The Story of Healing Kashmir

You could say that the most lasting damage of war is to the mind.  In the case of the disputed Kashmir Valley, in North India, twenty years of fighting has caused inordinate long-term mental damage to a high percentage of the population.

In 1989 a separatist insurgency erupted in The Valley, demanding independence from India. The Indian military response was draconian, and the fighting soon became entrenched as Pakistan backed, trained and armed many of the insurgent groups that were fighting in The Valley. This conflict has moved far beyond its own geographical borders, and many jihadi groups were formed in order fight in the name of ‘freedom for Kashmir’. Some of those groups now have an international agenda, as was witnessed during the attacks on hotels and public places in Mumbai in November 2008.

Across twenty years of watching this conflict, and beyond the politics and khaki uniforms that are so omnipresent in Kashmir, it has become increasingly apparent that there has been the rapid and pandemic deterioration of mental health in the state. When the conflict began in 1989 there was one psychiatric hospital in The Valley. The doctors who were practicing at The Government Psychiatric Diseases Hospital said then that they would have perhaps one patient a day. By 1994, five years into the conflict, the doctors were seeing up to 300 patients a day, around 80,000 patients a year.

You could say that the most lasting damage of war is to the mind.  In the case of the disputed Kashmir Valley, in North India, twenty years of fighting has caused inordinate long-term mental damage to a high percentage of the population.

Across twenty years of watching this conflict, and beyond the politics and khaki uniforms that are so omnipresent in Kashmir, it has become increasingly apparent that there has been the rapid and pandemic deterioration of mental health in the state. When the conflict began in 1989 there was one psychiatric hospital in The Valley. The doctors who were practicing at The Government Psychiatric Diseases Hospital said then that they would have perhaps one patient a day. By 1994, five years into the conflict, the doctors were seeing up to 300 patients a day, around 80,000 patients a year.In 1989 a separatist insurgency erupted in The Valley, demanding independence from India. The Indian military response was draconian, and the fighting soon became entrenched as Pakistan backed, trained and armed many of the insurgent groups that were fighting in The Valley. This conflict has moved far beyond its own geographical borders, and many jihadi groups were formed in order fight in the name of ‘freedom for Kashmir’. Some of those groups now have an international agenda, as was witnessed during the attacks on hotels and public places in Mumbai in November 2008.

The idea

As I witnessed this cruel trajectory of mental illness it became clear that one of the highest costs of this conflict to the Government of India would be the budget for mental health, and most specifically the many and varied disorders associated with post-traumatic stress disorder, otherwise known as PTSD.

PTSD is an acronym that makes many people either roll their eyes, or even argue that this is a modern invention, a by-product of our softening society. I would counter this by suggesting that these doubters have probably not witnessed war: they have not seen their children being blown up; they have not had their son delivered to their doorstep, his body barely recognisable; they have not been raped, over and over by ten or fifteen soldiers during a military crackdown. Those suffering from these brutal realities of war rarely manage to slot back into their lives, or, to put it as someone expressed it to me in their need to disprove the existence of PTSD, ‘couldn’t they just pull themselves together and get on with their lives?’

The answer is no, they cannot. The shock of these things often results in a nervous breakdown, reducing the individual to a barely functioning state in which they cannot look after themselves, let alone carry on whatever work they were previously doing in order to support themselves and their families.

To put it in simple terms, it is not possible to rebuild a society that is only functioning partially on a mental level.The answer is no, they cannot. The shock of these things often results in a nervous breakdown, reducing the individual to a barely functioning state in which they cannot look after themselves, let alone carry on whatever work they were previously doing in order to support themselves and their families.

In the case of Kashmir the government response to the huge numbers of those who are psychologically scarred has been to medicate the problem with high doses of tranquilisers, sedatives, anti-psychotics and anti-depressant drugs. The side effects of many of these high doses have been as difficult to manage as the disorders they have been prescribed to treat.

As we researched this subject we spoke to psychiatrists, psychologists, and therapists who specialise in trauma treatment. It became increasingly apparent that an integrated approach was needed for recovery, enabling people to find their way back to a quality of life that would allow the society as a whole to begin to progress and heal. The idea of combining conventional and  alternative therapies, counseling, and treatment was the route that we wanted to pursue, but on the condition that it could be done with the full participation of local doctors and psychiatrists. For a project like this to work it has to be sustainable, and for local people to have ownership. It will not survive if it is simply an import from the outside. But most of the psychiatrists we spoke to in Kashmir barely had time to breathe, let alone think beyond the prescription pad. Typically they were seeing up to 200 patients a day.Then in 2007 we met Dr Arshad Hussain, a psychiatrist at the Government Psychiatric Diseases Hospital, and lecturer at the government teaching hospital. Though he was in his early thirties he had a depth of

understanding that went beyond his training and experience. Unlike many in the medical profession in India, Dr Arshad was not from the successful and educated middle class, a stratum that can afford the high costs associated with qualifying in this profession. Dr Arshad is from a village in Kashmir, one of those particularly badly affected by the conflict. He came from the same kind of place and situation as so many of his patients. Not only was he open to the idea of addressing mental health holistically, but he saw it as being vital for progress in mental health in Kashmir. Our aim is to treat psychologically traumatised patients with a combination of conventional and alternative therapies and treatment that will support the fullest recovery they can make, allowing them to return to their families and communities.

Stage One

In November 2009 Healing Kashmir brought therapists from the UK to work on the project in Kashmir. Over the course of six weeks we worked with patients who had been selected by Dr Arshad and his colleagues. We treated them in both the clinical environment of the hospital, and also in their villages. The average number of treatments for a patient during this time was between four and seven sessions that included counseling, homeopathy, psychotherapy, cranio-sacral therapy and Reiki. We also began to train some of the junior doctors and counselors in the basics of these methods in order that they could continue to work with patients until stage II of the project.

The results of this first stage were dramatically successful. Rather than being too cocky about this we must factor in two things: the first is that the people of Kashmir derive a great sense of support when people come in from the outside, aiming to ease their situation. They have felt very isolated during the course of the conflict, so just the arrival of foreign therapists in itself had a positive effect. Add to this the fact that many Kashmiris feel that they can speak much more freely and openly to outsiders’ about their problems, rather than to another Kashmiri, even if he or she is a doctor.

 

This is because there has been a great breakdown of confidence and very few people trust each other, particularly with sensitive personal information. The second factor is that most patients are used to having a maximum of two or three minutes with a doctor or psychiatrist in a crowded, noisy and chaotic outpatients’ department setting. We were treating patients individually in a quiet room, for up to an hour at a time. The combination of these things added to the therapies that were being given. To gauge the success of the treatments requires on-going assessment of the individuals. Dr Ashad Hussain and his staff will be making these assessments between the treatment phases.

Stage Two

This involved on-going assessment of patients by Dr Arshad and his colleagues at The Government Psychiatric Diseases Hospital. We returned to Kashmir in February 2010 for follow-up clinics. As there had been another recent round of violence it was not possible to see all the patients that we had treated in November and December 2009. Those who could get to the clinics that we held in Srinagar were doing well, and those who had made full recovery were sustaining these recoveries. We were able to extend the local clinics in the Srinagar area with the help of local doctors and psychiatrists, who referred trauma patients to the clinics.

What became increasingly apparent during the initial stages of the project was the urgent need for a fully integrated mental health support system in Kashmir. This has led us to Stage III of the project.

Stage Three

We have now expanded the project to include a suicide and mentaltrauma helpline and an integrated mental health Centre, Kashmir LifeLine and Health Centre.

Shahid, our IT consultant, at his first desk in our temporary roof office in Srinagar

This stage of the project was initiated in conjunction with Barbara Krieger, a senior multi-media producer and team leader at Swiss TV. Barbara’s skills enabled us to increase our mental health reach in Kashmir to a level that we had not previously thought possible. During the pilot phase, from November 2010 to March 2011, this meant developing the first mental crisis helpline and support system of this kind in the region.

Barbara Krieger and Justine shopping for office essentials. Photo © Jonathan Foreman

Due to the violence of the past twenty-three years, and especially the events of recent summers in Kashmir, pressure has increased on the people of the Valley – particularly young men and women who have grown up with no experience beyond conflict and violence.

 Broad objective of the project

The success of trauma helplines has been well-documented globally. After extensive research we recognised that there are two main problems facing those who have been psychologically damaged by the seemingly intractable violence in Kashmir. The first is the profound social stigma in Kashmir attached to going to a psychiatric hospital or clinic. For example, if a young village woman is known to have been to a psychiatric clinic it will be seen as a stain on her personality, and her marriage chances, regardless of how temporary her

psychological problem may be. A helpline staffed by highly trained listeners addresses this problem because it offers anonymity and total confidentiality. This is particularly powerful in a society where it is hard for people to be able to speak in private about the emotional and mental problems that they are facing.This project is also targeting a sector of Kashmiri youth that feels disenfranchised and disempowered by the situation in the state. One of the fundamental issues is that these young people do not feel that they are being heard, and therefore, in some cases, they resort to violence, as has been witnessed during intense periods of civil unrest in Kashmir in recent years. A helpline that allows callers to talk, and that guides them towards examining their frustrations and fears, has been proven one of the most effective ways of breaking through to this youth sector. Our project emphasizes this by use of multi-media options, giving callers the options of live on-line chat, and email, as well as being able to call the toll-free number. In addition to this the caller is given the option of coming to our mental health centre for further treatment, if required, or to one of our outreach centres. If it is not possible for them to get to the centre we have a well-researched referral network.

As a tool of referral the helpline offers this network to callers. Information about medical and mental health facilities is very limited in Kashmir. We have created a system of Social Resource Mapping (SRM) that collates information on hospitals, clinics, primary health centres, de-addiction centres, NGOs and their services, and other support organisations. Our team of listeners has been trained to use this referral system when speaking to callers. As a part of the Social Resource Mapping we continue to do liaison work with those on the list in order to keep information up to date, and to check that referrals are being seen, and treated.

We are very conscious of the fact that the ‘burn-out’ rate amongst mental health workers in Kashmir is high. We have put a premium on training our staff to understand how the work impacts them personally. We have trained them in methods of self-awareness, self-analysis, and physical and mental relaxation techniques. All of our senior staff are already experienced counselors, with a minimum of two years work in the field in Kashmir.

Using art as one method of self-analysis for training of listeners

The second major problem is the one of time, or rather the lack of it. A patient has roughly two or three minutes with a psychiatrist in an out patients’ clinic. This only allows time to prescribe medication at high speed. The pressure on doctors and psychiatrists is enormous, and they have no option but to work this way. Our mental health centre works on an appointment basis that allows a minimum of an hour per patient, offering a combination of counseling, mental trauma therapy, and medication advice.

 

Our helpline office and mental health centre opened in January 2011. We ran the first training course for our listeners in January and February 2011, and we now have a very impressive and motivated team of young Kashmiri men and women, trained to be both listeners and counselors. In addition to this we have a management team in place, headed by our senior doctor. Our centre is located within the Civil Lines area of Srinagar, so that it can still be accessed, even during full curfews in the city. It is also close to a main bus stand so that it is easy for patients and staff to reach. We have chosen a quiet area so that it is a peaceful and unthreatening environment for both our staff, and for patients coming to the centre, particularly those from village and rural areas who are not used to the chaos of the city.

Kashmir LifeLine and Health Centre staff on the balcony of our premises

To sum up recent progress we now have a very punchy three tier-system in place: the suicide and mental trauma helpline is the top layer, and the phones are ringing all the time. Callers can speak to a listener for as long as they need. This also acts as a referral system to our next tier: our main mental health centre, or to one of our five outreach centres around the rest of the state, situated in some of the worst-affected areas. People coming for appointments have a minimum of one hour with a therapist or counselor, as against the maximum of the three minutes face time that was referred to earlier. The third tier is a broad-based awareness programme. We are training the local network of female primary health care workers (Anganwadi workers) across the state so that they can give basic mental health care within the community, and be a referral system to our centres.

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