Behavioral Health
FAQs for Health Care Providers
Behavioral Health Considerations with Afghan Evacuees
Risk and Prevalence Considerations
A 2021 cross-regional study of Afghan mental health surveyed more than 4,000 Afghans and found that 86.16% of the population had experienced or witnessed at least one traumatic event, most experienced war trauma, accidental injury, earthquakes/disasters
The same survey found that men have twice the probability of exposure to trauma (except for sexual violence), and that people 35 and older were significantly more likely to have been exposed to collective violence and bodily harm-related trauma
Psychological Distress was reported by 47% with 39% reporting substantial impairment
Women reported more psychological distress, related impairment, PTSD, and suicidal thoughts and behaviors than men. No differences were observed related to depressive episodes or anxiety disorders
Women
Gender-based violence
87% of Afghan women report experiencing at least one form of physical, sexual or psychological violence. 62% report experiencing multiple forms of violence.
Higher rates of gender-based violence have been observed in post-conflict settings. Men who have experienced or been exposed to political violence are more likely to perpetuate gender-based violence.
This has been observed to be especially prevalent in unstable or impoverished settings when men are unable to “provide” for their families.
Survey reports asking about the past 12 months have found as high as an 80% positive rate of intimate-partner violence (IPV) reported by Afghan women refugees.
Rates/risks of IPV have been shown to increase during periods of conflict or displacement; displaced women are particularly vulnerable to high levels of IPV.
IPV has been linked to several deleterious general, reproductive and mental health outcomes for affected women.
80% of suicides in Afghanistan occurs among women, most choose poisoning
Principal causes are reported to be gender-based violence, COVID-19, and joblessness
Prolonged separation from family is of concern
There are many cultural/religious barriers to talking openly about suicide and related thoughts/actions
Depression
Rates of depression among Afghan women have been observed to be as high as 78% under periods of Taliban rule, and 73% in displacement contexts.
Women have been observed as experiencing more somatic symptoms of depression than self-identified mood symptoms.
40-60% of pregnant women and new mothers report depression, postpartum depression is likely contributing to this statistic.
Children
Children are also exposed to trauma and have a similar risk of physical, sexual and emotional abuse.
Best practices for children who have experienced mass trauma
When possible, do not separate children from their caregivers.
When possible, provide a verbal overview of what is about to happen prior to acting.
Allow them to keep and/or utilize comfort objects they may have or may have adopted.
Ask prior to making physical contact; explain the purpose of physical contact.
Respect cultural family roles and hierarchy.
Cultural Do’s and Don’ts
Things to avoid
Close contact across genders; being alone in private with a member of the opposite sex who is not a close family member.
Men inquiring about the female members of an afghan man’s family
Complimenting children to their parents more than once (this is related to a strong cultural belief in the evil eye)
Using [only] your left hand to touch someone or point to something. Additionally giving a thumbs up has a negative meaning in Afghan culture.
Do not use the term “Afghani”. This refers to currency
Use the term mental health
Things to try
Gender-matched contact and examination whenever possible. Provide females a safe space and privacy with female staff to open up.
Ask them about themselves
Offer supplies, services, or help more than just once (initial responses are likely to be to decline out of modesty)
Use your right hand (or both hands) when touching or pointing to someone.
The appropriate term is “Afghan”
Talk about stress and social support
Culturally-specific idioms of distress
Idiom
Jigar Kuhn/ Jigar Kuhni
Comparable concept
Grief due to interpersonal loss or a deeply painful experience; dysphoria (may be more temporary, a reaction to an immediate event)
Asabi
Irritability, anger; nervous, highly stressed
Fishar (commonly communicated as “high or low blood pressure”)
Emotional pressure/agitation (fishar-e-bala)
Low energy or motivation (fishar-e-payin)
Beating oneself
Self-harm; extreme distress (typically only observed in women)
Esterab/tashwish
“Thinking too much”/psychological distress
References
Masfety, V. K., Keyes, K., Karam, E., Sabawoon, A., & Sarwari, B. A. (2021). A national survey on depressive and anxiety disorders in Afghanistan: A highly traumatized population. BMC Psychiatry.
Mannell, J., Grewal, G., Ahmad, L. & Ahmad, A. (2021). A qualitative study of women’s lived experiences of conflict and domestic violence in Afghanistan. Violence Against Women, 27(1). 1862-1878.
Delkhosh, M., Khoei, E. M., Ardalan, A., Foroushani, A. R., & Gharavi, M. B. (2019). Prevalence of intimate partner violence and reproductive health outcomes among Afghan refugee women in Iran. Health Care for Women International, 40(2). 213-237.
Safi, S. (2018). Why female suicide in Afghanistan is so prevalent. BBC Afghan Service.
Ventevogel, P., & Faiz, H. (2018). Mental disorder or emotional distress? How psychiatric surveys in Afghanistan ignore the role of gender, culture and context. Intervention: Journal of Mental Health and Psychosocial support in Conflict Affected Areas.
Omidian, P., & Miller, K., E. (2006). Addressing the psychosocial needs of women in Afghanistan. Critical Half.
The National Child Traumatic Stress Network. (2021). NCTSN Resources in Response to the Terrorist Attack and Afghanistan Transition. https://www.nctsn.org/resources/nctsn-resources-in-response-to-terrorist-attack-and-afghanistan-transition.
Brymer, M., Elmore Borbon, D., Frymier, S., Ramirez, V., Flores, L., Mulder, L., Ghosh-Ippen, C., & Gurwitch, R. (2021). Psychological First Aid for Displaced Children and Families. Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress. Thank you to Heidi Ellis for reviewing this adaptation.
Contributors
Will Carlson, MSW, LICSW
Patricia Shannon, Ph.D., L.P.
Mehria Sayad-Shah, M.D.
Samira Melatyar, MSW, LGSW