The stigma attached to mental illnesses in society is probably the single most difficult hurdle in diagnosing and treating mental health problems. Mental health patients in all cultures and corners of the world face cruel prejudice and discrimination, regardless of how wealthy or educated a community is. The stigma, myths and misconceptions surrounding mental illness are the root cause of much of the discrimination experienced by people with mental disabilities (Baldwin and Marcus, 2011). Moreover, “people with mental illness are robbed of the opportunities that define a quality life: good jobs, safe housing, satisfactory health care, and affiliation with a diverse group of people.” 
In countries like Afghanistan, where the healthcare system is poor, the provision of mental healthcare services is neglected the most, and mental health patients suffer. Mental health stigma throws major obstacles throughout a patient’s journey. The misconceptions associated with mental health symptoms, mean that many patients never get a diagnosis, and continue to suffer cruel and inhuman practices.
While there is some ongoing work to improve the mental health service in Afghanistan, we believe the major social obstacle in achieving an improved mental health situation in the country is the stigma associated with mental health, and the discrimination, prejudice, and inequality that result from it. As such, work to improve mental health services should include efforts to changing social perception.
During this Discourse Hour session we tried to identify some of the causes of mental health stigma, and discussed ways to discredit the phenomenon.
1- What are some of the most stigmatizing beliefs about mental health illnesses, and how do they hinder access to mental healthcare services?
The participants believed that in Afghanistan patients with neurotic disorders, or functional mental illnesses like depression, stress, Post Traumatic Stress Disorder (PTSD), anxiety, etc, which make up the majority of mental illnesses, suffer in silence. Most of the mental illness stigma in Afghanistan is projected on patients with psychotic mental illnesses like Schizophrenia, Bipolar Affective Disorder, etc, whose behavioral symptoms are more apparent to other people.
In some rural areas, where education rates are low, psychotic mental illnesses are not recognized as a medical problem, and thus are dealt with in traditional and non-medical ways, which are often cruel and inhumane. People believe that psychotic people are under the influence of supernatural forces, locally described as “Perian” or “Jens”. Patients that exhibit psychotic behaviors like delusions, hallucinations, self-neglect and other such behavioral symptoms reinforce people’s beliefs about the causes of these illnesses – that is, that they are possessed by some supernatural entity.
They are often sent to be treated or cured by local Mullahs and herbalists, and traditional practitioners who lack basic medical knowledge of mental illness. In some cases, it has resulted in tragic consequences for people with psychotic illnesses.
Individuals with psychotic mental health disorders tend to have a poor insight into their illness, and so are unable to explain their condition or to resist the mistreatment that they are subjected to. In some cases a patient’s hallucinations result in threatening behavior towards the public, and such behaviors reinforce public belief that mental illnesses are actually the “influence of evil powers”, and consequently these patients are subjected to inhumane treatments.
In many cases, individuals with severe psychotic illnesses are taken to shrines or Ziarats, and are chained there for months or even years. Hygiene issues, starvation, and physical illnesses and infections frequently result in a distressing and early death for these patients. The “Mia Ali Saib Ziarat” is one such shrines in Nangrahar province where dozens of mental health patients are left to the mercy of the caretakers of the shrine, who often receive financial gains from the families of these patients.
A lack of education is often blamed for many of our misfortunes in Afghanistan, and rightly so. When it comes to the understanding of mental illnesses, it is quite clear that nation’s knowledge of what mental illness is and how it should be dealt with is frighteningly poor – not only among the public, but also among healthcare professionals. At the discussion participants shared examples where doctors have referred mental health patients to traditional and religious institutions for help – which is not only a testament to their limited knowledge, but also reflects a lack of resources required to treat this group of patients. Moreover, limited inpatient treatment facilities, and absent community care for mental health patients have made it easy to perpetuate stigmatization of these patients in society.
The other factor that indirectly contributes to the maintenance of mental health stigma is the association of mental illness to the use and abuse of illicit drugs. Addictions and dependence to illicit drugs like opium and marjuana are not only the cause of many mental illnesses, but also responsible for a large portion of stigma and prejudice towards these patients. It is often believed in society that all or most mental illnesses are the result of illicit drug use, and that the patients are to blame for their plight, and therefore deserve little sympathy.
2- How can we discredit these misconceptions, and destigmatise mental health illnesses in order to enhance mental health status of the society in Afghanistan?
The discussion participants unanimously believed that in order to address the problem of mental health stigma and prejudice, with the aim of improving society’s mental health, a multi-faceted approach is required on all levels. The public, the government, healthcare professionals and institutions, and the media should all play a role in achieving this goal.
The government may need to join forces with media outlets to devise public and professional awareness campaigns to inform the nation about mental health illnesses and its management. The aim should be to medicalise mental health illnesses, and treat patients where they should be treated – in a healthcare facility and by a capable medical doctor. This requires firm steps not only to enhance mental healthcare provision but must also include adequate mental health training for undergraduate and postgraduate professionals in the medical field.
Public awareness campaigns will prove to be effective in detaching the stigma surrounding mental health. Media avenues, such as TV, radio and posters should be leveraged. In doing so, particular care should be taken to use appropriate language and imagery, such that it is sensitive and incites empathy and compassion.
The experience has shown elsewhere in the world that the use of prejudicial and insensitive language makes mental health services less approachable. In Afghanistan some of the terminology used in relation to mental health patients is not only insensitive, but also insulting and degrading.
Once effective public awareness campaigns are run for long enough, then it would be appropriate for the government to consider necessary legislation to criminalize prejudice against mental health patients. Such legislation would protect mental health patients from all forms of abuse, from domestic abuse to discrimination in the workplace. Ensuring equality and equity in mental health provision will also be important in discrediting mental health stigma and stereotypes.
In the end it is only effective, evidence-based mental health management and follow-up that can pave the way for a society that is open, safe, and caring of patients with mental health disorders.
- Corrigan PW, Watson AC. Understanding the impact of Stigma on people with mental illness. World Psychiatry. 2002 Feb; 1(1): 16–\
- Davey G C L. Mental Health and Stigma. Available on line athttps://www.psychologytoday.com/blog/why-we-worry/201308/mental-health-stigma
- WHO-AIMS REPORT ON MENTAL HEALTH SYSTEM IN AFGHANISTAN: A report of the assessment of the mental health system in Afghanistan using the World Health Organization – Assessment Instrument for Mental Health Systems (WHO-AIMS). Available on line athttp://www.who.int/mental_health/evidence/Afghanistan_WHO_AIMS_Report.pdf
- Enayat Q. Integration of a collaborative mental health care in primary care in Afghanistan. Discourse Afghanian. Available on line at http://discourse.apn.af/integration-collaborative-mental-health-care-primary-care-afghanist