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Table of Contents
ARTICLE
Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 28-35

The impact of persons with mental health problems on family members and their coping strategies in Afghanistan


1 Ph.D. Student, Simon Fraser University, School of Education, Burnaby, Canada and Instructor, Kabul University, Faculty of Psychology and Educational Sciences, Kabul, Afghanistan
2 BA, Kabul Mental Health Hospital, Kabul, Afghanistan

Date of Submission27-Mar-2021
Date of Decision10-Feb-2022
Date of Acceptance02-Mar-2022
Date of Web Publication31-May-2022

Correspondence Address:
Spozhmay Oriya
Simon Fraser University, School of Education, 8888 University Dr, Burnaby, BC V5A 1S6
Afghanistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/intv.intv_13_21

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  Abstract 


Afghans are suffering from mental health problems because of 40 years of war and its consequences, and their distress is exacerbated by the lack of professional mental health services. This study is one of few to shed light on this challenging situation. It explores the experiences of families who have a family member with mental health problems and its effects on their wellbeing and coping strategies. Using qualitative methods, the research questions guided the sampling of the informants (purposive sampling), the data collection method (semi-structured interviewing) and data analysis (comparative analysis). After 60 interviews, the study achieved saturation. Findings show that living with a person with mental health problems impacted caregivers' wellbeing. In particular, living with a family member with a mental illness impacted caregivers' behaviour and practical life and caused severe stigma for the family. Caregivers tried in a variety of ways to cope with the situation. Due to the high level of distress experienced by caregivers, they need equal, though different, caring attention to their ill family members. Because of a lack of awareness related to mental illness, families feel helpless when it comes to effective coping. There is therefore a great need to pay attention to people with mental health problems and their caregivers.

Keywords: Afghanistan, coping strategies, family caregivers, mentally ill family members


How to cite this article:
Oriya S, Alekozai T. The impact of persons with mental health problems on family members and their coping strategies in Afghanistan. Intervention 2022;20:28-35

How to cite this URL:
Oriya S, Alekozai T. The impact of persons with mental health problems on family members and their coping strategies in Afghanistan. Intervention [serial online] 2022 [cited 2022 Sep 29];20:28-35. Available from: https://www.interventionjournal.org/text.asp?2022/20/1/28/346321

Key implications for practice

  • There is a need for mass awareness regarding mental health issues in Afghanistan.
  • The country must train a sufficient number of skilled psychologists, counsellors, psychiatrists, and social workers and provide free professional psychosocial counselling services for persons with mental health problems and particularly for their families.
  • The Afghan health system would benefit from involving local mullahs, teachers, elders and community leaders in providing basic mental health literacy.





  Introduction Top


Despite the country's desolate situation in Afghanistan, in recent years no research has been conducted on the families of persons with mental health problems. The present study starts filling this gap by exploring the impact persons with mental health problems have on their family members and caregivers and how they cope with their situation.

After decades of war, Afghanistan's population are experiencing psychosocial distress at a personal and collective level. According to the National Mental Health Survey in Afghanistan (2018), 50% of Afghans suffer from psychological stress and 20% have problems with their daily work because of mental problems. However, in the absence of effective therapeutic interventions, this phenomenon is part of ongoing life to various extents.

Since 1978, Afghanistan has suffered from occupation, armed political and interethnic conflicts and the generations that were born after that year have never seen their country at peace. The impact of these conflicts is all pervasive; it permanently affects every aspect of daily life and causes desolation in families and society. Experiences such as witnessing violence, losing loved ones, bearing the trauma of forced migration or internal displacement, serving as a combatant in the army, etc., affect the mental health of individuals. In addition, large portions of the Afghan population are poorly educated and misunderstand mental disorders, seeing them as the result of some wrongdoing or as magic, and then tend to stigmatise those affected. This complicates the life of people with mental health problems and makes getting access to therapy and support difficult (Canadian Women for Women in Afghanistan, n.d.).

In Afghanistan, the struggle against mental illness is often conceptualised as a “silent war” (Ahmad, 2017). Mental health services are limited: There is one mental hospital plus four psychiatry units in general hospitals along with some mental health and community-based outpatient facilities. Some nongovernmental organisations work with the Ministry of Health, but this is not enough for the needs of the whole country and there is a lack of accessible treatment for persons with mental health problems according to international standards. Hence, many mentally ill family members cause “additional trauma” to their relatives (Ahmad, 2017; Kovess-Masfety et al., 2021).

The mental illness of one family member likely affects the whole family and changes their life in various ways (Angermeyer & Bernert, 2006; Glozman, 2004). Most affected families feel overwhelmed by problems and may express their frustrations towards their ill family members in the form of either aggression or violence, or excessively dedicated caring. These behaviours have impacts on ill family members and relatives (Boyd, 2005).

In Afghanistan, in recent years, several studies on the prevalence of mental health problems have been conducted in different populations such as students (Ayubi & MVR, 2020; Oriya & Hilal, 2021), female workers (Oriya, 2019) and children and their caregivers (Eggerman & Panter-Brick, 2010) of persons with mental health problems. This study has a different emphasis in exploring the impact of persons with mental health problems on their family members and their ways of cooping.


  Mental Health Related to Family Members Top


Mental health problems not only affect those who suffer from mental problems, but it also affects family members who give care and support to the ill family member (Pearson, 2015; Senthil, 2017). A literature review on severe mental disorders between the years 1970 and 2000 reported that family caregivers of persons with severe mental illnesses suffered from severe stress and experienced a higher level of psychological burden and the services they received from mental health experts were not enough (Saunders, 2003). According to a World Health Organisation's survey in 19 high-, middle- and low-income countries, close relatives of persons with mental health problems reported psychological and financial burdens (Viana et al., 2013).

Focusing on the literature from Asian countries, a number of studies in Iran (which is culturally and geographically close to Afghanistan) found that long-term family care giving negatively affects the primary caregivers, their whole family and care. In addition, in the Iranian culture superstition, magic belief systems, and lack of awareness regarding mental health issues lead to stigmatisation of ill family members and caregivers. As a result, the families concerned get little social support and many caregivers experience burnout (Akbari et al., 2018; Navidian et al., 2001; Zuladel et al., 2006). Iseselo et al. (2016), citing Sscebunnya et al. (2009), confirm these findings in their study in Tanzania. Besides the lack of social support, families experience turmoil in terms of family functioning, stigma and discrimination, the turbulent behaviour of the ill family member and economic burdens. In Nepal and Zimbabwe, researchers found that caring family members were under stress and, experienced physical, mental, emotional, social and financial challenges. They sought social, religious and spiritual support to cope with the situation (Darlami et al., 2015; Marimbe et al., 2016). In India, Pakistan, Turkey and Indonesia, similar observations regarding the challenges of caregivers and their ways of coping were found (Alvi et al., 2014; Chadda, 2014; Kokurcan et al., 2015; Yunita et al., 2020). In Canada and England again, caregivers experienced similar difficulties. A significant difference between these studies and those mentioned previously was that they were able to get social support and information (Pearson, 2015; Turner-Cobb et al., 2016). Most studies agree that the major impact of a mentally ill person is on primary caregivers (Alvi et al., 2014; Pearson, 2015; Senthil, 2017).


  Methodology Top


The Research Board of the Afghan Ministry of Public Health approved the study. We used a qualitative research approach for the study (Merriam, 1998; Taylor, 2001). Data were collected using face-to-face, semi-structured interviews with caregivers of mentally ill persons in Kabul Mental Health Hospital. We used interviews to explore the emotional suffering of family members of the persons with mental health problems in a holistic manner (Ventevogel & Faiz, 2018). Before the interviews began, the informed consent form was read to the study participants, as the majority of them were unable to read. The interviews were conducted following the research main questions in Dari and Pashto and then translated into English. Notes were taken during the interview. After interviewing 24 female and 36 male relatives, data saturation was attained. Each interview lasted between 45 to 60 minutes. The interviews were conducted just before the start of the Covid pandemic in 2019.

Data were analysed using comparative analysis approach, identifying similarities and differences, extracting themes and clustering them into appropriate categories (Taylor, 2001). To optimise the validity of the findings, we asked two clinical psychologists1 to compare the study results with their clinical experience. They confirmed the credibility of the findings.


  Results Top


Our findings based on in-depth interviews exploring the emotional suffering of the family members of the persons with mental health problems are grouped into four main categories: the impact on caregiver mental, emotional and physical wellbeing; the impact on caregivers' lives; the impact on caregivers in relation to behaviour in the family; stigmatisation of families and coping strategies.

Impact on Caregiver Mental, Emotional and Physical Wellbeing

The majority of participants stated that they experience sadness, hopelessness, helplessness, bewilderment, weakness, worthlessness and shame because of their family member's illness. Many of them repeated that same sentence, “We became 'mental' and have developed problems, and all of us became irritable and nervous”. A 22-year-old woman, the daughter of a person with a mental illness, said: “I cry a lot. Sometimes I cannot breathe and think that something is stuck in my chest; I want to get out of my home and shout in a loud voice, but I only cry and don't come out of home”.

Besides emotional problems, many participants suffered from mental and physical challenges. An older mother of a young woman with mental health problem pointed to red spots on her hands and said: “When I become sad, I crunch my teeth, cry, and because of severe sadness red spots develop on my hands”. Some male participants reported that all of their family members have suffered because of caring for their ill family member. In this regard, a 14-year-old boy, the son of a person with a mental illness diagnosed with an obsessive–compulsive disorder, said: “All of us in the family felt obsessed. My mother also had this problem; my sisters and brothers do not eat food from the hands of others. We are worried that everything is dirty”. The participants of this study, men and women alike, worried about their ill family member's future, and these worries, naturally, affected their psychological wellbeing.

Impact on Caregiver Lives

Daily life, time management and the caregivers' financial situation were affected because of having a mentally ill family member. Most of the time they spent caring for their ill family member and this kept them away from their job and normal daily life. Some did not even have enough time to look after their small children. A 42-year-old father of a person with a mental health problem said: “In caring for my son, we forget ourselves, our happiness, job, relatives and daily life. For days I do not ask about my wife and other children, and I am sunken in our own future”. Similarly, a 34-year-old woman, the sister-in-law of a mentally ill woman, expressed that because of paying more attention to the ill family member to make sure that she would not harm herself, she could not look after her own children and for days they would go to school hungry.

Most of the participants – men and women alike – stated that because of their ill family members they could not visit their relatives and friends. Our study also showed that looking after the ill family member made the already poor families even poorer. Some of them even lost their jobs because of caring for a family member with a mental disorder. In addition, most of the participants stated that they are the only breadwinner of the family and that they had to look after their mentally ill family members at the same time. A 65-year-old farmer, the father of a person with a mental health problem, said: “Our economic situation is bad. I have 16 family members, my other children are young, and I am the only breadwinner in the family, and my relatives say that I should sell our house and take my son for treatment to India or Pakistan. I have one house only; with selling that, should I kill all my family members?”

A 65-year-old father said: “I spent all the money on my son's treatment, I don't pay attention to our nutrition and even spent the money for my other children's stationery to buy my son's medicine”.

Persons with mental health problems indirectly created obstacles in their relatives' education. In this regard, a 17-year-old boy said that he and his brothers could not concentrate on their school and university studies, because of their sister's continuous screaming. Some other participants were hampered by their continuous worries.

Impact on Caregivers in Relation to Behaviour in the Family

Male and female participants stated that due to caring for their ill family members, they faced undesirable behaviour in interacting with their mentally ill family member and other family members. As caregivers, they sometimes behaved aggressively themselves and then regretted it and felt remorse. Sometimes even they beat their ill family member. In this regard, a 27-year-old mother of a 8-year-old child with a mental health problem said: “When I become emotional, I beat my son who is already 'mental' or when my ill son beats his small brother or sister, I beat him and then feel regret and say to myself that he has a problem and does not know anything, why do I beat him”. Similarly, a 19-year-old boy said of his father: “When my father fights with others, I become emotional and sometimes beat my father. He also was beating me, but for me it is ok, fathers beat, now that I understood that he is sick, I regret that why I beat him”.

Some participants stated that the ill family member's behaviour made them frustrated, and felt that they had no other way than to behave aggressively with them. This led to fastening, beating, incarcerating or threatening the ill family member. A 59-year-old man, the father of a mentally ill person, said: “I said to my son that if you behave like this, you will no longer be my son. I became compelled to chain his hands and legs, and even I asked the police to give me handcuffs to tie him in the home. In the hospital, they broke the locks; sometimes we even locked him to the hospital bed”.

Stigmatisation of the Family

Stigma was experienced by participants of the study in different ways, such as social isolation, labelling, mocking, feeling shame, blaming, etc. Many participants of the study stated that their relatives do not have proper relationships with them and reduced contact with them. A 45-year-old woman, sister of a woman with mental health problem said: “Most of our relatives don't come to our house; if they come, they get humiliated and offended by my sister; they get involved in bitter and abusive speech”. Some other participants could not handle their guests, and their relatives mock them due to their ill family member's mental illness. A 45-year-old woman, mother-in-law of a woman with mental health problems, said: “People taunt us and say that you marry a sick girl, and they mock us. Our relatives come less to our house and say that our daughter-in-law has a 'Jinn'2 and they blame us for oppressing our daughter-in-law, so she became sick”.

Most participants in this study felt ashamed of having a mentally ill person in their family. They thought that their family honour was blemished, so for this reason, they hid the mentally ill family member from the eyes of their relatives and guests. A 65-year-old mother of a woman with mental health problem said: “This girl shamed us in front of our relatives; she utters abusive words and beats everyone who comes in front of her. When she says bad things in front of men of the family, we feel even more ashamed, so when guests come, we hide our daughter, but they discovered and our family honour got destroyed”. Some other participants faced sarcasm and allusions because their relatives did not understand what mental ill health meant and so they accused the person with mental health problems and the family of immorality. As a 35-year-old father said: “I feel ashamed of my relatives because of my daughter's illness. My relatives tell me that my daughter behaves immorally and accuses me about my daughter and says that she is a dishonour for us. Our people are illiterate, and they suspect my daughter becomes sick because she may love another man despite being married. Sometimes, I cannot mix with other people in public, because they think that we are sinners; sometimes I even feel like to end my life”. Other participants stated that they feel bad, ashamed and as sinners when their relatives relate having a mentally ill family member to religious issues and label them as sinners. A 35-year-old brother of someone with a mental health problem said: “Our relatives say that the whole family is mad and does not have a good upbringing, maybe they do not pray and therefore Almighty Allah gave them this penalty”.

Some participants were advised by friends and relatives to hand over their mentally ill family member to the government or to terminate the ill family member's life or put him/her in a dark room for 40 days until he or she becomes healthy because they did not believe that their mentally ill family member will be healed.

Almost all the participants in this study reported that their relatives and neighbours labelled their mentally ill family member as “being mad, mental, having bad nerves, pretending to be sick, addicted, being immoral and barbarous”. They also labelled the whole family of the person with mental health problems in inappropriate terms such as a “powdery, dizzy or sick” family. A 28-year-old brother of a person with a mental health problem with addiction problems said: “Our relatives make sarcastic remarks toward us and our mentally ill family member, no one understands us, and we always get insulted in public. Because of these problems, we feel dizzy, and people think that like my brother all of us use drugs. No one trusts us. They call us 'heroiny', powdery, theft, dishonoured, and shameless family. They don't come to our house, even no one is willing to give their daughter in marriage”. Similarly, a 42-year-old father of another addicted person said that his younger son left school because his classmates and other people labelled him with such inappropriate expressions.

Not believing the ill family member's illness was another issue that most of the study participants mentioned. A 20-year-old boy whose mother had mental health problems due to the loss of her two sons in the war, said: “When my mother fainted, people spoke behind our back and said that my mother is 'Tag'3 and intentionally faints, she is not depressed because of her sons' death, she is depressed because there will be no one to bring money to her”.


  Coping Strategies Top


The coping strategies identified in the study included positive and negative strategies in dealing with the impact of having a family member with a mental health problem.

Observing Religious Practices

Worshipping and practising customary religious traditions were the prevalent coping method for the majority of participants, especially for women. In addition to seeking medical and psychological help, they practised spiritual and religious activities as coping strategies such as praying, saying “Salawat” (praising Mohammad Peace be upon him), reciting the Holy Quran, being patient, relying on and being thankful to Almighty Allah, going to the mosque and repenting, doing “zikr” (reminiscing Allah) and “Raz, Niyaz” (sharing needs and secrets with Allah and wanting help from him), having strong faith and surrender to destiny, going to a shrine, taking “Tavez” (words, shape or pray written on paper), “doody” (paper with shapes or writings on it for smoking at home), “shoyest” (words written on paper for wetting in water and then eating), “band” (a type of Tavez) from “Mullah”, giving charity to poor people. A mother of a person with mental health problems said: “When I become upset, I go to the mosque and cry, pray for my son's health, repent for my sins and then become calm. I pray a lot, going to shrine… I took “band” from the Mullah, personally I don't believe… but my heart does not have patience”. Similarly, a 59-year-old man said: “I have strong faith in Almighty Allah, always say “zikr”, and believe that everything is from the side of Allah and everything which is in human destiny, tragedy or happiness, they will achieve that, so I am surrendering to fate”. A 15-year-old girl, the niece of a woman with mental health problems, said: “My grandfather gives more charity to needy people, makes more Quran recitations, and prays to seek Allah's mercy until their daughter become healthy”. Similarly, a 27-year-old brother of a person with mental health problem said: “My mother goes to Mullahs. There is no Mullah in Kunduz, Badakhshan and Takhar provinces that we have not gone to… we get all the things from Mullahs, “doody, shoyest, Tavez” for his health. Even though our financial status is not good, despite that my mother gives more charity until my brother becomes healthy. Once she even borrowed money to buy a sheep and give it for charity to people”.

In some cases, men and women perceived their family member's mental illness as a punishment of Almighty Allah and said: “We did not do any harm to anyone and we are not cruel, so why this illness comes over us?” A 35-year-old mother of a girl with mental health problem said: “I think, that maybe, I was not grateful enough in life and the disease of my child is Allah's wrath”.

Hope and Acceptance

Hoping for a better future and the health of the ill family member was another coping method practised by most participants. Most of the interviewees, despite the deterioration of their ill family member's disease and their complaints about treatment possibilities, continued hoping for a better future and healing. Most of them repeated the following sentences: “Allah is kind, I am not hopeless, we are hopeful that our ill family member becomes healthy…” A few were disappointed and had lost their hope and thought that their situation would not change. Some participants accepted the situation and said that with proper caring and paying attention to the needs of their mentally ill family members they tried to feel calm.

Sharing Problems

Another frequent coping method used mostly by women in this study was sharing problems. This took the form of crying, expressing unpleasant sorrow and grief, narrating, sharing the pain they felt in their heart and speaking about problems. A sister-in-law of a woman with a mental health problem, said: “In the home, we gathered and told each other that we should not be upset anymore, otherwise we will also develop mental problems. It is from the side of Allah. We say that Allah is kind, and Allah will heal her. Here in the hospital I also sit with other caregivers and speak with them and this makes me feel better”.

However, unlike female participants, most of the male participants chose not to share their problems, especially in front of their family members. A 52-year-old said: “I think a lot about my daughter's problem, even in my job I think how her future will be if she does not heal. I don't share my problem even with my brother and close friends when problems remain with me, I become dizzy”. A 17-year-old boy, the brother of a person with a mental health problem who came to the hospital from another province, said: “In our province, there are lots of small mountains and hills, I go there and scream in a loud voice… loud screaming makes me calm, and then when I come at home, I encourage my family to be strong”.

Taking Time for Recreation

Going outside for amusement, spending time with children and friends, enjoying sports, driving, riding a bicycle, reading, supporting family members, watching TV, being alone for some time, going to gardens and parks, arranging parties on different occasions were common coping methods for men. Similarly, some male participants said that they receive good social support from their friends, and this helps them to cope better with problems. Some women also used constructive methods such as watching TV, giving consolation to themselves, keeping themselves busy with chores, visiting close relatives, especially parents, sports and sitting near flowers in the garden. One woman said: “I go to the garden near my house and sit near the flowers and then my heart becomes happy”.

Dealing with Aggressive Behaviour and Feeling Remorse

Self-blaming and feeling guilty was the prevalent coping method in women participants in this study. They blamed themselves, family members and those with mental health problems in their families in order to cope better with the problem. A mother said: “I blame myself for having married my daughter to my sister's son. My daughter was not agreeing … but I said that she will go to my sister's house and maybe she will have a good life, but she became sick”. Also, this woman and her husband blamed their daughter for not looking after her family properly. Self-beating as a way of coping was used by some other participants. A 22-year-old girl daughter of a person with mental health problem narrated: “For being calm, I beat myself, cry a lot and express my sorrow…. Then I become a little bit calm…, but again return to my first state of pain”.

Fighting and behaving violently with other family members was another prevalent way of coping for many participants, especially men. Some fought with and blamed the mentally ill family member and occasionally beat them. Some were also aware that they behaved aggressively towards other family members to calm down themselves.

Findings Ways to Protect Oneself

Defensive behaviour in interactions with others and not caring about what people say was another coping method used by some participants. Others used denial as a way of coping. A 54-year-old father said: “People are asking about my daughter's illness…. in what situation my daughter would be, I say to them that she is ok”.

Some participants were stuck and frustrated with their problems, due to a lack of awareness related to mental health problems. Therefore, they had no effective coping strategies. Instead, they had dark and vague visions about their mentally ill family member's future. In this regard, a 75-year-old father said: “In these 13 years of my son's illness, there was no doctor to whom I did not bring my son. I went to Mullahs and got “Tavez”, and I pray a lot. But sometimes I think about ending my life and burn myself and my son”. Similarly, some participants felt unable to cope and were ashamed and uncomfortable because of their ill family member's illness. Some did not want other people to become aware of their family member's mental illness, so they hid their feelings.

Some participants felt threatened. Some felt hopeless and helpless in coping with the problem, and they experienced a kind of mental paralysis. As a 19 year-old daughter said: “Our mentally ill family member has made us angry, she made my father nervous, I always cry because of her behaviour, my father also has mental problems because of her illness, and we don't know what to do”. Other participants felt frustrated and said: “We are agreeing on our ill family member's death, we wish that Allah gives him death and we become free”. Some felt helplessness, due to lack of proper medical and psychological services in the country and stated that “we become disappointed because there is no good treatment… we go from one hospital to another, why does our government do not pay attention”?


  Discussion Top


The findings of the present study show that the illness of a family member with mental health problems affects every aspect of the caregiver's wellbeing and worries about their own and their ill family member's future increase their suffering. This is consistent with Koschorke et al. (2017) and Senthil (2017) in India and Pearson (2015) in Canada which indicate that the mental illness of a family member could affect the health of others in serious ways. Some parts of the present study are also in harmony with the Polish study by Hadrys et al. (2011) that identified worries about the ill family member's future in other family members.

On the one hand, it may seem surprising that the way the mental illness of a relative affects the rest of the family is comparable between Afghanistan, India, Canada, Poland and other countries. However, at the same time, it seems that having a loved one who is suffering from an inexplicable mental health issue is so distressing that it touches caregivers and the rest of the family at a personal level beyond cultural norms that it becomes a universal phenomenon.

This study found that the daily life, family economics and education of the participants were affected by their mentally ill family members. These findings are in line with Koschorke et al. (2017) in India, Van der Sanden et al. (2014) in 19 countries of the world, and Viana et al. (2013) in The Netherlands. They all found that the families of mentally ill persons experienced social and time constraints and financial burdens. Hadrys et al. (2011) mentioned especially the financial burden and Chadda (2014) described how children of families with a mentally ill family member in India could not concentrate on their studies.

The reason behind the similarities of these findings may be that caring for the mentally ill family members requires more energy and time that it does not allow caregivers to interact with other family members and that it imposes a huge burden on them regardless of where they live.

Another finding of the present study is that persons with mental health illness affect the behaviour of family members in undesirable ways, which is in line with findings by Van der Sanden et al. (2014), Senthil (2017) and Pearson (2015). Participants in their studies also reported frequent conflicts within families, but there was no aggression towards the ill family member or themselves.

As was shown above, caring for a mentally ill relative may imply that the needs of main caregivers remain largely unmet. This means that in addition to the primary long-term stress they suffer from, they have less opportunity to cope in a constructive way. Furthermore, most Afghan families have less information about mental illness and persons with mental health problems. This gives way to numerous distressing assumptions and beliefs, regarding why a person gets a mental illness. Mental hospitals do not adequately educate relatives in constructive ways of dealing with family members who are ill and how to cope with situations that arise. In addition, the Afghan people have been living with armed conflicts. This may explain, in part, why many do not know how one can peacefully negotiate conflicts, find a way of living at peace with themselves and even less so with a mentally ill relative. This may be an essential difference with other studies which found no aggressive or self-destructive behaviour in relatives.

Stigmatisation and being blamed for having a mentally ill relative were another finding that is in line with other studies from Iran (Akbari et al., 2018), Tanzania (Iseselo et al., 2016) and Israel (Miller et al., 2013). This may be accounted for by low mental health awareness in these countries, especially in Iran with a similar culture to Afghanistan. In Afghanistan like in Iran, social stigmatisation goes along with low social support (Akbari et al., 2018).

The participants of this study used different cultural, religious and spiritual coping strategies. A few families found relief by accepting and sharing their problems. These findings reflect others from India (Chadda, 2014) and Africa (Iseselo et al., 2016; Nxumalo & Mchunu, 2017). Another key finding of the present study was the difference in coping strategies of men and women. Men were hiding their problems and feelings and women were keener to talk about their problems, but both men and women were using different cultural and spiritual coping strategies, and both had to hope for a better future. As Eggerman and Panter-Brick (2010) found, hope and resilience are the primary cultural values that give order and promise to life. Also, the present study findings related to the use of cultural, religious and spiritual coping strategies are completely in line with the need assessment reports of the International Medical Corps in four provinces of Afghanistan which is related to acceptance and tolerance, going to shrines, sightseeing and giving charity (International Medical Corps, 2021).


  Limitations Top


The present study faced some limitations:

  • The lack of national research on the problems of families with mental health persons
  • The difficulty of participants in understanding and expressing their feelings
  • The teaching responsibilities of the primary researcher meant it took longer to complete data collection and analysis.



  Conclusion Top


Results show that relatives of persons with mental health problems are stressed under the burden of caregiving. In addition, they suffered from multiple daily life stressors such as poverty, unemployment, violence and family problems. This greatly affected their psychological wellbeing, emotional stability and potential to cope effectively. The findings revealed that mental health literacy in Afghan society is very low, so because of lack of awareness, they tend to relate such phenomena to magic or moral issues. The results of this study give rise to the assumption that the caregivers do not have a proper understanding of their own condition. With the high level of distress the caregivers experienced, it could be argued that they need equal, though different, extents of caring attention to their ill family members. This study also indicated the need to strengthen resiliency, care and support mechanisms within the families which represents a good culturally relevant intervention in the practice of mental health work in the country, reflecting the work by Trani and Bakhsh (2013) and Ventevogel et al. (2012) in strengthening psychosocial elements in the Afghan health-care system.

Acknowledgments

We thank Silvia Kaeppeli, Ph.D., former director of the Centre for Nursing Research and Development, University Hospital Zurich, Switzerland, who helped with the qualitative analysis, Zaher Wahab, Ph.D., Professor, Lewis and Clark College, Oregon, and Dr. Ghulam H. Saadat, Senior Research Fellow, John H. Stronger Hospital of Cook County, Chicago for editing the article before sending it to the Journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

1Both psychologists (Dr Sayed Jafer Ahmadi and Sayed Rohullah Rizwani), have counselling centres in Kabul and they work with Afghans and have a clear knowledge of the Afghan context.

2According to Muslim's beliefs, “jinn” is a spirit that can be enter human's body and can influence the humans.

3”Tag” (pretending to be sick).







 
  References Top

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2.
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Abstract
Introduction
Mental Health Re...
Methodology
Results
Coping Strategies
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