Culture, Context,

& Mental Health in

Afghanistan
Ken Miller
Senior Researcher
War Child Holland
Rationale for the Project
n MH assessments of war-affected populations rely heavily on
western measures of psychopathology.
n Reflects the essentialist or universalist assumptions of western
psychiatry and clinical psychology

n Risks prioritizing” western” mental health constructs that may

have less meaning in other contexts (the “category fallacy”)

n Overlooks local expressions of distress & local MH priorities

n Impedes communication with folks in need of support
Goals of the Project
1. To field test a methodology for developing culturally
grounded mental health assessment instruments in
conflict and post-conflict zones

2. To understand what it means to be mentally

healthy, to have good mental health, from an
Afghan perspective

3. To identify the ways that Afghans talk about

distress and common mental health problems
Goals (cont’d)
4. To develop a culturally grounded, empirically
sound mental health screening tool for Afghans
for clinical and research use
Afghanistan
Demographics
n Landlocked, about the size of Texas
n One of the world’s poorest nations
n Life expectancy: 42 years, Median age: 17 years
n Infant mortality rate: 165 deaths/1,000 live births (vs.
5/1,000 in the US)
n Literacy: male=51%, female=21% (statistics vary
markedly)
n Ethnicity: Pashtun (42%?), Tajik (27%?), Hazara (9%?),
Others (22%?)
History of Violence

n 1979-89: Soviet Invasion and Occupation

n 1989-1992: Gradual collapse of communist Government
n 1992-1996: Civil War, the destruction of Kabul
n 1996: Taliban victory
n 2001: US-led removal of Taliban from power in Kabul
n 2001-2019:
n Gradual reconstruction in context of ongoing violence
n Widespread and growing Taliban resistance
n Warlord control of provinces
n Heavily narco-based economy
n Widespread corruption in all levels of government
n Extreme poverty in much of the country
n Social indicators remain near bottom.
My Grandfather Lived Here…
Houses by a Cemetery
City Life: The Bazaar
City Life: Shari-e-Naw Neighborhood
Girls Returning Home from
School
Afghan Categories of Psychological
Distress
n Suffering caused by biology (schizophrenia)

n Suffering caused by djins (spirits)

n Suffering caused by life stress (war, poverty,

etc.)

n We have focused on the 3rd category: Life

stress
Method
n Phase 1: Narratives of suffering and recovery

n Aim: To ID of indicators for new measure

n 10 women and 10 men
n “Please describe 2 people you know, both of whom suffered
during the war, one of whom is still suffering, and one of whom
is doing well now.
n Please tell each person’s story.
n How could you tell they were suffering?
n How could you tell that one person got better?”
n Why do you think s/he got better?
n Why is the other person still suffering?
Content Analysis of Data
n Culturally specific indicators of distress were identified: asabi,
jigar khun and fishar, and beating oneself
n Local terms not easily translated

n Other indicator of distress familiar to western clinicians:

symptoms of sadness, trauma, anxiety
Sample Narrative
The daughter of the woman who is the focus of this story told us the story. She said “We
were four sisters and fours brothers. Only two of our sisters were older and the rest of our
brothers and sisters were younger when our father died of natural causes. Our mother
raised the children under very poor circumstances. During that time the fighting was very
bad. One of our brothers left home to go get groceries, he was only 21 years old. The
fighters asked him where he was from then they killed him. This affected our mother very
much. Then our 18-year-old brother left to go get groceries, too, and a bomb hit that area
and he died. Our family was at home but they brought the bodies to our mother. Our
second brother died two months after the first brother. Our mother continued to live her life
but she is very weak. She works at a hospital. Her pay, which is 1700 to 1800 Afghanis
[about 36 dollars] a month helps her live her life. And her two sons live with her. She
always has a severe headache. Her fishar is always high and she has diabetes. She
doesn’t have much of an appetite. She often becomes jigar khun and cries a lot and tries
to stay away from people when she is at home. She tries to stay away from gatherings
and if she does go she becomes very impatient while she is there. Every time she thinks
about one of her sons and how one was shot with holes in his body and how the other one
was shattered into pieces because of the bomb she becomes asabi. When she is very
asabi she becomes angry and starts fighting. She is always talking about her sons. There
are tears in her eyes all the time and when she cries too much her eyes turn red. When
she is at home she puts a curse on the people who took her sons away from her. She
prays, and she does not have a good relationship with her family.
Method
n Phase 2: Development of ASCL
n Design of measure using indicators of distress
from the narratives

n 23 items

n Answer Choices: How often in the last 2 weeks

have you _______________?
Sample Answer Choice Graphic
(ASCL)
Procedure
n Women were approached in their homes by
female surveyors, 100% participation rate

n Men were approached by male surveyors

in stores, on the street, and in a mosque.
95+% participation rate
Method (cont’d)
n Pilot testing (n=60)

n Survey of 320 adults in 8 districts of Kabul

n Validity: correlation with Afghan War Experiences Scale

n 17 item adapted version of the Bosnian War Experiences
Scale; Weine et al., 2001; Miller et al., 2002)
Results
n Psychometrically sound, culturally meaningful, and easy
to use measure
n Good internal consistency = .93
n Good (provisional) construct validity (correlation with AWES) =
.70
n Items reflect ways that distress is actually expressed
n Important culturally specific indicators of distress identified

n “Thinking too much” identified as most frequent symptom

n Also contributes to distress
n Survey revealed high levels of distress among women,
especially widows
Results
n In subsequent research, the ASCL:

n Correlated strongly with the HSCL-Depression scale (.74)

n Correlated moderately with IES-D (PTSD) (.56)
n Correlated moderately with WHODAS II (functioning) (-.51)
n Was superior to the SRC in measuring distress among Afghan
women (similar for men)
n Has been used in research and practice with Afghan refugees
Brief Summary, Study #2: Daily Stress
and Mental Health in Kabul
n Aims

n To identify most salient daily stressors as perceived by

residents of Kabul

n To assess the relative contribution of daily stressors and

war experiences to MH status

n To examine the interaction of daily stress and war

exposure as predictors of MH status
Why Focus on Daily Stressors?
n Daily Stressors are the indirect effects of organized violence.

n Research with refugees has found that daily stressors exert an

enormous toll on mental health.
n Social isolation, lack of social support, discrimination, poverty, lack of
environmental mastery
n Strongly linked to depression, anxiety, and trauma/PTSD

n Some evidence suggests that daily stress may moderate impact of

war-related traumatic stress on mental health
n Resource depletion hypothesis
The Stressful Nature of Daily Life in
Kabul
n Widespread unemployment and poverty

n Social networks have been devastated

n Relatives killed or displaced

n Illiteracy is widespread

n Infant and maternal mortality are among the worst in the world

n Domestic violence is common and widely tolerated

n Traffic and pollution are terrible

n People often travel 2 hours each way to get to jobs due to congestion and
roadblocks.
Why Focus on Daily Stressors?
n Previous studies in Afghanistan had focused mostly on direct war
exposure, and assumed that exposure was cause of distress.

n Our hypothesis: daily stressors would be even stronger predictor of

distress than war exposure

n Some evidence suggests that daily stress may moderate impact of

war-related traumatic stress on mental health
n Resource depletion hypothesis
n We wondered whether higher daily stress would leave people
more vulnerable to effects of war trauma.
Development of Afghan Daily
Stressors Scale (ADSS)
n Items drawn from narratives gathered in 2004

n Initial translation into Dari

n de facto common language of Kabul

n Initial pool of items shared with team for revision, modification

n Back-translation

n Final review for clarity by team, ease of understanding

n Asks: “How stressful has each of the following been for you in
the past month?”
Method
n 320 adults, 8 districts (160 women, 160 men)
n Measures:
n Afghan Daily Stressors Scale (ADSS)
n Afghan War Experiences Scale (AWES)
n Afghan Symptom Checklist (ASCL)
n Hopkins Symptom Checklist (HSCL-A and –D)
n Impact of Event Scale-Revised (IES-R)
n WHO Disability Scale II (WHODAS II)

n ALL measures went through same “cognitive

interviewing” and backtranslation process.
RESULTS
Daily Stressors
n 10 of 12 most stressful items on the ADSS were
the same for women and men
n Major stressors included
n Roadblocks/Traffic
n Air pollution (linked to >2,000 deaths annually)
n Poverty-related stressors
§ Being unable to afford basic necessities
§ Poor housing conditions
n Health problems
n Illiteracy
n Unemployment
n Social isolation
Daily Stressors (cont’d)
n Others were more salient for women:

n Being beaten at home

n The security situation in Afghanistan

Analyses
n Hierarchical Multiple Regression Model Used to Test
Contribution of War Experiences and Daily Stressors to
Mental Health

n Age and Gender entered at Step 1.

n War Experiences and Daily Stressors entered at Step 2.

n Interaction of War Experiences and Daily Stressors

entered at Step 3.
Multiple Regression Model

Block 1 Block 2 Block 3 Depression

Anxiety
War Experiences Interaction Term:
Age & Gender War Experiences PTSD
& X
Daily Stressors Daily Stressors Impaired
Functioning

ASCL
Findings
n Daily stressors were a better predictor than
war exposure of

n General psychological distress (ASCL)

n Anxiety
n Depression
n Impaired functioning
Findings (cont’d)
n Daily stress moderated the relationship of war
experiences to PTSD.

n Under conditions of lower daily stress, war exposure was

significantly related to PTSD.

n However, under conditions of higher daily stress, war

experiences were not significantly related to PTSD.
Summary & Conclusion from Study #2

n Daily stressors were strongly related to

every mental health outcome in this study.

n Clearly important to broaden our view beyond

war trauma.
Example
n The Noor Education Center
n A women’s organization based in Kabul, working
throughout the country.
n Provides group interventions to women aimed at
n Improving social support and social networks
n Literacy training and work skills training
n Psychosocial support
n Kabul Orthopedic Organization (KOO)
n Replacing limbs lost to landmines & shells
Summing Up
n An adequate understanding of mental health in any non-
Western conflict or post-conflict zone requires an emic
perspective that identified local concerns, and local ways of
understanding, experiencing, and expressing distress.

n A culturally and contextually grounded understanding can

inform the development of appropriate and effective mental
health and psychosocial interventions.