Mental health impact of APS attack begins to surface

Islamabad
The mental health repercussions of the terror attack on Peshawar’s Army Public School (APS) are just beginning to surface. Clinical experiences already indicate a massive 10-fold increase in the number of APS students predisposed to post-traumatic stress disorder (PTSD). Yet, Pakistan neither has the professional expertise or institutional back-up to support traumatised children, nor even the required medicines to decrease their level of anxiety. In fact, it does not even have a public awareness programme to positively harness the depleting resilience of a population constantly living under the threat of terror.
Views to this effect echoed at a lecture organised by the Department of Psychiatry, Pakistan Institute of Medical Sciences (PIMS), here on Tuesday. The lecture featured eminent child and adolescent psychiatrist Dr. Lubna Bukhari, who is currently practicing at the Staunton Clinic, Heritage Valley Health System, Pennsylvania. Dr. Lubna travelled to Pakistan in her personal capacity, spending most of her time counselling victims of the APS tragedy. The head of the Department of Psychiatry Dr. Rizwan Taj also spoke on the occasion.
As Dr. Lubna shared details of her clinical experiences with APS students, it became evident that mental health simply does not feature on the government’s list of priorities even though the country is stuck in a cesspit of recurring terror events. Five years ago, a PC-1 was submitted for the establishment of a National Psycho-Trauma Centre at the Pakistan Institute of Medical Sciences (PIMS); the document was revised at least five times, only to be shelved, indefinitely.
Dr. Lubna shared heart-breaking details of the impact of the APS attack on students, parents and teachers. “If there are 800 students at APS, 240 students can develop PTSD, a mental health condition triggered by experiencing or witnessing a terrifying event; this is a huge number for one institution,” she highlighted. Post-traumatic stress affects an estimated 2 per cent of adults and children after a natural disaster, and 30 per cent of adults and children after a terrorist attack or plane crash.
Dr. Lubna stated that while ordinary children have limitless ideas about the future, the traumatised children of APS have “lost the shield of invincibility” or basic trust. “They don’t trust the police, and do not count on anyone to protect them; not even their parents. They feel insecure at school; are fearful of attending classes; cannot concentrate on studies; do not want to study in the same classrooms as they feel they cannot escape; and prefer classes being held in the play area,” she said.
Dr. Lubna maintained that the APS attack has robbed students of hope. She narrated, “When a therapist told a 17 year-boy (who had lost his best friend) that he would see him next week, the student questioned: ‘How do you know you will be there next week? How do you even know that I will be there when I step out of this room?’ Now, a 17 year-old does not talk that way, unless he has lost hope.”
The child psychiatrist recollected that the energy of a majority of the students goes into re-working the past, which leads to feelings of guilt. “One student said he felt guilty because when he was leaving the APS auditorium, some of his critically wounded friends were still breathing,” Dr. Lubna shared. Many students also claimed feeling guilty being alive when hugged by parents of deceased friends. She underlined the need to restore self-worth and hope in students.
Dr. Lubna regretted that many parents are also highly de-motivated, and unable to cope with trauma. “Some parents are concerned; they know that a problem exists. Others are totally unaware and cling to fixated beliefs. In one particular instance, a mother narrated that her husband told their son “to end this drama; stop shedding tears; revert to studies; get good grades; and behave like a normal human being.” Dr. Lubna suggested that parents should neither have very high expectations of performance from their children, nor should they lower their expectations to a point where their potential to excel fades away.
Dr. Lubna said, since the act of seeking mental health services is still taboo in Pakistan, parents generally resist consulting a psychiatrist. “I was expecting a lot more people, but very few came forward to actively seek help,” she stated.
The psychiatrist also recommended the need to monitor teachers for effects of trauma. “Many teachers have accepted the workload of colleagues who have passed away. There have been occasions when teachers too feel they are unable to carry on. Yet, they are hard-pressed to complete the syllabus. This adds to their stress,” she pointed out.
Dr. Lubna shared that a majority of the APS students wants to join the Army so that they can kill terrorists and avenge the murder of their friends. “We need to change this mindset because violence begets violence, and in the long run, change has got to come from within youth themselves. We need to generate hope and build ways to deal with trauma,” she emphasized.
Dr. Lubna was of the view that while it is important to secure school buildings with raised walls, barbed wires, walkthrough gates, and security guards, the empowerment of students so that they are able to deal with life in a positive manner must precede all other interventions.
Many important topics came up for discussion during the question-answer session as well. Almost every participant agreed that the Punjab government’s visual tribute to the APS martyrs, in which the attack has been re-enacted, reflects very poor taste, and should immediately be withdrawn. Similarly, the ISPR song ‘Baraa dushman bana phirta hai jo bachhon say larta hai,’ which initially gained wide public acceptance, must also be withdrawn to save children from further trauma, it was recommended.
Earlier on, during a more generalised discourse on the subject, Dr. Lubna compared childhood trauma to diabetes. “As a complication of diabetes people develop heart disease, blindness, kidney failure, etc. Childhood trauma leads to number of mental changes that eventually develop into adult personality problems, psychotic thinking, extreme passivity, violence and self-mutilation,” she explained.
The psychiatrist also shared how preschoolers, school age children, and adolescents react to trauma. While school age children come to expect that life will be dangerous and they may not survive, adolescents can experience flashbacks, nightmares, and depression.
Dr Lubna lamented the non-existence of child psychiatry services in Pakistan. “To begin with, child mental health needs to be talked about in schools, as well as with parents and teachers. Group sessions can be arranged to build awareness around mental health issues. The media can play an important role here. We also need psychosocial centres, and most importantly, a child psychiatry department in a hospital,” Dr. Lubna pointed out. She also underlined the need for capacity-building of psychologists.
Earlier on, while referring to the economic burden of stress, Dr. Rizwan Taj said, it leads to an average work loss of 3.6 days per month, and an annual productivity loss of $3 billion.
Discussing the role of the media, Dr. Rizwan referred to the findings of a study conducted by PIMS. According to the research, which included 494 respondents from Islamabad, 29.5% of the people who watched coverage of traumatic events for more than one hour daily were positive for PTSD, and 47% for depression. Dr. Taj called for better understanding of psychosocial consequences of trauma on children, more research on long-term consequences, and age-appropriate culturally-relevant interventions.