Our team of psychologists and psychiatrists went to the Combined Military Hospital in Peshawar, where they met about eight students. The physical wounds weren’t too bad for these students; in fact, they were to be discharged the day we went to see them. Among them was a boy with a gunshot wound on his left arm; everyone seemed to gravitate towards him.
His father, whom the team spoke to first, was a very strong, resilient man. What he said to our team was “we are army people, and my son is the son of an army person. We don’t cry, we don’t feel sad, we will deal with this.” This was perhaps just a facade of strength, but in those moments, that man was quite inspirational.
The army officer told themthat his son was the one who took care of the other children in the ward, that he made sure that they were happy and kept laughing, that they were distracted from their pains and their own stresses.
When the team spoke to the child, he was very thankful that we had come to see him. He was very proper and well-behaved. When we tried to offer him chocolates and cards that we had taken from Karachi, which students of the Karachi Grammar School had made for us, he said don’t give these to me, give them to the other children here. “They need it more, give it to my other brothers,” he said.
Photos by author
At that point, our psychologists and psychiatrists told him that the others are taken care of, and this is for you. They gave him some extra chocolates too, and told him that if he felt the need later on, he could distribute them to the others. He said thank you, we moved on.
When the team was about to leave the ward, they went back to say goodbye to him. He greeted them again.
When they asked the chid why he was greeting them again — he had already greeted the team five minutes ago, he simply apologised. “These days, once I have spoken to someone and I turn away from them, I don’t remember ever speaking to them before if I turn back,” he said.
This was an immediate sign of very severe trauma. For this child, it was acute dissociation, which was manifesting itself in the form of short-term memory loss, or not being able to make new memories.
Dissociation is a mental state that people go into when they are faced with severe trauma that their mind simply cannot comprehend or deal with at that moment. In the short-run, it is easier to deal with reality by not acknowledging the traumatic event’s existence or by pretending that you are somewhere else or something else is happening. It is a complicated front that people put on; in the most basic terms, it is a defence mechanism of the human mind to deal with trauma.
Dissociation cannot and should not be confused as Attention Deficit Disorder — that is a chemical imbalance or a neurological digression that someone is born with. In practice, this simply means that some people are chemically more active than others. Dissociation manifests itself differently: someone can forget who they used to be, they can just wake up being someone else. It can manifest in different personas even. Sometimes, it is just forgetting a traumatic experience, with no conscious memory of it ever happening.
There are two different kinds of reasons why this child could not be making any new memories, instead forgetting meeting moments ago. It could either be that he suffered head trauma during the incident, that he fell and hit his head somewhere. We asked him and he said no. The other explanation is that this ailment is purely psychological. It is because his body, going into self defence mode, is trying to save him from the trauma of the memories he created over the past week that it is dissociating. This is why his mind is not making new memories, until he deals with the old ones.
While there was lots of dissociation, there was also lots of denial. “Everything is okay, everything is fine, I just need to get out, I am leaving the hospital today, everything will be okay.” I asked him if this problem of forgetting people he had just met moments ago always existed. He replied that it had only started in the past couple of days. But he did not refer to the incident at all, or refer to why it could have started. That denial was there towards his dissociation; he was very casual about it; a very friendly child.
Our initial assessment in Peshawar, as well as monologues printed in the media or shared on social media, confirmed for us that many of those who stayed alive — students, parents and teachers — may now be suffering from survivors’ guilt: the idea that somehow, they have done wrong by surviving the Peshawar attack when the others, their children or colleagues or friends, did not.
Survivors’ guilt can be dangerous, because it can be debilitating not only in terms of the psyche of an individual, but in the long-run, it can affect and change your personality. In children, for example, it can lead to disorders such as Conduct Disorder or Oppositional Defiant Disorder.
It can start off by something as simple as not listening to parents or other authority figures; and it can lead to juvenile delinquency. If children are kept in such environments, then by the time they reach 18 years of age, they can develop anti-social personality disorder. In laymen terms, such people would be called sociopaths — people who have no remorse when they kill someone.
Put another way, we are breeding entire generations of terrorists — maybe not at the Army Public School, but in places where all those drone attacks took place. We constructed sociopaths by killing off anything that they felt anything for.
The service and sacrifice offered by the doctors of the Lady Reading Hospital in dealing with the massacre was heroic. But it also came at high personal costs for those who served selflessly. This is a story that was first related to us at the Health Director-General’s office, and then repeated at the Lady Reading Hospital by medical officers.
When the disaster happened, a senior surgeon became terribly occupied with all emergency cases that were coming in. The bodies kept piling in, the doctor kept working. Somewhere in that process, he remembered that his wife, who was a teacher at the Army Public School, had been calling him around 11am earlier in the day.
He asked someone to check up on her, to call her back and ask if she is okay. But she wasn’t answering her phone. As he walked out of the operation theatre worried, he saw another pile of bodies lying there. His wife’s body was amongst them. The surgeon went back to work.
Then there were the medical officers, the lowest tier of doctors in hospitals. Two male medical officers we spoke to explained that since Peshawar has now seen so many terrorism-related disasters, junior doctors often find the strength to cope from the medical superintendent and other heads of departments, and how they work in times of crises.
In most Peshawar hospitals, when an emergency is declared in the aftermath of a terrorist attack, everyone in the hospital tends to leave their departments, and instead gravitate towards the trauma and emergency rooms, where it is all hands on deck.
That morning too, the Lady Reading Hospital medical officers were working, sorting out bodies, seeing paramedics bringing people in, when all of a sudden, they saw their medical superintendent burst into tears. In an emergency, it is adrenaline that gets us through the situation. They said that when they saw senior people break down and cry, they lost their strength as well and broke down themselves.
There were two gentlemen who spoke to us together. One of them was telling the story while the other one had his hands on his eyes. They could not keep it together even then; it was a very emotional moment.
We had to go to the Qissa Khwani Bazaar one day to buy things and get some printouts. As we waited for our colleagues to return from the copier’s shop, we met a traffic policeman there and promptly got into a conversation with him. While we spoke, we introduced to him what mental health is and how mental health is affected by circumstances such as urban or natural disasters and terrorist attacks.
Perhaps it is the general host culture of the Pakhtun people, but the cop insisted on buying us some tea. We invited him to sit in our van, to have that tea with us.
This gentleman had worked through three bombings or shootings in the Qissa Khwani Bazaar; and there was very obvious stress or residual trauma in his behaviour. He was very touched by the mental health initiative, and the fact that people had come to help him from a place as far as Karachi — a place that he had never even dreamt of going to because it was that far away. Just the fact that we sat him down, had a cup of tea with him, and spoke to him made him feel very special.
When we first sat down, this gentleman broke down into tears. He put his glasses on, his face mask on, to hide his tears from us; but he was crying. He too was shattered by what had happened at the Army Public School. “Whoever did this aren’t human, let alone Muslim or non-Muslim. They are animals,” he asserted.
He just could not comprehend how something like that could have happened. The way he described it was that Pakhtuns had their distinct rules and ethics when it comes to war. If someone is above the age of 25, he is considered a man; if there was ever any enmity amongst parties, killing him would be fair game. But women and children the Pakhtuns would never touch, because it was a matter of honour. There are certain spoken and some unspoken rules in Pakhtun culture that were to be followed even in war.
This traffic policeman is a citizen of a city that has been facing 10 years of insecurity on an everyday basis. There are bombs and shootings that you are exposed to daily. Everyone is scared, and to cover up their fears, almost everyone has to pretend that life is normal. To wake up every morning in this situation, and to go to school or to work is a challenge in itself.
In an emergency situation, you don’t find the time to face what you are going through. It turns into an alarm stage, where your body is working at its most optimal level, everything is on go, you are sleeping less and working harder, you are just dealing with things as they happen.
But to wear this facade 24/7 is exhausting; especially for the men in that society, who are required by culture to be brave and strong. People become emotionally numb; they don’t learn how to deal with their own issues. What happens is that when you get a moment just to breathe and relax, you tend to break down.
Which is exactly what happened to the traffic police gentleman: he broke down because he saw a little safe place inside that van where nobody was looking at him, where he could just be himself, and nobody judged him for breaking down. Learning about mental health, he later said that he had finally found words to put to how he had been feeling for so many years.
An ex-student of the Army Public School, Peshawar had contacted us on Facebook while we were still planning this trip. He is a young man living in Islamabad, but was very eager to help out. We had a database of around 300 mental health experts, doctors, and volunteers who wanted to contribute in some way, but his association with the Army Public School provided us with a unique insider’s perspective.
When we met him, we discovered that this young man had applied to become a teacher at the Army Public School, Peshawar, and he was supposed to start teaching in January.
In Peshawar, when he went back to speak to his former teachers to tell them that he was joining them in January, the teacher — a man in his late 40s — broke down and said, “Who will you teach? We don’t have a ninth grade anymore.”
Sharmeen Khan is a Karachi-based mental health professional. She was among the leaders of the Naya Jeevan initiative of providing psychological help to survivors of the Army Public School, Peshawar attack. Their team spent four days in Peshawar, between the 24th and 28th of December, delivering psychological first-aid and carrying out an initial assessment of mental health damage. Sharmeen is also running the Sindh chapter of her foundation, Resettling the Indus, and is currently working towards a PhD in Disaster Psychology from the University of Karachi. She can be reached at firstname.lastname@example.org.
A psychological epidemic
After any major disaster, there is always a risk of an outbreak of disease. After the attack on the Army Public School, Peshawar, the perils are of a spate of mental illnesses, some of which are going undiagnosed and untreated
Around Pakistan today, children are scared of going to school. There is a fear among kids that masked gunmen can come inside their classrooms and kill them — just as it happened at the Army Public School. This is a mental health epidemic.
Epidemics are typical of disaster situations, whether natural or man-made (including terrorism-related disasters). When the floods happened back in 2010, doctors rushed to the affected areas to inoculate against malaria and typhoid, and to ensure that there was no outbreak of disease among local populations.
In the same way, when disasters take place, there is also a risk of psychological disorders among large populations due to the trauma inflicted. Losing homes or losing lives, for example, will both cause trauma.
A psychological epidemic will break out when an entire group of people is affected by similar, traumatic circumstances, the fallout of which everyone needs to face. When such trauma is not dealt with in an appropriate manner, it can lead to mass psychological disorders in the long-run. To protect against this eventuality, psychological first-aid is required in the short-run.
But speaking about trauma or running from it (fight or flight) have particular pros and cons. In either situation, the consequences can be debilitating if not handled professionally. Any tweaking with due process can destroy someone’s life.
Administering first aid to at-risk populations
The highest-risk populations in psychological epidemics are those who have directly survived the attack. We tend to forget that survivors from Peshawar also included teachers, administrative staff, and even gardeners (of whom, two were killed during the Army Public School attack).
In the second tier are the families of the victims and the survivors. Those few hours when they aren’t sure if their loved ones are going to make it home dead or alive, preparing for funerals, or just dealing with the worst tend to take their toll.
The last segment of at-risk populations includes doctors, relief teams, as well as law enforcement personnel. If you live in an area that is at risk of a psychological epidemic, and you get a call to reach a site of violence, you know you are on a suicide mission. Apart from those at the receiving end, nobody else can begin to understand what it is like to drive to your death.
Protecting the mental health of this group is critical, because they ensure the physical health and security of the rest of us, and they allow the proper mental health rearing of our children. If they collapse, the system collapses with them.
But most of these scars are invisible. The pain of trauma simply keeps adding without a victim recognising the burden that they are living with or the impact trauma is having on their lives. In truth, it is similar to going to a hospital after sustaining physical injuries; hospital staff will typically first treat any obvious wounds or gashes, before sending a patient off to get an x-ray check for internal injuries.
In the same way, psychological first-aid becomes important whenever a disaster happens, because it helps a survivor to deal with the topical effects of what has happened. This can simply be about actively listening to the survivor. What often happens in traumatic situations is that people simply shut up and their systems shut down. They don’t speak about what has happened, they believe that nobody will understand what they have been through, that it disturbs others to hear about it. As a result, survivors decide not to speak of it to begin with.
But active listening, giving them support without judging them, or without offering them any unsolicited advice, can also be a form of psychological help. Sometimes, it doesn’t happen in a closed room, sitting on chairs across a table. It can happen in a crowded ward too. This is part of psychological first aid.
There is a traditional versus eclectic counselling debate that erupted in the wake of Peshawar. Some argue that as per tradition, therapy should only be carried out one-on-one between a therapist and a client in a secluded, safe space. But the reason an eclectic approach needs to be adopted in disaster situations is because one cannot approach someone and bully them into undergoing therapy. One has to work through how society has been shaped and the social stigma of mental illness before help can be provided to those who need it.
As time goes by, there are certain stages of grieving that every human being must go through. Grieving can be divided into two parts: uncomplicated grief and complicated grief.
In uncomplicated grief, the basic stages are denial (this cannot happen to me); anger (I only want revenge); bargaining (if I hadn’t done such and such, then this calamity would not have happened); depression; and then acceptance.
A lot of the children that we met in Peshawar were understandably angry. They wanted to be in some armed force — one wanted to join the army, another wanted to be a fighter pilot, for example. They wanted revenge for what happened to their friends.
The stage that we are now passing through is bargaining, when everyone is blaming themselves for a traumatic incident. Accounts of mothers that have been published in newspapers or recorded by the media reflect that they are trying to find reasons to explain their grief. “If I hadn’t missed Fajr prayers, this wouldn’t have happened” or “If he had missed his school van, this wouldn’t have happened” is something that we listen to a lot of mothers say.
Depression can be long-term (which is a disorder), but when going through grieving, it is normal and expected.
Complicated grief, on the other hand, can lead to different, more complex issues. If someone gets trapped in one of these stages, it can lead to changes in sleep, appetite, not wanting to socialise, ill health or even perceived ill-health.
Complicated grief manifests itself in different people in different ways; many times, it arrives as psychosomatic disorders — unexplainable physical ailments of the body, for which doctors won’t find any medical cause. A common complaint among those who suffer anxiety, for example, is pain in the solar plexus. We know there is no organ there, so the pain is psychosomatic.
If these symptoms are not dealt with in time, they can lead to depression, anxiety, adjustment, somatoform or even post-traumatic stress disorders.
Handle with care
In Pakistan, people often don’t see someone as mentally unwell unless they are chronic or beyond any hope of recovery. The prevalent notion is that these people have been affected by witchcraft or magic (jaadu kar diya/jinn charh gaya), whereas the reality is different.
Providing mental help, therefore, has to done in a culturally sensitive manner. It starts off with making bonds, being empathetic to people’s sufferings and situation, and establishing rapport. Once rapport has been established, we monitor clients from a distance. If and when help is needed, only then can professionals step in.
Group counselling can be counter-productive in such situations, because survivors can feel compromised in some way. For some people, going through a mental health checklist might make them feel defensive. This is why group counselling has to be carried out in a socially appropriate manner, where nobody feels that they are being analysed or seen as mentally compromised or unwell.
It has its benefits too in the long-run: emotions that are kept bottled up out of the fear that others wouldn’t understand can be let out in group therapy sessions, when participants have more in common with each other. Group therapy allows people to face what they went through together.
On the other hand, awareness for the need of counselling is critical because Pakistan seems to be in denial that we live in a warzone. War has skewed some normal realities for our people, and it is imperative that people’s normal is recalibrated.
Consider heads of families in Peshawar: when someone deals with trauma alone, or perceives to be dealing with mental health issues on their own, makes them more vulnerable to mental illness than they were to begin with. Heads of families are also human, and they need someone to iron out their insecurities and what needs to be done to sort them.
If they can’t speak to their wives or family members, they still need someone who they can speak to and share their stress with. If their issues remain buried, then in the long-run, these dynamics manifest themselves as depression, anger, feelings of loss or defeat or reckless behaviour.