A board showing ‘Welcome home, boys’, is seen after rescue effort has begun for the 12 schoolboys and their coach in Chiang Rai, Thailand. Image Credit: Reuters

June 23: After a practice game, the Wild Boars football team full of minors head off to explore a cave. Their coach runs after them into the Tham Luang cave complex.

And rain starts to pour, eventually blocking the entrance.

It’s a muddy labyrinthine complex that cannot be navigated without extreme flexibility and fitness – some of these boys are only 11. The oldest person on this expedition is 25.

After trudging through 3.2 kilometres of dangerous terrain the boys find a 10-square-metre ledge that’s elevated. Now they must wait. And wait.

Reuters

It’s freezing and dark and dank in the cave. The rations are whittling away. Muddy, bracken water is rising slowly, swallowing precious space. The air is thinning; light retreating. Scared. Cold. Hungry. Thirsty. Homesick. Twelve boys - aged 11 to 16 - and their coach are stuck.

There’s a cloud of hopelessness in the air.  “I’m sure they felt like they are going to die; they felt like insecure, [hopeless], and of course they were far away from their parents, far away from [people] who can help them; from [people] who are [going to] support to them,” says Dr Mrabet Jihene, clinical psychologist at Life Psychological Counselling Centre, taking a deep breath. “I’m sure it has been a really, really difficult in the physical and psychological aspects [for these kids]”.

Nine days later, there is a flicker of hope. They are found by divers; they know they are missed, they feel they can make it back. But not just yet. The logistics are dumbfounding – the weakness that has seeped into their bones is not helping matters. But they know their parents - along with the world – are waiting with baited breath to see them home and safe.

Now, on July 9, eight of those stuck have been ferried outside, joking of fried rice and smiling at their fortune. They were in survival mode, explains Dr Jihene. But the relief of the survivors may be short-lived. “What they have been through is trauma, and of course going outside the cave now they will go through [what is called] post-traumatic stress,” she explains.

What can we expect?

“Post-traumatic stress is about experiencing intrusive memories,” explains the doctor, “they could have a panic attack – because even if they safe they will continue to feel that they are somehow insecure [and] emotionally overwhelmed. Chronic pain and headaches can appear sometimes. Especially because you are talking about kids.”

The psychological stress can also manifest in physiological ways. “Some of them can experience asthma, for example, [or have a] respiratory problem.”

They may also exhibit aggressive behavior and irritability. Also, they may try to cope with the scenario by replaying it over and over – using toys -or through video.

Dr Jihene says some of them will have little or no memories…because they are trying to forget them. ”Because each time they will remember what will happen, they will feel insecure again. So some of them unconsciously will contain their memories of [the trauma]".

They can also be something like hyper vigilant, and it’s a physiological reaction on exposure to internal or external cues that remind them of symbols or aspects of the traumatic event, she explains.

Sleep patterns may be disturbed. “This can also come with insomnia, nightmares and flashbacks again and again, a decrease in concentration, and of course they can [get some] specific phobias like claustrophobia.”

“Sometimes we can see some of them going through regression attitude. Which means that some of them can have secondary enuresis, or bed-wetting. Moving back to a child-like situation can help them feel secure. We can see some sleeping issues in children – them wanting to sleep with their toys, or refusing to sleep alone. Or asking for their mother, or father, or both their parents to sleep with them because they need the [reassurance].”

What can we do to help?

Dr Jihene explains that the authorities are already on the top of things. They are being provided with medical and safety aid. Next comes dialogue and therapy.

Once out, “We have to increase the social support, which allows them to express their feelings together. The emotional bonds can help them to realise what really happened to them, to understand that it has been shared by others,” she says. “The self will move from individual self to group self and group self will have enough power and to calm the fear”.

“We need also need to address the trauma in a nurturing way – for example, they can talk about what happened. Because if you are under the emotional fear, you will not be able to control your [reaction] or understand what happened.”

She says practical solutions must be presented to the children. The questions to be asked are: what is the problem or how can I protect myself if something like this happens again?

Another coping mechanism is desensitisation. “It means that we are going to little steps, starting with imagined exposure to the trauma and after that we can move to the [real] trauma…going to the site for example of the event. And repeating that [exposure] until the person is no longer responding with high levels of the stress; [explain] it’s not about the cave, not about the place, it’s about a situation that happened.”

Speak rationally. “The most important thing is, what we can do to avoid being in the same situation again. But not what can we do to avoid the cave, for example,” she says.

“Of course, some of them may not have the ability to use the resilience. So they will experience a high level of post-traumatic stress [disorder] – and in that case we should refer them to professionals to help them go forward,” she says.

Older and wiser or just more traumatized?

When those trapped could finally write letters to their well-wishers outside, one of the first things the coach did was apologise to the parents. His guilt was palpable; his torment absolute. Not only was his own life at stake he was also in-charge of a group that looked up to him and trusted him with their lives.

“I don’t know his personality or coping skills but a normal person in that situation can be under a very high depression. [He may resort to] substance abuse, or [have] suicidal thoughts – because they [people in such a situation] can feel, ‘I don’t deserve to live because I was not responsible enough.’

“It’s not about just a message saying that we forgive you and we know it’s not your fault; [getting over trauma] is a process. Because when we are depressed and are under such stress it will take some time to get relieved from it,” she says.

The fact that the parents were forgiving may have loosened the knot of guilt around his neck, but it is sure to leave emotional scars.  “He knows that those people [who are affected] somehow understand, they do not blame him [and this may keep him from taking drastic steps].”

“100 per cent it [forgiveness] will help.”

The line of retrieval

The children are being taken out in batches; so far eight have made it and are being checked for any health trouble. But then isn’t it normal to feel sidelined when you are in a scary dark space where the air is getting thinner and people other than you are getting out?

How does one help a child understand that he is important – even if he is the last one out?

Here’s what they need to hear: “We were here waiting for you.”

“The children must feel the support,” explains the doctor. “It’s all about support, dialogue and love. Showing to the kids that they are so loved and they are so precious the whole country was their just waiting for them to go out safe. And this feeling will help them overcome the trauma after sometime."

Possible physical trouble
Even after completing the dark, treacherous journey from the depths of Tham Luang cave to safety, the rescued members of the Wild Boars football squad face additional barriers to resuming their normal lives. Before the boys can enjoy a warm embrace with their relatives, doctors must be confident they will not make anyone ill.

Thongchai Lertwilairattanapong, a Thai health department official, told the local news site Kom Chad Luek there would be "no hugging or touching" until blood tests proved the boys were free of infections.

He named leptospirosis and meliodosis - bacterial infections that can be transmitted through soil or water - as possible risks. Hugh Montgomery, a professor of intensive care medicine at University College London, said caves presented a risk of tick-borne relapsing fever as well as histoplasmosis, a fungal lung infection commonly known as "cave disease".

The policy of separation between the boys and their loved ones marks a departure from the initial plan described to the Guardian by a member of the mental health crisis assessment and treatment team at the rescue site, which was to arrange for at least one parent to accompany each boy in an ambulance on the way to Chiang Rai's Prachanukroh hospital.

Dr Andrea Danese, a child psychiatrist at King's College London's Institute of Psychiatry, Psychology and Neuroscience, said a parent's presence in these first few moments of freedom would be an important first step towards a healthy reintegration. "After a long time spent underground, the boys will be tired, possibly mildly confused - almost as if they were jet-lagged - and likely quite emotional," he said. "Bringing them together with a parent will certainly be a positive experience."

These comforts will have to be delayed, despite the fact that none of the infections mentioned by doctors is transmittable between people. At a press briefing on Monday evening, Narongsak Osatanakorn, the head of the joint command centre coordinating the operation, declined to tell reporters whether any of the boys had been reunited with their relatives. Since the first rescue operation was launched there has been a strict policy against releasing the names of any of the boys who have come out of the cave. Instead they have each been referred to as "Wild Boar" and assigned a number.

On Monday morning Osatanakorn chastised a Thai news outlet for publishing the names of the first four boys. "It is doctor-patient confidentiality, so we couldn't name them," he said during a press briefing. "Some of you have disclosed it. What you should realise is that it affected the parents of those who are still inside."

Banyong Suwanpong, a member of the ethics committee of the Thai Journalist Association, wrote in a Facebook post: "Using a code instead of naming them is to protect children's rights and to avoid the ethical issues especially when the society is closely monitoring the press." The policy is unusual for a story of global interest, especially since the names of those who were trapped are already known.

However, this is common in Thailand, where media are traditionally very careful with the identities of children. In cases of crimes involving children, especially when they are the victims, names are often omitted. In the case of the Wild Boars, though, hiding identities goes beyond tradition.

The boys who have exited the cave over the last two days are entering a new world where millions of people want information from them. By keeping their names secret, even temporarily, the joint command centre is giving the boys one additional layer of protection from the threat of trauma. Dr Thornnin Kongsuk, director of Suan Prung hospital in Chiang Mai, where the boys will receive checkups in the months following their rescue from the cave, said he supported the policy.

"I'm concerned that the media won't stop interviewing them and reminding them of this event in their lives," he told Kom Chad Luek. "If the boys and coach view being trapped in a cave as a test of their bravery or as an adventure, that will be fine. But if they [are forced to] remember it as torture, their mental health will suffer." -- Guardian News and Media