Psychiatric Bulletin (2006) 30: 454-456. doi: 10.1192/pb.30.12.454
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 454-456
© 2006 The Royal College of Psychiatrists
When mountains weep: psychological care for those affected by the earthquake in northern Pakistan
Murad M. Khan
Department of Psychiatry, Aga Khan University, Stadium Road, PO Box 3500,
Karachi 74800, Pakistan, email:
murad.khan{at}aku.edu
Declaration of interest
None.
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Introduction
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Fate, it seems, conjures up all sorts of ways for us to be in a certain
place at a certain time. In 1982 as a trainee psychiatrist in the UK, I found
myself co-facilitating a group at the Castlewood Day Hospital, then part of
the Bexley psychiatric rotation scheme, in the south-east of London. Group
psychotherapy was part of our training. Held thrice a week the groups were
open-ended and patients ranged from those with interpersonal relationship and
personality problems to those with anxiety and substance misuse problems. At
the time the experience was somewhat baffling. Not only was I from a different
country and culture, my exposure to psychiatry was limited to about 12 months.
More often than not I felt lost as I tried to come to terms with ‘group
dynamics’, ‘reality testing’, ‘transference’,
‘multiple transference’, ‘group cohesion’,
‘group pressure’, etc.
I was fortunate to have an extremely skilled and experienced
co-facilitator, who not only guided the group through its various stages but
had the patience and tolerance to supervise and teach me as well. It was
therefore with a mixed sense of relief and trepidation when I came to the end
of the 6-month period, with the experience of group psychotherapy (like
learning how to fire a gun) safely tucked away in some remote corner of my
mind but hopefully never to be used in real life.
Twenty-three years later, I find myself sitting cross-legged on floor mats
under a UNICEF canopy in a remote area of northern Pakistan, which was
recently devastated by a massive earthquake measuring 7.6 on the Richter
scale. Thousands have died, thousands more are injured and millions are left
without shelter. It is a human tragedy of unfathomable proportions, compounded
by the nature of the terrain, with many areas inaccessible except perhaps by
helicopter.
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Emotional scars
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Sitting some 800 miles to the south in the coastal city of Karachi, we
watched the events unfold on our television screens. We were aware of the
psychological traumas many survivors would face. Unlike broken legs and arms,
many would have wounds that would not be seen but would scar them for
life.
A group of us - psychiatrists and psychologists - got together to discuss
how best we could respond. None of us had ever faced this kind of disaster
before and there were so few of us in the country that it would be virtually
impossible for us to address the problem. The best and perhaps the only viable
solution was to train large numbers of health professionals and volunteers in
counselling.
We quickly developed a training programme for the development of
counselling skills, using role-playing and experiential learning. We held the
first workshop in Karachi. More than 100 people applied for 60 places. As it
was the month of Ramadan, the workshop was held on three consecutive mornings.
The participants were incredibly enthusiastic and we received excellent
feedback.
Emboldened by the response we decided to conduct similar workshops in the
northern affected areas. However, logistical issues were a major problem. Who
do we train? Where will they be deployed? Who will supervise them?
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Noble intentions
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There is a saying in our part of the world that ‘if your intentions
are noble, God creates openings for you’. And so it was. Out of the blue
we had the general secretary of the Pakistan Medical Association (PMA) drop by
on the second day of our training. He had visited the affected areas and told
us of the large numbers of people in need of someone who could listen and hear
their stories. In collaboration with a non-governmental organisation (NGO), he
had organised a group of about 30 volunteers who could carry out counselling
of survivors in camps and hospitals. He requested us to do the training.
Three of us decided to go to the northern areas. Landing at Islamabad we
were on our way to our first stop in Abbottabad, some two hours drive. In
Abbottabad we saw the first signs of the earthquake. The boundary wall of the
main teaching hospital - the Ayub Medical Complex - had collapsed and the
upper floors of the hospital had sustained damage. Many patients were being
treated in tents put up in hospital grounds. We saw some other collapsed
buildings in the city.
The next day we went to Mansehra, a town of about 100 000 people, which was
spared major damage but had received large numbers of casualties from the
surrounding villages. The hospitals were overflowing with patients, and tents
had been set up in grounds to accommodate them.
We conducted our first training workshop in Mansehra for a group of about
18 people. They included survivors of the earthquake, people working with
survivors and some from various NGOs operating in the affected areas. Some of
the stories we heard from the survivors gave us an idea of not only the
magnitude of the destruction but also the suddenness of the quake, which was
truly amazing. There was no warning, thereby resulting in a huge number of
casualties and injuries. The death toll kept climbing to almost 100 000, as
more and more affected areas were reached. Tragically, half of those killed
were children, most of them crushed to death in their classrooms.
The workshop went well and participants gave us useful feedback. For most
this was the first time they had participated in anything to do with
nafsiyat (psychology). They were all eager to learn and to help
others but also to understand what they themselves were going through.
On the following 2 days we conducted two more workshops - one each in
Abbottabad and Islamabad – to groups of volunteers and staff of various
NGOs.
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Weeping mountains
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The following day we were taken to Balakot, a bustling town high up in the
mountains, which in other times must have been a spectacular place and a
compulsory stop for tourists. Surrounded by mountains on all sides Balakot is
located in a valley with the River Khunar running through it. Now it seemed as
though a giant had walked through it stepping on each and every building. Such
was the devastation that not a single building was left standing. Many bodies
lay buried under the rubble. Many people had refused to move away, waiting for
the rubble to be cleared so that their loved ones could be properly buried.
Many people walked around as if in a daze and others sat around staring in
space. One had to be there to believe what we saw. The contrast between the
destruction on the ground and the stunning scenery surrounding Balakot was
almost surreal.
Landslides following the quake had shorn the mountains of their dark
surface layers, exposing the lighter inner layers. From a distance it seemed
that even the mountains were weeping. Yet, amid the ruins we could see signs
of life returning to normal. We saw a roadside barber giving a haircut to a
customer. Fruit and vegetable vendors had set up stalls in the ruins of the
destroyed buildings and there were many buyers. This was only a few yards from
the relief camps where anyone could go and register and would have received
free food, shelter and medical care.
Life, it is said, is relentless and people are resilient.
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Stories of grief, stories of courage
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We then went on to Ghari Habibullah, another picturesque place where three
rivers meet, now turned into a giant relief camp catering for more than 2500
people. We met different groups of people there. There were women and men,
young and old, pre-school and school-age children and elderly people. All had
lost something. Some had lost their houses but their families had survived,
whereas others had lost all close family members but their houses had been
spared. There were many who had lost both. There were children who had lost
both parents and parents who had lost infants and young children.
The stories we heard were heart-wrenching. Almost everyone we met told us
they felt it was doomsday as the deafening roar that accompanied the shaking
of the earth, the sight of mountains literally falling apart, the sudden
darkness because of the dust in the air, the destruction around them and the
fact that everyone was only concerned about trying to save himself or herself,
were all things they had been told would happen on the day of judgement.
We heard stories from teachers who lost all the children in their class
when the roof suddenly collapsed on them. Many told us how helpless they felt
and how the voices of the children from under the rubble went on for up to 3
days before dying down. Many told us how they were haunted by the voices which
prevented them from sleeping at night.
Many mothers told us of how their infants died as a result of falling
debris while they were outside either washing their clothes or working in the
fields nearby. The bodies of some had been found but many remained buried
under the rubble. There was no way to retrieve them as there was no
heavy-lifting machinery available in the affected areas.
We heard stories from children whose parents had perished and who had
become orphans in a matter of seconds. They had no idea what the future held
for them. Some had family members who were half-buried and they had tried
everything to get them out. Almost all of them had died from blood loss from
their leg wounds.
We heard stories of how many women who had sustained spinal cord injuries
and had become paraplegic were abandoned by their husbands who considered that
they had become ‘useless’. There were also stories of courage as
many people risked their lives to pull people from the rubble, of how people
refused to break their fast despite sustaining severe injuries and how they
got organised and helped each other.
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Humbling experience
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Story after story. Everyone we met had incredible stories of grief and
tragedy, of lives turned upside down in a matter of seconds, of the voices of
their loved ones crying out for help from under the rubble and of their utter
helplessness to do anything. However, their stories were also of courage and
fortitude, of their amazing faith in their religion and God, of their
acceptance of the event as an act of God, and of their refusal to apportion
blame or show anger towards anyone.
We listened to all the stories. Some people were more vocal and expressive
than others. Some wept openly, others sobbed silently. However, everyone we
met had a story they wanted to share. Wherever we went people wanted to keep
on talking and wanted someone to listen to them. We listened as much as we
could. We listened until there were no more stories to tell and no more tears
to shed. We listened until we were completely drained emotionally. It was one
of the most humbling experiences of my life.
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From Castlewood to Kashmir
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As I sat there in the camp in Ghari Habibullah, surrounded by the mountains
and the stunning scenery, listening to the incredible experiences of these
brave people, I could not help but think of my time in group psychotherapy at
Castlewood Day Hospital all those years ago. All the processes experienced
then could be witnessed here as well, but these were groups beyond training,
beyond experiential learning and beyond role-playing.
On the long drive back to Abbottabad a thousand questions crossed my mind.
How can so much tragedy befall so many innocent people, so suddenly? What
justification is there for so many young innocent children to die? How do you
erase the trauma of what your eyes saw, what your ears heard, what your hands
felt and what your mind experienced? How does one pick up the pieces of
one’s life after a calamity of this proportion? Where does one get the
strength to carry on after losing one’s loved ones, one’s house
and one’s community? Can a people ever recover from a tragedy of this
magnitude? Listening to the accounts of these brave people of Kashmir, there
is every reason to believe this too can be overcome.
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Acknowledgments
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Members of the team included Professor Syed Haroon Ahmed, Pakistan
Association of Mental Health, Karachi, Dr Mohammed Naim Siddiqi, Aga Khan
University, Karachi and Dr Murad Moosa Khan, Aga Khan University, Karachi.
eLetters:
Read all eLetters
- Mental health needs of India
- Rajvinder S Sambhi
- PB Online, 16 Feb 2007
[Full text]
- Neglect of mental health care in India and Pakistan
- Murad M Khan
- PB Online, 26 Feb 2007
[Full text]
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Introduction
Emotional scars