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.

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

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.

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.

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.

Understanding grief

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.

Published in Dawn, Sunday Magazine, February 1st, 2015

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