Tsunami Disaster & Tamil Eelam
Qualitative Assessment of
Psycho-Social Issues
Following the Tsunami
Report prepared on behalf of the Mental Health
Task Force in Disaster - Dr Kate Danvers, Prof. Daya
Somasundaram, Dr S. Sivayokan, Dr Sivashankar
Final Draft: 17th March 2005
Introduction
The tsunami which affected South Asia on 26th December 2004 is now
known to have caused over 175,000 deaths worldwide, and displaced
millions of people from their homes and livelihoods. Figures
compiled by local government officers show that in the Jaffna
District, 1256 people lost their lives, and 1240 are still missing.
48,769 people were displaced as a result of the disaster. As of 19th
January 2005, 3758 families were still housed in welfare centres and
6651 families were housed with relatives and friends. In the
affected areas family and community structures, which are so vital
for psychosocial wellbeing, have been drastically altered by the
tsunami.
This document outlines the work carried out by the Mental Health
Task Force in Disaster to date, our initial impressions of the
psychosocial needs of the community following the disaster, and our
initial recommendations about the likely ongoing needs of the
community, in the short- and long-term.
Psychological context
Throughout their response to the disaster, the Task Force has
attempted to base their decisions on what we know of normal
psychology, stressing the need to avoid pathologising natural
reactions to trauma. Research suggests that for most people,
psychological reactions resolve during the first or second month
post-disaster. In the immediate phase, in-depth psychological
interventions that push the client to talk about their experience in
detail can prove harmful to some, so this approach should be
avoided. Instead, dissemination of information about normal
psychological reactions, with an emphasis on the expectance of
natural recovery can be helpful (WHO, Mental Health in Emergencies,
2003).
Long-term planning will also need to take into account normal
psychological processes such as grief. Usually after a severe loss,
there is a period of mourning, which can last a year or longer,
during which time the person begins to adjust to their loss and
rebuild their life, supported by their family, friends, and other
social and religious support systems. Although grieving people may
at times experience psychological �symptoms� they do not always
require help from counselling, psychological or psychiatric
professionals. Therefore, even though the present circumstances are
very unusual, we should not assume that all those people who have
experienced losses will need input from psychological services.
Instead, we need assessment and referral procedures which can
identify the minority with more severe or abnormal grief reactions,
to ensure they receive appropriate help from higher level
psychiatric, therapeutic or psychological services.
Similarly, PTSD and depression will only be possible to diagnose
after some time has passed, when people with lasting mental health
problems become distinguishable from those who will go on to
naturally recover. Therapeutic interventions are more likely to be
successful if they are carried out after the individual has been
able to restore a degree of normalcy to their lives, for example,
when they have a semi-permanent residence, and some security about
their basic needs. However, given the widespread nature of the
disaster, general community psychosocial measures can be implemented
with the aim of promoting mental health, particularly amongst
children and adolescents.
Qualitative assessment of issues arising after the disaster
� Immediately, a high number of people experienced an acute stress
reaction, feeling distraught, dazed and highly emotional. This
reaction lasted only a few days, so those affected have now got over
this initial reaction.
� There has been a high degree of loss of life: e.g. many family
members lost in one family, all families in a community losing
family members or close friends. Consequently whole communities are
grieving together. One of the main psychological problems identified
was grief reaction, some atypical in nature, commonly complicated by
guilt, anger and hostility, and suicidal ideation. Psychotic
reactions needed medical treatment.
� Those who have not lost family members may have experienced a high
degree of property and financial loss. There was one case of suicide
due to property loss. The economy has been massively affected by the
disaster.
� Usual support systems have been destroyed, as many or all in a
community were affected, the individual cannot receive community
support. Village structures and organisations were also destroyed,
and people were displaced from their familiar surroundings and
social context.
� The fact that people were unprepared, and that the scale of
devastation from the tsunami was unexpected may have contributed to
people�s distress, as they would not have been able to use their
usual coping mechanisms for times of stress.
� Affected people have to deal with practical stresses: e.g. the
registration system, trying to reunite surviving family members,
perceived inequities in the distribution of aid, leaving welfare
centres and settling in temporary shelters.
� Families have been separated after the disaster between different
welfare centres, or were separated at the time of the disaster.
Unresolved emotions, hopes and unanswered questions relating to
missing relatives, or cases where bodies have not been recovered or
identified are common, and may interfere with the natural grieving
process.
� There has been less opportunity to carry out the traditional
funeral rituals, which may also interfere with the natural grieving
process.
� Initially, fear of the sea and nightmares have been commonly
reported. A brief survey carried out by VIVO, of 71 children (aged 8
� 15), showed 40% were at risk of developing Post-traumatic Stress
Disorder, and many others showed symptoms. For some of these
children, symptoms will resolve over the next few months, but a
significant minority are likely to need specialist help.
� Mistrust in nature has been reported by many as a consequence of
the disaster, expressed as a description of the sea as: �She, who
gave everything, also destroyed everything�. Fears relating to the
future and the return to coastal areas are also common.
� Guilt feelings have been commonly reported, particularly family
members questioning themselves about what they could have done
differently to save loved ones, particularly in relation to not
holding on to children, or having gone elsewhere. Guilty feelings
and associated depression were risk factors for suicidal ideation.
� Anger was a common reaction. After a natural disaster, it may be
difficult for people to know where to direct their anger, and
feeling angry at nature or gods is common. We have also observed
anger being turned inwards, so that people blame themselves and feel
guilty, or people blame each other, for example criticising the
actions of their family members and blaming them for deaths in the
family. We have also observed anger being turned or manipulated
towards the authorities, for example, people have described problems
in aid distribution, or made criticisms of the government.
� There is an elevated incidence of schizophrenia in the Jaffna
community compared to other East Asian communities. The disaster
increased stress on vulnerable individuals, causing people to
develop relapse of schizophrenia, exacerbation of symptoms, and
making it difficult for people with a diagnosis of schizophrenia to
follow their regular treatment routine. Some lost their medical
records and medications, and defaulted clinic appointments and
treatments. There were concerns that some cases of schizophrenic
illness were misidentified as normal reactions to the disaster, and
managed only with psychological methods. People with schizophrenia
are particularly at risk of suicide, so it is vital that they
receive professional psychiatric support.
� We have heard of many rumours relating to the cause of the
tsunami, and frequent reports of another tsunami coming were common.
These rumours can be seen as people�s attempts to make sense of what
has happened to them, and in a similar way, some people have
developed magical thinking about the disaster, or about ways to keep
safe.
� There was a lack of organisation and co-ordination between
agencies, which many felt lead to aid and psychosocial interventions
not reaching all those in need. In particular, the referral process
for those experiencing severe psychological reactions was not widely
used.
� There were reports of a lack of sensitivity and sympathy in some
authorities dealing with tsunami survivors (like principals,
government officers etc). Political interference and people pursuing
their own personal needs has caused difficulties for the affected
people in getting psychosocial work and other relief items.
� Initially, few structured activities were available in the welfare
centres.
� Many of the affected people have experienced displacement and
losses in the past, which might increase their resilience in the
present circumstances. However, the present trauma may also bring to
the surface memories and emotional reactions related to previous
traumatic experiences, thus making it more difficult for individuals
to cope.
� There was a high number of widowers (men who lost their wives),
many of whom were finding it difficult to cope with young children
and babies. Some had taken to alcohol as a way of coping.
� Another vulnerable group identified after the tsunami as having
specific needs were adolescents, particularly those having lost a
parent. They were seen in the welfare centres as quiet, withdrawn
and angry. If specific programmes are not advanced to this
vulnerable age group, there is a risk of deviant personality
development, such as anti-social personality and exploitation by
authorities for their own purposes.
� We noted there was some over-enthusiasm to carry out psychosocial
activities, even from organisations not specialising in the
psychosocial field, which could have caused problems for some of the
affected people.
Psychosocial intervention to date: Immediate post-disaster phase
1. Training and co-ordinating workers to visit the welfare centres
The Task Force advised and co-ordinated over 110
individuals from various NGOs, all of whom had previous training in
counselling and / or psychosocial skills, and experience working in
a psychosocial and counselling context. A short workshop was
provided focussing on how these workers could adapt their skills to
the immediate post-disaster context. Many psychosocial NGOs sent
individuals to the welfare centres, and approximately 30 additional
volunteers (workers not attached to a particular NGO) were
co-ordinated by the Task Force to visit 7 welfare centres.
Monitoring of this work was provided via the usual supervision
arrangements of each of the NGOs. The Co-ordinating committee in
Vadamaratchi had representation from the Task Force, and oversaw all
the psychosocial work going on in the camps.
The aim for immediately sending workers to welfare centres was to
provide psychological first aid and support which included:
� Providing an opportunity for people to talk about their
experiences, should they wish to do so, with a listener trained to
be empathic and non-directive.
� Educating and reassuring people about the normal psychological
reactions to trauma, and discouraging labelling of people as having
a mental illness. Encouraging the expectation of natural recovery.
� Protecting people from harm, by identifying those people judged to
be at risk of committing suicide, or suffering severe psychiatric
problems, and referring them on to the multi-disciplinary team and
hospital-based psychiatric clinics.
� Encouraging the use of normal coping strategies, where possible.
� Facilitating access to aid required to meet basic needs, by
speaking up for people and explaining procedures where appropriate.
� Visiting welfare centres regularly, so that psychosocial workers
become familiar to people. People are then more likely to approach
these workers for help, if and when psychosocial problems arise.
The primary health care workers (e.g. Public Health Inspectors,
Midwives etc.) were given an awareness raising programme and asked
to look into psychosocial issues as well as their normal work.
2. Providing information to the media
The Task Force has co-ordinated articles in the
local papers, interviews and a press conference on the following
topics: The work of the Task Force, psychosocial work carried out in
the affected areas, how to help yourself psychologically,
understanding how the tsunami occurred, listening to affected
people, risks of developing PTSD and depression and how to contact
services if needed, requests for support for affected people and
using traditional methods of psychosocial support.
Aims:
� To educate and reassure people about the normal psychological
reactions to trauma, and to discourage labelling of people as having
a mental illness. To encourage the expectation of natural recovery.
� To encourage newspapers to report in a way that does not
needlessly increase the distress of the public.
� To encourage social agencies to bring normalcy and resettlement as
much as, and as early as possible.
3. Writing and disseminating leaflets
The Task Force has produced two publications, the
first, a booklet designed for community, NGO and local government
workers, and the second, a pamphlet designed for those affected by
the disaster. The aim was again to educate about the normal
reactions to trauma, reduce labelling of people as having mental
illnesses, and promote positive coping strategies at the individual,
family and community level.
4. Developing a referral system for those with severe difficulties
The Task Force developed a 3 tier referral
structure: Field workers can refer to the Multi-disciplinary Team at
Base Hospital Point Pedro, General Hospital Jaffna and District
Hospital Tellipallai, and the MDT can refer to the Psychiatrists.
(Please see appendix 1).
5. Developing links with Killinochi and Mullativu
The Task Force has offered to liaise with
psychosocial workers in Killinochi and Mullativu, and in the first
week after the disaster, sent a team of workers to Mullativu to
offer crisis intervention. A representative of the Task Force
attended the weekly co-ordinating meeting in Killinochi at UNICEF,
and set up an ongoing programme at Marathenkerny area with a clinic
at the local hospital.
6. Liaising with government and non-government agencies
The Task Force aimed to attend co-ordination
meetings of the various agencies in order to highlight and advocate
for psychosocial issues, and contribute to co-ordinated planning.
Recommendations
Immediate (e.g. 0 � 4 weeks post-disaster; this is now past)
Social interventions should focus on meeting basic needs, re-uniting
families, providing opportunities for structured and normal
activities, and supporting usual coping mechanisms. Structured
activities for children (such as games and schooling) should be
organised.
For most people, psychological interventions should be limited to
supportive listening, with the aim of educating the public about
normal reactions to trauma, and emphasising the likelihood of
natural recovery. Any worker offering this type of intervention
should be regularly supervised by an experienced colleague, trained
to offer guidance in intervention and to take account of the
psychological impact on the worker. Regular, in-depth counselling or
psychotherapy should be avoided. Vulnerable individuals can
experience severe reactions after a trauma, so people at risk of
self-harm or suicide should be referred to the psychiatric clinics,
particularly those expressing serious suicidal intent, or
experiencing a psychotic episode.
Short-term (e.g. 1 � 6 months post-disaster)
During this period, many people will begin to naturally recover from
their psychological reactions to the trauma. People who have lost
relatives will still be grieving, and energies may be focussed on
the practical issues of rebuilding lives. Many may experience
continuing psychological problems, and a minority may develop
serious problems like pathological grief, PTSD and depression. Fear
of returning to the sea, lack of motivation to re-start life
activities and suicidal ideas will have to be dealt with. WHO has
estimated that 50% of those directly affected will have psychosocial
problems needing help and support, whilst 5 � 10% will develop
severe problems needing specific intervention and treatment.
Suggested activities for this period include:
1. Education and awareness-raising
WHO suggests a need to educate the public about the
difference between normal distress and mental illness, so that those
experiencing continued difficulties can access appropriate support.
Those working in the welfare centres or affected villages could be
offered a short training programme, and similar programmes could be
made available for the public, as well as by providing information
through the media. Authorities such as educational and government
officers should be sensitised to the effects of the disaster, and
given advice about how to deal with the survivors in a kind and
sympathetic way.
2. Needs assessment to determine the developing long-term
consequences of the disaster
Local services should carry out a needs assessment
of the likely long-term psychological impact of the disaster. In
particular, research from other natural disasters can tell us about
mental health problems following the disaster.
3. Promote access to existing services and begin longer-term
counselling and therapy for those in need
Information should be given to all about how and
when to access professional services. A self-referral system to
psychosocial NGOs for counselling, psychiatric clinics and the
Multi-disciplinary team could be implemented. Longer-term support
should begin, taking into account for each individual degree of
stability and normalcy in their lives. Individuals should have
access to specialist interventions where needed, using the three
tier referral system (see appendix 1). Two such referral units have
been set up at Base Hospital Point Pedro and Marathenkerny hospital.
Tertiary referral of severe cases needing medical treatment can be
referred to Teaching Hospital Jaffna and District Hospital
Tellipallai.
4. Ensure quality of psychological interventions given.
It is important that psychological interventions are
of a high standard. Any increase in counselling resources will have
to occur over a long period of time, as counselling training is a
long process, requiring months, if not years. WHO states that short
one-week to two-week (or less) skills training without thorough
follow-up supervision is not advised. The Task Force will therefore
advocate careful planning rather than quick solutions to the
potential increase in demand placed on existing services. It is
expected that until new counsellors are trained, existing services
will be under increased strain over the next year.
Rather than focussing on training new counsellors and psychosocial
workers, it is important to mobilise existing resources and
facilitate networking between already trained workers. Existing
workers include the hospital based Multi-disciplinary Team,
Psychosocial Trainers (Shanthiham), Counsellors (Shanthiham,
Ahavoli, Wholistic Health Centre, Family Resource Centre), Teacher
Counsellors & Befrienders (GTZ � Becare), Psychosocial Advocates
(UNICEF), Samurdhi Workers and Graduates (previously trained
Psychosocial Trainers who left Shanthiham for government
appointments). The primary health care staff, particularly Family
Health Workers, should be mobilised and given training on
psychosocial issues, so they can contribute to this work with
ongoing support from mental health professionals.
5. Community work
In view of the widespread nature of the disaster,
psychosocial work in the emerging communities should be organised,
to ensure and encourage positive psychosocial functioning (e.g.
cultural and religious rituals, organisation of community centres,
yoga, structured play activities and schooling for children). These
activities would be designed to prevent later mental health
problems, encourage a return to normalcy, and promote mental health.
A programme to involve adolescents in organised group activities,
responsibilities and vocational training will be needed.
6. Extra training on specialist topics
Those workers expected to do in-depth counselling at
the secondary and tertiary levels (and in particular, the
Multi-disciplinary team, who see people with more severe mental
health problems) may require short, top-up training on specific
topics, such as grief, therapeutic approaches for PTSD, play
therapy, and relaxation techniques and yoga. Logistical support for
such programmes would have to be funded.
7. Co-ordinated planning and networking
Communication and co-operation between organisations
should continue to be encouraged, in order to plan training and
psychosocial services and avoid areas of overlap in services, or
gaps in service provision. Networking (both within and outside of
the psychosocial field) will enable organisations to be aware of the
variety of services on offer, and organisations should be encouraged
to refer to one another if they do not provide a particular service
themselves.
8. Awareness of the needs of special groups and a wholistic approach
to care
Certain special groups emerged as a result of the
disaster, for example, widowers (males who have lost their wives),
orphans and adolescents. These groups may have particular needs that
should be identified and planned for. Group meetings of men to
reduce alcohol use, and other social activities should be started.
In all cases, a wholistic approach should be taken in planning
psychosocial services. Services should aim to take into account a
person�s family, community and cultural context, as well as their
other needs (e.g. practical, financial etc), rather than solely
focussing on psychosocial issues.
9. Expressive activities
Activities such as drama, folk dances, rituals,
vows, songs, stories and poetry, may help people to express their
feelings and aid the recovery process. Sharing these activities in
groups may contribute to community cohesion.
10. Sustaining effective relief efforts
Psychosocial well-being will be enhanced if material
provisions and aid are regularly and reliably provided to those in
need. We observed during previous displacements that shortages of
certain aid items greatly increased stress for displaced people. The
psychosocial well-being of workers involved in the relief effort
will also contribute to overall recovery of the communities. If aid
workers are stressed, they will be less able to deal sympathetically
with the affected people. Workers should be encouraged to support
each other through regular meetings, and manage their own stress by
taking tea and lunch breaks during their work, and making time for
relaxation and leisure activities in their free time.
Long-term (more than 6 months post-disaster)
We expect the majority to gradually and naturally recover from their
traumatic experience. However, there will be a minority who
experience continuing mental health problems, such as depression,
complicated grief reactions, alcohol abuse and Post Traumatic Stress
Disorder. This minority will require highly specialised
interventions from a team of experienced mental health
practitioners.
In the long-term, it is desirable that any mental health needs
arising from the disaster should be addressed by accessing the
usually available and developed mental health services (e.g.
referrals to the psychiatric clinics and multi-disciplinary team,
input from the NGO counselling associations), rather than setting up
separate services for disaster survivors. Services should be
accessed through traditional resources at the community level, but
may need to be supplemented to cope with the increased demand.
Following the needs assessment described above, decisions will need
to be made about how existing services can be expanded to cope with
an increase in demand, and how existing services will link with
rehabilitation and reconstruction efforts. If new counsellors and
psychosocial workers are to be trained, their long-term
sustainability will need to be addressed, and staffing and equipment
costs in the long-term must be funded, as well as the short-term
costs of the training programmes.
A community level approach of empowering local resources like Family
Health Workers, Village Leaders and Government and NGO workers to
handle the majority of psychosocial problems will be the most
effective way to address the massive mental health consequences of
the disaster. Community level workers would need to be able to
identify the more severe cases for referral, and so would require
training in basic mental health, as recommended by WHO. The manual
�Mental Health in the Tamil Community� could be used for this.
We stress that the psychosocial component should be taken into
account in all rehabilitation, resettlement and development
programmes. An integrated, wholistic approach that includes
psychosocial and mental well-being will enhance the recovery
process. For example, in the design of new communities, provision
should be made for community resources such as play centres and
community halls. Communities should be rebuilt and improved with the
promotion of psychosocial well-being in mind, rather than recreating
only the resources that were present before the disaster. This will
require continued co-operation and communication between the varied
agencies dealing with different aspects of the relief effort.
Attached: Appendix 1
Diagram showing the three tier structure of
provision of mental health and �psychosocial services
We welcome any comments and feedback on this document.
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