Thursday, January 28, 2010



       With Haiti now much in disarray with its people suffering from a major earthquake, what can we expect in the coming weeks and months about the emotional reactions of the victims as they struggle to recover?
        In the Oklahoma City National Memorial and Museum built after the 1995 Oklahoma City bombing, we have excellent follow-up and documentation of what the human response is to disaster.
        Is the behavior documented at the memorial a model of what we can expect of individuals from other countries? Are the emotional responses the same for those whose lives are devastated by another type of trauma?
        My international experience with disasters as a psychologist and team member with the University of Missouri’s International Center for Psychosocial Trauma would lead me to say definitely yes to both questions. As humans our responses to near-death experiences, to the loss of loved ones, and to the destruction of our way of way of life have much in common. The exhibits at the memorial, which I toured this month (January), are arranged to let us see what those emotional responses are over time.
       The Memorial Museum covers three floors of one end of the former Journal Record Building also damaged in the explosion. I started the tour on the third floor where the scene is set by taking us to the hour before nine a.m. on April 19, 1995. It is a peaceful day; we see scenes of the city and what is happening outside and inside the building.

168 lighted chairs sit on the south lawn of the Memorial inscribed with a name. 19 smaller chairs represent the children killed. Image from Wikimedia Commons.

        Next we enter a quiet room where the one recording made that morning is played. A case is being brought for permission to use ground water from under a home to bottle water for sale. Two minutes into the meeting there is an explosion, the room goes dark, and then on the wall are flashed the faces of the 168 people killed in the explosion. It takes my breath away.
       Appearing on a screen in the next room are images of chaos and destruction taken from a helicopter when it still was not known exactly what had happened. We learn 700 people were injured, nine other buildings were destroyed and 25 were seriously damaged. In the background we hear police and emergency calls and reporters describing what they see. Hovering over all is a sense of confusion.

The Alfred P. Murrah Federal Building after the bombing. Image from Wikimedia Commons.

        As we pass through the debris-filled rooms on the third floor, we are listening to comments by three groups of people: (1) those who survived the immediate explosion and destruction, (2) those who had lost loved ones in the explosion and (3) the first responders who dug out the bodies and attended to the injured and dying. The interviews on the large screen televisions are high definition, which gives scenes an almost three dimensional quality.

Survivors of the bombing
        The interviews indicated that the immediate response of the survivors was confusion and shock. It was difficult for them to know what had happened. Some came out of the confusion quickly and began to look for an escape route out of the building and to help others make their escape. Much of the initial rescue work was done by victims. Most of the initial injuries of those who survived were caused by flying glass and stone and flames from the explosion. Eye injuries were common as were injuries from imbedded glass.
        Stories from survivors focused on how they helped and were helped. One blind man led some others out because the air was so filled with smoke they couldn’t find their way out and he could. Many stories stressed how people acted bravely and cooperated well.
        The most horrendous stories came from those trapped under the rubble. They had needed to talk themselves into remaining calm. “I’m still alive, I can’t quit, I can’t fall asleep.”
        Once out of immediate danger victims felt relief, but then they thought about how close they had been to death. “The man next to me died. It was matter of inches.” “All six of my staff were crushed under the rubble.” It became clear that who died and who lived was often dependent upon some change in normal behavior that changed physically where they had been--a doctor’s appointment, a stalled car, or coming early to an appointment at the building.
        Early after the bombing most of this group reported intrusive memories of the experience and hyper arousal. That is, any cues that reminded them of the experience caused anxiety and in some cases flashbacks. Many felt numb and tried to avoid thinking about the incident. Many of the survivors had to undergo long term rehabilitation because of their injuries before they could get on with their lives.
        All felt that the bombing had changed their lives. A follow-up study found 34 percent still suffered from post-traumatic stress disorder years later. Some mentioned in their interviews that they felt surviving the incident had made them stronger.

Relatives of the deceased
        The responses of the relatives of the deceased were initially of loss and grief. Some had been panicked about finding their wives, husbands or children in the rubble. For some it was a matter of waiting until the bodies were found; and until the bodies were identified, they still held out hope that their loved ones were alive.

Memorabilia left by visitors remains on the fence out side of the Memorial

        As a result great care was taken with the recovery of bodies, even to the point of endangering the rescuers, so that bodies would be in the best possible condition. All methods possible were used to make correct identifications. In the end only one leg remained unidentified; it may have belonged to a 169th person.
        This group saw their suffering as different from that of the first group, which led to some disagreements as to how the memorial should be designed. This second group had a strong belief that only someone who had lost a loved one would be able to understand what they were experiencing. At one point both groups saw themselves as different from each other, but as time passed they recognized they were all sufferers from the bombing.

First responders
        To preserve the bodies the diggers worked slowly to remove the debris. The pain of survivors waiting for their loved ones to be recovered affected how carefully the workers took their task. Dogs had been brought in to sniff out live bodies
        The emotional responses of first responders, police, firefighters, medical personnel, are often overlooked. After all, rescue work is what they were trained to do. Some did not want to admit they were responding emotionally to what had happened, but they talked about the nightmares and the flashbacks indicating the bombing had had a big impact on their lives. Some doctors had to amputate limbs without the use of anesthesia. One tells the story of amputating a leg where he had to lie in an awkward position on the victim while working with dull instruments.
        We learned about critical incident stress and how it affects the first responders, and how they need to defuse by talking about their experiences. The Red Cross had been available for debriefings, but not everyone had wanted to talk about painful material, thinking it would only make them feel worse. Because of the resistance the debriefings were provided anonymously as much as possible because professionals don’t like others to know how much they are affected by death and destruction.
        Of the rescuers one was killed by falling debris and 26 received severe enough injuries to need hospital attention.

The Survivor Tree, an American elm was one of the few things to survive the blast.

One of the gates of time overlooking the reflecting pool

       On the second floor a film showed how Timothy McVeigh was caught almost by accident when he was stopped for driving without a car license and he indicated he was carrying a loaded gun. Only because he was held an extra day was the FBI able to find him so soon after the explosion.
       Two rooms have special impact. One has pictures with mementos of all 168 who died. In the other room the focus is on how to spot a terrorist attack. One section has each of the major television news anchors telling what their reactions were to the bombing, what it meant, and what their thoughts were about terrorism.
       The documentation at the memorial gave a picture that was consistent with my experiences working in trauma zones: earthquakes in India and Pakistan, Katrina and the tsunami in Indonesia and Sri Lanka.
       From a mental health point of view the memorial gives the visitor important information that will fit any major catastrophe whether it be an earthquake, a hurricane or a terrorist attack. These interviews reveal how humans respond to life threatening events or events in which their loved ones are killed or injured.
        I came out of this memorial emotionally exhausted, but knowing more about what it is like to undergo a major life threatening experience or to lose someone close due to a sudden and unexpected calamity.

Personal background
       In the summer of 1995 fifteen teachers from Oklahoma City attended a two month workshop the International Center for Psychosocial Trauma was running in at the University of Missouri.  The participants included 30 teachers and doctors from Sarajevo, Bosnia.  This was my first experience with the center and demonstrated to me how universal people's responses are to disaster.   Later I went down to Oklahoma City with Kathy Dwein to run some additional training and I stayed over to visit the site with Dr. Paul Heath, a Veteran's Adminstration Psychologist who had been in the Murrah Building when it exploded.  Glass was still working it way out of his neck at that time.  When we were at the site he told the crowd gathered there that he was one of the surviors and they indicated a great deal of interest in hearing his story.  That interest in what happened has continued to be high and the site has 300,000 visitors a year.

Monday, January 11, 2010

Saddam Hussain's Grip of Terror


       Our contacts with Iraq came after the American army invaded the country and removed Saddam Husain. Teams from the International Center for Psychosocial Trauma were not allowed into Iraq because of the danger. Instead physicians were brought to adjoining countries for training conferences on the recognition and treatment of post-traumatic stress reactions. Meetings were held in Kuwait, Jordan, Turkey and United Arab Emirates. This first report is the center’s initial contact with Iraq physicians in 2003. The final report in this series on Iraq will be an attempt to explain the suicide attacks by the insurgents.

Psychiatric cases overwhelm nation.

       Even though Dr. Arshad Husain, as the director of the International Center for Psychosocial Trauma, had been to most of the major zones of conflict in the since 1994 years, he found the stories of torture and abuse told to him by the Iraqi physicians who were participants in this training program among the most disturbing he had encountered. He told me that "The stories of Saddam Hussein’s terror tactics I heard from Iraqi psychiatrists caused me to have symptoms of post-traumatic stress.”.
        Arshad had met with the group of psychiatrists from Iraq in Kuwait, along with an international array of mental health workers for a round-table discussion of "Iraq’s Mental Wellbeing: Training and Educational Workshops." The program had been sponsored by the USA Marafie Foundation. The opening ceremony speaker was Ambassador Nathaniel Howell, U.S. ambassador to Kuwait during the Gulf War and chairman of the Marafie Foundation board.
          Many patients reported suffering multiple psychiatric problems because of Saddam’s reign of terror. One woman in treatment had been the mother of a highly placed minister in Saddam’s government. During the war with Iran, Saddam had been especially cruel to Iraqis who were Shiites, which pushed them to favor Iran. The minister suggested a more moderate approach, including the suggestion that perhaps Saddam should consider resigning. His position was no protection from Saddam’s anger, and his dismembered body was returned to the mother.
         Another patient’s son had been randomly arrested, tortured and then brought back to the family. The mother was given the choice: She could either shoot her son or the rest of the family would be arrested over time, tortured and killed. After shooting her son to save the rest of the family, the woman became extremely depressed and suicidal. The intent of these actions was to demoralize Iraqis who might consider doing anything to remove Saddam.
        Clearly no one was immune from the terror campaign, Arshad said. "At first the psychiatrists from Iraq were very guarded, almost to the point of paranoia. They did not even trust the men who had come with them to the meeting."
        Saddam had spies everywhere, and even family members learned not to trust one another. Iraqis feel that, even in hiding, he had the power to arrange for people to be punished and killed. They reported that until they saw his dead body, they would continue to believe he was a force to be reckoned with.
       It seems caution extended to the coalition forces, who allowed only 10 of the 20 Iraqi psychiatrists invited to the conference to cross the Kuwait border for the meetings.

Saddam Husain after his capture
(Photo Department of Defense)
Mental health treatment in Iraq
       Almost 1,000 years ago, Baghdad started the second mental health facility in history. Before Saddam took charge, the government had been in the forefront of mental health care. More recently, the government had taken a negative stand toward mental health. In one of his speeches, Saddam Hussein said, "Depression doesn’t exist in Iraq; depression is a sickness derivative of Western societies: We are all happy here."
       Even under Saddam’s rule, each of the six sections of the country had a psychiatrist running outpatient and inpatient services in either a psychiatric hospital or within a medical ward. Immediately after the war with the coalition, the hospitals were looted of supplies and equipment.
       The psychiatrists Arshad met are well intended, but he feels they are not up to date on treatment methods and have much to learn about modern techniques and training mental health workers and teachers to help with the tremendous numbers of people needing psychological help.
       Iraq, with a population of 25 million, had only 100 psychiatrists. With half of the people suffering from post-traumatic stress reactions, that’s too few to deal with the ranks of patients needing treatment. Millions of children have post-traumatic stress reactions in a country without even one child psychiatrist. Adding to the hopelessness, many of the psychiatrists plan to leave the country now that Saddam’s restrictions on foreign travel are gone.

What is the present state of affairs?
       Almost half of the Iraqi population is younger than 18. UNICEF reported that because of the country’s problems and the sanctions placed after the Gulf War, many children are very vulnerable to disease and malnutrition. One in four children younger than 5 is chronically malnourished. One in eight dies before age 5. Their lower physical resistance also makes them more vulnerable to emotional disorders.
       Many parents feel their children are not safe because of abductions, the ongoing conflict and the children of former Ba’athists being targeted for violence. There are widespread complaints that Americans might have brought freedom but that freedom doesn’t mean anything if there is no security and no chance to live normally.
       With the history of the war with Iran, the Gulf War, the terror campaign of the government and the U.S. invasion, post-traumatic stress disorder (PTSD) is rampant. Psychiatrists say it affects the children’s ability to learn and their hope and plans for the future.
       No help is available. The coalition has developed plans for a national PTSD center in Baghdad, but it is still only on paper. There are questions about how to put this into operation. Iraqis will run it with the funding and support of the coalition.
       There was rivalry among the professionals, Arshad said, because some are in line to get money to work with the center and others are not. Turning the program over to the Iraqi psychiatrists might cause some problems because they are out of touch with what has been learned in recent years about treating PTSD. They are following old models of treatment and relying on traditional psychiatric training.
       There is an additional problem that even professionals in Iraq have lost much of their creativity and flexibility because of the traumatic conditions under which they have been working. As Arshad said, "Even the professionals are acting like robots."

What are future possibilities?
        Many recommendations that came out of the conference struck Arshad as big pie-in-the-sky plans having little to do with reality. His hope for action lie in physician Ayad Fattah, the Iraqi national manager of the mental health program in the Ministry of Health. Fattah is a family practitioner, not a psychiatrist. Given the tremendous scope of the mental health problem, he sees the wisdom of training mental health paraprofessionals and teachers as soon as possible in psychological interventions.
        Fattah was impressed with the expertise of the team from UMC’s International Center for Psychosocial Trauma and would like to have made arrangements for them to come and train Iraqis in intervention techniques. Arshad is considering a small pilot study in the schools to learn about the special nature of the problems of Iraqi children. This would be similar to the studies done by the center in Bosnia, Kosovo and Afghanistan.
       Where would the training take place? Kuwaitis have abundant negative feelings about Iraq and did not want to cooperate. The southern part of Iraq, on the other hand, was relatively quiet, and Arshad felt a team from the University of Missouri would be safe.
       Arshad’s major problem was finding the funding for an operation that would involve bringing a large number of teachers to a central place and hosting them for a five-day training program. Once that hurdle is overcome, the team would be in a position to make repeated trips to further the treatment skills of the teachers and mental health workers. (It was decided that even the southern part of Iraq was not safe and other arrangements were made for where to go for training.)

Friday, January 1, 2010



A psychology workshop with Afghans is a step toward rebuilding a nation

Three predictions: There will be no internationally recognized free elections in Afghanistan in 2004 -- though some sort of charade may be arranged. U.S. forces will pull out within three years. The Taliban will be back in power within five.
                                                                      - The News International, Jan. 2, 2004

        I returned from a trip in early 2004 to Islamabad, Pakistan, more optimistic about the future of Afghanistan than the news reports and these three predictions from the News International would have led me to expect.
        Our team from the University of Missouri’s International Center for Psychosocial Trauma was in Pakistan facilitating workshops on the treatment of post-traumatic stress reactions for Afghan physicians, teachers and mental health workers.

Afghans stand in the rubble of government buildings near Eidhga Gate in Kandahar city, bombed by American fighter jets.
        The U.S. Department of State, Royal Oaks Hospital and Children Mental Health Advocates sponsored the workshop, and the participants were selected by Doctors Worldwide. Many of our students were academics who would be responsible for training mental health workers back in Afghanistan. My interviews with participants put a different, more hopeful slant on what was happening in their country.

Security and more security
       Islamabad, the capital of Pakistan, was under lock and key. A restricted red zone had been declared and 28,000 troops and police patrolled the streets. Leaders of the South Asian countries were meeting in early January, and with the recent attempts on the life of the president of Pakistan, no chances were being taken with security. When the UMC team entered hotels or clubs, armed guards at the gates greeted us with mirrors on rollers that were run under our van to check for bombs.
       These security precautions fell particularly hard on the participants in our training program, because 20 of them were from Kandahar in Afghanistan. Each wore a security badge. Despite the fact that they were physicians and leading academicians, they were restricted to the area around their dormitory at a nearby university. Only on the last day of our six-day program were they allowed to tour the city.

Our students were cautious about what they would say in front of each other. I suspect that several of the members were Taliban and that they would report back statements they heard.

       The UMC team led by Arshad Husain, child psychiatrist at the UMC School of Medicine, included Judith Milner, a child psychiatrist from Seattle; Stuart Lustig, a child psychiatrist from Boston and assistant professor at Harvard Medical School; and myself.
       The U.S. State Department had originally invited the Afghan professionals to our 2003 summer training session at UMC. However, they were unable to get visas because they were seen as security risks. The State Department was unwilling to let our team go to Kandahar, so as a compromise, arrangements were made for us to meet with the participants in Islamabad.
       When Husain got back from his first meeting with the men from Kandahar, he was concerned they might be difficult to work with. They were disappointed with being treated as security risks and seemed upset with U.S. policies toward Afghanistan. Many of them seemed depressed.
       We were pleased when the first day went well, with much sharing of ideas and even laughter. Language turned out to be a problem; we had been told everyone spoke some English, but for many their familiarity was minimal. A number of the participants, however, spoke good English, and they served as interpreters.
       The reactions of the participants at the end of the workshops were positive, indicating they had been exposed to many new ideas and procedures. They had special praise for the sessions on group therapy, attachment and grieving, and new approaches to the use of psychotropic drugs. The participants felt that more education in the treatment of trauma is urgently needed in Afghanistan, and arrangements are being made for the UMC team to present a program in Kandahar. (Because of security problems this has never taken place.)

Fear of the Taliban
       In addition to listening to the Afghans in the workshop, I was able to interview seven in more depth about the possibilities and problems in the rebuilding of their nation.
       A primary care physician reacted in a manner I have frequently found in survivors of conflict situations.
       “I wouldn’t want my name used. The Taliban are still a problem and cause us fear. If I say anything they don’t like, some night someone may come knocking at my door,” he said.
       One incident in particular haunted him. “Four years ago there were four young girls who misbehaved sexually. They were arrested and prosecuted by the Taliban. They were taken to a stadium that had 10,000 people to observe the punishment. At 3 p.m. they were executed. At 5 p.m. they brought the bodies to the hospital. One of the girls told me, ‘I’m still alive, please help me.’
       “The Taliban who brought her in saw she was still alive, and they called the high court, who told them that if she was still alive to kill her. They shot her in the back of the head, and the front of her face exploded all over me. I was so upset that for three months I couldn’t return to work in the hospital. I had to take many medications to get my mind working again,” he said.
       Like all of my informants, he believed there was no chance of the Taliban regaining control of the country because so many people had been disturbed by their misuse of power, destruction of education and enforcement of fundamentalist Islamic laws. However, the Taliban are still a danger to individuals because of their support from some people in Pakistan, and many of those hiding in Pakistan can pass over the borders at will.
       This physician bears scars from neck and hip wounds he received during the wars. He said many people are depressed as the result of 25 years of war in Afghanistan, and they don’t see anything they can do to change the situation.

A more positive view
       A number of other participants expressed a more hopeful point of view, especially those connected with the University of Kandahar. For example, Payenda Arghandabi said: “The problem of education is a very real one in areas controlled by the Taliban. The boys had schools, but the emphasis was on learning to read the Quran. Girls were not allowed in school.”

Three Afghani boys play in the streets of Kandahar. They now have educational opportunities after years of no school.

       Another professor said special Taliban schools with a wider range of courses were available for boys, but only in the cities.
       Several participants pointed out that few students were available to enter colleges and universities because the education system at the primary and secondary levels had been all but closed down. Older women are getting refresher courses so that they can take examinations to enter the university.
       Despite the lack of high school graduates, Arghandabi was upbeat about the future and said the education system is being rebuilt after years of destruction.
       “Our people were in the dark,” he said. “We kept them in the dark. Bad things can happen in the darkness. With education there will be light.
       “We started running classes in a small building with three rooms and soon found there were 6,000 students who wanted education. We added tents where the students study sitting on carpets and where there is one blackboard with chalk. Teachers are working for $40 a month.
       “We need 100,000 teachers, and there are only 3,500 studying in Kabul at the School of Education. We are drawing in old people who remember how to teach. We are working on publishing books and getting teaching materials. Some people work at jobs in the morning and donate their time to teaching in the afternoon. Everyone is eager to learn and to catch up with everything they have missed,” he said.
        Professors have a problem because few up-to-date books are available in the Pashto language. Consequently, they are trying to find up-to-date books in English that they can use to make notes for their lectures.   After I got back to the University I asked colleagues for any extra books they had, and mailed several hundred to the Kandahar.
       “We are starting to teach English because books are in English. I have never seen so much enthusiasm, and the cooperation is overwhelming,” Arghandabi said. “When I became chancellor, there was no chair for me to sit in. We now not only have chairs, but dormitories. We are publishing our own magazine. We are not waiting for outside help but are starting in on our own.”
       Although Arghandabi at first sounded as if education was starting from scratch, it soon became clear that Afghanistan is getting considerable help from a number of countries.
       “Most help for education is coming from Japan, with funds provided for building schools. Saudi Arabia is helping with the library, and Germany is providing material for higher education. Other universities are sending books. Holland and India are providing computers. U.S. aid is providing some help with education,” he said.
       Other informants said South Korea is developing an information-technology center. The World Bank has also promised help. Japan is discussing a medical building at the university in Kandahar.
        In stark contrast to the situation in secondary and college education, there has been an overproduction of physicians. Wahid Wasiq, dean of the medical school, said there were 12 universities before the Taliban, and each had a medical school. The Taliban allowed them to stay open. As a result, the country has been producing more physicians than it can place. Refugees went to Pakistan for their basic education and returned to Afghanistan for medical school. The World Health Organization, the Ministry of Education and the Ministry of Health did an evaluation and will close some of the medical schools.
       Wasiq was distressed, because well-educated professionals had been leaving Afghanistan since communist rule. He was hopeful that some of these refugees might return when a stable government was established.

But will there be food?
       Of course, if there is no food, starting up the education system will be meaningless. One of my interviews was with the dean of agriculture at the University of Kandahar. He had been appointed the leader of the 20 professionals who joined us in Islamabad.
       The dean said Afghanistan has some assets that will provide a solid foundation for rebuilding. First, it has water, much of which now goes to Russia, Iran and Pakistan. But it’s available to re-establish the farms and orchards of the country. The men who have been fighting wars for the past 25 years did not lose their ability to farm, because when they weren’t fighting they were back running the farms. The Kandahar area is rich in fruit trees, with pomegranates and apricots the most popular. Sixty varieties of grapes are grown. They are dried because Islam forbids the making of wine.
       Besides the availability of food to help rebuild the economy, Afghans will be able to charge for the gas and oil lines that will pass through their country, so they are counting on water, food, oil transport and the enthusiasm of their people to help them through the rebuilding process.

Orphans at a home in Kandahar

(Pictures in this story were provided by the participants from Afghanistan.)