Decades of conflict, displacement, poverty and unemployment have taken a huge toll on Afghans, and left a health system ill-equipped to provide them with mental healthcare.
Suffering through more than three decades of war, most Afghans have experienced the destruction of their country’s economic, social and cultural infrastructures, forcing them to live through challenging conditions on a daily basis.
Since 1978, recurring cycles of violence have left people with not only physical but psychological injuries for both those in Afghanistan and in the diaspora.
“It is important to understand the mental health of Afghans prior to their forced migration as their trauma is complex and multiple,” Husna Safi, an Afghan-Canadian psychotherapist and social worker based in Ontario, told TRT World. “Generations of Afghans have been born during the conflict and some have never known peace.”
“All Afghans share similar stories of witnessing violence, losing loved ones, sustaining war injuries, becoming refugees or internally displaced, being separated from family members, all of which are traumatic experiences and inevitably have mental health impacts,” she said.
And the available data reflects a highly traumatised population. A 2018 EU survey found that 85 percent of Afghans had witnessed at least one traumatic event. According to the Ministry of Public Health (MoPH) Afghanistan, one in two Afghans suffer from psychological distress, and a fifth of the population experience problems in accomplishing routine tasks.
Yet, fewer than 10 percent of Afghans have been able to receive sufficient mental health support from the state, with the situation even worse in large swathes of the country’s rural areas.
Hans Grootendorst, Managing Director at HealthNet TPO, pointed out that the impact of war and conflict on mental health in Afghanistan remains insufficiently researched.
“However, the studies that have been conducted in both high-income and low-income countries reveal that war and political violence are associated with high rates of mental health disorders and are associated with risk of long-term mental health problems,” he wrote in a statement to TRT World.
A nation-wide study published this year was unique in that it was based on a demographically representative survey of 4,445 Afghans covering inaccessible regions to measure exposure to major traumas and the prevalence of common mental health disorders such as Post Traumatic Stress Disorder (PTSD), Generalised Anxiety Disorder (GAD) and suicidality.
It found high exposure to trauma, with 86 percent of respondents either having personally experienced or witnessed at least one traumatic event in their lives. 47 percent experienced psychological distress and nearly 40 percent grappled with substantial mental health impairment, with women suffering more than men on average.
The study also compared the Afghan data with the World Mental Health Initiative (WMH) – surveys that pooled together 24 countries, among them low-income and where violent conflicts took place.
Overall, the collective violence trauma related to war was higher among the Afghan sample than the WMH pool: 60.77 percent of Afghans as a witness and/or personal experience versus 9.40 percent in WMH.
The PTSD prevalence was similar to what was reported in countries exposed to war, like Lebanon. Remarkably, the study notes PTSD diagnosis were not as familiar to psychiatrists in Afghanistan – something the authors believe could be because traumas are so frequently experienced by the population, that possessing PTSD symptoms did not prompt mental health consultations.
After the US-led invasion that toppled the Taliban in 2001, many international NGOs filled the gap to develop a mental health infrastructure in the country. And while there has been an increase in community-based services, accessibility remains a problem for the vast majority.
“The health-seeking behaviour of Afghans with mental health conditions is influenced by their personal beliefs, cultural and structural barriers, ranging from poor knowledge about health and available services, stigma, gender discrimination (more females than males seek help), poverty and ongoing conflict in the country,” Safi argued.
Among the largest health NGOs in Afghanistan, HealthNet TPO has worked to improve access to and quality of mental health services in the country since 2015.
To date, the organisation has managed to train 325 psychosocial counsellors to deliver support to community members and patients within health facilities, in addition to coaching over 260 doctors and 265 midwives and nurses on basic mental health support, while establishing 56 mental health focal points in the process.
HealthNet TPO has worked closely with the MoPH to integrate its training into the government education programme, and to build a National Strategy for Mental Health 2019-2023.
However, sizable gaps remain.
While the Afghan government trained over 800 mental health counselors over the last decade, Grootendorst said there is still a need for additional psychiatric nurses, clinical psychologists and psychiatric social workers.
He highlighted inadequate financing and psychosocial interventions; increased behavioural and substance abuse among youths; limited supervision and monitoring of services; and poor public mental health literacy as ongoing challenges.
Another factor is the fear of social stigma in a largely conservative culture, leading many to abstain from seeking help.
“To Afghans, mental health is not just about mental well-being, it is a reflection of one’s whole self. Most mental health experiences are normalised and viewed as everyday emotional experiences,” said Safi.
To overcome these hurdles, some mental health professionals have turned towards unconventional approaches to raise awareness.
Before the Covid-19 pandemic hit, a theatrical performance called Tanhai (‘Loneliness’) tackled trauma and depression in Afghan society through the story of a suicide blast survivor and victim of sexual assault, uniting characters and audience members on an emotional journey.
Sponsored by Peace of Mind Afghanistan, the play ran fifteen times to over 2,600 people in Kabul, Herat, Bamyan and Mazar-e-Sharif.
For those in the diaspora that arrive in host countries having escaped their war-torn homeland, the long-term effects of trauma continue to manifest in heightened stress and survival responses.
“Many face stressors during resettlement as they try to rebuild their lives, while they navigate their new culture and their culture of origin, and cope with the traumatic stress of the war,” Safi stated.
Discussing the growth in research into intergenerational stress, Safi points to a study which found how descendants of Holocaust survivors exhibited changes in stress hormone levels, suggesting a change in their genetic makeup.
“This may mean that even before children are born, they can be affected by stressful experiences their parents and grandparents have lived through.”
“Even when the threat is over, once they’ve resettled in a safe country, the body does not return to baseline (un-stressed state) and the traumatic stress response leads to physical and psychological issues for several generations.”
Having worked in mental health for seven years in both community-based organisations and clinics in Ontario, Safi has encountered only a small fraction of Afghan-Canadians that sought out counseling services. “And of those Afghan clients that sought therapy, they were predominantly females.”
She emphasised several barriers that prevent diaspora Afghans from gaining access to mental health care, including language difficulties, lack of knowledge and information about mental health, and fear of judgement by the community.
Additionally, Ontario residents can wait up to six to twelve months for counseling services. Even then, many services might exclude individuals with trauma-related disorders like PTSD and dissociation since they require specialised treatment.
Back in Afghanistan, the latest developments with the Taliban seizing control have led to thousands of people scrambling to flee the country, added to an estimated 3.5 million that are internally displaced.
What this might portend for an already underfunded mental health system is bleak, at best.
“The current situation will further deteriorate due to uncertainty and the collapse of the economy, limiting certain mental health services in the country,” predicted Grootendorst.
Meanwhile Peace of Mind Afghanistan, one of the few organisations working the mental health field in Afghanistan, has halted all its mental health projects.
"Since the takeover of Kabul by the Taliban, our normal operations have ceased and we are focusing solely on caring for children [housed in shelters] and evacuating the kids and our staff," it said in a statement to TRT World.