Personality disorder programme No longer a diagnosis of exclusion

The day started on a sad note – a member of staff here was a close friend of a local man whose brother’s family have all just been murdered. Everybody around them feels very traumatised and upset. A few of us talked about it first thing this morning, and we were all affected by the horror of it – especially for those who are closest to the family.

Today is weekend – although it is a Thursday, today and tomorrow are on all the calendars and computers as the two days of rest. Thursday is traditionally just a half day and Friday is the day for prayers – as in all Islamic countries, of course. Modernisers recently tried to pass a parliamentary bill to change the weekend to Friday and Saturday, so it would be at least aligned with the western world of commerce and business for four and not three days of the week, but the government did not approve – as it was considered anti-Islamic. So Saturday remains the first day of the week and Sunday the second: while we are feeling Monday Morning Blues, people here are already nearly half way through their working week. However, like home, many shops and businesses are open at weekends (including the psychiatrists seeing their private patients – see day 2). I wonder if there has ever been a Friday equivalent of the British ‘Keep Sunday Special’ campaign here – I suppose it is an inevitable consequence of global commercialisation that such sentiments do not have the same priority as economic ones.

But in a quirky way, the shifted weekend is an extra ‘disorientator’ that keep humans aware that different places in the world are actually different – however hard we try to homogenise our lifestyles in the name of progress. So alongside the daily and annual astronomical ones (time zones and seasons), we have the cultural one of religious beliefs: the weekly one of weekends, and the annual one of festivals and holidays. So – and perhaps this is getting a little far-fetched – we have the astronomical or cosmic anchors to the land (day and night, winter and summer) and the cultural or spiritual anchors to our fellow humans (weekends and festivals). And anchors like these, I would propose, provide an internal experience of containment through ‘knowing what’s when’ – and keeping the terrors of uncertainty safely at bay. Which is, of course, just what we do with our time boundaries in psychotherapy and therapeutic communities…

But for me, the experience here is definitely of a Saturday – ignoring the alarm clock, getting up for a leisurely breakfast, and not worrying exactly what needed doing today. And the extra bonus of having interesting conversations with my house mates about many things as we just chill out and hang loose, as they say.

And indeed, on that theme, one was language and idioms. Yousuf’s first language is Persian (also known as, or nearly the same as, Farsi or Dari), and Raymond’s is Swahili. But like most under-educated Brits, my only language is English, so our chewing of the fat had to be in English. Though I did notice that we used quite a lot of hand-gestures to describe nuances and subtle grades of meaning, especially when the English wasn’t quite good enough to express something. With IMC (International Medical Corps) being an American NGO (Non-Governmental Organisation), and many of its senior staff being from US homes it was interesting that, though both Yousuf and Raymond have lived in the UK for many years, there are many American idioms used here that they do not understand – but I do. For example ‘chew your ass’ – which left them quite puzzled, and others (for example ‘pull up your pants and go’) which actually caused consternation and tension by covertly communicating something about a power dynamic without being explicit or understood by them. In that case, interestingly, the American who used it seemed somewhat irritated when he was later asked to explain what the phrase meant.

Another aspect of language which is more directly relevant to our mental health work is analysis of the qualitative data on our teaching evaluation forms. The numerical data is simpler – one can either cheat with the analysis, or do it correctly; and we all trust our staff to not cheat when entering the quantitative data into spreadsheets. However, in mental health, it is often the qualitative data that gives more information about meanings and relationships: and here, even the process of translation may introduce bias. For example, the evaluation forms have comments on them which are written in Persian, but need analysing in English. Our interpreter is a member of the team, but also a local young woman, and both English and Persian are second languages to her. To help with some of the trickier written responses, she discusses them with one of the psychiatrists who has good English. At least three sources of bias come in here: (i) she will try to choose a psychiatrist of or close to her own ethnicity; (ii) the psychiatrist is senior to her, so she is culturally unable to disagree with any of his or her opinions; (iii) both of them may, probably unconsciously, choose wording which does not offend local or national sensitivities. This is a life and death problem in the war – as deliberately distorted interpretations are known to have caused fatalities. To prevent the danger of this, the British forces now train their own interpreters and translators – and recruit, for example, Afghanis resident in the UK to translate between the local languages (Persian, Pashto and Uzbecki, mostly). I heard that in North London, the forces run a ‘training village’ to replicate many of the cultural and religious factors, to help accuracy of understanding for translators who are learning the subtleties and nuances of the three main local languages.

We had quite a scare after lunch today, when we were at the IMC headquarters: in the finance office there, Yousuf received a phone call from his wife in England telling him that there had been a suicide bombing in Kandahar Red Mosque, where the President’s brother’s memorial service was happening – and one of Yousuf’s close family members was with the Presidential party.

It’s interesting how this news got to us quicker via England and the BBC than it did through the NGO channels. But apparently this is nearly always the case: large news organisations have many more pairs of eyes and ears in their journalists (who are all networked together) than the NGOs and even the national and UN security forces do (who often have uncoordinated communication between each other). Although President Karzai was known to have left and flown back to Kabul after the funeral and before the memorial service, there was confusion as to whether the family member was still in Kandahar, or had also come back to Kabul. The fact he could not be reached by mobile phone made it more worrying and reassurances from officials on the phone were not convincing, and only when Yousuf had directly spoken to him on the phone an hour or so later (the phone also kept getting jammed by the ‘blockers’ – see day 1) did he feel able to relax. We later learned that four people died and he was indeed in the mosque at the time – but at the other side from the entrance. Also, Pashtoons normally wear turbans – which are never searched, and it was the turban in which the bomb was hidden, which we thought was a new thing – so this will probably lead to routine searching of turbans from now on.

There was also a ‘minor scare’ from the security staff in the HQ office, who said that they had just had a report that our way back to the house was blocked by a large demonstration – and we wondered if we were marooned in the office, just as everybody was due to go home. However, a conversation with a native man on the security staff soon established that it was a gang of schoolchildren – and the girls were shouting and attacking the attacking the boys for being chanting sexist insults at them. We would have gone and joined them if we were allowed!

But this illustrates how the ‘being in a war zone’ is more dangerous to mental well-being than it is to physical health. With the protection and regulation imposed on us by IMC, it takes no great statistical analysis to say ‘I am more likely to get killed as a cyclist on the Euston Road to Paddington station (which I do most weeks) than I am to be murdered as an ex patriot in Kabul’: several cyclists get killed in London each month, and nobody here can remember when an NGO ex patriot was last murdered. But what does happen nearly every day are these ‘anxiety bombs’ – which transmit their shock waves like electricity through all the personnel here: often with personal worries about loved ones, or colleagues. And they are used very effectively by the security staff to keep us in line – and obeying the rules of where we can go (IMC premises and projects and not much else) and where we can’t (almost everywhere else). At least one of those anxiety bombs, of different severity, has gone off each day I have been here. And it’s OK for me – because I’m going home on Sunday: but what effect must it be having on the mental health of all the permanent staff, people like Yousuf who know so many people here, and even more on the residents of Kabul, who know no other home –and surely can never feel safe from this anxiety and dread?

There is a real, and I think insoluble, muddle about ‘us and them’ in discussion of ethnicity over here. At first, I kept hearing words like Tajik, Hazara, Dari, Uzbeck and even Shia without understanding whether they were religious, tribal or linguistic. So I asked a few questions and concocted the following ‘idiot’s guide’ to help me through conversations without putting my metaphorical foot in it (and feet are another sensitive matter – my iPhone etiquette app told me that it is extremely insulting to show anybody the soles of your feet, or to point with them or to use them for anything except walking – but Yousuf tells me he has never heard of such rubbish! Or is it that comes from a different Afghani group, or is somebody trying to start a silly urban myth, or just make me paranoid?)

Families are extended and huge, and often the line between who is family and who is tribe becomes indistinct – especially in matters like job application and recruitment. In our Western ‘we can manage anything’ style, beloved of arrogant clinicians and authoritarian managers alike, Raymond and I soon had it sorted out. We said – ‘don’t you just need to agree an equal opportunities policy, so all the tribal factions and ethnicities are fairly represented? Surely it’s not beyond the wit of man to find something that is fair and agreed by everybody?’. But no, said Yousuf, what we casually call ‘equal opportunities’ would be seen here as what we call ‘racism’ at home – and certainly if it is written down or spoken on the public record. The paradox is that to even think these thoughts of respecting everybody equally does not respect everybody at all. The collective cultural sensitivities are seriously offended, and although it may happen ‘in private’ – any such behaviour would never tolerate public exposure. Publicly, all Afghanis will profess that “we are all brothers together in Afghanistan” – but in private, and out of media or outsiders’ gaze, they will gently joke with each other about their differences, poke fun at their different characteristics, be friendly or less friendly rivals and perhaps even make sure that those of their own kind are preferred for jobs, favours or contracts – and be suspicious and spread rumours when the preferment goes to others.

Perhaps this very deeply ingrained process becomes entirely understandable when we think of it not as a matter of individual rights or conscious and rational decision-making, but more as a phenomenon of the collective unconscious – where decisions and actions necessarily come about through a complex and emergent process most of which is conducted at a level where words fail, and logic is largely that of the limbic system, or primary process. And this could then be framed as actually being more respectful , but of cultural, collective, emotional, social and relational values – rather than our own predominantly mechanistic, operationalised, materialistic, reductionist and individualised ones. And who is in a position to say which of those two positions is more ethically, morally or philosophically right? I’m sure somebody will have done research and a great deal of thinking about this somewhere, but it is so far out of my own field of understanding that I wouldn’t know where to start looking. Has anybody any ideas?