While potentially not capturing all relevant studies, a disproportionate gap in the literature is identified in that currently, publicly available research on trauma-focused interventions validated for or specifically tailored to displaced AW are almost entirely lacking, with the exception of first-line programming or other “low intensity” (30, 31) interventions. Those interventions that have been assessed for suitability for Afghans have been studied primarily with male participants [e.g., (31–34)], who inhabit a separate sphere of social expectations and constraints (35) within Afghan society. The limited literature focusing on females therefore constrains the theoretical grounding from which researchers can draw in order to develop evidence-based interventions able to meet the needs of displaced AW.

Tribe, region of origin, individual family dynamics, as well as socioeconomics and related educational levels all play an extensive role in the degree to which AW are subjected to patriarchal constraints and limited social and spatial mobility (36). In terms of education, while low relative to the overall population and very low compared to international standards, the number of women graduating from tertiary education in Afghanistan during the years of 2016–2020 (Table 1) was nonnegligible (37, 38). Furthermore, Afghanistan has traditionally been highly pluralistic (18, 20, 39, 40), and political opinions within the country therefore differ. As socioeconomic levels can often have significant impact on a person's outlook and life outcomes (41), conceptualizations of women's rights within families of higher educational attainment may vary, often differing from the prevailing norms (42, 43).

Indeed, despite the well-documented restrictions on women's education in Afghanistan, some families support the education of their female members (44), and many Afghan activists, both male and female, have risked their lives to advance equitable access to justice and education (45–47), revealing a country with a greater diversity of ideological orientations than popular discourse might suggest. As identity is multifactorial, and as attitudes on education vary, scholars and clinicians are urged to avoid making unverified assumptions (48–50).

Indeed, the divide between the experiences of women with high educational attainment and those with little or no schooling is stark enough that Shin, et al. (51) propose that “specific support and interventions are needed for two risk groups in Afghanistan: women with many years of education, and women with no education.” This consideration is also reinforced by the findings of clinicians working with clients from Arabic-speaking countries, since “educational level is traditionally one of the central variables to control in neuropsychology” (41).

Still, while educated women may theoretically have better access to social resources upon resettlement than their less educated counterparts, the difficulties facing most AW, even those from families of relatively higher socio-economic status, should not be minimized, since most would still endorse significant life challenges and gender-based concerns (39, 42). Therefore, to better sensitize practitioners to the wide range of obstacles that AW face, this article maintains an enhanced focus on those originating from family systems where access to education and other social resources has been encumbered due to social constraints, including GBV and familial violence (FV).

The individualistic freedoms that inform Western concepts of human rights are often used as a barometer for gauging societal health (52); however, setting aside arguments of individualism vs. collectivism with reference to rights, women worldwide face numerous challenges to achieving gender equity beyond the restriction of their personal autonomy (53, 54). Still, by most human rights standards, as well as by international consensus, Afghanistan has very poor accountability in the protection of women and minorities, despite language to this effect in the constitution and updated penal codes (55–57).

Numerous scholars [e.g., (36, 55, 58)] have explored AW's understandings around the implications of both patriarchy and poverty on their lives, and in particular, on their access to social and material resources. Often highlighted is how the social attitudes that enable these oppressive patterns are in direct contradiction to the Afghan constitution and the rhetoric of the Karzai regime² around the improvement of women's status in the region, as well as related laws aiming to present an image of a previously globalizing Afghanistan.

Public discourse on women's rights in pre-2021 Afghanistan was highly constrained, since authorities were largely reticent to engage in sustained, public, and collective action that would lift the stigma around discussing the violation of women's rights and bodies (8), as well as the reporting of gender-based crimes (56). Moreover, since crimes implicating a woman's honor could have repercussions for the family's reputation and even safety (44), bottom-up pressure on the government had been slow to arise, and when present, had been further compromised by the meddling of government officials and aristocrats (8, 56).

Add to this social imbalance protracted conflict, whether between warring domestic factions or foreign powers, and the likelihood for an Afghan woman to emerge from her social context without some major risk factor for psychological distress becomes distant; however, scholars argue that care needs to be taken to avoid further othering women by oversimplifying their suffering or minimizing their agency given that their narratives have become “rhetorically useful,” (8) already repeatedly co-opted to legitimize dramatic political shifts (8, 21, 58).

Worldwide political instability is liable to lead to an increasing number of displaced persons, many of whom will contend with the impacts of trauma sequelae (60); Furthermore, crises may also have ongoing impacts on subsequent generations. Schaal, et al. (61) use the case of the Rwandan genocide to examine intergenerational post-traumatic stress disorder (PTSD) in countries with longstanding conflict, including Afghanistan. Their work on Rwanda reveals a conflict that eradicated more than 10% of the country's population and that left only 8% of households without the loss of a family member by “violent death.” They found that cumulative stressors and poor physical health were the strongest predictors of a PTSD diagnosis among Rwandans, who, like Afghans attempting to recover from chronic wartime trauma, may struggle with issues of complex grief.

While Afghanistan has not suffered a genocide on the scale of the Rwandan genocide (the slower-paced trend of minority persecution notwithstanding) (1), both societies share similar societal scars in that almost every household has been touched by "violent death” and that for years, the social and physical environments were characterized by unremitting chaos and fear (61). The conflicts in Afghanistan also left many orphans and widows assuming roles as heads of household within a distinctly patriarchal system, with Omidian and Miller (21) noting that 37% of the women they surveyed in the early 2000s were widows, while none of the men surveyed were widowers.

The violence inflicted on Afghan society, whether by domestic forces or foreign powers, has the distinct potential to create lingering inter-generational trauma (62). Moreover, it has led to forcible displacement and community disruption through social reorganization (61, 63), and cycles of distress are perpetuated in large part by the fact that caregiver MH is correlated with negative MH outcomes in children and adolescents (64, 65). In light of this most recent emergency, Qamar et al. (66) have declared the trauma potential on Afghan children as “an impending catastrophe,” a sentiment supported by a prior school-based study, which found that even by 2006, in certain areas of the country, one in ten children had lost one or both parents (65).

Turning to the domestic sphere, the situation of AW is not wholly unique in the world, since women are subject to disproportionate levels of systemic, intimate partner, and familial violence as compared to men, with one in three women globally having been subjected to violence (67). While women in other Islamic contexts (e.g., Iraq and Syria) may be said to face similar challenges (68, 69), the Afghan milieu has a unique combination of social, geopolitical, and tribally influenced religious interpretations (70) that maintain an elevated potential for adverse health outcomes among women. Not least among these factors are the length of military occupation and complete foreign dominance over national systems, which, from the time of Soviet occupation onwards, have fomented social volatility (21). Additionally, women in general have been observed to have poorer MH outcomes from displacement than men (71).

Rasmussen et al. observe that gender greatly circumscribes experiences in Afghanistan since “men and women inhabit different social and emotional spaces… with downstream implications for psychosocial and physiological well-being.” Though some women may well lead fulfilling lives, far more would describe some variety of imbalance between the genders, regardless of whether it is framed in familial, political, social, spatial, or religious terms (36). FV, including IPV, impacts a disproportionately high number of AW.³ Though natal families can sometimes confer protection from gender-based abuses (73, 42), married Afghan women may be mistreated not only by their husbands, but also by their in-laws in manners similar to those observed in other Central Asian and subcontinental regions (74, 75), as well as in various areas of the broader Middle East (76, 77). Women who do not wish to conform to the obligations imposed on them have little social or legal recourse, as laws against FV are not consistently enforced, and since household conflict is typically viewed as a private, domestic matter in which it would be shameful for outside parties to intervene. This heightened perception of FV as a private matter is seen in a variety of low-income countries and is rendered more complex due to a broader understanding of kin relationships (55, 78, 79).

Intimate partner violence (IPV) specifically poses challenges in Afghan communities, with Metheny and Stephenson (57) finding that the “acceptability of IPV in Afghanistan is widespread, with 80% of women and 72% of men in the 2015 [Afghanistan Demographic and Health Survey] agreeing physical IPV is justified.” There has also been a near-direct connection of FV to the economic insecurity and feelings of financial powerlessness experienced by males struggling to maintain ever-scarce employment, and feelings of inadequacy may subsequently be displaced onto female relatives (36, 55). Often exacerbated by substance dependence (80), multiple risk factors have rendered a generation of Afghan men increasingly incapacitated, leaving women to assume greater responsibilities. As a result of these economic hardships, many Afghan women engage in significant amounts of domestic labor, while also engaging in some form of income generation, though these activities are frequently limited in scope to preserve their dignity as married women (36, 55). Moreover, the gendered agendas of foreign intervention have added to the friction between the male and female spheres (45, 81) in manners reminiscent of the “continuums of violence” described by Yadav et al. (82).

All of these factors combine to create a highly volatile environment in which women must negotiate numerous expectations. Given the weight of expectations placed on them, many women feel resigned to their roles, even if they think these dynamics unjust (36). Many also perceive their struggles to be intractable (83) and feelings of helplessness and anger were further ingrained by inadequate and complicit lack of policing, as well as the lack of enforcement of protections for women (36, 55, 57, 84). The intersection of low educational attainment and female sex can thus lead to high psychological and physical morbidity in Afghanistan (42, 85). Women, especially those situated in the more resource-scarce tribal regions, are often born into poverty and restricted to minimal, if any, schooling, and many are married quite young with the intention of protecting them multiple outside dangers, economic insecurities, or perceived threats to family honor (86).

While not all AW endorse MH consequences stemming from these adversities, a great number of women from a variety of backgrounds would (36, 55), and many women who have experienced conflict trauma and displacement, might cite their daily stressors as being more significant (21, 24, 28, 42, 87, 88). This is supported throughout the broader displacement MH literature (DMHL) which posits that the trauma symptoms that many resettled women face could be ascribed more to ongoing stressors than to acute conflict exposure (89). In displacement contexts, this is due in part to continuous upheaval in the host environment (48), creating a “permanent state of emergency” (90). Therefore, chronic distress, poverty, isolation, lack of access to medical care or legal services, and lack of stable food and water may act syndemically within an environment in which women's roles are already highly constrained (29, 57, 65, 85, 91, 92).

Currently, the literature on clinical approaches for working with Afghans is seriously lacking (51), and, at times, contradictory. Most conspicuous is the absence of rigorous, evidence-based and trauma-focused interventions appropriate and specifically designed for their psychosocial needs. Firstly, PTSD as defined by the DSM (136), has been said to have good construct validity in that it aligns with the symptom clusters reported by Afghans having experienced trauma, and in that it has a positive, yet “modest” correlation with war-time events (137); however, it has been postulated that it has poor clinical utility (137, 138). As Miller et al. note, “traumatic stress was marginally more highly correlated with depression, and significantly more highly correlated with generally [sic] distress, than it was with PTSD.” They also observe that “… cumulative lifetime challenges lead to sadness being among the most salient experiences in high-conflict environments.” (137)

Clinical assessments with Afghans may also be affected by “‘gender-appropriate’ expressions of emotion” (137), and some individuals may feel that divulging too much of their experiences might burden others suffering from similar issues, while for others, concerns of modesty may restrict disclosure to clinicians (29, 139, 140). Therefore, women often turn to confidants within their social circle, including the approximately 20% of women who seek support for IPV by consulting with extended family (28, 29, 57, 137). To this end, Ahmad, et al. (141) note, “The high prevalence of PTSD, its association with social support and self-rated health are important issues to be considered for refugee resettlement programs.” They also add that this communal orientation might be particularly true of client systems that “originate from communities with strong social bonds and ‘collectivist’ values” (141). In terms of other coping strategies, studies have found high numbers of respondents attesting that their greatest comfort lies in religion, while other studies demonstrate that women from Islamic contexts may attribute their trials the supernatural (24, 29, 51, 106, 138, 142–144).

With reference to applicable interventions, there exist benign approaches designed for emergency contexts, but which are malleable enough for adaptation to specific populations. Among the more well-known of these is the World Health Organizations' Problem Management Plus (PM+), which can be adapted for individuals or groups (145–147); however, a limitation of this and similar formats is that sustained intervention is rarely feasible in camps or other settings with severe challenges. Therefore, approaches such as the PM+ do not target the trauma itself to any great degree and instead focus mainly on quickly building problem management skills and self-regulation techniques to better manage feelings of overwhelm (30, 147). Nevertheless, scholars such as Knefel et al. (133) support adaptations of the PM+ for Afghans, with Knefel et al. finding that the model is positively received by MH professionals. Importantly, though, several of the clinicians in their study reported that they found the intervention too limiting and that those “with more work experience with refugees were less likely to use the interventions than those with less experience” (133). Models of this sort might therefore serve more as introductory training for clinicians rather than robust, stand-alone treatments. Still, the perspectives afforded by the PM+ and similar systems could help supplement more intensive trauma-focused therapies.

As for preferred intervention formats, displaced persons expressed appreciation for group-based models in a study by Mitschke et al. (148). Other studies have investigated modalities falling outside of the standard dyadic talk-therapy format with Afghans^5,6 [e.g., (31–34, 134, 135, 149)]. Various works by Kananian and colleagues, for example, provide an insightful overview of trauma-informed approaches for working with resettled Afghan and Iranian males in group settings. In addition to employing some of Hinton's work on Culturally Adapted Cognitive Behavioral Therapy (150), Kananian et al's collective works (31–33)⁷ are noteworthy for: delivery of services in the target language; the articulation of MH concepts in a manner congruent with participants' conceptualizations of health; the centrality of somatic concerns to the project; sensitivity to TTV history; the consideration of logistical challenges (which they reduced through schedule optimization); an emphasis on client psychoeducation; and the real-time incorporation of client feedback.

In other work, Droždek, et al. (34) conducted a ten-year study on a program for Iranian as well as Afghan refugees and asylum seekers who had survived torture and had been resettled in the Netherlands. The participants were enrolled in trauma-focused group therapy administered within several different intensive day program regimens. The study compared the efficacy of different treatment intensities between the various groups, as measured by the number of weekly sessions. The major findings of the work were that intensive, yet less expensive day treatment programs decreased symptoms greatly as compared to the control group, and that “more intensive and expensive inpatient treatments are not necessarily more efficacious than the less expensive day hospital alternatives” (34). These findings are reinforced by a study with non-Afghan refugees that observes that participants preferred more frequent outpatient group sessions to meet their needs (148).

Importantly, Droždek et al. (34) found that exposure to others' trauma histories within a group setting was not found to have any harmful effect despite the concern about secondary traumatization, nor did it cause any group members to drop out, since, as the authors speculate, the universality of these narratives among the members appeared to create social cohesion (34). The importance of community may also be reflected in the work of Griner and Smith (152), who concluded that “MH programs targeting culturally homogenous client groups were four times more effective than those targeting culturally heterogeneous client groups” (152). Though it offers an interesting perspective, a limitation of Droždek et al.'s work is the inclusion of only men, since the intersectionality of women's experiences (21, 24) may require specific attention. This is particularly salient for widows, who have been reported as having the highest levels of stress within Afghan society (24).

In other interventions, Berdondini et al. (135) worked alongside both male and female Afghan MH professionals to develop a cross-institutional program in which the Afghan clinicians themselves served as clients. The colleagues then exchanged perspectives arising from the experience, deliberating about how to best address (or not address) taboo topics, as well as how to draw out information from clients without seriously violating norms (135). Their work highlighted the potential incompatibility of approaches primarily dependent on frank speech with Afghan values. In their assessment, not only are certain subjects and emotions entirely taboo in the Afghan context, but too candid of expression of familial conflict, personal worries, or insecurities also violates social convention within a highly collectivist and interconnected society (135).

Ultimately, Berdondini et al. (135) concluded that psychodrama, molding, and other activity-based methods for processing interpersonal conflicts could be much sounder than questioning or probing some issues directly. They write, “this methodology proved it was possible, in a culture where clients cannot explicitly disclose their worries and concerns, to run therapeutic sessions that are non-diagnostic, non-directive, [and] very respectful of client's needs…” (135). One might thus be able to regard Berdondini et al. (135) and Drozdek et al.'s (34) studies of group therapy as potentially at odds in some respects, especially with regards to candor; however, results may be dependent on the topics that emerge when debriefing members' traumatic experiences. Nevertheless, a possible takeaway of Berdondini et al. (135) is that group-based approaches that too overtly name feelings or that too explicitly detail personal matters might therefore be considered inappropriate, or at minimum, they might warrant caution.

While not a clinical intervention in itself, Ramezani et al. (153) offer a noteworthy resource on neuropsychological assessments with Afghans. The authors offer a brief review of historical and cultural considerations, as well as approaches deemed potentially generalizable to the wider Afghan population. Critically, they offer commentary regarding the utility of certain diagnostic tools, as well as an appendix of applicable instruments, which constitutes a highly valuable contribution of this work. The text also addresses Afghans' tendency to attribute distress to supernatural causes, as well as observations on male and female dynamics during clinical interviews, such as deferential behavior and situations in which it might be acceptable for a woman to speak on behalf of a male family member to preserve his dignity.⁸

Notably, future interventions could also integrate the principles of a growing movement that emphasizes the inclusion of restorative justice within trauma-based work (154). Literature on such approaches, as well as literature on “ecological” models, emphasize the importance of simultaneously attending to individual, as well as societal health (104, 155). The Center for Victims of Torture (CVT) has worked on one such initiative, and in addition to providing other interventions as appropriate, CVT and its partners offer survivors the opportunity to share their torture narratives in a manner which not only carries therapeutic utility for the interviewee, but which also augments the global documentation of mass human rights abuses (156, 157).

In so doing, “testimonial therapies” (26) afford survivors the opportunity to articulate visions of what proper justice might entail, and reports compiled from the aggregate data could be made available to entities with the ability to act upon these insights (156, 157). An emphasis on concepts of justice when working with Afghans is also supported by the work of Lopes Cardozo, et al. (84), who found that “a substantial number of respondents reported that revenge would not be necessary if a justice system existed. Establishment (or reestablishment) of a justice system may be essential for postwar societies to decrease feelings of hatred and revenge.” (84) Though testimonial therapies would not constitute formal redress, the fields of restorative and transitional justice continue to evolve, enhancing the meanings and responsibilities inherent to working with individuals having sustained trauma or TTV.

Answering the call for equitable MH models (27, 183), significant progress has been made over the last couple of decades in fostering practitioner awareness of differing conceptualizations of MH across cultural contexts; however, the terms “multicultural” or “intercultural mental health” might, at first, seem to serve as an umbrella term covering a breadth of studies on a variety of discrete social systems. It may, therefore, be helpful to disambiguate “multicultural/inter-cultural MH” as an overall approach, vs. collective bodies of clinical work with specific populations. Though there are varying definitions, the driving force behind the field of “multicultural health”, in broad form, could be said to emphasize the exploration of philosophical frameworks, competencies, and methodologies (50, 159, 160) characterized by “reflective self-awareness” (161) and inquiry, among other tenets. To this end, Sabnani et al. (162) write “The single most significant advancement in cross-cultural counseling practice and research in the last decade centers on the salience of both the client's and the counselor's racial identity development to the cross-cultural encounter.” This same inquisitive ethos would be critical to working with any population, including Afghans; however, literature of this variety does not always easily translate into actionable approaches that health workers could readily employ. Overall, actionable translation of the aggregate findings of clinical and anthropological investigations might be more helpful in this regard.

In the absence of actionable frameworks, treatment centered on ill-fitting diagnostic models can be alienating to the intended beneficiaries and may therefore have limited, if not poor viability (26, 50). They may also be perceived as invasive among individuals who have already been subjected to severe incursion on their bodily autonomy and rights throughout their lives (28, 29). Furthermore, few programs are directly shaped by the voices and preferences of participants themselves, reflecting a wider problem within health system and social service development (163).

Additionally, the studies discussed in this article have mostly focused on group formats. Though dyadic formats may not necessarily be contraindicated for AW, as close relationships to a provider can have rehabilitative properties through the “therapeutic use of self” (164, 165), some of the points raised by the literature around the viability of certain approaches would call into question many of the standard, one-on-one talk-based interventions commonly used within the wider U.S. MH environment. Questions emerge around client preferences for format and level of disclosure, as well as gender and other power differentials described in the studies mentioned. Also, their findings may be influenced by the fact that group-based approaches may have been preferentially researched due to greater feasibility and efficiency. Future research may therefore wish to verify preferences surrounding group vs. dyadic formats.

Moreover, when faced with high numbers of individuals from a relatively new or underserved population, the response by the provider community might be to turn to the closest body of evidence-based information. This may include consulting studies performed with those populations most closely resembling the socio-linguistic backgrounds of the clients in question if sufficient literature on that group is lacking, and some clinicians with less training in working with the displaced may presume Arabic-speaking groups to be a suitable proxy for Afghans.

The collapse of the Syrian state has yielded an abundance of literature on displaced Syrians' MH (166), including related interventions (167). Yet, however useful the resulting literature may be for understanding "refugee mental health" as a discipline, challenges exist in applying these learnings to the Afghan context. Sociolinguistics aside, practitioners must consider that in exceedingly broad strokes, the economic and educational contexts of Syria (in which, prior to the war, 93% of the general population had or was in the process of attaining basic education) were much higher as compared to those in Afghanistan. During the 2012/2013 academic year, approximately 659,394 Syrians were enrolled in higher education institutions, whereas in 2015 Afghanistan, the adult literacy rate was 38%. This is a level substantially lower than the international average (84%), and also lower than the averages of neighboring Iran (87%) and Pakistan (56%) (168, 169).

Another aspect to note is the impact of terrorism and foreign dominance over the political landscape. While ISIS eventually rose to power to occupy the vacuum created in the Levant following the collapse of Syria, the Afghan situation differs significantly in that known terrorist groups have held considerable sway over geopolitical realities for decades, allowing for widespread violence against women (170, 171) and minorities (172). It should also be noted that for approximately twenty years, the development and maintenance of Afghanistan's national infrastructure had been largely dependent on U.S. and NATO country presence, resulting in many families having ties to global powers –ties which were abruptly severed following U.S. withdrawal. Though Syrians have expressed feelings of betrayal by the international community (173), the impacts of these long-standing relationships, dependencies, and any related feelings of betrayal (42), may differ among Afghans and Syrians. In this respect, the literature on Iraqi SIV recipients could possibly demonstrate some similarities, though here too, there would be reason to question wholesale applicability (106).

Other concerns arise regarding the choice of modality. Many of the interventions in DMHL are also limited by factors such as an overemphasis on mindfulness, other benign grounding or self-regulation techniques, and “expressive therapies” (26), such as art therapy and photovoice (174). The collective scholarship on MH within displaced populations that does engage in more intensive clinical work demonstrates an overreliance on modalities based in Cognitive Behavioral Therapy (CBT) (26). While researchers would need to validate the suitability of more intensive therapies targeting hyperarousal of the autonomic nervous system for this population, in the general population, therapies such as EMDR and exposure therapy have at times been found to have equal if not greater effect on traumatic stress symptoms than CBT (175, 176). Moreover, these approaches have been shown to help with complex grief, which affects many AW (177). Attention to chronic hyperarousal could thus offer women much needed relief from trauma sequelae and may support the increased daily functioning which Afghans and other persons suffering from Disorders of Extreme Stress Not Otherwise Specified (DESNOS) have been seen to prioritize (178, 179). Additionally, these approaches are often less verbally reliant than CBT, mitigating interpretation challenges, as well as discomfort with addressing socially unacceptable topics. Possibly assuaging concerns about non-adherence, some studies have shown that modalities of this sort do not necessarily lead to increased attrition in the general population, with Hembree et al. (180) finding “no difference in dropout rates among exposure therapy, cognitive therapy, stress inoculation training, and EMDR.” It is possible that the quality of preparatory psychoeducation may factor into client receptivity.

Though the increased global interest in “refugee mental health” could be seen as a net positive, the field on the whole still requires significant investment. Along with associated benefits, intense surges of interest in a given crisis may also cause harm in that entities not grounded in the practice of working with impacted populations can reinforce hurtful paradigms and can engage in counterproductive underestimation of client-agency, especially since the broader DMHL demonstrates “a variety of methodological concerns”, as well as limited understanding of the dimensionality of trauma (26). Many studies that engage in more detailed discussion of trauma also focus on psychometrics with little disambiguation of precursors beyond the well-established traumatogenic experiences that refugees have, by most definitions (181), lived thorough, including persecution, exposure to conflict, resettlement, and post-resettlement frustrations (26, 106). This non-specific characterization of trauma leaves the clinician unfamiliar with working with the displaced without many consolidated, evidence-based, and actionable resources for deconstructing challenging client presentations. In remedying gaps around trauma-focused work with Afghans (and other displaced populations), practitioners are encouraged to continue building on the existing literature by investing in works that move beyond pure psychometrics, through to a more inquiry-based ethos combined with actionable content.

Numerous research teams over a wide array of destination countries speak of “low MH literacy” as a strong predictor of poor health-seeking behavior among refugees and asylum seekers (132, 183), including Afghans (184, 185); however, while many scholars account for the contributions of daily obstacles to lower service uptake, practitioners should still be cautious in taking assertions about health-seeking behaviors at face value, as research demonstrates that system use could vary according to logistical variables (107, 185).

In sharing their perspectives on health interactions, AW and their families have reported benefiting from the support of healthcare navigators or community supports, demonstrating a desire to engage with systems (29, 186). While their desire to engage with services has been documented through such works, the health-seeking behaviors of AW must also be reevaluated, as the absence of compatible services may lead to decreased engagement. Firstly, ascribing low MH literacy to a displaced person without sufficient investigation of context, especially if the client is unfamiliar with the host country language or systems, may accurately describe a client's unfamiliarity with biological and psychological principles; however, incorrect meaning can be ascribed to women's decreased pursuit of medical resources when reduced to statistics without sufficient qualitative investigation, especially since poor uptake may instead stem from repeated failure to reach adequate help, or the inability to obtain it through the prescribed channels (28, 29).

Moreover, women may already identify their grief as being problematic since it leads to decreased functioning or the inability to fulfill responsibilities (21). They may also be aware of the situational etiology of their symptoms and may be familiar with formal or informal means of alleviation, and they may also take steps to restore their psychological health via their physical health or vice versa (29, 106, 189). Such agency could constitute a reasonable level of MH literacy, whether or not it adheres to the Western clinical model. Researchers will therefore need to better capture these client understandings, and practitioners should know how to work with and redirect such clients as needed.

Nevertheless, the surge of Afghan arrivals to host countries presents a unique opportunity to reevaluate “risk and mitigating factors for mental illness” (84), personal coping strategies (187), as well as the “societal and individual” factors (188) affecting resettled women's health-seeking dynamics. This would be an especially important undertaking for AW, who have traditionally been marginalized in both society and clinical research, despite ethnographic studies finding Afghan communities “eager for culturally adapted interventions“ (103). This is further supported by findings noting a high level of trust placed in the ”biomedical community” (inclusive of psychologists and psychiatrists), as well as their view that that certain conditions can be ameliorated with their help (106, 189).

The aggregate literature on Afghan family systems indicates a variety of pressures with which women contend, and ongoing stressors are often endorsed as being more impactful than emotional concerns (21). Contributors to MH presentations include social constraints, such as societal tolerance of GBV and FV, as well as logistical barriers, such as lack of familiarity with health systems, distance from health centers, poverty, and food and water insecurity, among other factors (85, 163). Unsurprisingly, war-related trauma also directly affects a great number of Afghan households (65, 85, 89). Though other frameworks may be developed, based on the available evidence, and building on the work of Omidian and Miller (21), the stressors most salient to AW's experiences can therefore be categorized into the following broad categories: war or conflict-related trauma; chronic/background environmental stressors not directly related to violence; FV and GBV; and resettlement trauma.

A first step in identifying promising clinical approaches could be to verify the proportionate impacts of these stressors, isolating which factors would be paramount to rapidly attenuating stress levels. One possibility would be to enroll married or previously married AW who have met the following four conditions: (1) have suffered direct, acute trauma in connection with war or conflict; (2) have been exposed to chronic, non-conflict environmental stressors; (3) have experienced FV; and (4) have been resettled. These and similar stressors could then be isolated and controlled across experimental groups. If desired, those groups addressing war/conflict-related trauma could be further divided to better isolate the effects of trauma endured prior to the 2021 withdrawal, as well as the trauma endured as a consequence of this event. Of note, given the social isolation experienced by many resettled women (29, 190), researchers could also consider controlling for increased social contact via interaction with personnel, even if contact is minimal. Symptom improvement could then be tracked over a number of months using the Afghan Symptom Checklist (24), the Hopkins Symptom Checklist (191), the Harvard Trauma Questionnaire (192), or other applicable instruments, and results could be analyzed via qualitative and quantitative methods. Other approaches could certainly be proposed, but targeted attenuation of baseline stress levels could lead to better daily functioning, which Afghans have been observed to prioritize (24, 106).

In addition to evaluating receptivity to different formats, content and intensities, researchers could explore various modalities, and sequencing of themes. For example, researchers could overlay differing subject matter with modalities directly targeting PTSD-symptoms (processing/exposure/desensitization/somatic therapies) or non-verbal modalities (91).

These approaches could then be compared to more “actionable” modalities targeting cognitively rooted symptoms, such as standard CBT. Comparative research of this sort would be insightful given that CBT is among the most frequently used modalities in research with displaced populations (26). This overrepresentation likely reflects the general palatability of CBT approaches for a variety of clients, as well as its flexibility and ease of incorporation into other methods, but it may also reflect the relatively higher barrier to clinician qualification in more expressly trauma-focused modalities. There is, therefore, significant need to explore the viability of non-CBT interventions for those desiring more intensive treatments. This sentiment is echoed by Kananian, et al. (31) who comment that CBT is appropriate for those needing, tolerating or desiring lower-intensity treatment. Stratification according to intensity is also encouraged by Panter-Brick, et al. (65) who observe that, “Emerging consensus advocates several layers of support for MH programs in emergency settings: those targeting the family and community, as well as those offering more specialist care for those in clinical need.”. Participant interest in focused mental health programming is further supported by the findings of Yaser et. al (106), who observe that participants”…viewed the use of specific psychotherapy in the treatment of PTSD favourably. The vast majority considered both' psychotherapy focusing on changing thoughts and behaviours' (84%) and 'psychotherapy focusing on the past' (86.7%) to be helpful.”

Whatever the approach, psychoeducation is advisable in the case of more intense treatment, since clients undergoing exposure-based therapies or similar treatments may question how uncomfortable stimuli and the disturbing symptoms which they elicit, such as intrusive thoughts and flashbacks, could constitute a pathway to relief. Also, populations experiencing ongoing adversity may default to avoidant coping strategies that may be correlated with PTSD (141), and intense therapies may trigger these behaviors, though as Wildt, et al. (138) write, “the direction of causality is unclear.”

Future research could also consider examining symptoms through the lens of C-PTSD, as defined by the International Classification of Diseases (ICD) (193) rather than through the Diagnostic and Statistical Manual's (DSM) framework for PTSD (136). Silove, et al. (194) observe:

It must be acknowledged that given the well-documented difficulties around resettled populations' access to health resources (195), implementing certain research designs with AW, especially those from more conservative or rural families, may remain partly aspirational. Even if they may wish to participate, obstacles may be encountered, such as: (1) participants may not be sufficiently forthcoming with their concerns to be properly assessed or categorized; (2) numerous logistical barriers to accessing services, such as childcare and transportation; (3) too few women actively seeking sustained care to create a valid study (196) and (4) women being denied permission to participate by their families. Attention should also be paid to the ethnic groups to which the women belong, as well as their perceptions of other groups (48) since some may be opposed to mingling with participants of different ethnicities. Still, the minimization of barriers should remain integral component of comprehensive social services since women may be motivated to participate absent any major logistical barriers (103).

In the face of myriad structural and ideological barriers, it is essential that health systems be prepared to interact with individuals for whom, due to multiple legacies of oppression, the present manifestations of the Western medical system might not be as desirable (50), but who nonetheless might benefit from some form of intervention. The past decade has seen a rapidly growing interest in the decolonization of international development, and by extension, the global health field's Western-centric orientations (197–199). Moreover, while it could be argued that psychiatric diagnostic labels are a useful shorthand for describing symptom clusters, studies of trauma across international contexts have raised questions over the universal utility of Western-developed constructs (24–26, 109). Kaiser et al. (129) describe differing conceptualizations of symptoms, stating, “Ethnographic research is informative here because it facilitates the identification of cultural concepts of distress that communicate the complex etiology, meaning, and response surrounding forms of suffering.” Some of these details may not be captured through works of the “quantitative research tradition” (200), so scholars increasingly advocate for the utility of medical ethnography and “community-engaged scholarship” (158) in the education of health professionals (158, 200), especially given the global lack of trained providers (183).

When designing interventions for understudied or marginalized populations, any results observed (and programs subsequently developed) should be further tailored through focus group input in order to verify compatibility with the social constraints of the new environment. Additionally, and in line with promising practices in trauma-informed participatory research (67, 201), all phases of the process should involve Afghans in both research and leadership positions so that they may shape the structure of the intervention. Furthermore, participants could have the function of optimizing the study environment so as to avoid re-traumatization, as well as establishing an atmosphere conducive to engagement. Practitioners would also need to maintain an eye toward “community-based system dynamics” for improved monitoring of feedback loops (163).

While paternalism should be avoided wherever possible, a related consideration centers on how to best integrate Afghan health professionals in participatory research while still observing the highest level of medical standards. Mismahl et al. (202) have found MH provider training within the Basic Package of Health Services (BPHS) to be inconsistent, with the authors stating that, “even doctors trained in internal medicine and specializing in mental disorders within MH hospitals require training in basic neurological examination skills.” This aligns with their findings that some psychosocial workers conflated “giving advice” with having performed quality intervention. Within the BPHS, many psychosocial workers received only a year or so of specialized training (202). Therefore, research teams should be aware of these potential gaps in training rigor and potential inclinations toward directive approaches.

There exist important ethical considerations surrounding FV, and given the vulnerable intersection of displacement and FV, the reality may be that until the legal and social service systems of the destination countries catch up to their ideals, these systems may not be equipped to handle the specific needs of refugees experiencing FV. This is especially worrisome given the lack of literature on appropriate responses to GBV in displacement settings. This lack of informed guidance is conspicuous, and in their analysis, Asgary et al. (203) wrote, “We did not find a single article evaluating either the prevention or treatment/management of GBV and its health consequences in displaced populations that met the inclusion criteria.”

Additionally, and with the exception of cases involving minors, isolating a woman from her family system before she feels empowered to leave on her own may cause considerable hardship, as seen with South Asian women, including immigrant women, who often face many obstacles in leaving their abusers (78, 204). Resettled women may face even more obstacles given the brief time that the systems allow for resettled individuals to attain financial security, with Wachter et al. noting that, “poverty interferes with women's ability to meet basic needs, forcing survivors to prioritize housing, food, and employment over safety and well-being” (205). Therefore, assuring that abuse is no longer ongoing would render studies safer for participation, while still helping to account for the impact of FV on AW's lives. Such measures cannot rule out all risks, and it remains incumbent on researchers to mitigate other possible threats to women's safety, including breaches of confidentiality when working in group settings. Researchers may also wish to review the resources to which Vaughan et al. (67) direct readers when engaging women having survived violence.

The consistency of findings around women's reliance on spirituality as a coping strategy may lead one to conclude that the integration of spiritual components during treatment is indicated. This is likely a reasonable assumption, though this may not be appealing to all women, and the suitability of religious components should thus be verified for all group members. Education may modulate religiosity and related coping strategies (106), so in addition to its other implications on client outcomes, educational attainment should be considered in all aspects of research design, including religious components. Moreover, respondents may feel socially obligated to overemphasize the importance of religion within their coping strategies, and women having survived life in a theocratic society may also have been injured by the rhetoric of religious figures, or they may hold dissenting political opinions (6, 36, 39, 206). Practitioners would therefore do well to gauge the degree of a client's religious attunement through means other than direct questioning.

Although the sociopolitical environment in Afghanistan has long been perceived as entirely repressive to women, it's important to explore the creative ways in which women have chosen to empower themselves, given that many households have lost men's financial support to disaster, disability, unemployment, or substance dependence (36, 55, 80). Anecdotally, some women claim that enhancing their economic power through microfinance has also led to reduced beatings by their husbands (36). Since monetization of their activities has been seen to enhance financial stability or serve as a protective factor, individuals working with families could consider supporting women in seeking employment or exploring creative outlets that afford greater socialization within their communities. Granted, any program proposing work-based or educational interventions should consider benefits and risks, including an escalation of violence due to perceived imbalances, as Ackerson, et al. (207) have observed sometimes occurs when women from India receive more education relative to their husbands.

Any clinical approaches thus derived could also integrate elements of justice-focused or socially conscious models, whereby women can articulate how they would like societal wrongs to be addressed, since approaches of this variety can engender a sense of healing through constructive social critique (154, 157) Though a complex and growing field of inquiry, “Displaced persons should be recognised as critical stakeholders in transitional justice and reconciliation processes, and their arbitrary exclusion should be challenged” (208). Of note, as AW are frequently energized by the success and wellbeing of their children, framing these activities as being in the interest of future generations may also prove motivating (39).

While it is possible that future research with AW could be applicable to resettled populations generally, the socioeconomic and environmental conditions that Afghans endorse may result a in a different set of thematic foci and formats as compared to groups from higher-income countries, where women may have greater socioeconomic mobility and a greater understanding of Western conceptualizations of MH. Though they would require tailoring, resulting interventions could be more applicable for women from lower-income countries having a greater number of environmental, GBV and conflict-related hazards. Other groups for whom such interventions may be applicable include those sharing ethnolinguistic commonalities, those from tribally organized societies, or those bearing religious similarities. They may also be more applicable to locations ranking high on the Political Terror Scale (209).