Afghanistan

The mental health crisis in Afghanistan

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By Dr. Amin Azimi
The deep scars of war are highly visible across Afghanistan. The destruction is not only the broken walls, rabble of towns and villages, and mounds of pulverized bricks; the most lasting damage can't be seen: the deep psychological wounds in the minds of Afghans after 23-years of war and terror. This collective mental health crisis is a huge obstacle to a better future for Afghanistan.

If a large group of any population suffers from mental illness, a society will have trouble rebuilding itself. A November 2001 report published by the World Health Organization (WHO) estimates that about five million Afghans suffer from various types of mental illness. Furthermore, the report considers the biggest health problem in Afghanistan the prevalence of mental illness.

Today, Afghan professionals don't have the experience and expertise to treat this huge group of people who have difficulty understanding their own psychological traumas or difficulties. Currently, there are only a handful of mental health professionals in Afghanistan, mainly psychiatrists. They are poorly equipped to treat patients, and their only method of treatment is medication. These professionals don't have training in psychotherapy. Medication is helpful for treating the patients symptoms; however, individual and group psychotherapy is essential in order to resolve the internal psychological conflicts the Afghan population has been experiencing. Afghanistan is in need of trained psychologists to design mental health programs, treat these patients, and train the art of counseling to qualified individuals.

Afghan society urgently needs information and education in order to understand the nature of mental illness, and to avoid stigmatization and labeling of patients in a derogatory fashion. Mental illness is not a sign of weakness or character flaw that has haunted Afghan culture throughout history.

Without proper understanding and compassion for patients, and acceptance of mental illness, progress and treatment will certainly be doomed to fail. The fact is, no patient feels better if their family labels them crazy and society views them as weak and different. Unconditional acceptance, encouragement by the family members, and strong visible community support is the positive base for successful treatment. Sometimes we hear and read the heartbreaking news that some of these helpless patients are being chained to their beds, and some have being beaten by their caretakers in order to keep them quiet and to make them to behave accordingly. The fact is, stress is the number one cause of mental deterioration in patients. Physical and emotional intimidation, a chaotic and abusive environment not only hinders the progress toward improvement, but rather makes the patient's condition worse and their behavior unmanageable.

Today, in Afghanistan one can witness various types of mental illness. The purpose of this article is to inform the reader about the characteristics and treatment methods of three major mental illnesses, among others, that the Afghan people are experiencing at the present time: schizophrenia, depression and posttraumatic stress disorder.

There are individuals who suffer from a severe form of mental illness called schizophrenia. Schizophrenia is certainly one of the most puzzling and profound types of psychological disorders. It is found in every culture and historic period. Today, most theories of schizophrenia suggest environmental stress contributes to the onset of the illness in those who are biologically predisposed to this illness. These patients suffer from delusional thinking, a fixed, false belief maintained in the face of virtually undeniable proof to the contrary.

Furthermore, they experience hallucinations and sensory perceptions without sensory input, or from distorted input. For example, they see things or hear voices. Sometimes the voices can be command type hallucinations telling the patient to do certain things like hurt themselves or kill others, and the patient may follow the command. There are different subtypes of schizophrenia.

Some subtypes are mute and totally unresponsive; others show strange, incoherent behavior. These schizophrenics' thoughts are disorganized, and their emotions are inappropriate, or even absent. They may cry at a joke or laugh at sad news. They may see themselves as a renowned person, or that they are being persecuted. These individuals may think that particular individuals, groups and organizations, are following them and they can be dangerous. They can be highly religious, believing that they are an important historical religious figure, or that they have an important mission to achieve in the world.

Antipsychotic medication is essential for stabilization; however, schizophrenics can hardly be free of the illness. Patients can be helped by individual psychotherapy that provides positive treatment relationships and therapeutic alliances. Supportive psychotherapy is the type most often employed. Establishing a relationship is often a particularly difficult matter; schizophrenic patients are desperately lonely, yet defend against closeness and trust and are likely to become suspicious, anxious, hostile, or regressed when someone attempts to become close. Exaggerated warmth or professions of friendship are out of place and are likely to be perceived as attempts at bribery, manipulation, or exploitation.

In hospital settings, at times staff may have a meal with the patient, sit on the floor, go for a walk, play soccer, or just sit silently with them. The major aim is to convey that the helper can be trusted, wants to understand the patient and will try to do so, and has faith in the patient's potential as a human being, no matter how disturbed, hostile, or bizarre the patient may be at the moment.

According to some reports, close to three quarters of the women in Afghanistan are suffering from clinical depression, and an equally large percentage of women and children also are the victims of Posttraumatic Stress Disorder (PTSD). Environmental stress is a major factor in producing depression. Stress may lead to neurochemical reactions that directly create the symptoms of depression. Most depressed patients report a loss of interest in pleasurable activities. They feel blue, hopeless, in the dumps, or worthless. Almost all these patients complain about reduced energy, resulting in difficulty finishing tasks, and decreased motivation in undertaking new projects. They complain of trouble sleeping, disturbing dreams and multiple awakenings at night. Many patients have decreased appetite and weight loss. Some patients, however, have increased appetite, weight gain, and increased sleep. Anxiety, in fact, is a common symptom of depression, affecting almost all depressed patients. Somatic complaints, concentration, and impairments in thinking are other factors that impair daily functioning for those who are depressed.

According to cognitive theory, common cognitive misinterpretations involve negative distortions of life experience, negative self-evaluation, pessimism, and hopelessness. One can't make a depressed person cheerful just through words or presenting goods. The essential theme of depressed people is a negative view of themselves, others, the present, past and future. They see the world as all or nothing. The goal of treatment is to identify and modify their negative thinking by using behavioral tasks, such as recording and consciously modifying thoughts. Depressed individuals need a daily schedule of activities in order to make themselves productive; this improves their self-esteem and lowers their depression. Medication can be helpful in many severe cases, especially when a person is suicidal. Individual psychotherapy has proved to be the best method for treating depression.

The most devastating and crippling psychological difficulties most women and children of Afghanistan are facing today are the horrors of Posttraumatic Stress Disorder (PTSD). PTSD develops in individuals who have experienced emotional or physical stress of such magnitude as to be extremely traumatic for virtually anyone. The major features of this disorder are the re-experiencing of the trauma through dreams and waking thoughts; emotional numbing to other life experiences and relationships, depression, anxiety, and difficulty in thinking and reasoning. This common trauma occurs from either a serious threat or assault to one's own life, life of family members, witnessing war, killing, physical violence, or destruction of one's own home or community. Symptoms may begin immediately after the traumatic experience or appear gradually over a period of several months. In some cases, symptoms do not emerge until years later.

Symptoms of PTSD include repeated disturbing thoughts about what happened, fearful reactions to the situation that are reminders of the event, nightmares or flashbacks and feelings of numbness, irritability or being constantly on edge. Intense psychological stress when exposed to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma are also characteristic of PTSD.

In general, the very young and the very old have more difficulty with traumatic events than those in mid-life. In the case of children, occasionally, a child may become mute or refuse to discuss the trauma, but this should not be confused with inability to remember the events. In younger children, distressing dreams of the event may, within several weeks, change into generalized nightmares of monsters as a threat to themselves and others. Children may exhibit various physical symptoms, such as stomachaches and headaches. Young children do not have the sense that they are reliving the past, and through their actions or repetitive play they are reliving the trauma.

Diminished interest in significant activities, and constriction of emotion and thinking both may be difficult for children to report on themselves. In children the signs of stress may include difficulty relaxing, and vacillation between withdrawal, friendliness, aggressive outburst and poor peer interactions. PTSD children will fear darkness, strangers, and being alone. The traumatic event has a strong negative impact on the emotional development of these children. If early intervention is not done, the crippling effects of PTSD may haunt them the rest of their lives.

Women, in particular, need to be informed about PTSD, because on average women develop it at twice the rate men do. Because on average women are more emotional and more vulnerable they are more susceptible to PTSD. In the case of Afghan women, PTSD, without a doubt, has crippled every aspect of their lives. Their symptoms have become more prevalent in recent years when they lost their freedom under the Taliban and the torture and suffering they experienced during that time.

These women may exhibit the following symptoms: difficulty falling asleep, irritability or outbursts of anger, difficulty concentrating, problems with memory, lack of trust, feelings of detachment or estrangement from others, and lack of interest in significant activities. They do not expect to have a career, marriage, children, or a long life. These women may exhibit high levels of depression, develop suicidal thoughts, and attempt suicide, and experience emotional numbing, chronic anxiety, extreme passivity, helplessness, intrusive memories or flashbacks, intense startle response, disturbed sleeping and eating patterns, anticipatory terror and low self-esteem, as well as physical complaints. They may also experience an overwhelming sense of danger, become dependent and suggestible and find it difficult to make decisions or carry out long range planning.

Research studies indicate that the impact of PTSD may be more dependent upon the particular type of outcome observed, with women at high risk for anxiety and depression, while man are at high risk for substance abuse. Men are at greater risk for exposure to traumatic events, but exposed women are at greater risk for developing PTSD. Women become more distressed than men when witnessing violent injury or death. When trauma occurs, women are more likely to endorse self-report statements reflecting greater fear and distress than men. Women also have greater sensitivity to the stress of others, or what is referred to as "network stress."

The treatment of choice for PTSD is individual psychotherapy with a therapist who is familiar with the culture, values and belief system of the victim. If treatment is not available, with children adults need to provide constant reassurance that the child is safe and encourage the child to express feelings and emotions freely. Since children with PTSD experience frequent nightmares, with fear of darkness, parents or caretakers should leave a light on, or in the absence of light, the child should sleep close to the parents or the caretaker in order to feel safe and secure. Having pets, such as a dog will provide unconditional acceptance and can bring comfort for PTSD sufferers. Furthermore, parents or caretakers can encourage the child to express the trauma through drawing, since children often have difficulty expressing their emotions with words.

For adults, writing a detailed description of the trauma, which the person reads to oneself several times a day is helpful. The reason for this exercise is to make the victim become desensitized to the trauma. The victim can be taught relaxation exercises and other mental techniques to use when anxiety takes over. Victims who provide well-developed accounts are more likely to develop a perspective on events, become more hopeful about the future, and provide closure regarding stressors. When people fail to talk about a traumatic experience, they tend to live with it, dream about it, and ruminate about it in an unresolved manner. By putting these images and their accompanying emotions into language, the event becomes more organized, understood and resolved. If the traumatic memory is not fully digested, it continues to keep the victim emotionally paralyzed. Basic education about PTSD is essential, as most sufferers do not recognize what their symptoms mean. Finally, maintaining cultural traditions and ties are a buffer to PTSD symptoms.

Time is highly crucial for the people of Afghanistan. Afghan mental health professionals currently living in the west bear the responsibility to extend their hands to each other and collectively work on a comprehensive plan of action to resolve the current mental health crisis in Afghanistan. It is our ethical and moral obligation to display our willingness to reach out to our brothers and sisters of our beloved country and search for a broader avenue to find a meaningful solution to an on-going devastating situation. Fortunately, the world is recognizing the suffering of Afghan people, and different organizations are already providing aid to Afghans; however, that is not enough. We as Afghans, can no longer afford to be passive and silent.