Wars, Insurgencies and Terrorist Attacks. By Dr. Unaiza Niaz
American Journal of Psychiatry - Review by Danial Savin, M.D
In this impassioned book, Dr. Unaiza Niaz, Professor of Psychiatry and Director of the Institute for Psychological Trauma at the University of Health Sciences in Lahore, Pakistan, calls for compassionate awareness of the "silent sufferers" scattered throughout the Muslim world. That the majority of wars, insurgencies, and terrorist attacks today take place in the Muslim world is not coincidental, Dr. Niaz argues. She and several guest authors from Egypt, Lebanon, Algeria, and the Palestinian Territories offer explanations and perspectives regarding the roots and downstream effects of this violence as well as possible solutions.
The book begins with discussions of the psychological, historical, and political roots of terrorism. Multiple psychological theories are reviewed, most notably social learning theory and transgenerational transmission of trauma, with no consensus regarding the psychological makeup of a terrorist. The primary conclusion is, instead, that most terrorists are not mentally ill. Dr. Niaz asserts that fundamentalists who are frustrated by their oppressive home regimes wage war against Western-supported governments because they lack other means to express their frustrations with society. The authors give much more attention to the perceived historical and political causes of terrorism. Some of these views might cause discomfort for Western readers, including this reviewer. For example, despite hard evidence to the contrary, including bin Ladin's own claim of responsibility, Dr. Niaz sees it as a "strong possibility" that the attacks of September 11, 2001, may be linked to a communist or fascist group or "a secret group in another state" rather than to al-Qaeda (p. 53).
She also argues that too much attention is paid to the events of 9/11 and not enough to "the worst degree of terrorism from [by] the powers who claim to bring peace and justice to the world" (i.e., the United States and those collaborating in U.S. coalitions) but who end up amassing Muslim casualties in the process. While Western governments label such casualties "collateral damage," Muslim civilians label them victims of "terrorism." In her view, Western-sponsored wars designed to end terrorism instead create more terrorists by traumatizing populations. Other Western actions,
including colonialism, support for oil-rich but oppressive regimes, and support for Israel also play important roles in tilting some Muslims toward fundamentalist views of Islam that encourage armed struggle against the West. In the author's view, the United States is no longer a moral leader but is spearheading human rights violations against Muslim populations.
Supported by quotes from the Koran, Dr. Niaz and her guest authors unequivocally assert that Islam is a peaceful religion in which terrorism has no place. To the author's credit, she does include (but does not support) opposing views from militant Islamic leaders who endorse violent acts, such as suicide bombing, and justify these acts with quotes from the Koran. These opposing views left this reader wanting to know more about the struggle within Islam between more moderate and fundamentalist forces.
The book provides excellent reviews of the psychosocial effects of war and terrorism on the civilian populations of Pakistan, Afghanistan, Kashmir, Palestine, Lebanon, Algeria, Bosnia, Chechnya, and Iraq. The authors draw attention to multiple research studies documenting the high prevalence of
nposttraumatic stress disorder, other anxiety symptoms, and depression in these civilian populations, most of which have been published in major North American and European mental health journals. In addition to mental health symptoms, poverty, environmental destruction, physical disability, and hopelessness are rampant. Dr. Niaz rightfully concludes that "in armed conflicts, no one is a winner but everyone is a victim" (p. 63).
Dr. Niaz devotes special attention to women, who find the strength to lead and provide for their families while their husbands are on the battlefield. Women find this strength through solidarity with a political (and sometimes military) cause, religion, group cohesion, and a genuine hope for a better life. Many women have a particularly difficult time when they do not agree with fundamentalist Islamic rules that force them to conform to restrictive dress codes and prohibit them from working or going out in public.
To ease the effects of violence on Muslim populations, Dr. Niaz offers several solutions. She describes model treatments, mostly cultural adaptations of Western models, which might help many people but are neither sufficiently effective nor widespread enough to significantly decrease the suffering caused by war. Realizing this, Dr. Niaz puts most of her emphasis on the need for political solutions, mainly primary prevention of war. She acknowledges the need for mainstream Islam to succeed against fundamentalist Islamic groups, and she asserts that a loosening of the clerical grip on the political process with a "demarcation of the state from religion" needs to happen in order to make life more tolerable for women. She asks health professionals around the globe to promote peace, tolerance, and justice.
Despite my disagreements concerning important historical and political issues, I found it highly informative to hear the perspectives of a psychiatric colleague from the Muslim world. Dr. Niaz is a member of the American Psychiatric Association, Fellow of the Royal College of Psychiatrists London, and Chair of the Section of Women's Mental Health of the World Psychiatric Association. She trained at the Royal Free Hospital, the Tavistock Clinic, and the Johns Hopkins University. Dr. Niaz accomplishes her goal of illuminating suffering and makes a genuine plea to create peaceful dialogue, a necessary step in conflict resolution, with the West. This plea should be heard. What the reader should not expect to find are answers on how to proceed when dialogue goes sour and justice for one group is seen as victimization by the other. Recent turmoil in Muslim lands, bringing with it opportunities for either heightened conflict or conflict resolution, makes this book especially timely.
Book review accepted for publication May 2011.
The author reports no financial relationships with
The Day the Mountains Moved. International Perspectives on Handling Psychotrauma
On 8 October 2005 the mountains moved in northern Pakistan and Kashmir, to cause human tragedy unparalleled in the history of a country ill-equipped to face such devastation. An estimated 73 000 lives were lost, 4 million made homeless and an entire generation of 8- to 14-year-olds wiped out as they attended school when the earthquake struck. I witnessed the devastation ten days after the event and listened to heartrending stories of loss and grief from those whose villages and towns were completely destroyed.
Unaiza Niaz, one of the few women psychiatrists in Pakistan and a prolific writer, has contributed a timely and detailed account of this tragedy. In a comprehensive manner she has brought together experts in the field of trauma to review the early
nresponse efforts, societal effects and both known and innovative intervention methods of a population having witnessed such devastating human loss.
The book reports how the experts of the country cooperated to set up and implement a national plan of action for mental health and psychosocial relief for earthquake survivors within days of the earthquake and started operating highly effective mental health relief units, while the capacity of local professionals to work with trauma victims was enhanced by training efforts spread across the country. A chapter on the role of non-governmental organisations noted that 55 agencies from other countries rushed to set up services and coordinated themselves, perhaps by the sheer pressure of the task facing them.
The book is divided into two sections with international and Pakistani perspectives. It was refreshing to read that Niaz and her colleagues formed an ‘institute in psycho-trauma’ and reviewed the importance of usually marginalised women in disaster settings in the patriarchal Pakistani society. Although some chapters of the book were repetitive and difficult to read, those on the role of the media in seeking assistance and the practical approaches to treating trauma in children came across as true experiential accounts. The contributors report the remarkable spread of post-traumatic stress disorder (PTSD) in the survivors, from 29 to 94%, and major depression, to 81%, as well as the sensitive issue of sexual harassment in these settings. However, the surveys would need the scrutiny of peer-review to assess their significance. Nevertheless, it shows an ambitious team gathering data, imparting training and working directly with survivors.
The chapters based on the Turkish experience with earthquakes gives a detailed review of the subject of stress following trauma and innovative new approaches to treating PTSD, such as single-session therapy, modified behaviour therapy and effectiveness of earthquake simulators as therapeutic tools. Hembree and colleagues, from Philadelphia, have contributed a useful chapter on prolonged exposure therapy, and Klien, from Aberdeen, has tackled the challenges to effective research in disaster settings.
The book is a welcome contribution to the literature and a timely reminder of the need for preparedness to work in disaster settings. I found it a difficult read but interesting as I had directly worked in the camps after the Pakistani earthquake. It makes a good reference book, but perhaps not an essential read.
Contemporary Topics in Women's Mental Health - Global Perspectives in a changing society
Contemporary Topics in Women’s
Mental Health: Global Perspectives in a Changing Society considers both the mental health and psychiatric disorders of women in relation to global social change. The book addresses the current themes in psychiatric disorders among women: reproduction and mental health, service delivery and ethics, impact of violence, disasters and migration, women’s mental health promotion and social policy, and concludes each section with a commentary discussing important themes emerging from each chapter. Psychiatrists, sociologists and students of women’s studies will all benefit from this textbook.
With a Foreword by Sir Michael Marmot, Professor of Epidemiology and Public Health, University College London; Chair, Commission on Social Determinants of Health