want to do this, it just happened --
04:43
they lost control.
04:45
The desperate try
04:48
to restore order and normality,
04:50
and if we are not able to cut this circle of violence,
04:53
it will be transferred to the next generation without a doubt.
04:57
And partly this is already happening.
05:00
So everybody needs a sense for the future,
05:03
and the Afghan sense of the future
05:06
is shattered.
05:08
But let me repeat the words of the woman.
05:12
"Because you have felt me,
05:15
I can feel myself again."
05:17
So the key here is empathy.
05:20
Somebody has to be a witness
05:22
to what has happened to you.
05:24
Somebody has to feel how you felt.
05:26
And somebody has to see you and listen to you.
05:29
Everybody must be able
05:34
to know what he or she has experienced is true,
05:36
and this only goes with another person.
05:40
So everybody must be able to say,
05:43
"This happened to me, and it did this with me,
05:45
but I'm able to live with it, to cope with it,
05:48
and to learn from it.
05:50
And I want to engage myself
05:52
in the bright future for my children
05:54
and the children of my children,
05:56
and I will not marry-off my 13 year-old daughter," --
05:58
what happens too often in Afghanistan.
06:01
So something can be done,
06:04
even in such extreme environments as Afghanistan.
06:06
And I started thinking about a counseling program.
06:09
But, of course, I needed help and funds.
06:12
And one evening,
06:14
I was sitting next to a very nice gentleman in Kabul,
06:16
and he asked what I thought would be good in Afghanistan.
06:18
And I explained to him quickly,
06:21
I would train psycho-social counselors,
06:23
I would open centers, and I explained to him why.
06:26
This man gave me his contact details at the end of the evening
06:30
and said, "If you want to do this, call me."
06:33
At that time, it was the head of Caritas Germany.
06:36
So, I was able to launch a three-year project with Caritas Germany,
06:41
and we trained 30 Afghan women and men,
06:44
and we opened 15 counseling centers in Kabul.
06:46
This was our sign -- it's hand-painted,
06:49
and we had 45 all over Kabul.
06:52
Eleven thousand people came -- more than that.
06:55
And 70 percent regained their lives.
06:57
This was a very exciting time,
07:00
developing this with my wonderful Afghan team.
07:02
And they are working with me up to today.
07:05
We developed a culturally-sensitive
07:07
psycho-social counseling approach.
07:09
So, from 2008 up until today,
07:12
a substantial change and step forward
07:15
has been taking place.
07:17
The European Union delegation in Kabul
07:19
came into this and hired me to work
07:22
inside the Ministry of Public Health,
07:24
to lobby this approach --
07:26
we succeeded.
07:28
We revised the mental health component
07:30
of the primary health care services
07:33
by adding psycho-social care
07:35
and psycho-social counselors to the system.
07:37
This means, certainly, to retrain all health staff.
07:40
But for that, we already have the training manuals,
07:43
which are approved by the Ministry
07:46
and moreover, this approach is now part
07:49
of the mental health strategy in Afghanistan.
07:51
So we also have implemented it already
07:55
in some selected clinics in three provinces,
07:57
and you are the first to see the results.
08:00
We wanted to know if what is being done is effective.
08:03
And here you can see
08:06
the patients all had symptoms of depression,
08:08
moderate and severe.
08:11
And the red line is the treatment as usual --
08:14
medication with a medical doctor.
08:16
And all the symptoms
08:18
stayed the same or even got worse.
08:20
And the green line is treatment with psycho-social counseling only,
08:23
without medication.
08:25
And you can see the symptoms almost completely go away,
08:27
and the psycho-social stress has dropped significantly,
08:30
which is explicable,
08:33
because you cannot take away the psycho-social stresses,
08:35
but you can learn how to cope with them.
08:37
So this makes us very happy,
08:40
because now we also have some evidence
08:42
that this is working.
08:44
So here you see,
08:47
this is a health facility in Northern Afghanistan,
08:49
and every morning it looks like this all over.
08:51
And doctors usually have three to six minutes for the patients,
08:54
but now this will change.
08:57
They go to the clinics,
08:59
because they want to cure their immediate symptoms,
09:01
and they will find somebody to talk to
09:03
and discuss these issues
09:05
and talk about what is burdening them
09:07
and find solutions, develop their resources,
09:09
learn tools to solve their family conflicts
09:12
and gain some confidence in the future.
09:16
And I would like to share one short vignette.
09:19
One Hazara said to his Pashtun counselor,
09:23
"If we were to have met some years ago,
09:27
then we would have killed each other.
09:30
And now you are helping me
09:32
to regain some confidence in the future."
09:34
And another counselor said to me after the training,
09:37
"You know, I never knew why I survived the killings in my village,
09:40
but now I know,
09:44
because I am part of a nucleus
09:46
of a new peaceful society in Afghanistan."
09:48
So I believe this kept me running.
09:51
And this is a really emancipatory and political contribution
09:54
to peace and reconciliation.
09:57
And also -- I think --
10:00
without psycho-social therapy,
10:02
and without considering this
10:04
in all humanitarian projects,
10:06
we cannot build-up civil societies.
10:08
I thought it was an idea worth spreading,
10:11
and I think it must be,
10:14
can be, could be replicated elsewhere.
10:16
I thank you for your attention.
10:19
(Applause)
10:21

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About the speaker:

Inge Missmahl - Analytical psychologist
By building psychosocial care into the primary health care system in Afghanistan, Inge Missmahl offers hope to a society traumatized by decades of conflict and insecurity.

Why you should listen

From dancer to humanitarian by way of analytical psychology, Inge Missmahl's unusual life trajectory led her to Kabul in 2004, where she saw that more than 60 percent of the population were suffering from depressive symptoms and traumatic experiences -- hardly surprising in a country that had lived with ongoing violence, poverty, and insecurity for 30 years. In response, Missmahl founded the psychosocial Project Kabul for Caritas Germany, a project that trained Afghan men and women to offer psychosocial counseling in 15 centers throughout the city.

The project has offered free treatment to 12,000 clients to date, helping to restore self-determination and well-being while breaking down ingrained gender barriers and social stigma of mental illness. Psychosocial counseling is now integrated in the Afghan health system thanks to Missmahl's efforts. She now works on behalf of the European Union as Technical Advisor for Mental Health for the Afghan government, and is founder of International Psychosocial Organisation (IPSO), a network of experts dedicated to developing and implementing psychosocial programs in various contexts.

More profile about the speaker
Inge Missmahl | Speaker | TED.com