Liu Yisi sits on a hospital bed, reading a comic book. His nose is bruised, swollen and cut, and his left arm is heavily bandaged.
While his physical injuries from China's May 12 earthquake are healing, mental trauma has made the 13-year-old withdraw into mostly silence.
Li Fuhong, a psychology professor who voluntarily drove nearly 200 miles to the disaster zone, speaks softly to Liu. He coaxes the boy to tell him what happened when he escaped the ruins of his school in the city of Mianzhu and makes him repeat these words: "The bad events are over. The future will be better. I need to be strong."
The teenager is lucky to be getting help. Across central China's disaster zone, many other such victims with mental trauma are going untreated because health services are already strained.
Hospitals and clinics were destroyed along with so much else across Sichuan province in the quake, leaving acute shortages of staff and facilities. In the immediate aftermath, medical services have focused on treating crushed and broken bones, amputated limbs and on preventing disease outbreaks.
Experts warn that mental trauma could be a hidden toll for many survivors.
Dealing with loss
The government says the quake may have killed more than 80,000 people, leaving many more to deal with the deaths of loved ones. Millions have had their homes shattered and their lives thrown into turmoil. No government estimate of people needing psychological help has been released, although the state-run Legal Daily newspaper quoted an expert as saying they could number as high as 600,000.
Teams of psychologists, psychiatrists and volunteer counselors like Li Fuhong have gone to the hardest-hit areas, where mental health professionals have been swamped.
"China has been struggling to help thousands of people distressed and traumatized in the unprecedented earthquake that ravaged many parts of Sichuan," the official Xinhua News Agency said last week. "Many volunteers and experts have rushed to quake zones but psychologists are still in great demand."
In the past, there has been a social stigma attached to mental illness in China. Increasingly fast-paced — and stressful — lifestyles stemming from two decades of economic success have forced a greater awareness of the problem.
Xinhua reported last year that there were 16 million mental patients in the country but services at the grass roots level were still lacking, and public awareness was minimal. Health officials have said that by of the end of 2006, there were only 1,124 mental institutions, with 146,000 beds and 19,000 psychiatrists or assistant psychiatrists.
Hospitals left standing by the quake have been overrun with serious injuries. The government has rushed more than 10,000 doctors or nurses to the area and a dozen field hospitals have been erected, Health Ministry spokesman Sun Jiahai said Tuesday in Beijing.
Signs of mental and emotional strain are widespread.
Relatives, weeping inconsolably, fall to the ground in front of plastic-wrapped bodies of sons and daughters killed in a school collapse in Hanwang. In the town of Beichuan, so badly damaged that it has been abandoned, villagers stare blankly in shock at what used to be their homes. Some talk with gratitude about having escaped with their lives — only to dissolve into tears.
Metin Basoglu, head of trauma studies at London's Institute of Psychiatry at King's College and the director of the Istanbul Center for Behavior Research and Therapy in Turkey, said 80 percent of the survivors could be expected to suffer short-term effects of post-traumatic stress disorder, a condition that can develop after a person is exposed to a terrifying event in which physical harm has either occurred or was threatened.
Half will have longer-term problems, which include obsession with the trauma, nightmares, flashbacks, emotional numbing, loss of interest in life, irritability, memory problems and hyper-vigilance — a state of constant alertness.
"Fear is the most serious problem," Basoglu said. "Many people will find that their fear of earthquakes interferes with their everyday activities," including sleeping, bathing — even walking into a building.
In the Deyang City No. 1 People's Hospital, the scene was chaotic last week as doctors and nurses rushed from one injured person to the next as they lay on beds cramming hallways and in tents on the hospital grounds. Away from the hubbub, Li — the counselor from Southwest University in Chongqing — talked quietly with the teenager, Liu.
Liu's mother, Zhao Xiaoxia, said the normally outgoing teen barely ate in the days after the disaster, and could not fall sleep unless she was holding his hand.
But the therapy by Li seems to be working.
"Now," Zhao said with a broad smile, "he wants fried chicken."
In another sign that health care professionals will not reach everybody in need right away, the Ministry of Health has issued a handout of guidelines on how to help survivors, rescue workers and volunteers who have experienced the carnage. Blue flyers circulated by Sichuan health authorities offer concern and compassion from the ruling Communist Party.
"When we're facing a disaster, the first thing we want to do is to continue living," it said. "That's the only way we can fight the disaster."
To make up for the shortage of counselors, doctors are encouraging survivors to look after each other, trying to create support systems in quake-shattered communities.
'It's a special thing'
In Shifang, a town surrounded by rice fields where two chemical plants collapsed and buried more than 600 people, a steady stream of people visited three tables lined with medicines and staffed by doctors from the Taiwan-based Buddhist Compassion Relief Tzu-Chi Foundation.
"It's different from America here. Social and familial support is strong and it makes people feel better, safer," said Chien Sou Hsin of the foundation. "It's a special thing."
China is officially atheist, and there were no signs apparent that people were taking solace in religious counseling.
Basoglu, the trauma expert, and his colleagues have developed a method for dealing with large numbers of survivors from disasters — work that grew from his experience after two quakes killed 19,000 people in Turkey in 1999. The method encourages victims to confront their fears and the simple message can be delivered through pamphlets, television or radio.
"Once they overcome their fear, all other PTSD and depression symptoms disappear," he said.
Recovery seems far away
The nights have been the hardest for retired soldier Luo Tiangui. He flails violently in his hospital bed, eyes unblinking and shouting incoherently. "I am a bad person," he says, over and over.
Luo, 57, was buried in his house but survived with a broken thigh and fractured ribs. His mental state is more fragile.
Lying shirtless and sweating, Luo stared at the ceiling, murmuring "It's on fire, it's on fire" — one of the many hallucinations his family says he's been suffering.
Doctors said Luo has suffered a great fright, and he's being given drugs to help him sleep. They have told his family they should share happy moments with him in the hope that it helps.
At his bedside, Luo's wife, Wei Yunqun, and 21-year-old daughter, Luo Cui, stroke his hands, which did not stop trembling. The TV above his bed is kept off so he isn't bombarded with news from the quake.
"It's too hard to bear," said Wei, 54, her eyes filling with tears as she looked at her husband, a former construction worker and furniture-maker.
"There was never anything wrong with his mind," Cui said.