Counselling Training in Afghanistan: the Long Term Development of the INSPIRE Project

Between 2010 and 2014, the British Council funded a project under a scheme called INSPIRE, which involved training a group of 20 Afghan practitioners in counselling skills. The participants were from Kabul and Herat, and the partners in the project were the University of Herat and the University of Strathclyde (UK). The ethos of the programme was based on co-constructing a model of transcultural training that could be applicable within the Afghan context (Berdondini et al. in International Journal for the Advancement of Counselling, 36(3), 305–316, 2014). As an outcome, in 2016 the Afghan Ministry of Higher Education approved the launch of a Counselling Department and a Student Counselling Service within the University of Herat. This article aims to present and analyse the long-term development of INSPIRE in Afghanistan from the perspective of participants. Reflections on future implementation of this approach and training programs are also included.


Introduction
Numerous studies report alarmingly high levels of mental health disorders among the Afghan population, including adversity-related distress and non-psychotic disorders (Alemi et al. 2018;Miller et al. 2009;Panter-Brick et al. 2009). In 2003, 'Mental Health in Afghanistan' became part of a basic package of health services, developed by the Ministry of Public Health. Psychosocial counselling was incorporated in 2010 (National Mental Health Strategy 2009-2014, and since then a number of intervention programs have been applied to develop mental health training and service resources for the Afghan population (Sayed 2011). One of the key aspects identified in the National Mental Health Strategy was the creation of a plan of action to overcome cultural barriers and to develop models of treatment compatible with Afghan traditions and belief systems.
Considering the challenges regarding the development of a mental health support system, Babury and Hayward (2013) highlighted how vital it was to engage the Higher Education Institutions (HEIs). In particular, they stressed the importance of implementing specific counselling training programs within Higher Education to overcome the lack of resources available for the professional development of this role and of other helping professions (such as social workers) in the country (Babury and Hayward 2013).
The INSPIRE Project (2010-2014 In line with the points above, in 2010 the authors of this paper were awarded a grant offered by the British Council, under a scheme called INSPIRE, for a three-year project. The aim of the project was to design a transcultural counselling skills training programme for Afghan practitioners such as doctors, nurses, lecturers, university students and psychosocial counsellors. The institutions involved in the project were the University of Strathclyde (UK) and the University of Herat (Afghanistan). Because of the success of the project and the high demands for services coming from the Province of Kabul, in addition to Herat, further funding was awarded to extend into a fourth year (Berdondini et al. 2014). During the 4-year project a total of 20 participants completed 120 h of training in counselling skills, while a sub-group of 8 participants were involved in an additional 60 h of training for trainers. This additional course equipped the 8 people with skills and competencies to design and facilitate counselling skills courses. The theoretical framework of the whole training project was humanistic and its nature was mainly experiential.
The structure of the counselling skills course included a variety of inputs: & Lectures on the theory of Person-Centred Counselling (Rogers 1951). & Skills practice sessions (in English and in Dari). & Activities focused on developing self-awareness and reflectivity. & Creative therapeutic techniques derived from approaches such as Gestalt therapy (Polster and Polster 1973) and Psychodrama (Holmes et al. 1994) in order to meet different cultural needs and values. & Supervision sessions (also used as a form of assessment) using Interpersonal Process Recall (IPR; Kagan and Kagan 1997). & Regular revision of the training, through feedback and evaluation forms, in order to modify/ adjust/amend the course according to the participants' experiences and learning needs.
Since the beginning of the project, it clearly appeared that both the content and process of the course needed to be negotiated between the trainers and the trainees. The group of participants was composed of practitioners from different fields (medical doctors, nurses, students and lecturers) and with different needs in regard to integrating counselling skills into their professional roles. In the original design of the training, the theories to be discussed in class (mainly referring to humanistic therapies such as Person-Centred, Gestalt and Psychodrama) were presented and integrated with a strong experiential element, in order to become easily understandable and meaningful to participants. However, this very same element, since day one, had to go through a series of negotiations and creative adjustments within the group, for cultural reasons. For example, one of the first issues encountered was the fact that in the Afghan culture discussing a number of topics are 'taboo', such as being in love with someone or feeling angry at close family members. Traditionally these subjects cannot be explicitly discussed between people. Thus, creative methods, culturally meaningful to the group, were introduced to work experientially on self-awareness, skills practice or live demonstrations of therapeutic sessions, such as the use of metaphors, psychodrama, stories and poems, arts, stones and toys (Berdondini et al. 2014). In this way, the emphasis around developing therapeutic skills was more focused on the 'process' rather than the 'content' and at times the sessions were carried out without overtly addressing the actual 'matter' concerned.
Participants felt comfortable to work with forms of art and creative tools that are part of their cultural expressiveness. At the same time, during live demonstrations between trainers and trainees and skills practice between trainees, the sessions were 'person-centred' in terms of respecting the client's pace and initiative as to when and how to use arts or objects to explore what they were bringing as issues. The counsellor's role was mainly to facilitate the client's connection with the experience of being in the 'here and now' and of feelings and meanings related to what was happening, without interpreting or trying to find a solution or directing the work. The outcome of this creative transcultural approach proved to be therapeutically very effective, with feedback from participants stressing the 'life changing' power of the sessions and the entire training (Berdondini et al. 2014).
Nevertheless, there were also topics that could be addressed explicitly within the teaching sessions, such as individual differences with regard to religious beliefs, lack of safety and security in the country, inner resources and resilience. The students decided the modality of delivery for each of these lectures and as a result, some of them were led by the trainees themselves and included creative writing, analysing extracts from traditional book texts and facilitating group discussions. The nature of the whole course, since the first year, was 'student-centred' and its structure was 'co-constructed' between trainers and trainees, in the sense that participants were engaged as much as the trainers in deciding what content was more relevant to their learning and which method of delivery was the most appropriate to their cultural values and needs (Proctor 2008;Berdondini et al. 2014).
Each year the training offered was a total of 120 h, organized into two blocks of 60 h each. At the end of each block, evaluation forms were filled in and these contributed towards adjusting and amending the next component of the training course for the following year. The last group, trained during the year 2013-2014, reached 100% in student satisfaction. When the training was completed, all participants were perceived to be able to carry out counselling sessions within their professional role. As indicated, eight selected participants from the training course in 2013-14 were also trained as trainers.
Largely as a consequence of the INSPIRE project, in 2016 the Counselling Department at Herat University was established, after a series of further training and capacity building programs. Some of the lecturers and students from the Psychology Department of Herat University were trained in counselling skills through the INSPIRE project. The Department is still active with about 100 students involved every year. A Student Counselling Service was also opened in the same University and run by the lecturers trained through INSPIRE.
During the 5 yrs post-completion of this project, psychosocial counselling training in the country has evolved and, in particular, the specific transcultural humanistic approach developed during INSPIRE has been implemented in a number of different contexts, such as Non-Government Organizations, schools, prisons, and mental health centres. Currently, there are only two cities that offer counselling training in Higher Education in Afghanistan: Kabul, with two Departments offering courses at BA level, and Herat with one (Afghan Ministry of Higher Education 2018).
This article aims to explore the evolvement and the impact of the INSPIRE project from the perspective of some of the participants who attended the courses and who are still actively involved in delivering counselling services in Afghanistan. In particular, the research question of this study was: 1) How did the implementation of the INSPIRE project evolve?
Sub-questions were: a) What seemed to work particularly well for Afghan clients? b) What seemed to work less well for Afghan clients?
In order to respond to these questions a semi-structured self-report form was distributed to those former participants who were able to be contacted. In particular, this self-report asked them to reflect on the impact that the training had on their personal and professional lives, on other aspects such as employability, and the strengths and limitations of the humanistic approach in relation to the Afghan context. The data were analysed qualitatively using Thematic Analysis (Braun and Clarke 2006).

Methodology
In Spring 2018, the Counselling Department of the University of Herat approved the Ethical proposal for the current study and a search was done to contact the 20 participants who were trained in the programme over the 4 yrs. It was possible to track down only 15 people from the original 20 participants (some had left the country). An invitation letter explaining the aim of the study and a consent form were sent to each of them.

Participants
A total of 10 participants, 7 men and 3 women, responded to the invitation letter and signed the consent form, agreeing to participate in this study. The data were collected electronically via email. At the time of the research all participants were working as counsellors in different contexts in Afghanistan, such as national and international Non-Government Organizations (NGOs), schools, prisons, orphanages, mental health centres in the provinces of Kabul and Herat.

Data Analysis
The data were analysed using Thematic Analysis in accordance with the guidelines of Braun and Clarke (2006). Eight of the reports were written in English and two in Dari, translated into English by one of the authors. The process for data analysis consisted of reading the materials several times in order to become familiar with them. Then followed the generation of codes, with consequently a review of identified themes, including a second re-coding of data until it produced what the authors considered to be a satisfactory 'thematic map' (Braun and Clarke 2006).

Findings
The final themes that emerged were organized as follows: 1. A different way of relating to self and to others. 2. Impact on professional life. Sub-themes: (i) Working experiences after the training, (ii) Approaches used with clients. 3. Applicability of the humanistic approach to Afghan clients.

1.
A different way to relate to self and to others.
All participants highlighted how the experience of INSPIRE had impacted their personal development and their perspective on life itself. They seemed to have gained more capacity to look after themselves and to relate to other people in a non-judgmental way.
P1: BIt changed my perspective on my life…I became more independent…P 2: BI always was taking care of my clients and now I got the importance of self-care as well^. P3: BI now accept people easily, make good relation[s] with them and finally it made my life easier in this society^. P4: BAfter the training I have decided not to judge people and accept them the way they are…I also received good comments from my friends who noticed my changes^.
These findings seem to support what was already reported at the end of the training itself through the course evaluation forms (Berdondini et al. 2014), with the experience of the programme being described as 'life changing' for most of the participants. From the current self-reports, it appeared as though this deep impact on themselves and their relationships with others had been maintained over time, in spite of the difficult environment and the continuous challenges of living in a country like Afghanistan.

Impact on professional life.
Reflections about the impact that the experience of INSPIRE had on the participants' professional life are represented though this theme. In general the reflections seemed to claim a stronger clarity about what counselling can and cannot provide and a deeper strength in their own abilities: P2: BI understood that I can establish a good relationship with clients and care for them2 P3: BI have learnt how to connect with my clients, how to psychologically help them and improve their ability to solve their problemsP 4: BI have learnt many techniques that helped me having better counselling sessions with various cases, I have learnt how to start a session, how to make the client comfortable and trust you, how to work with people who are not willing to speak^. P9: BIt helps me go deeper into the problems with the clients^.
From the analysis of the data, two sub-themes emerged.
(i) Working experiences after the training. Each participant described their career since the end of the training. Most of them started working with children (some as volunteers) in schools and in orphanages. At the time of the study, participants shared how they saw adult and children clients and worked full time for international humanitarian organizations in the role of professional counsellors. All of them provided training and 'awareness sessions' for parents and family in the community. Some of them were now specialized in working with vulnerable women, and victims of domestic violence.

Some of them became Lecturers at the University of Herat in the Counselling Department:
P9: BSince the very beginning, I used to work as a teaching assistant and counsellor as well as conducting Person-Centered therapy training for a huge number of Herat University students with other members of this program and I also conducted this training on my own for two separate groups of psychology students^.
One participant worked in a female prison. Here are her reflections on this experience and a feedback from one of their clients in the prison: Indeed some of the participants kept studying counselling after the INSPIRE project with postgraduate courses in other institutions abroad -for example in India -and developed an integrative stance with a pluralistic philosophy (Cooper and McLeod 2011) where different approaches are used for different clients, depending on what seems more useful and suitable for each one.
3. Applicability of humanistic approach with Afghan clients. Sub-themes (i) Useful aspects, (ii) Less-useful aspects, (iii) Gaps in services.
In reflecting about their professional experiences and the impact that INSPIRE had on their work with clients, participants identified some useful and some less useful aspects, and also there were concerns about gaps in services.
(i) Useful aspects. Some of the aspects that seemed to be particularly useful, referred specifically to the Person-Centred theoretical stance.
P1: BThe Person-Centred approach gives time to the client to vent their emotions and make decisions by themselvesP 2:BWomen are empowered, supported and resourced to claim their rights […] and to refer them to their internal and external resourcesP 3:^Women who suffer from domestic violence are rejected from their family and society. ..[..] person-centred counselling helps them a lot to build a good trust and relationship with themselves…most of my clients are grateful to be listened to and [be] respected^. P9: BThis approach and its techniques are amazing for the process of rapport building or trust building( ii) Less-useful aspects. At the same time, all participants identified aspects of this approach that did not always seem beneficial for all clients; for example, when they suffer from 'Bsevere mental health issues^(P4), or when they come with a specific question looking for guidance and find that starting a dialogue means the counsellor wanting to interfere with their life: P1 BMost of them stop speaking and say 'Guide me to solve my problems and don't ask me about my secrets'^.
Disclosing personal matters is a quite challenging issue in the Afghan culture: P4: BIn a close society like Afghanistan it is really difficult for people to trust and say their personal issues to others, even a counsellor. It is because of bad experiences of being judged; people are too much worried about the confidentiality.Î n other examples, especially related to women clients, participants highlighted the fact that at times families can get in the way of accessing therapy or represent an insurmountable obstacle: P2: BPatriarchy and families that do not allow women to go to counselling centres^. P3: BAt times it was a big challenge for me because I wanted to help them but their problems was because of others, like husband or family^.
(iii) Gaps in services. Finally, some participants identified gaps in the services that were currently offering counselling support in Afghanistan and in the structure that supports the professional status of counsellors themselves. Many issues seem to be related to difficulties in making the counselling services more accessible, but some issues seem also related to the absence of specialised trained counsellors and of supervision.
P2: BLack of consultants and counselling centres, people lack of trust in counselling, absence of professional and expert counsellors and distance, lack of access to available counselling services.P 3: BOne thing is lack of supervision sessions for counselling. When I started my work it was very difficult for me to get out of my clients' problems…it affected me a lot^.

Conclusions
This paper presents some reflections and follow-up analysis on how the INSPIRE project, which was carried out between 2010 and 2014 in Afghanistan and focused on developing a transcultural training course in counselling, has impacted on the long-term personal and professional development of the participants.
From the data collected, it seems that at least half of those originally trained were still practicing as counsellors and some of them even engaged in further post-graduate training and development. They were working in a variety of contexts, from mental health centres, to schools, women prisons and orphanages. The INSPIRE project indeed contributed notably to the creation and implementation of the profession of counselling in Afghanistan and the Counselling Department of the University of Herat is still offering undergraduate counselling courses.
Another element that emerged from the data was that the transcultural approach developed during the project was still applied and valued and it was contributing to the wellbeing of vulnerable people in Afghanistan, especially women and children. One quite interesting factor was the explicit recognition from all the participants of some specific benefits of the Person-Centred approach for Afghan clients; for example, when establishing an initial rapport and as a process of empowerment, particularly for women. This argument is quite interesting, as nondirective counselling has been considered as less-suitable for certain cultures (MacDougall 2002), including Islamic culture (Moracco 1978). That said, there have been studies that discuss the power of this approach in the Middle East, when introduced with Binsider sensibility^(Al-Thani and Moore 2012). It is important to stress though, that some of the participants of this study also highlighted limitations of this approach; for example when 'severe mental health issues' were involved, or when the clients were less conceptually literate.
It was also reported that family and community systems may represent obstacles for individuals wanting to access counselling services and it was argued that there is a lack of trust towards the certainty of confidentiality. The stigma related to mental health in this culture is still very high and has been recognised in several studies (Ciftci et al. 2013;Soheilian and Inman 2009). Further research needs to be conducted in order to explore in much more in depth the impact of this specific counselling approach on Afghan clients, especially from their personal point of view and experiences.
From the data it emerged that additional improvements could be developed for the model of counselling that was designed within the INSPIRE project. One could be the expansion of its psychosocial/transcultural aspects by creating and introducing other culturally sensitive and meaningful interventions, such as community/family psychosocial programmes that could impact the perception and knowledge about counselling and facilitate accessibility to services.
Finally, a crucial aspect, also from an ethical point of view, seems to be the need to introduce training in and access to supervision in the Afghan counselling system, as it is an essential dimension for the safety of clients and for counsellors (Proctor 2008;Page and Wosket 2003) and it is still currently non-existent in that context.

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Conflict of Interest The authors declared that they have no conflict of interest.
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