Violence, Psychological Trauma,
Muhammad Tahir Khalily PhD, Senior Clinical psychologist Department
of Psychology and Addiction Treatment Unit Mental Health Services Roscommon
HSE (west) Ireland. Email:
Suzane Foley, Clinical Psychologist in Training, Doctoral Programme School of Psychology National University of Ireland, Galway.
Ijaz Hussain, MRC Psych, Specialist Registrar Psychiatry Mental Health Services Nenagh Ireland.
Maher Bano, PhD, Chairperson Department of psychology University of Peshawar Pakistan.
Muhammad Tahir Khalily PhD
Senior Clinical Psychologist
Clinical Psychologist in Training,
Ijaz Hussain MRC Psych
Specialist Registrar Psychiatry
Maher Bano PhD
The aim of the article is to explore the extent of the current violence in Pakistani society as a consequence of the global war on terrorism, and the resultant physical damage and high incidence of psychological trauma among survivors.
It also examines models of mental healthcare system response, which do not exist currently nor exist at the policy level. In fact, there is no indication that planning to address this problem is in the pipeline of government planning.
The paper also proposes a comprehensive treatment modality in line with international standards to meet the current challenges in collaboration with non-governmental organizations on an emergency basis. It is also suggested that a centre of excellence to train mental health professionals, and policy makers about this burning and important issue.
At the dawn of the 21st century, it was thought that it would be a century of civilization, knowledge, reasoning, dialogue, cyber technology, free communication among the nations and the so-called globalisation and above all a century of peace. However, war, ethnic violence, crime, massacres, prejudice, discrimination and racism continue to reign in most parts of the world. Physical, emotional and sexual abuses are endemic (Somasundaram, 2004), and intimate relationships disintegrate under the impact of uncontrolled anger (Khaled, 2004). In fact, the anger problem is not confined to a specific group or community but prevails throughout the world ( Cardozo et al., 2004 ). Psychological effects of a certain magnitude will affect almost all who are exposed to it (Scurfield 1985) or have the potential if under enough stress or strain (Beck, 1999).
However, the current wave of violence and aggression in Pakistani society and particularly in the Swat Valley of the Northwest Frontier Province (NWFP) of Pakistan is not a simple phenomenon (Medicines Sans Frontiers, 2008). Suicide attacks, explosions, and even safety precautions such as long curfew hours have caused damage on an unprecedented scale. The local inhabitants are experiencing a heavy battle between the security forces and insurgents; therefore there is no real protection. In addition to the continuous violence and threat to life, there has also been a damaging effect to the psychological health of many people (Haq, 2009). Psychological trauma is on the rise, prevailing in the whole area (Medicines Sans Frontieres, 2008). As a result, individuals are manifesting a number of symptoms of psychological trauma, which is impacting on all aspects of their lives.
Therefore the article aims to highlight the current persistent violence in Pakistani society as a consequence of the war against terrorism, with particular focus on the District of Swat and its potential link to psychological trauma. Previous research indicating effective models of healthcare in similar war situations, are also examined to provide an evidence base for models to be used in Pakistan. Finally possible strategies to help to provide psychological support are discussed.
There has been an increase in violence over the past 3 years in Pakistan. Data obtained from the Institute for Conflict Management (2009) shows an increase in suicide attacks over the past 3 years (See Figure 1.) The number of fatalities, which include civilian, armed forces, and insurgents (Terrorists), are also increasing year on year (See Figure 2). The Swat District in particular has considerably higher fatalities in the past year (Haq, 2009). Moreover, the residents of that district are caught between the actions of insurgents and government reprisals, as well as being exposed to danger during combat operations between the security forces and insurgents. As a consequence, people are feeling a great sense of helplessness and experiencing psychological trauma in addition to the severe physical damages. The severe prolonged massive-scale war, and associated abuse of power, sense of helplessness, pain and severe losses, inevitably inflicts a severe psychological trauma in the survivors of the violence.
Figure 1: Suicide Attacks in Pakistan (2006-2009)-(Institute of Conflict Management)
Figure 2. Terrorism related fatalities in Pakistan 2006-2008 (Institute of Conflict Management 2009)
Psychological trauma is a unique individual experience of an event or the enduring of conditions where the individual experiences a threat to life, bodily integrity and sanity and is in danger of annihilation and mutilation (Pearlman & Saakvitne, 1995). However, the continuous traumatic situation in Pakistan results in psychological disorders that could be acute or chronic and manifest themselves in different forms and subsequently affect the lives of the survivors.
Historically, trauma-related difficulties have been continuously observed since the 19 th Century (Gelinas, 1983) and many disorders have been identified that constitute difficulties as the sequel of extreme stress. Although, the impact of trauma can be different for individuals, in war-like situations where individuals are exposed to the same stressor of the same magnitude, the result could be a collective trauma for the whole population (Somasundaram, 2004). Nevertheless, the manifestation of the symptoms can be different in terms of interpersonal or social issues, physical or behavioural problems, substance abuse, and symptoms of psychological disorders. There is strong evidence to suggest that psychological disorders are a likely response to such a violent situation (Institute of Conflict Management, 2009)
The immediate symptoms reported by survivors to such considerable emotional distresses or to trauma range from extreme fear, anxiety and anguish to shock and disbelief (Green, 1993). In the first instance the victims need medical attention, emergency safety shelter, food and drinking water and financial assistance, etc. to protect against further harm and prevent deterioration (Resnick, Acierno, Holmes, Dammeyer, & Kilpatrick, 2000). However, a large number of people can develop psychological problems (Gray, Maguen, & Litz, 2004) following such traumatic events that need immediate psychiatric intervention. While some individuals demonstrate a remarkable resilience to cope with such situations, the majority of the survivors need early interventions in this critical moment of life (McCaughey, 1987; Sokol, 1989).
It is still too early to assess the full psychological effect of the war on the people of Swat. However previous research indicates a high incidence of psychological issues following such wars (Cardozo et al., 2004; Khaled, 2005; Somasundaram, 2004 ). It is important to learn from history and previous research to inform what can be done over both the short- and long-term to cope with the psychological emergency and identify strategies to help to provide psychological first aid and a comprehensive treatment plan in line with the international standards (Gray, Maguen & Litz, 2004).
Studies in Afghanistan (Cardozo et al., 2004), Sri Lanka (Somasundaram, 2004), and Algeria (Khaled, 2005) were carried out after almost similar war-like situations to establish the potential link of the aftermath to psychological issues. The studies indicated a high rate of prevalence of somatizations, depression, anxiety and post-traumatic stress disorder (PTSD) among the survivors. They further found a gross deterioration in social and ethical values in the communities, shown by an increased incidence of relationship problems, child abuse, violence against women, crime, brutalization among individuals and the abuse of drugs and alcohol.
It is also highlighted that the impact was found to be wide-ranging and included individuals, families and the communities at large. In these studies another important factor was pointed out regarding the response of mental health services. It was indicated that despite the increase in psychological issues, there is a lack of resource provision in mental health care facilities, non-availability of trained professional staff and a lack of realization at the policy level. For instance there is no awareness program (Psycho education) in place or basic psychological skills training for the community workers. There is also poor coordination and networking between the governmental and non-governmental organizations working for the rehabilitation. As a consequence many activities were done in isolation and scattered. A need of effective social assistance and culturally compatible interventions in dealing with trauma were highlighted (Khaled, 2004, Cardozo et al, 2004).
Indeed, emotional and psychological reactions of the survivors to such tragedies are unavoidable and are considered normal human emotional responses in times of such tremendous jeopardy (Gray, Maguen, & Litz, 2004). Therefore there is a need to explore effective and evidenced based treatment strategies and to educate policy makers particularly the healthcare management about forward planning to adopt short and long terms measures to deal with such calamity in time and effectively.
A systematic review search ( Mulrow, 1995) was carried out and identified studies in areas with similar war situations as Pakistan. The studies identified evidence-based treatment approaches that might suggest immediate, short- and long-term psychological interventions in the context of treatment policy and service development.
Subsequently it was explored that in addition to the emergency services, psychological first aid that includes information for emergency services, and provision of emotional support and meeting of pressing practical needs are very important (Litz, Gray, Bryant, & Adler, 2002). In the case of acute post trauma, Psychological Debriefing (PD) should be provided soon after the traumatic events, to allow the victims to express their reactions in the presence of mental health professionals in a supportive and safe environment. Critical Incident Stress Debriefing (CISD) is a part of this intervention (Mitchell & Everly, 1996) that could help to prevent PTSD by enhancing the interconnection among neural networks in the brain (Cozolino, 2002). In addition, Forward Psychiatry for combat stress in the immediate period of the battle when the soldiers’ capability to continue fighting is essential to the achievement of military goals (Solomon & Benbenishty, 1986). However, the availability of forward psychiatry services in a civil framework and run by civilian mental health professional would be more friendly and effective to the clients.
To lessen the chances of morbidity of the high-risk population, Crises Interventions (Raphael, 1977) and CISD (Mitchell & Everly, 1996) are needed to educate the survivors about the stress reactions, and to distinguish between normal reactions from the traumatic reaction and to provide information about further intervention if necessary. Through this intervention, the individuals could be referred for further assessment and trauma counselling with the aim to heal the psychological hurt and to put off any developing PTSD (Raphael & Dobson, 2001). Further, more extreme and prolonged stress results of chronic PTSD reaction could stimulate the production of endogenous opiods, and consequently would increase incidents of self-harm and suicide (van der Kolk, 1988). There is some other evidence that chronic PTSD may increase substance abuse (Acierno, Kilpatrick, & Resnick, 1999); Kosten, Fontana, Sernyak, & Rosenheck, 2000). CISD has been found effective for such cases (Cozolino, 2002). However, the above-mentioned interventions do not exist currently in the Pakistani healthcare system and there is a lack of realization for the need of these services at the policy level (Haq, 2009).
Considering the psychological trauma as a result of the current violent situation in Pakistani society, it is necessary for mental health professions to demand system-based interventions in collaboration with different governmental agencies, religious support groups, community-based organizations and non-governmental organizations to deliver appropriate services. The time frame for such intervention is not automatically clear; the interventions depend upon the circumstances, availability of infrastructure and resources and technical know-how. A model has been drawn up in line with the international standards, which include evidence-based interventions (Gray, Maguen, Brett & Litz, 2004) and are depicted below (Figure 3).
The proposed model integrates different agencies under one umbrella, to provide information and to create awareness, cater for immediate psychological aid, screen individuals for further appropriate intervention, and educate and update the mental health workers through training and workshops. This integrative strategy aims to promote confidence, social support and deep understanding of the different roles in a joint venture and a referral pathway would be created composed of family members, Ulemas (religious leaders), school teachers and general practitioners underpinning better coordination.
However, to date the healthcare system does not have any proposed interventions and there is no plan to introduce such psychological trauma services. Even the security forces are deprived of these interventions. There is an immediate need for policy makers and healthcare providers to seriously consider the availability of these interventions on an urgent basis. However there is a dire need (Haq, 2009) of a focal organization for monitoring and human resource development to pursue the availability of these services persistently. It is therefore suggested that a centre of excellence at the University Level be established for psychological trauma to study this problem in depth in the context of religious and cultural norms and to provide intensive and long-term training for the mental health professionals to ameliorate this complex situation efficiently and scientifically. The centre would explore treatment strategies compatible with people’s beliefs in procedural treatment such as the non-invasive treatment modality known as Neurofeedback (Othmer, 2007) in addition to psychiatric treatment and talk therapy. The centre would also organize short courses, seminars and workshops to create awareness in the people in general and particularly to sensitise policy makers to play their role in the development of psychological community services in collaboration with international and national organizations to meet the current demand and challenges.
Last but not least, the international organizations should come forward to assist the health sector of the government of Pakistan in this complex situation as a consequence of global terrorism.
The traumatic situation in the northern part of Pakistan and particularly in Swat is unprecedented. Consequently a severe psychological trauma in the survivors is inevitable. It is also evident from the previous researches that emotional and psychological reactions to such tragedies are unavoidable. Howevere, the current violent situation in Pakistani society is not a simple phenomenon. It is a serious and complex problem of high magnitude, which will need multidimensional strategies to deal with it effectively and scientifically. Community level strategies and interventions could undo the effects of communal trauma. Psychological treatment is one of the most important aspects of the multifaceted strategy. Currently the psychological services in response to such traumatic situation do not exist in the healthcare system. The availability of these interventions (proposed above) is a dire need for this suffering community, to heal their psychological hurt as quickly as possible before it gets worse or develops into chronic PTSD. These include awareness programmes such as psycho education for general public and exposed population, psychological interventions, and basic psychosocial skills training for community workers. In addition there is a need of coordination between governmental and non-governmental organizations to rebuild community structures, to ensure social justice and human rights and to encourage non-violent conflict resolution strategies. A resource centre at the university level for continuous professional development and scientific and academic activities is suggested.
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Massey University, New Zealand
28 June, 2011