Shaken by the collapse of the old, communist certainties, then tormented by the hatreds of a vicious civil war, then harassed by unemployment and armed gangsterism, many people will crack - even the resilient citizens of Tajikistan. When MSF did a mental health assessment last year, all the classic symptoms of trauma and stress were readily identifiable: pervasive anxiety about physical safety, widespread depression and hopelessness, increased drug use and family violence.
Now that the first counsellors are starting work, the stories they coax from their clients are clear cries for help. Muyassara Kurbanova heard how this man's life had fallen apart: "During the street fighting in the war, he saw his best friend skinned alive in front of him. He escaped but could not hide from the memory. He could not sleep, took to drink and drugs, had problems with his wife and family, had headaches that pills would not touch." After three counselling sessions he is beginning to be able to re-live the events and to think of ways of putting his life back together.
Muyassara is among the first batch of community mental health counsellors who have been selected and trained by MSF to work in local medical centres in the country's capital, Dushanbe. The plan is for 15 counsellors and five trainers to form the core of a service that, after two years, will be spread across the country's six million population by the Ministry of Health.
Part of their task is to shift the widespread rejection and fear of psychological problems. One of the male counsellors, Vali Sayordrekov, knows that men are particularly resistant.
"Many are suspicious and will not open up their hearts," Vali said. "It takes time to get their confidence. We need to convince them that perfectly healthy people can need and benefit from counselling "
The taboo about looking for help is being addressed by a public information campaign on radio, TV and local meeting centres. That involves another educational message, summed up by Muyassara: "Most people believe they can solve their emotional problems with drugs. We have to convince them that this is not necessarily the solution. Talking through their problems is more beneficial."
Learning how to talk them through is the major skill being cultivated in the counsellors. Jozef Hegeman from Holland is in charge of the recruitment and training. He says the important selection criterion is the level of commitment to the people with problems. And he wants to know how his counsellors coped themselves with stress and trauma. Many of them talk about how the civil war made everyone victims, so they certainly identify with the clients. And the techniques for engaging with them are already developing. Mahbuba Ahrarova recalls one of her recent cases in which a university student was picked up by armed men in a car and raped in the centre of the city. Her mother came to MFS for help because her daughter was emotionally and socially paralysed by the experience. She could not go out of the family home and was intensely depressed.
"The first contact was very difficult", says Mahbuba, " I had to talk to the younger sister who was with us. Then the older one began to join in. She had very sad eyes and she said she did not want to live in this world."
Rape is a source of great shame in Tajik society and families usually prefer to hide it. The main reason is that girls have to be virgins when they marry. If they are raped, they become "spoilt" and will not get offers. That pressure is a cause of many suicides, according to the counsellors.
Muyassara points to another growing source of psycho-social problems: "Drug addiction is increasing because of the availability of smuggled drugs from Afghanistan and because of the massive unemployment of the youth. They are turning to drugs. There is a family near here with all five of their children who are addicts. People like this are certainly starting to come to counselling."
Other specialists point to the wider collapse of social order and the old certainties that had existed for so long under the Soviet regime. That system controlled everything in people's lives. The new freedoms mean that they are overwhelmed by having to make their own decisions. That stress, combined with the added insecurity of street violence and economic decline, mean that MSF's growing expertise in this field is filling a considerable need. The counselling route that has been taken in Tajikistan is based on the principle that the best way of reaching out to the population at risk in this way is through community based schemes. It connects with the existing NGO's, it makes use of the local cultural resources and sensitivities, it works to change attitudes at the grass roots and, from the outset, it builds the capacity of the Ministry of Health to continue the work after the training phase.
The results today are only at the anecdotal level because the work has hardly begun but monitoring and measurement is an essential part of the project. For the counsellors, the satisfaction is already clear. Nigina Mamojanova says that after a day of listening to the terrible stories that people bring to her, she often cannot sleep because she knows they will expect her to have a solution. That's not how counselling works. Nigina knows that her job is to help the clients rediscover their own equilibrium. She tells of a twenty two year old student who wanted to slit her own wrists at their first meeting. After a couple of painful sessions, Negina says the woman is now admitting that she is still able to feel some human warmth.
"They always ask 'I know why I come; to tell you my story. But why do you want to listen to me?' I reply 'Do you feel better that you have spoken to me?' And when they reply 'Yes', I say, 'That is your answer'."