A Pakistani doctor helps people cope with the trauma of extremist violence
By: DR. MIAN IFTIKHAR HUSSAIN/GUEST AUTHOR
About the author: Dr. Mian Iftikhar Hussain has been running the Iftikhar Psychiatric Hospital in Peshawar, Pakistan, since 2003. From 1985 to 2010 he worked at the Sarhad Hospital for Psychiatric Diseases. He has served as a consultant psychiatrist for the Khyber Teaching Hospital, Lady Reading Hospital and several others in the region. He is a member of the executive committee of the Pakistan Psychiatric Society and an international member of the American Psychiatric Association.
A man in his mid-20s who was suffering from severe panic attacks as a result of post-traumatic stress disorder (PTSD) was brought to me by his family. He had been riding with five friends in a Jeep in the southern part of Pakistan’s Khyber Pakhtunkhwa province when the Taliban attacked. The vehicle was riddled with bullets, and he watched three of his friends die in the hail of gunfire. The Jeep burned, but he and one friend were able to jump out and survive.
The young man is just one of the thousands of civilians coping with deep psychological scars caused by extremist violence.
Source of the problem
The psychological impacts of terrorism in the Khyber Pakhtunkhwa province of Pakistan must be examined from the psycho-socio-economic perspective rather than as an offshoot of terrorism alone. This will also be helpful in the search for possible remedies. Primarily, it is the byproduct of the Afghan war. The phenomenon of “Talibanization” spread from Afghanistan to Pakistan over a border thousands of kilometers long in a tough, hilly region that serves as a safe haven for terrorists. Other factors contributing to terrorist activities in the Khyber Pakhtunkhwa province are poor living conditions, such as high unemployment and lack of developmental projects and education.
At one time, there was a strong system of traditional “jarga,” or councils of elders, that would settle all the matters and conflicts within the tribal community and act as law givers. But in the initial stage of terrorism, almost all the elders were either killed or forced to migrate and the vacuum was filled by the Taliban. All this provided a solid foundation for the nourishment of terrorism. And so a very distorted, ugly and chauvinistic shape of extremism evolved.
The initial wave of terrorism created strong feelings of fear, terror and insecurity as suicide bombings, targeted killings, kidnappings and brutal public executions were propagated in videos. At the mercy of terrorist organizations and suffering the loss of the so-called writ of the government, many citizens were left with feelings of insecurity, vulnerability, helplessness and hopelessness. All this has led to greatly increased rates of generalized anxiety disorder, phobic anxiety disorder and panic disorder, which are generally associated with threats to one’s life or the lives of those near and dear. The risk of economic loss and loss of prestige also can trigger symptoms.
After the violence
By my assessment as a practicing consultant psychiatrist, the numbers of psychological/psychiatric cases have increased up to fourfold. Patients have been showing symptoms of marked anxiety, difficulty going to sleep, irritability, intolerance, aggressiveness, temper tantrums, lack of concentration, restlessness, tremulousness, palpitation, sweating, muscular tension, various somatic symptoms and sexual dysfunction. Patients have developed marked social phobias and agoraphobias. They avoid going to gatherings and public places. This adversely affects their quality of life and quality of work. The intolerance and irritability in society in general and in psychological/psychiatric cases in particular have increased.
Children usually develop phobias of going to school and exhibit signs of marked irritability; intolerance; aggressive behavior; fighting with siblings, parents and other children; stubbornness; noncompliance; disobedience; manipulative behavior; sleeplessness; lack of appetite; and lack of interest in leisure activities. Children also express their feelings of aggression through body language by fighting and also by performing the roles of violent characters while playing with other kids. Some teens, snubbed by their parents and teachers over lapses at school, have committed suicide.
Other cases of PTSD are emerging in people who have witnessed catastrophic events such as suicidal bombings or who, like children, have been exposed to such violence on television. They show signs of insecurity, hyper arousal/vigilance, flashbacks, panic attacks, avoidance of places or any cue that reminds them of violent events, restlessness, lack of concentration and nightmares.
Many patients also exhibit depression, which in my practice is generally a syndrome associated with loss. Such patients have lost close relatives, their homes, property, businesses, social status and families. Some have even lost organs or other parts of their bodies. Such patients suffer from loss of sleep, loss of appetite, decreased libido, loss of pleasure, as well as loss of interest, motivation and confidence. They are negative thinkers with ideas of guilt, death wishes and suicidal ideations. A few young adult patients were brought to me with ideas of going to Afghanistan for jihad, an act that is religiously and culturally approved, with underlying motives to commit suicide as the result of depression.
Almost 56 percent of the population in Pakistan is younger than 25. Children and young adults, in the process of developing their personalities, are more vulnerable to psychological and psychiatric problems. Moreover, they have not gained enough experience to cope with stressful events. Terrorism interrupts, disrupts and adversely affects all stages of the developmental processes in children. The various psychological traumas can hinder the mental and physical growth of children, their autonomy, self-confidence, capability of exploration, creativity, novelty of thought and positivity in perception and behavior. Such children grow up with marked long-lasting phobias, lack of initiative and confidence and decreased achievements relative to their inherited potential. Severe and persistent stressors can lead to various physical illnesses, such as peptic ulcers, asthma, ischemic heart diseases, arthritis and overall weakening of the immune system.
Because of socio-economic losses and overall deterioration of life, survival has become more difficult. It has paved the way for all sorts of crimes. I would like to say that our society is speeding more toward “de-civilization” than to full anarchy. Drug dependence, especially on cannabis, and the use of anxiolytics drugs have increased tremendously. Psychological traumas caused by terrorist acts have caused stable psychotic patients to relapse.
Individual stories
The experiences of some of my patients help illustrate the issue.
- In one case, a child about 14 years old watched a video of a man slaughtered by the Taliban after he was deemed a spy. As a result, the child developed severe panic attacks.
- A man about 40 was kidnapped in Miranshah. He belonged to the family of a key social leader. He was chained and held in captivity in a cave for almost a year in very bad conditions along with others. Eventually he was able to escape from the clutches of Taliban, but was left with marked generalized anxiety disorder.
- A teenager, about age 16, was kidnapped on the outskirts of Peshawar by Taliban and criminals. He was physically and mentally tortured for 40 days, plied with narcotics and then thrown away after his captors received a ransom. When he was admitted to the hospital to see me, he had very severe PTSD, was experiencing panic attacks, screaming and repeatedly attempting to run from the hospital because of repeated flashbacks.
- Another young adult about 24 years old developed marked generalized anxiety disorder when, along with other family members in Waziristan, he took weapons and followed a group of Taliban that had kidnapped one of his brothers. Upon encountering the Taliban, he and his family were forced to surrender their weapons. When he turned back, he discovered another brother lying on the ground, shot dead in a pool of blood.
People dealing with severe, prolonged and sometimes lifelong bereavement represent another category of victim from extremist-based violence. Normal grief of a natural death usually lasts a maximum of six months.
Funeral rituals and burial help family members come to terms with the departure of the deceased. For people dealing with losses stemming from terrorism, bereavement is more intense. For example, a mother came to me in June 2013 for consultation after suffering from bereavement for five years. Her son and his cousin had been missing since December 2008 following a suicide bombing of a Peshawar market. The family had searched every hospital, every market and every police station but in vain. The mother continues to look in the hope that her son may be alive and return one day.
Personal captivity
I, my family and my friends have also passed through great physical and psychological traumas. I was kidnapped by force on the night of September 8, 2009, while leaving my hospital. Those first moments were terrible for me as I realized I was losing my freedom. All of sudden I decided not to compromise, even at the cost of my life. I told one of the kidnappers to go ahead and shoot me, as he pointed a pistol at my chest to persuade me to sit in the car I was refusing to get into. I was pushed into their car and masked, handcuffed and eventually chained by one leg to a bed for 11 days.
Five of the kidnappers once staged a “drama” – pretending to slaughter me by firmly holding a big curved knife around my neck, with a bucket placed under my bed to collect my blood. It was captured on video. My family was constantly terrorized by threats that I’d be slaughtered and my body cut into pieces and sent to them. The kidnapping was retaliation for a large number of articles I published in local newspapers against Talibanization and terrorism. I had also participated in dozens of interviews and on panels as an expert speaking out on the psychological impacts of terrorism.
My friend and professional colleague, Dr. Muhammad Farooq, my partner in many of the talks and who stood at the forefront against Talibanization and terrorism, was assassinated in his own clinic a few years ago in the city of Mardan.
Countering the problem
We need short-term and long-term strategies to counter terrorism. Communities, nongovernmental organizations, governments and militaries each have roles to play. The short-term strategy includes imparting awareness and information about the different aspects of threats and events of terrorism to the community, its preventive measures and how to respond at the time of a terrorist event to minimize the damages and maximize safety. We also need more disaster management centers, emergency hospital departments, and counseling centers at different levels to cover the psychological, social and economic aspects of post-terrorist events with multifaceted approaches to help victims and their families.
The long-term strategy involves simultaneous establishment of accountable, genuinely elected democratic governments, and the military must fall under the authority of civilian government. All political parties must agree on a one-point agenda to stand against terrorism. We also need to support the eradication of corruption, provide justice, create economic and social prosperity, provide career-building opportunities for youth, increase education particularly for females, gradually replace the huge network of religious educational institutions with formal government schooling and introduce healthy activities such as sports and the arts. We need to expose terrorists organizations, alienating them from the masses by cutting off all their sources of support and eliminating them militarily.
Ultimately, we need to amend the Pakistani constitution regarding the noninterference of religion in affairs of the state with the slogan: Religion belongs to everyone, and the state belongs to all.
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