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The mental health of people who have worked in Afghanistan since 2003

Over recent weeks there has understandably been a huge amount of media coverage of the situation in Afghanistan. This has focused on the threats faced by the Afghan people in the wake of the Taliban resurgence and the stark changes to their way of life. There is no doubt that Afghanistan’s future is uncertain and only time will tell how the situation will evolve.

However, we should not forget that over the last twenty or so years, many non-Afghans have been heavily involved in trying to de-risk the security implications of Afghanistan’s previous state support for terrorist organisations and, equally as importantly, trying to improve the lives of the country’s war-torn population. These Non-Afghan Workers include military personnel, diplomatic staff, media professionals and aid workers to name but a few.

I am a professor of Defence Mental Health based at King’s College London. I served in the United Kingdom Armed Forces for more than 23 years and was deployed, as a psychiatrist and researcher, to a number of hostile environments including Afghanistan and Iraq. I am not an expert in Afghanistan, but I have been there and understand how complex an environment it was.

Recent developments since military withdrawals in Afghanistan may have left some Non-Afghan Workers asking themselves “My colleagues and I risked our lives, what was it all for?” or similar questions relating to sacrifices they, their colleagues, and families made during and after their deployments to Afghanistan. Non-Afghan Workers, often deployed for lengthy periods of time, were exposed to risks to their life and wellbeing as well as seeing, and working, with Afghans who lived in terribly deprived conditions.

These personnel may also fear reprisals against those who assisted them during the war with whom they had often built up trusting relationships and, in some cases, would have developed friendships with.

Most Non-Afghan Workers would have strongly valued the work they did and there is evidence that work which has a positive and meaningful purpose is likely to promote good mental health. There is now the potential for some to perceive that their efforts may have been futile given the return of the Taliban to power.

The possibility that Non-Afghan Workers may feel distressed that they have ‘abandoned’ Afghanistan can be understood in the context of appraisals that people make about their experiences. This topic very much falls under the umbrella of what has been termed ‘moral injury’ which describes the strong emotional and cognitive reactions that people can experience as a result of actions that breach their own moral or ethical code.

Unsurprisingly, being exposed to morally challenging situations can lead to significant feelings of guilt, shame, disgust or anger. Although the usefulness of the moral injury construct is debated by some, the growing evidence base shows that it is associated with PTSD, depression, and suicidality.

Unfortunately, media coverage of the withdrawal can exacerbate mental health issues in those who worked in, and for, Afghanistan. For instance, many stories have emerged in the international media of the “wasted years” in Afghanistan.

This sort of language may increase the likelihood that some Non-Afghan Workers will develop moral injuries and thereby compound depression and PTSD. Those who comment publicly on the situation in Afghanistan should ensure that messages to media emphasize the merits of the international support to Afghanistan deployments such as the lives saved and improved as a result of the support.

For example, in the wake of the withdrawal the NATO Secretary-General Jens Stoltenberg noted that “Due to our military presence and the support of the international community, a new generation of men and women have grown up in a new Afghanistan. Able to get an education, take part in the political process, run their own businesses… Today’s Afghanistan is very different to the Afghanistan of 2001. So those gains cannot be easily reversed”.

Whilst it is somewhat inevitable that the media will focus on what has not worked, a balanced view is likely to help protect mental health. Furthermore, no one can accurately predict the future despite the media rhetoric that Afghanistan is doomed which can so easily adversely influence the mental health of Non-Afghan Workers.

Awareness of the potential psychological fallout of the situation in Afghanistan has implications both for employers of Non-Afghan Workers and clinicians who interact with them.

Employers of Non-Afghan Workers are likely to have focused efforts on getting staff out of Afghanistan before the closure of Kabul airport, but having done so they need to consider their ongoing duty of care towards them. Just as the NHS, and other key worker employers, have had to take account of how the Covid-19 pandemic may impact the mental health of staff so should Non-Afghan Worker employers take reasonable precautions to monitor staff and ensure that managers actively ask these workers about their wellbeing. Those who appear to be experiencing distress symptoms related to the current situation should be supported, and where that does not help resolve the situation, they should be helped to access professional support in a timely manner.

Clinicians who provide care for Non-Afghan Workers should also be attentive to concerns about the current situation in Afghanistan in those they provide care for. These individuals may experience a new-onset mental health problem, or a worsening of a pre-existing condition, because of the guilt, shame, disgust or anger about the situation especially in relation to their perception that ‘it was all for nothing’ or that their prior allies in Afghanistan are not being properly protected.

There is good evidence that treatment approaches which address appraisals regarding guilt, shame, and regrets in military personnel may be helpful. These approaches should focus on separating one’s actions and their outcomes or one’s intentions, from the eventual outcome of the conflict. The tendency to interpret the withdrawal as proof that it was all futile and my efforts were for nothing should be countered with discussion that a Non-Afghan worker did their duty, helped as much as they could, and their efforts may have still had positive impacts and outcomes for Afghans.

Overall, the recent events in Afghanistan are likely to have mental health impact for many people. Most of these psychological reactions are likely to be short-lived; however, some may develop a moral injury or indeed a formal mental health disorder.

It has been encouraging that many international leaders have voiced recognition of the positive aspects of support provided to Afghanistan over the last twenty or so years. Balanced messages about the impact of that support need to be echoed in the months ahead regardless of whatever unfolds in Afghanistan.

Employers and clinicians also need to remain aware of the potential for the recent events in Afghanistan to cause intense distress and ensure that they take proactive measures to protect people’s mental health in the months and years ahead.


Editors Note: We, at Inspire the Mind, are proud to continue to provide a platform and an opportunity for those affected by the events in Afghanistan to share their stories. You can read more at the following: DURING THE LAST 20 YEARS, WOMEN HAD BECOME MUCH MORE CONFIDENT IN AFGHANISTAN, BUT EVERYTHING HAS CHANGED THIS WEEK THE PERIL AND PLIGHT OF AFGHAN WOMEN NEEDING TO ESCAPE: THE MOSAIC EDGES OF AN AFGHANISTAN IN TRAUMA THE GROWING MENTAL HEALTH CRISIS IN AFGHANISTAN


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