I was recently invited to a hospital in Fata to assess the mental health of their healthcare providers, many of whom live and work far away from home, often in compromised living conditions. This hospital is situated in a relatively peaceful area but the trauma it presents reflects an immense battle within.
“You are upset about the APS school attack? Is that really the worst you think they are capable of? I was recently transferred here from Hangu, where every day, men women and children are brought in with traumatic injuries. I cannot count the number of dead children I have had to stitch up before returning their lifeless bodies to their parents. Do you even know what a toy bomb is?” said a gentleman during a group session. When I said that I did not, he went on to explain that it was a warfare technique where bombs were hidden in pretty toys to attract the attention of children. In the story he was about to tell me, the bomb was a shiny red toy car.
“A five-year-old boy was playing outside his house and found this little toy car. Excited, he picked it up, brought it home and gave it to his mother, to show her his newly acquired asset. He had only just handed it to his mother, his brother running towards her to get a closer look when the toy exploded. The mother died on the spot, the brother had to have both his legs amputated. And the five-year-old boy has to live the rest of his life with the knowledge that he was responsible for the death of his mother.”
The attack on APS-Peshawar should have desensitised us but everyday trauma still goes undiagnosed and unaddressed
It isn’t just about 144 children being massacred in cold blood. It’s about hundreds more nameless and faceless men, women and children dying in terrorism-related incidents, sometimes leaving families to grieve and sometimes not even that. It’s about the thousands affected by floods, earthquakes, tsunamis, cyclones, heat waves and newly emerging natural disasters in the wake of global warming. Just like physical health is important, and one goes to the doctor for routine checkups every once in a while to make sure their cholesterol level is in order, their blood pressure in the normal range, that the cut is not septic or their child is not in need of a tetanus vaccination, a psychological once-over after a difficult or stressful period is not a bad idea. Most people forget that helpers are humans too, and go through their own traumatic experiences, being exposed to adversities on a regular basis, like the medical staff at the hospital in Hangu. As the gentleman in later confessed, each case that he treated left a heavy toll on him, always making him think of the security and well-being of his children at home and their mortality. This was his daily struggle.
It is important to understand that as a nation, Pakistanis have an external locus of control, meaning that we are inter-dependent on our friends, families and communities in good as well as bad times. We plan weddings collectively as well as deal with our losses through a collective distribution of the grief and its subsequent responsibilities.
This is why psychological first aid works very well in our culture.
Contrary to what many believe, psychological first aid is not intrusive. It does not involve forcing people into one-on-one sessions or professional environments where an individual is barraged with an onslaught of questions which may make them feel vulnerable. It is a simple conversation, where the therapist or volunteer or field worker just listens, empathises, provides support, allows the affected individual to speak — what we call catharsis — and establishes rapport and a baseline for future sessions, if required.
Psychological first aid is like applying antiseptic on a wound. The wound heals better and may not require future treatment post-follow up. Psychological first aid has been shown to have better prognosis in the long run. Why wait for symptoms to show if a bit of empathy can help those affected heal better, realise that they aren’t alone, that the world cares, has not forgotten them and is there if and when required?
Research has shown that Pakistani men and women also cope differently in the face of adversities. While men cope by fixing things, asking for information, being on ground, seeking instrumental support and helping others, women seek emotional support by speak to other women. They depend on their men. They blame themselves.
Men and women both turn to God for help equally in Pakistan. The anger for the government is the same for them as well, but that is not just because of the shortcomings of the system, but a method of coping, of overcoming their grief by finding someone to blame. Sometimes it’s God. In Pakistan, most times it’s the government. Substance abuse has also been seen to increase in affected populations where no external support was received. People try to alter their realities to find one they are more comfortable living in.
Often, one hears a field worker complain of fatigue, forgetfulness, inability to concentrate or sleep, crying spells, anger or just a general state of detachment when back home. A feeling that no one will understand what they have seen or done. This is a normal reaction to abnormal circumstances. Helpers are humans too and require attention, support and debriefings.
There is a school in Karachi that I frequent as a visiting psychologist, to assess the progress of Montessori students. The school is based in Landhi, a part of Karachi that was very insecure during the 90s. The children that attend this school today are children of children who grew up during those times. Mental health was not a matter of concern back in the 90s. Those were simpler times.
Some argue that mental health awareness has led to more mental disorders. But that isn’t true. On my first visit to this school, I met many children. A particular six-year-old stood out. He did not know how to smile. His face had never used those muscles before. When I physically manipulated his face into a smile, his eyes showed confusion. They were the only way he could express himself. When I complimented him for how good he looked when he smiled, and encouraged him to do so more often, that six-year-old boy froze. His eyes showed shock. It took me two days to realise the boy had never received a compliment before.
For the parents of such children, group therapy sessions to address their long-term angst are a good place to begin. Allow them to open up, go beyond the anger, anxiety, regret and guilt and find words to articulate their feelings. To realise and understand that they are not alone. To begin the journey forward, with their community to heal themselves as well as create a safe haven for their children where they can learn and grow more appropriately.
For others, though, one should not wait that long. Why wait for the time when psychological issues manifest themselves on a community level when precautionary measures and timely follow-ups can avoid such extremes?
Published in Dawn, Sunday Magazine, December 27th, 2015