Introduction

The psychological impact of war on its participants has been discussed since ancient times, but in-depth research in this field started only during and especially after the First and the Second World War. In the aftermath of these wars, it became accepted that to deal with the psychological trauma of soldiers and veterans, some form of clinical psychological treatment is required. Importantly, after the First World War, the official recognition of ‘shell shock’ (precursor of a diagnosis of post-traumatic stress disorder, PTSD), allowed veterans to receive treatment and pensions in several countries.  

Resent research in various post-conflict areas – including Afghanistan, the Balkans, Cambodia, Chechnya, Iraq, Israel, Lebanon, Palestine, Rwanda, Sri Lanka, Somalia, and Uganda – shows that women women’s mental health is affected by various disorders, such as PTSD, anxiety, depression, and prolonged grief, after the conflicts more frequently than men’s mental health is.123 It was thus to be expected that various psychological disorders became an urgent problem for female family members of war veterans and soldiers who died in the conflict in Karabakh on both sides.

This study thus proceeds from the assumption that the Second Karabakh War in Azerbaijan had an impact on women whose families were directly affected by it. Its aim is to study the level of access to professional psychological assistance for female family members of veterans and soldiers who fell in the Second Karabakh War in post-war Azerbaijan.

Methodology

The study rests on the grounded theory research approach, a qualitative approach where hypotheses are generated based on data collection and analysis; the work thus proceeds without any hypotheses being in place in advance. This method was developed by American sociologists Anselm Strauss and Barney Glaser during their joint study of terminally ill patients in hospitals.4

I started with a theoretical sampling of two main target groups: female family members of veterans of the Second Karabakh War (n=1) and female family members of soldiers who died in that war (n=17). The obstacles to a sampling of target groups have been described in the chapter on Limitations. At this stage, the opinion of experts (on psychology, law, etc.) has also been consulted. 

In conformity with the grounded theory approach, I did not start with any particular hypothesis. Instead, hypotheses were formulated in the course of the research process, which included data collection, coding, and analysis based on a comparison of similarities and differences in responses of the interviewees.

In the course of the study, I have interviewed 18 members of the target group and consulted 7 experts. During the initial stage of the study, I consulted five experts and seven female family members of war participants from Baku, Barda, and Aghdam. To start with, I spoke with two psychologists about diagnosing and rehabilitation of PTSD. Then seven study participants were asked about their mental health after the war, the mental health services they received, and the quality and accessibility of these services. After that, three further experts were consulted: ‘Institute for Citizens Rights’ staff member working with persons affected by the war in the rural region of Aghdam, a female community leader in this rural region (who also happens to be a mother of a soldier who died in the Second Karabakh War), and a head of an NGO called ‘Yuva’ Humanitarian Centre (meaning ‘Nest’). The purpose of these consultations was to crosscheck the information gathered from the target group and to learn about various procedural details, such as the organisation and administrative details of services offered and/or provided to family members of war participants. During this process, I formed a hypothesis and then there emerged new findings and consequently also new questions.

After each interview, information was immediately carefully examined. Data collection and data analysis were viewed as intertwined processes, at times replacing each other, sometimes running simultaneously. Analysis of data from the initial stage drove the sampling of new data and led to the formulation of new questions needed to verify hypotheses which arose at the end of the initial stage. Ultimately, insights from the initial stage required an expansion of our sample and further consultations, which is why I interviewed 11 more female family members of war participants from Baku, Barda, and Aghdam, and spoke with one more psychologist as an expert and with member of the Board of Trustees of "YASHAT" Foundation in the final stage.

Initial results

To start with, I consulted two psychologists to acquire information about PTSD, its symptoms, treatment, and prevalence. The core information coming out of these meetings was that PTSD can appear in persons who experience a dangerous or tragic event which causes deep stress. Acute stress is part of the initial reaction, which usually lasts from two hours to two days after such event. Acute stress can, however, persist from two days to one month after the traumatising event. If the reaction lasts longer than one month, the person is at risk of developing a PTSD and if the symptoms are still present after six months, a diagnosis of PTSD is likely. PTSD may appear in consequence of stressful occasions such as car accidents, fire, criminal acts, sex-related offences, or war. It manifests itself by periodic sleep problems, insomnia, nightmares, clear flashbacks, dissociation, hands trembling, as well as highly emotionally charged reactions, such as anxiety, sadness, but also disappearing emotionality and disappearance or excess of sexual behaviour. During disassociation, the person who suffers from PTSD feels with all of their senses the same as when the traumatising event occurred. Anything even slightly reminiscent of the event, even things such as sunset or knocking on the door, can trigger the disassociation.5

One of the experts I consulted, the clinical psychologist Rovshan Suleymanov, added that not only experiencing but even personally witnessing a stressful event may cause PTSD. People suffering from PTSD tend to try to escape their recurrently surfacing thoughts and feelings and/or any environment that reminds them of the traumatising event, including people with whom they associate the event.

Information about PTSD and its symptoms acquired in consultations with experts helped me to interview seven women from the target group to see whether PTSD appeared among them or their family members and if so, how they dealt or deal with it. One of the seven participants interviewed during the initial phase was a veteran’s wife, the rest were other family members (including one sister) of the war dead. Although six of the seven respondents mentioned that the war, and especially the loss of a family member, had an ongoing impact on their mental wellbeing, only one had accepted help from a mental health professional. Two of the seven interviewees had not been offered any such assistance due to their family status: it turned out that psychological assistance has not been offered to the sibling of fallen soldier and the wife of the veteran. The wives of four persons who fell in the war rejected the offer of counselling. When asked about their reasons for this rejection, the interviewees were unable to answer. In short, the finding was that one female family member of a war participant had accepted counselling, two had not been offered any due to their status, and four rejected counselling that had been offered. 

In view of these findings, I have consulted three more experts to clarify the current situation regarding access to and quality of mental health services and to better understand the reasons motivating the rejection of such services by female family members of war participants.  All experts have confirmed that post-war psychological assistance was suggested only to the families of the war dead and to the veterans themselves. Veterans’ families were not suggested any psychological assistance. In the families of the war dead, mental health services were suggested mainly to their spouses and children, and in exceptional cases also to their mothers. However according to Rena Tahirova, head of abovementioned ‘Yuva’ Humanitarian Centre, counselling for family members of the war veterans along with family members of war dead could be provided upon request if they apply to local authorities. In this cases local authorities try to meet their needs, including psychological assistance. ICRC office in Azerbaijan also provides psychological support, particularly to invisible traumatized groups such as civilian victims6 of the war.7

In an effort to identify the reasons driving the rejection of an offer of psychological assistance by family members of the war dead, I have consulted experts other than psychologists (i.e., the community leader, the NGO representative, and a lawyer). Their answers led to the identification of three main reasons: 

1. Dissatisfaction with psychologists: The main reason for this is the quality of psychologists whom people encounter in practice. For example, according to ‘Institute for Citizens Right’ staff member Ilhamiz Guliyev, of the three psychologists who had visited Aghdam region so far, only one managed to win the approval of the local rural population.  People who are dissatisfied with psychologists usually refuse to get assistance. And in the above-mentioned case, people who were dissatisfied with the first two visiting psychologists stopped taking assistance until they liked the 3rd visiting psychologist. In small villages such dissatisfactions from first visitors spread very soon and affect other rural people's opinions and decisions. Given the low quality of education in the country, the training of professionals is a difficult task – and psychologists are no exception. Unlike for instance surgery, psychological counselling cannot solve the problem within a few days or weeks. This is also why professional psychologists from abroad who had been invited for a short period of time could not make much of an impact, especially given the numbers of people with psychological traumas. Training for psychologists by the ICRC in Azerbaijan is a more sustainable instrument but the clinical psychologist Rovshan Suleymanov noted that the psychologists hired by Administration of the Regional Medical Divisions (known in Azeri as TABIB) are not clinical psychologists and therefore not trained to work with patients affected by disorders such as depression or PTSD. They would require further long-term training and practical experience.

2. Economic problems: Although none of the respondents attributed their rejection of counselling to problems from other areas of life, the experts I consulted noted that rejection of psychological assistance on the part of families of men who died in the war may have been due to financial problems which these families usually face. Rena Tahirova, head of the ‘Yuva’ Humanitarian Centre, noted that one of their projects focused on provision of psychological assistance to war participants and their families had failed. All persons who were offered psychological help refused it because they first had to deal with more pressing economic problems. Community leader Maya Guliyeva noted that economic problems in the families of veterans have on the one hand pushed the psychological problems into the background and on the other hand became the source of new stress. According to her, the families of veterans suffer more from unemployment and when veterans are unable to work, economic problems at home create further tension in their families.

3. Accessibility: The community leader Maya Guliyeva also linked the rejection of counselling to problematic access to these services. According to her, it is difficult for victims and their families to travel from the village where they live to the central town of the region and then stand in line all day to see a psychologist, because no system of appointment is in place in provincial hospitals. She added that it would be more effective if at least a separate day was set aside for each patient. There has not been revealed any precise structure of spreading and promoting information on offered mental assistance among the target groups during the study. According to rumors the war veterans themselves and the families of the war dead are directly suggested mental assistance just once by local authorities. After that authorities do not follow up with those people. In rural areas, information about visiting psychologists is disseminated among target groups through community leaders.

Final results of the research

During the initial stage, Maya Guliyeva, the community leader and herself a mother of a fallen soldier, along with identifying availability of psychological assistance as problematic also questioned the need for such services in general, stating that ‘one must have the will, the determination to overcome mental issues’. This made me search for other reasons driving the rejection of counselling among interviewees, reasons additional to those mentioned by experts during the initial stage.

During the second stage of the study, interviews with the families of eleven fallen soldiers revealed that nine of the interviewees rejected psychological assistance. One of these women stated that inaccessibility was the reason why she did not see a therapist: she claimed that she did not have time to go to see a psychologist because she was working, but if a mental health professional were to come to her home after work, she may accept the counselling.

Two of the women interviewed during the second-stage interviews stated that they declined counselling because they were afraid of recalling their loss, which could be related to the abovementioned distrust of psychologists. On the other hand, their continuing suffering was noticeable during the interview. Six respondents said that the help of a psychologist was generally unnecessary: they claimed they were strong enough to overcome their problems and did not need a psychologist. But the same women also confessed that they continue to suffer from depression and prolonged grief. Despite this, they felt it would be inappropriate to accept psychological assistance, that it is unacceptable and indecent. For example, one of the respondents said in an interview, ‘since my brother passed by, we live by the rules he set, we cannot betray his memory.’ At the end of the second stage, what emerged as the main reason for rejecting help from mental health professional was that female family members of the war dead felt it would be somehow wrong, inexcusable, a betrayal of the dead family member.

In general, during both the first and the second stage interviews with the target group, I observed that the tone of voice and emotions of those who have received psychological support differed from those who did not. The three study participants who had received counselling were calmer and more positive about their future. They were not prone to lamenting and expressions of sorrow in their speech and behaviour, which stood in sharp contrast to those who have not accepted any therapy.

To reflect on these results, I decided to consult another expert, a psychoanalyst Narmin Shahmarzadeh, to discuss with her the reasons for rejection of psychological assistance which emerged from interviews with the study participants.

According to Shahmarzadeh, ‘Although people continue to suffer from mental issues, they must care about their financial wellbeing more than about their psychological wellbeing. And since their financial wellbeing is not fixed, they constantly focus on solving these problems by protesting, demanding, etc. That is why their financial problems should be solved in parallel with the psychological ones.’In 2021 Ministry of Emergency Situations invited 20 psychologists from Turkey to provide services to the veterans and families of the war dead and civilians who have been psychologically traumatized during the war. The project continued till the August 2021 and covered around 2000 people from the target groups. The project will restart from September 5 2022 with new invited psychologists from Turkey by Ministry of Emergency Situations and will implemented in 6 regions of Azerbaijan.8

However, psychoanalyst Shahmarzadeh noted that the reports about arrival of psychologists from Turkey are not quite true. According to her, the psychologists from Turkey were Turkish citizens who had just graduated from Azerbaijani universities with her. Shahmarzadeh also questioned the quality of education received in local educational institutions in Azerbaijan.

To become fully trained therapists, these psychologists would have required additional courses and classes. Shahmarzadeh also claimed that a therapist who does not speak the Azerbaijani language cannot work with Azerbaijani patients, especially not with those who speak various regional dialects.

Regarding the interviewees’ rejection of psychological assistance, Shahmarzadeh said that the families of the veterans and the war dead indeed feel that they ought to remain loyal to the war participants, that they should as if protect their name. At the same time, this is a significant stress factor. They feel they cannot just go and talk to a psychologist and most believe that their problems are the norm. In their view, a person who goes to a therapist and talks about trauma or some kind of violence, be it physical or psychological, is a complainer. They feel they should not complain because a loyal wife or child does not complain. Therefore, they do not speak at all: they do not focus on speaking because they are struggling with a sense of guilt. They also cannot leave a person who is violent towards them, because they feel a sense of obligation to the person who fought and protected them during the wars, and they pay back him with their loyalty. They assume that if they were to complain, it would detract from that heroism.

At the same time, there are also stereotypes about psychologists in the country. In other words, going to a psychologist is not a luxury, like in some western cultures, but rather a sign of weakness or flaw.

According to the member of the Board of Trustees of "YASHAT" Foundation Rena Safaraliyeva, psychological services in Azerbaijan exist but these services are not proactive. She mentioned the Mental Health Center under the Ministry of Health which provides free-of-charge services for the veterans, families of war dead and civilians living on the front line. Those veterans who had head injuries during the war are directed for psychological help by default The rest of the people from the target group to receive psychological assistance should first apply to the polyclinic at their permanent address. Then the polyclinic refers them to the Mental Health Center where they are examined by a neuropathologist, psychologist and psychiatrist and treated based on the diagnosis. However, according to Rena Safaraliyeva, there are two main obstacles here.

1. People often find it difficult to apply to their local polyclinics because they do not live at the registered address.

2. People have stereotypes about psychological help and mental disorders. Rena Safaraliyeva notes that since veterans often do not apply themselves, in some cases their mothers and wives apply for the mental assistance for their sons and husbands.

Discussion

Current trauma problems of veterans

Over 14,274 people from Azerbaijan took part in the Second Karabakh War, and 2,908 of them died.9 According to various sources, 13.5–30% of veterans may suffer from PTSD,10 which means that between 1,500 and 3,400 war veterans may currently suffer from it. According to the Facebook post of journalist Habib Muntazir, 35 veterans committed suicide and about 50 attempted suicide in Azerbaijan between the end of the war and July 2022. But how many people in Azerbaijan receive counselling for PTSD and related issues?

Even though I have requested to provide me the statistics on the number of affected by war people, who have received mental assistance, TABIB has not provided any information. According to information gathered from media and interviews, veterans tend to reject offers of counselling. Nahid Salayev, chairman of the Public Union for the Protection of the Rights of Participants of the Patriotic War, stated that psychological assistance should not be voluntary because it is ‘ridiculous’ to expect that veterans may confess their psychological problems and voluntarily seek psychological help. Salayev also mentioned artificial bureaucratic obstacles which make access to psychological support even more difficult.11

Psychoanalyst Shahmarzadeh says that after returning from the war, veterans try to maintain that heroic stance to such extent that they forbid themselves to cry and complain. And this ‘heroes’ cult’ makes them afraid of looking miserable in the psychologist’s office. According to the information taken from media sources, there were during the Second Karabakh War 19 hospitals in different regions where 3,316 injured persons received psychological support.12 At the moment, there are several state bodies in Azerbaijan – such as the Ministry of Labour and Social Services13  and the Ministry of Emergencies14

 – that organise hotlines and psychological support groups aimed at dealing with mental health issues precipitated by the war. Still, interviews with psychologists indicate that the usual appropriate treatment of PTSD takes about 15 weeks: one-off visits or phone calls cannot help resolve such serious mental issues.

Clinical psychologist and psychotherapist Shabnam Islamli explains when an event occurs, we primarily react with our amygdala. Then the prefrontal cortex processes the event and strives to provide a logical explanation. PTSD emerges because an event (or events) is not processed but rather saved as raw material in the hippocampus. Psychologists treating PTSD sufferers usually focus on processing this raw material using various types of therapy. For example, Shabnam Islamli uses the eye movement desensitisation and reprocessing (EMDR) approach, which artificially invokes a sleep phase in patients to facilitate the processing of the traumatising event. According to her, the EMDR is the optimal therapy for traumas such as those suffered in the war, because sleep disorders do not allow the trauma to heal.

Rovshan Suleymanov uses prolonged exposure therapy, which starts by ‘gradually approaching trauma-related memories, feelings and situations’. Suleymanov described his therapy as consisting of three stages: explaining the therapy to a patient, breathing and muscles exercises, and hierarchically listing the fears of patients and going over these fears. According to the psychoanalyst Narmin Shahmarzadeh, PTSD is usually described as something that occurs immediately after the war, but that is not always the case. It can emerge months or even years after the war, persist through a certain period of life or even a person’s entire life and shape the sufferers’ character. If PTSD lasts from six months to two years, the sufferer’s identity may change: it can lead to a degradation of personality and result in alcohol or drug addiction or suicide.15

Domestic violence in the post-war period

According to clinical psychologist and psychotherapist Shabnam Islamli, people who suffer from PTSD sometimes vent their anger at other people, whereby these angry feelings are often driven by loss of sexual function/desire or their extreme increase, and by feelings of guilt. PTSD sufferers often exhibit diminished empathy and start inappropriately blaming themselves and their surroundings.Psychological consequences of wars, such PTSD, also have a bearing on domestic violence. Existing research suggests that about 43% of veterans use abusive behaviour with their partners.16 The previous researches also shows that the proper treatment of by applying psychological therapies such as Narrative exposure therapy (NET) for forensic offender rehabilitation (FORNET), Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Cognitive Behavioral Therapy (CBT) may significantly reduce the aggression and violent behavior among veterans as well as among civilians who live in conflict violent regions.17181920

Psychoanalyst Narmin Shahmarzadeh notes that she encountered three cases where female family member and a partner suffered abuse from veterans of the First and Second Karabakh War diagnosed with PTSD. Such cases of domestic violence where veterans are involved are usually not spoken about, mainly because of the status of veterans. This is also most likely why no cases of domestic violence were mentioned in my interviews with veterans’ female family members. Nevertheless, previous research by Aytan Farhadova and Heydar Isayev revealed several cases where female family members were injured by veterans of the Second Karabakh War with PTSD.21

Rena Safaraliyeva also mentioned 2 cases of domestic violence with the participation of a veteran suffering from PTSD she has witnessed. In the first case, the wife of the veteran applied for mental assistance for her husband because of his violent behavior, but after he received some mental treatment she said 'although he still shouts at me, but no longer beats me'. In the second case the veteran applied for mental assistance with the advice of his wife when he first hit her and felt guilty. Safaraliyeva also noted that divorces among veteran families have also increased.

In Azerbaijan, there were 1,499 cases of domestic violence cases registered in 2021, which means an increase of 19% compared to 2020,22 and a 15% increase over 2019.23 According to official statistics, 46 women were murdered in domestic violence in 2021, 41 in 2020,24 and 37 in 2019.25 According to media sources, though, the number of published femicides 2021 was 72.26 A platform dedicated to femicide in Azerbaijan that lists victims by name arrived for 2021 at the number of 61 women murdered in domestic violence.27 Statistics for 2022 have not been released yet, but media reports show that as of the 3rd of June 2022, domestic violence has already claimed 30 female victims.28 This shows that although the official statistics do not reflect reality, even their underestimated numbers show an increase both in the number of domestic violence cases and in the number of women killed in these cases in post-war period in Azerbaijan. Moreover, statistics show a general increase in criminality: in 2021, the number of offences increased by 12% in general over the previous year and by 40% for serious offences.29

Recommendations

Various initiatives have been implemented in other countries to increase the availability of psychological help to people affected by war. For example, informative online videos have been prepared by the Department of Veterans Affairs (VA) in America in order to motivate veterans and explain the ways to reach psychological assistance. Meanwhile VA has prepared a special telehealth program to deliver therapy for PTSD sufferers, particularly in rural regions, and the results have shown that the effectiveness of therapies provided with telecommunications technology is more than offline therapies. Non-professionals and professionals who work and communicate with PTSD sufferers also could take special education and training within different programs which aim to increase the number of informed people as well as the quality of the treatment of people with PTSD.30

In view of all of the above, the government should take action to help war affected people including veterans and their families as well as families of war dead access psychological services in order to heal post-conflict traumas and decrease gender-based violence in the country.

  1. First of all, to provide easier access to psychological assistance, bureaucratic obstacles should be removed and most client-oriented conditions created for people in the regions, especially for women whose life turns around their homes.
  2. In order to  destigmatize seeking mental health treatment the importance of counselling should be stressed by government officials and the message promoted in the media
  3. To help war participants and their families, the government should organise rehabilitation centres for veterans and family members of men who died in the wars, where various kinds of therapy would be provided along with recreation. Such collective approaches might help overcome the entrenched stereotypes regarding psychological services and mental disorders and encourage participants to accept further individual counselling.  
  4. Government should involve social workers in this process to work with war-affected vulnerable persons and families to find out their problems, inform them about the opportunities and advantages of psychological help and facilitate relationships between the target group and state bodies.

Limitations

The main difficulty this study had to tackle was to find willing respondents from the target groups in the provinces and to set up interviews with them. Taking into account that women in regions are depend on their male family members, it was more difficult to find veteran family members who agreed to give an interview. Thus only 1 female family member of the veteran has been interviewed during the initial stage of the study.  Many respondents could only be interviewed by telephone. Most did not give consent for recording their voices, meaning the data was collected and analysed during the interview. Moreover, because it was impossible to provide a phone connection where the respondent could speak in reliably private settings, it was impossible to obtain detailed information about their personal encounters with domestic violence. 

Conclusion

All previous researches show that wars affect people not only physically but also mentally. While the parties of conflicts win or lose depending of the results of a war, various gender-based and social trauma, both individual and collective, takes place regardless of war’s outcome.31

This study shows that although the mental health of family members of men who died in the war and war veterans continues to be impacted, most of them for various reasons reject counselling and treatment. All these people, including war participants, are left with their traumas without proper care, treatment, and attention. If not appropriately addressed now, this trauma – which will be passed on to future generations both via mechanisms of copying family dynamics and via epigenetics – will reverberate in the form of suicides and violent behaviour for years and perhaps decades to come.

The aim of the study was not to diagnose any mental disorders of the interviewees, although it is important to note that most respondents stated that they feel the impact of the war of their mental health to this day. Nevertheless, based on information gathered from psychologists regarding the symptoms of likely relevant mental disorders and based on the interviewees’ descriptions of the state of their mental health, it seems likely that most respondents in the sample do suffer from PTSD and/or prolonged grief.

Acknowledgements

This research was supported and financed by Kvinna till Kvinna's programmes: EU4Peace - Strengthening dialogues and building confidence across the Armenian-Azerbaijani and Peace in practice: Promoting an inclusive Women, Peace and Security (WPS) Agenda in South Caucasus. The manuscript was proofread and edited by Anna Pilátová, Ph.D.

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