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Psykologisk nybrottsarbeid – Speilvendt
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Psykologisk nybrottsarbeid


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I krigsherjede Afghanistan jobber fire psykologer og to psykiatere for at en befolkning på 30 millioner mennesker skal få et verdig tilbud innen psykisk helsevern.

Foto: Anniken Volden
Foto: Anniken Volden

– Vi afghanere har levd med krig i mer enn tre tiår. Blant flere grusomme konsekvenser har befolkningens mentale helse lidt, og helsetjenestene er blitt ødelagt, sier Frozan Esmati.

Den afghanske psykologen besøkte Oslo i oktober 2013. Innimellom møtene med Utenriksdepartementet og Afghanistankomiteen, besøkte hun Psykologisk Institutt, for å snakke om status for mental helse og psykisk helsevern i hjemlandet. Det er mye som ikke vites om afghanernes psykiske helse, men de få studiene som er gjort, peker i samme retning.

– Det forventes ofte høy prevalens av PTSD, men studiene viser langt flere symptomer på depresjon og angst. Kvinnene sliter særlig mye, sier Esmati.Hun er en av fire afghanske psykologer som jobber i landet. På universitetet i Kabul hører psykologi inn under pedagogikkutdanningen. Det finnes ikke fullverdig utdanning med praksis for klinisk psykologi. Selv studerte Esmati klinisk psykologi i Malaysia, og har også en mer forskningsrettet utdanning.

-Vi hadde bedre tjenester innen psykisk helsevern på 1930-tallet. Vi har to psykiatere, og en befolkning på 30 millioner mennesker. Det finnes leger med noe videreutdanning innen psykiatri, men kvalifikasjonene er ofte tvilsomme. Kliniske psykologer eksisterer omtrent ikke i afghansk helsetjeneste, sier Esmati.

Utfordrende arbeidsforhold

Da Esmati kom tilbake til Afghanistan i 2005 jobbet hun først som frivillig på landets eneste psykiatriske sykehus med heldøgnstilbud, i Kabul.

– Det var ikke noe rom hvor jeg kunne møte pasientene alene. Grunnleggende konfidensialitet var ikke mulig å opprettholde, med opptil ti andre pasienter og ansatte til stede under samtalene, sier Esmati.Behandlingstilbudet er i stor grad basert på medikamenter.

– Dersom problemet passer inn en diagnose, får pasienten medisin, men nesten aldri tilbud om samtaleterapi eller rehabilitering, sier den unge psykologen.

– Medisiner er lett tilgjengelig, du trenger ikke engang resept, ettersom mange av apotekene ikke drives av farmasøyter. Du kan få så mye antidepressiva eller antipsykotika som du kan betale for. Kvaliteten er ofte dårlig, for å gjøre medisinen så billig som mulig. Det andre problemet er lav bevissthet rundt nytten av samtaleterapi. Folk forventer å få piller, nesten uansett hva problemet er.Esmati forteller at da hun jobbet på det psykiatriske sykehuset, ble pasientene ofte frustrerte fordi hun tilbød samtale og ikke medisin.

– Jeg har lært at jeg må være svært tydelig når det gjelder min rolle, forklare at jeg tilbyr samtaleterapi som kan hjelpe dem mye, og at de kun vil foreskrives medisin dersom de trenger det.

 

«Problemet er lav bevissthet rundt nytten av samtaleterapi. Folk forventer å få piller, nesten uansett hva problemet er.»

– Frozan Esmati, psykolog i Afghanistan

 

Overtro og farlige behandlingstilbud

Med få ressurser og mange mennesker som sliter psykisk, har helsedepartementet gått inn for at helsepersonell på alle nivå skal få trening i psykisk helsearbeid. I små lokalsamfunn forsøker departementet å trene helsepersonell i grunnleggende psykiatri, klinisk psykologi og rådgivning slik at de kan oppdage folk som sliter, gi råd og henvise videre.Det profesjonelle tilbudet kommer i stor grad an på hvor i landet pasienten befinner seg. I byene er det ofte polikliniske tilbud, hvor privatpraktiserende tilbyr billige og svært korte konsultasjoner hvor pasientene kan få diagnose og resept etter å ha rapportert kun få symptomer.Et annet tilbud er «House of chanted» for familier som ikke kan ta vare på familiemedlemmer med for eksempel psykose, autisme eller demens.

– Tilbudet er dårlig. Det hender at pasientene blir slått, sier Esmati.En gruppe som tjener godt på behandling av psykisk syke er tradisjonelle «healere» og sjarlataner som ber for pasienten eller tilbyr ritualer og urter, iblant inkludert opium.

– Noen av disse overbeviser pårørende om at pasienten er besatt av en ond ånd og kan ta opptil 200 dollar for å hjelpe til med å bli kvitt den på ganske ekstreme måter. Mange har stor tro på dette, mange kvinner går for eksempel til slike dersom de har ekteskapsproblemer. Dersom noen kommer til psykologisk behandling, spør vi om de benytter slike tilbud, og dersom det er skadelig forsøker vi å overtale dem til å slutte, sier Esmati.Islamske religiøse ledere tilbyr også iblant et slags behandlingstilbud bestående av bønn, meditasjon og problemløsning.

Lys i tunnelen

Esmati orket ikke mer etter seks måneder som psykolog på mentalsykehuset i Kabul.

– Arbeidet til psykologene verdsettes ikke. Betingelsene for at jeg kunne utføre mitt yrke var ikke tilstede, sier Esmati.Hun begynte å arbeide i helsedepartementet, i en liten avdeling som arbeider for å få i stand retningslinjer for psykiatrisk behandling, først som frivillig. Senere arbeidet hun sammen med den norske psykologen Anne Hertzberg, i et prosjekt støttet av EU, for å starte opplæring av personell til sentre for fysisk rehabilitering.I dag jobber Esmati som stressmestringsterapeut for FN-ansatte i Afghanistan. Flere internasjonale organisasjoner forsøker å hjelpe til med å forbedre tilbudet innen psykisk helsevern, og sender også helsepersonell til landet. Esmati mener at holdninger og praksis har endret seg siden hun returnerte, men at svært mye arbeid gjenstår for å bygge opp et verdig psykisk helsevern i Afghanistan.

– For fem år siden ble psykiatriske pasienter for eksempel bundet fast med lenker både på sykehus og hjemme hos familien sin. Dette ser det ut til at vi har klart å endre, sier Esmati.


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