In Afghanistan, a rocket pounds into a home--orphaning a 14-year-old girl and her older sister, whose legs are so badly wounded they have to be amputated. An uncle takes them in, stealing their inheritance, repeatedly abusing them physically, and the older sister eventually commits suicide.
As community psychologist Ken Miller, PhD, describes it: Welcome to Afghanistan.
The incident happened during the country's civil war, which lasted from 1992-1996. The civil war, together with the war against the Soviets that preceded it and the oppressive rule of the Taliban that followed, devastated the country and exposed Afghans to extreme violence and loss.
However, the effects of such violence and loss on the mental health of the Afghan people remains unclear since mental health services are scarce, Miller says.
To shed light on the matter, Miller is studying distress and trauma, as well as resilience, among the Afghan people and exploring the ways they've been able to recover from such loss and devastation.
A second aim was to field test a methodology for developing culturally grounded assessment measures in conflict zones. To do this, he teamed with medical anthropologist Patricia Omidian, PhD, who was already working on Afghan mental health issues in Kabul and who speaks Dari--one of the country's two major languages. They collaborated for six weeks this past summer to collect--in collaboration with a team of Afghan surveyors--40 narratives of Afghans' experiences of trauma and distress as well as resilience.
They then used the narratives to create the 22-item Afghan Wellness Questionnaire, which assesses the degree of emotional distress people experience in a cultural context. Miller and Omidian administered the questionnaire to 324 adults in eight districts of Kabul, revealing high to moderate levels of depression, anxiety and traumatic grief.
The next step on their agenda: Use the results to provide a culturally sensitive mental health needs assessment and program evaluation with the goal of improving Afghan mental health services, says Omidian, a representative for Afghanistan in the American Friends Service Committee, a service organization that helps war victims.
"After 25 years of war, such services are sorely needed," Omidian says.
To spur their delivery, Miller and Omidian helped form a task force of Afghan government, education and health officials and community organizations. The task force, they hope, will brainstorm interventions to help Afghans--such as the 14-year-old girl who lost her family--cope with the violence, grief and poverty that plague the country. Further, they hope the lessons they have learned about the patterns of resilience and recovery among Afghan survivors of catastrophe can guide interventions to help others cope too.
Indeed, psychological interventions may particularly benefit Afghan women, the researchers' surveys indicate. Specifically, they found in administering the questionnaire:
Women have the highest levels of depression, traumatic grief and anxiety. By comparison, most men report moderate levels.
Widowed women are at greatest risk for emotional problems and impaired psychosocial functioning.
The more children men have, the better their mental health. However, the opposite holds true for women: The more children they have, the higher their levels of emotional distress. A possible explanation for this, Miller says, might be that because of scarce pediatric and maternal health care, women are unable to provide basic needs for their children. In addition, women face structural discrimination throughout the country, the researchers say.
As men age, their mental health gets worse. However, age is not related to mental health for women.
That said, despite the violence and great loss both Afghan women and men face, many of them show surprisingly high resilience, the researchers note.
"Afghans are high-functioning in spite of the many signs and symptoms of mental distress," Omidian says. "Most studies carried out do not address this or explain it."
Particular contributors to resilience, she and Miller find, are a combination of internal and external resources, such as financial and social support and faith in God.
"Those who kept faith got through better than those who lost faith," Miller notes.
For example, Miller recalls one man who stopped at a mountain-top checkpoint and forgot to set the hand brake when he jumped out of his truck to show soldiers his paperwork. The truck rolled off the cliff, killing several of his family members inside.
This man, who headed the data-gathering team in the research collaboration, told Miller he used his faith in God and "hope"--a deeply important concept in Afghan cosmology--to cope with the loss. In fact, Miller learned, Afghans describe losing hope and withdrawing socially as "leaving the world" and not using the resources God provided them by withdrawing into grief.
"For Afghans, whose sense of self is deeply rooted in their social networks and in their faith in Islam, 'leaving the world' is really a kind of psychological suicide," Miller says.
Keeping efforts going
Now, to help supply Afghans with their psychological fuel--hope--the newly formed mental health task force aims to help the country improve its mental health and psychosocial services with interventions geared specifically to the Afghan culture. For interventions to work, they must incorporate the country's religious and cultural context, Miller notes.
"This is a particular challenge for Western-trained psychologists who are unaccustomed to integrating religious and cultural values into the development and delivery of mental health services," Miller says.
He envisions, for example, interventions that incorporate Islam or cater to women meeting over tea or needlework. Such approaches may work better than one-on-one interventions since Afghans tend to place their identity in their family and community.
"Nobody mentions self-esteem there," Miller says, adding that this differs from Western culture, in which individuals often put themselves at the center of the social world and the family, community and society. "It is hard for Afghans to talk about 'I' without thinking about 'we,'" he explains.
Further, Miller says, the country needs mental health programs that specifically serve youth as well as women, particularly emotionally vulnerable war widows.
He and Omidian hope to team again later this year or early next to work out specific steps to develop such programs. In the meantime, they are both providing consultation to other organizations engaged in mental health work with Afghans in Kabul and in exile.
"We both believe in action research," Omidian says. "This means we need to think about ways to bring a meaningful program that is culturally appropriate and of benefit to the Afghans."
Miller, K., & Rasco, L. (Eds.). (2004). The mental health of refugees: Ecological approaches to healing and adaptation. Mahwah, N.J.: Lawrence Erlbaum Publishers, Inc.
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