Reporting from Kabul, Afghanistan — The group therapy session at Afghanistan's flagship mental health hospital began, as many do, with sharing.
Foruzan, 28, a slight woman in a black and silver head scarf, told the psychologist she was possessed by an evil spirit, or jinn. She sought help at a shrine, she said, and thought she was healed. But then the heartburn returned.
Beside her, Parvin, 20, a rosy-cheeked student, who like other patients at the hospital asked that only her first name be used, said she suffers intense headaches and needs medication to think clearly at school.
Worst off was Shaima, 35, hunkered in a corner weeping into her blue burka. Her husband beat her, she said, and threw her out of their house the night before, leaving her at the mercy of her brother, who calls her crazy because she is always crying.
It was a typical morning for Abdul Wahab Yarzada, a psychologist at the 60-bed Kabul Psychiatric and Drug Dependency Treatment Center. Each day, he hears a flurry of maladies, many related to the ongoing conflict, from fishar (stress) to asabi (nerves) to jigar khun, which literally means "liver blood," but describes a sense of hopelessness.
Some have already chosen to, as they say in Dari, "leave this world": withdraw rather than confront the adversities of life in the war-ravaged country.
Experts estimate that 60% of the Afghan populace suffers from mild to severe mental illness. Yarzada and the rest of the hospital's three dozen psychiatrists and psychologists see as many as 160 patients a day at the crumbling 26-year-old facility that they are still rebuilding after a bombing six months ago.
Afghan leaders have vowed to use an infusion of international aid to improve medical services and have made mental health a priority. Yet the Kabul hospital is struggling to improve therapy and expand neighborhood clinics in an extremely poor country where mental health treatment remains a luxury.
The hospital is supposed to receive $300,000 from the Afghan government this year, but it has not yet been paid, said the hospital's director, Dr. Timono Shah Musamim. The hospital recently received a $1.6-million grant from the European Union to renovate the buildings, provide medical supplies and staff training.
At the group therapy session last month, women took turns as they sat in a circle of folding chairs in the high-ceilinged former German factory. The only decorations on the chipped aqua walls were a map of Afghanistan and a diagram of the brain.
Parvin said that talking about her problems has helped relieve her depression as much as the antidepressant medication a private doctor had prescribed.
"When I speak out, I say what is inside me and they understand and give me direction on what to do," she said.
Dr. Peter Ventevogel, an Amsterdam-based psychiatrist who has worked to improve Afghanistan's mental health care through the nonprofit Healthnet TPO, said the hospital's staff has advanced in recent years.
"It's a new way of thinking that a patient with a mental disorder is someone you have to consult," Ventevogel said. "Those are notions that are not yet ingrained in the healthcare system in Afghanistan. The whole idea of client participation is a difficult one."
Yarzada and other Afghan therapists at the hospital have been training with a medical anthropologist to practice more transcultural therapy, which incorporates patients' traditional beliefs about mental illness, treating them for what they believe ails them.
It is still common in Afghanistan for families to chain the severely mentally ill at home or at Sufi shrines such as Mia Ali Baba outside Jalalabad, where they are left to subsist for weeks on water and peppered bread.
Patricia Omidian, a medical anthropologist who has studied Afghanistan's mental health system, said the Kabul hospital is confronting overwhelming need. Though doctors cannot provide all the social support patients come looking for, they have come a long way since 2003, she said, when she saw patients chained to the metal-framed beds.
"They got the shackles off. There was a real effort," Omidian recalled. "I work in Pakistan, and there are still shackles in some of the mental institutions. In some ways I think Pakistan is actually behind Afghanistan. For instance, in Afghanistan you can talk more openly about mental health and, maybe it's because of the war, but there is a recognition that people need help when they suffer."
The greatest challenge for the Afghan therapists probably will be the limits on what they can accomplish in a society that, even after NATO forces leave, will remain in crisis, said Ken Miller, a Cambridge, Mass.-based psychologist who has published several studies about mental health in Afghanistan.
"We think about war zones and attribute many of those mental health problems to the war. And there is certainly some truth to that. But the conditions of everyday life have a tremendous impact on mental health," Miller said.