Brief Treatment and Crisis Intervention Advance Access originally published online on September 19, 2006
Brief Treatment and Crisis Intervention 2006 6(4):349-365; doi:10.1093/brief-treatment/mhl014
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Waves Amidst War: Intercultural Challenges While Training Volunteers to Respond to the Psychosocial Needs of Sri Lankan Tsunami Survivors
From the Smith College School for Social Work
Contact author: Joshua Miller, Professor, Smith College School for Social Work, Lilly Hall, Northampton, MA 01063. E-mail: jlmiller{at}email.smith.edu.
This paper describes workshops offered in Sri Lanka to volunteers from 4 villages affected by the Asian tsunami to train them in basic psychosocial skills for working with survivors, 6 months after the tsunami struck. Questions about the appropriateness and viability of applying Western conceptions of disaster mental health responses to an ethnically diverse South Asian country are raised and intercultural challenges explored. The concept of the social ecology of natural disaster is presented and applied to Sri Lanka, an economically poor country recovering from a tsunami amidst ongoing lethal ethnic conflict. The efficacy of the trainings and suggestions for future interventions are considered.
KEY WORDS: tsunami, natural disaster, disaster mental health, Sri Lanka, social ecology, psychosocial, intercultural work
On December 26, 2004, an earthquake in the Indian Ocean, off of the coast of Indonesia, caused a huge tsunami that overwhelmed people in Indonesia, Thailand, India, Myanmar, and Sri Lanka. All told that the tsunami resulted in an estimated 232,000 deaths (Bearak, 2005); injured huge numbers of people; destroyed many homes; wiped out property and possessions; left many survivors without their partners, children, parents, family, and friends; and ripped apart the fabric of many communities. It was one of the worst natural disasters in the history of the world.
Many of the nations in the tsunami's wake were already poor, some already wracked by the devastation and destruction of war. Sri Lanka lost 40,000 people due to the tsunami, most in an instant (Virtual Library Sri Lanka, 2005). But for the past 25 years the country had experienced almost 70,000 deaths in a war of ethnic conflict as well as the deaths of tens of thousands of people when poor Singhalese leftists rebelled against the government in the 1970s and 1980s (Plunkett & Ellemor, 2003). Any one of these events would be tragic and debilitating for a country to endure, but the combination of all three in a poor country of 19 million people has had catastrophic consequences.
Many Western relief organizations and workers sought to help individuals and communities by responding to the psychosocial needs of survivors. Western disaster mental health practice carries a number of assumptions: that it is helpful to talk about what happened individually and in groups, expression of feelings is useful, and trained responders can help people to recover psychologically and emotionally (Dyregrov, 2003; Everly & Mitchell, 2000; Gist & Lubin, 1999; Miller, 2003; Roberts, 2005; Rosenfeld, Caye, Ayalon, & Lahod, 2005). Western disaster mental health methodologies also assume an autonomous self (Catherine Nye, personal communication), which is the locus of intervention and that talking about experiences, losses, and problems is helpful. The countries affected by the tsunami were non-Western, and it is not clear if Western models of disaster mental health responses were appropriate or effective. It will take time, reflection, and analysis to know how helpful these interventions were.
This paper describes a program to train Sri Lankan volunteers to respond to the psychosocial needs of tsunami survivors under the auspices of a local Sri Lankan nongovernmental organization (NGO), offered 6 months after the tsunami struck. Trainings were provided by two Western psychotherapists, including the author, who have practice and teaching experience in responding to disasters in the United States. The paper will briefly describe the principles of disaster mental health, the social ecology of natural disaster, and then consider the impact of the tsunami on Sri Lanka, placing this in a historical and social context. The workshops with volunteers are described with a particular emphasis on what volunteers were reporting: posttsunami reactions of villagers, volunteer concerns about survivors, and areas where Western notions of psychosocial responses to aid disaster survivors seemed dissonant with local customs and cultural practices. The paper will then consider the implications of this for future interventions.
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Disaster Mental Health |
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TOP
Disaster Mental Health
The Social Ecology of...Readers of this journal are familiar with the burgeoning field of disaster mental health. There has been a great deal written about helping victims and survivors of natural, technological, and complex disasters, including terrorism (Everly & Mitchell, 2000; Everly, Phillips, Kane, & Feldman, 2006; Miller, 2003; Raphael, 1986; Rosenfeld et al., 2005; Straussner & Phillips, 2004). Concepts include critical incident stress debriefing (Everly & Mitchell, 2000; Miller, 2003) and psychological first aid (Everly et al., 2006). Trauma theory and theories of grief and bereavement are incorporated into disaster mental health work (Miller, 2003). The field is closely related to that of crisis intervention and shares many precepts and techniques (Roberts, 2005).
The concept of psychosocial needs is used by international humanitarian groups responding to large-scale disasters. Although there is not unified agreement on its meaning, as the name implies, there is an emphasis on responding to psychological and emotional reactions and social relationships and to be respectful of "culturally appropriate social codes" (Loughry & Eyber, 2003, p. 1). Some of the foundational concepts of disaster mental health work include providing comfort (Everly et al., 2006); offering emotional support and ventilation (Everly et al., 2006; Miller, 2003; Raphael, 1986; Rosenfeld et al., 2005); debriefing, processing, and constructing narratives (Everly & Mitchell, 2000; Miller, 2003); grieving, mourning, and memorializing (Klicker, 2000; Rosenfeld et al., 2005; Straussner & Phillips, 2004; Zinner & Williams, 1999). All these concepts have embedded assumptions, many of which reflect Western views of mental health.
One assumption is that it helps to talk about problems with someone else. Western psychology is predicated on the notion that it is valuable to share with another person thoughts, feelings, and problems. There is disagreement over what responses are most helpful—for example, cognitive behavioral treatment emphasizes thoughts and behaviors while psychodynamic practice places a greater emphasis on feelings and latent content—but they both involve discussing what is troubling the consumer. Is this assumption valid for all cultures?
One vehicle for processing reactions to disasters has been critical incident stress debriefings (Everly & Mitchell, 2000; Miller, 2003; Raphael, 1986). Such interventions stress the importance of sharing stories and reflecting on physical, cognitive, and emotional reactions to the disaster. In the wake of 9/11, many debriefings were offered to thousands of people and cautions about the iatrogenic effects of these interventions, such as flooding or group contagion, were voiced (McNally, Bryant, & Ehlers, 2003). There were also concerns about whether or not such interventions were effective (McNally et al., 2003). However, even in studies critical of debriefings, there was support for other talk-oriented approaches, such as cognitive behavioral therapy, to aid survivors (McNally et al., 2003). Are conversational and discursive techniques useful for all cultures?
Disaster mental health practitioners also put a great deal of stock in grieving, mourning, and memorializing (Klicker, 2000; Rosenfeld et al., 2005; Zinner & Williams, 1999). Most Western approaches to bereavement not only involve talking and listening but also place an emphasis on the stages, phases, and process of grief (Becvar, 2001; Sprang & McNeil, 1995). An assumption is that this process takes time and that it is important for mental health workers to be mindful of meeting a client where they are and not pressuring them or rushing them to recover at too fast a pace. Are the stages of grieving universal in all cultures?
Western disaster mental health approaches also stress inner strengths, sources of resiliency, and the value of mutual aid and social support (Miller, 2003). A familiar refrain is that people are experiencing normal reactions to abnormal events (Everly & Mitchell, 2000). Many disaster mental health models, particularly those in the debriefing tradition, emphasize peer support and utilize the services of trained volunteers (Mitchell & Everly, 2001). How can such methods be adapted to be effective in non-Western cultural contexts?
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The Social Ecology of Natural Disasters |
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"Natural" disasters are often referred to as "acts of God," implying that they are inevitable and unpreventable. Natural disasters include tsunamis, floods, hurricanes, cyclones, earthquakes, volcanic eruptions, mud slides, and devastating monsoons and blizzards. Although it is certainly true that such events occur and will continue to occur, and in many instances are not preventable, there is a social ecology of each event which is very much a human enterprise. The social ecology of a natural disaster influences what happens before, during, and after a disaster (Park & Miller, 2006). The social ecology includes the political economy, historical legacies, level of resources and social and economic capital available to nations, communities and families, cultural and religious values, and linguistic assumptions. The dynamics of racism, ethnic conflict, class privilege, sexism, ageism, and other dimensions of social privilege and oppression are central to the ecology of disaster. All these factors influence where people live and the safety of their living situations. They shape which countries or regions in the world have early warning systems of natural disasters and those which do not. The social ecology determines who receives help and who is neglected. This complex set of variables ultimately influences who lives and dies among survivors and who recovers or are left by the wayside.
The social ecology of a natural disaster is accompanied by narratives and discourses that tell certain stories while marginalizing others (Park & Miller, 2006). There are micronarratives—the stories people tell of their own encounter with the disaster—as well as meta-narratives generated by communities and spun by politicians and the media, which dominate public discourse. The media encodes, replays, echoes, shuffles, and amplifies certain narratives while marginalizing others. All levels of narratives are infused with cultural meaning, social values, and implications for political action or inaction. The images and stories that are presented further influence those who receive help and who do not.
The social ecology of disaster is made manifest in how government and NGOs respond to affected communities. Relief efforts are mediated by political philosophies about the role of government, designating responsibility for rebuilding and recovery, as well as commitment to prevention and future readiness. There are debates about the role of government versus that of the private sector and assumptions about the responsibilities of residents for taking initiatives to rebuild their own lives. These guiding principles are in turn enacted through social policies and influence the allocation of resources toward disaster prevention and response.
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The Social Ecology of the Sri Lankan Tsunami |
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Sri Lanka is a country that is roughly the size of Ireland or of West Virginia and has about 19 million inhabitants. It gained independence from Great Britain in 1948. There are three main ethnic groups in the country. The Singhalese, who are predominantly Buddhist, constitute 73% of the population and have dominated all governments since independence. Tamils, who are Hindu, make up 18% of the population. They are mostly concentrated in the North and East of the country and in the central hills where tea is grown. There are also large numbers of Tamils in Colombo, the capital of Sri Lanka. Distinctions are often made between Sri Lankan Tamils, who live in the North and East, and "upcountry Tamils," who live in the central highlands; the latter group immigrated more recently to Sri Lanka, mostly from the Indian state of Tamil Nadu, drawn to work available at tea plantations. They tend to be less educated than other Tamils and many have not yet been granted Sri Lankan citizenship. A third ethnic group is Muslims, who are 7% of the population. Some Muslims trace their ancestry to Arab traders. Muslims tend to live in the North and East, as well as Colombo, and speak Tamil but view themselves and are viewed by others as a distinct ethnic group. There are three major languages spoken in Sri Lanka—Singhalese, Tamil, and English. Most Singhalese speakers do not speak Tamil and vice versa. English tends to be spoken by wealthier and more educated classes.
Sri Lanka is a beautiful country, with striking beaches, jungles, savannahs, plains, and mountains sustaining an abundance of flora and fauna. Agriculture ranges from subsistent home gardens and slash-and-burn framing to large plantations for commercial production. There is a great deal of fishing and mining and a textile industry.
Sri Lanka is a poor country. According to The World Fact Book, the GDP per capita income in 2004 was $4,000 (Central Intelligence Agency, 2005). Despite this there is an excellent mandatory school system, with different schools teaching in Singhala, Tamil, and English. The educational curriculum as well as the political system is strongly influenced by the legacy of British rule. The country has a few rail lines that use aging equipment, much of which appears to come from the colonial era. There are many buses, but the roads are of poor quality and highly congested. The major thoroughfare from Colombo in the West to the Eastern provinces is a two-lane road, which traverses a major mountain range with sharp curves and a multitude of switchbacks. Sharing the road are trucks, buses, cars, vans, auto rickshaws, motorcyclists, bicyclists, pedestrians, schoolchildren, oxen-driven carts, livestock, dogs, and the occasional working elephant. Thus, it takes a full day to travel the 250 km from Colombo to Kalmunai in the East, which has serious implications for communications and the ability to move goods and services around the country at times of disaster.
All three ethnic groups maintain distinct traditional cultural practices, such as dowries among Tamils and hijabs for Muslim women, although there are overlapping customs, such as greetings and styles of dress. It is much less usual for women to work outside of the home than in Western countries and very few cars and virtually no motorcycles, buses, or trucks are driven by women. However, Sri Lanka has also experienced modernization, particularly in urban areas.
A tragedy for Sri Lanka and a major factor in its social ecology of disaster has been a 25-year-old civil war, which not only has claimed nearly 70,000 lives but has displaced nearly 1 million people, left thousands disabled, led to thousands of former child soldiers, increased the number of female-headed households, and dramatically decreased the standard of living of those in the North and East (Frerks & Klem, 2005a; National Peace Council, 2003). There are many narratives about the war that vary according to the perspective of the author (Frerks & Klem, 2005b). Tamils cite the "Singhala-only" language statute passed in 1956, which privileged Singhala as the only language to be used in official and governmental activities, as well as the enshrinement of Buddhism as the state religion in 1972 as serious threats to Tamil citizenship and cultural survival (Loganathan, 1996). The Singhala-only language requirement severely restricted Tamil access to government jobs and as a result, Tamils sought other jobs through attaining education (Chelvanayakam, 2005; Gunasekera, 2005). However, education is a highly contested social sphere and due to a variety of government policies, the score levels for Tamils entering university were, at least for a period of time, required to be higher than those for Singhalese students and there was a drop in Tamil university enrollment (Banda & Abeyratne, 2005; Chelvanayakam, 2005; Gunasekera, 2005).
Whereas some Tamil leaders have worked to make Sri Lanka a truly multiethnic state, others have argued for the need for secession, creating a Sri Lankan Tamil homeland where cultural practices and group ethnicity can be preserved (Liberation Tigers of Tamil Ealam [LTTE], 2005). The secessionists have in turn fueled strong Singhalese nationalism, with fears of the country dissolving into ethnic zones and federations. While Tamils can look to other Tamils living in the Indian state of Tamil Nadu and in a Tamil Diaspora around the world, Singhalese people view themselves as the only representatives of their ethnic group, leading to the phrase that they are a "majority with a minority complex" (Loganathan, 1996).
The ethnic tensions have led to one of the world's bloodiest and seemingly intractable civil wars. There have been massacres perpetrated by the government and by all ethnic groups toward one another. There have been charges by the Tamil Tigers of government genocide and ethnic cleansing. Villages have been attacked and inhabitants wounded and slaughtered due to the ethnicity of the residents. Internecine warfare among Tamil organizations has also claimed many lives. There are many maimed people in Sri Lanka who were either attacked or accidental victims of war, such as stepping on landmines. The war has been primarily fought in the North and East, although there have been pogroms, bombings, and assassinations in Colombo. While conducting the workshops described in this paper, the foreign minister, who was one of the few Tamils in the government, was assassinated by a sniper. The major suspects were the Tamil Tigers. The North and East of the country were economically devastated before the tsunami, with industries damaged and neglected, fishing curtailed, education interrupted, and the ability to transport and exchange goods severely diminished. In addition to the civil war, there are still psychic and social scars from the uprising in the South as well as persistent poverty.
These were the conditions in the country before the tsunami struck. The worst affected areas were the South, which is predominantly Singhalese and the East, which has been a site of intense inter- and intraethnic conflict. Six months after the disaster, the coastline still bore the imprint of the tsunami. All buildings for about one fourth to one third of a mile from the beach were damaged and most destroyed. On the East coast, the area was strewn with piles of rubble: bricks, stones, shoes, waterlogged toys, and articles of clothing, entwined around blackened and decaying palm tree branches. Roads leading to the beach were ripped from their beds and had yet to be replaced. People were still frightened of the sea, and beaches were nearly empty and deserted compared with pretsunami activity.
A formal cease-fire had been declared 2 years before the tsunami, partially brokered and strongly supported by the international community, particularly the European Union, Sweden, and Japan. However, there had been many violations until the tsunami struck, an event which initially brought the warring factions together ("Stop Killings," 2005). The government even entered into an agreement with the Tamil Tigers (LTTE) to jointly administer foreign aid called the Post-Tsunami Management Structure [P-TOMS], which was a groundbreaking accord. However, some Singhalese political parties, concerned about having an agreement with the LTTE, contested the legal status of the P-TOMS and blocked this arrangement. There have also been concerns that the government was slower to respond to the Tamil areas than the Singhalese areas. In turn, some Singhalese Sri Lankans claimed that the international community gave more help to the Tamils in the East than the Singhalese in the South.
In both the East and South, psychosocial resources were limited. There were few psychiatrists, psychologists, or social workers available to offer counseling to affected people. Although some therapists and counselors volunteered from abroad, they were minimal when compared with the need of survivors and there were significant cultural and linguistic barriers to their work. Indigenous ad hoc groups emerged to assist survivors but had limited resources and many of those living in the tsunami-affected areas were struggling to rebuild their own lives.
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The Trainings |
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Organizational Auspices
The Center for Peace Building and Reconciliation (CPBR) is a Sri Lankan NGO founded about 5 years ago by a lawyer turned peace builder and a professor of philosophy. The vision of CPBR is underpinned by a belief in the need for unity through diversity and its goal is to create a "united Sri Lanka, in which all of us can live in harmony and peace, guided by the principles of justice, power sharing, and dignity for all people" (CPBR, 2005a). CPBR targeted their efforts toward Buddhist monks, the university community (professors and students), and the media (CPBR, 2005a). However, after the tsunami, CPBR concluded that "the devastation caused by the tsunami in December 2004, and the ongoing ethnic conflict of many years have heaped on those affected and their families unbearable poverty, hardship, loss of their livelihoods, and loss of hope of the future, especially among youths" (CPBR, 2005b). To respond to this, CPBR recruited 160 young adults from four villages struck by the tsunami, three in the war-torn East and one in the impoverished South to serve as volunteers in a program called "Friends in Need" (CPBR, 2005b). Of the three villages in the East, two were predominantly Tamil and one Muslim, while the village in the South was predominantly Singhalese. Although a few volunteers were taking courses in college, the vast majority had at most a high school education. Using an empowerment-based philosophy, CPBR encouraged the volunteers to plan and implement recovery efforts for their villages, which the volunteers designed. They were trained and oriented by CPBR, but each group developed their own community and economic recovery plans. Volunteers in all four villages were eager to learn more about how they could respond to the psychosocial needs of tsunami survivors.
Description of Workshops
After consulting with the leaders of CPBR, workshops were designed for each village where there would be a discussion of the volunteers' work, identification of psychosocial problems, clarification about what they wanted help with, and training about basic psychosocial techniques. In the three villages in the East, participants spoke Tamil and in the one in the South, Singhalese. Few participants spoke fluent English, so the workshops were conducted through a translator. Although the translators worked hard and made a valiant effort, they were not professional translators and had no experience with psychosocial concepts, so in three of the villages the level of translation was very basic and the pace of the discussions slow moving.
CPBR had formed six workgroups for the volunteers in each village, which focused their efforts on target populations: children, youth (adolescents and young adults), women, men, the elderly and disabled, and a meta-group that focused on the environment. Each training session began by asking the volunteers what they were noticing in their workgroups about the psychosocial needs of villagers, what they were concerned about, and what were their questions about how to best help people. The responses to these questions served as the basis for the rest of the workshops as well as the foundational data for this article. Other data emerged from discussions during the workshops, conversations with program leaders, and conversations with other key informants involved with providing psychosocial relief.
The four workshops were held in four different villages: Thirukkovil and Periyaneelavenai, which are predominantly Tamil; Ninthavur, which is predominantly Muslim; and Madiha, which is predominantly Singhalese. Each workshop was held for two full days. There were approximately 40 volunteers who participated in each workshop. The local volunteer coordinator for each village also attended the workshops.
The locations for workshops were halls in schools or temples. The conditions were hot and humid and there would usually be one blackboard or whiteboard to write on. There were no handouts, and in one village participants did not have pencils and paper. In the Muslim village, males sat on one side of the room and females on the other, although both genders interacted with one another during exercises and role-plays. There were distractions, such as dogs entering the halls and at times fighting with one another. A variety of pedagogical techniques were employed: lecture, question and answer, small-group discussions, simulations and enactments, role-plays, and games and exercises. Due to the difficulties with translation, illustrating issues and concepts through role-plays and simulations often proved to be the most effective teaching strategies. In all workshops, participants seemed eager to learn and were actively engaged.
Appendix A lists the components of each training. Every workshop began with an icebreaker and then a discussion about what the volunteers were seeing in their villages, what concerns they had, and what questions were arising for them. Although there were some workshop components that were consistent across all workshops, such as common psychosocial reactions to a tsunami, each workshop was adjusted and tailored to meet the specific questions and issues raised by the volunteer participants. Thus, Appendix A lists typical topic areas, but in each workshop they were given different weights and approached with different pedagogic strategies, depending on the flow of the workshop. The common reactions to a tsunami were based as much as possible on international research about reactions to disasters (Rosenfeld et al., 2005). We stressed how a tsunami affects people internally (psychologically and emotionally) and socially and has an impact on the entire community.
Appendix B lists the key points that were made in each workshop about reactions to the tsunami. Care was taken to frame these reactions in the light of international research and to identify our own localized, culturally bound assumptions and biases. We always would ask if our points seemed to fit with the volunteer's own cultural constructions and understandings. The notion that precipitated the most discussion was that it helps to share your problems with others. Although there were concerns about "burdening people" with one's own problems, there was agreement among the volunteers that relationships help us to heal. In all workshops there was discussion about whether or not the key psychosocial points appeared be valid based on the experiences of the volunteers and their knowledge of their own cultures and villages.
Before covering psychosocial techniques, we asked volunteers to describe to us what they already were doing well. This was an effort to encourage self-empowerment as well as to gain a baseline understanding about their efforts thus far. The results from the four villages are listed in Appendix C. As can be seen from the list, there was an emphasis on gathering data and helping people regain a "positive attitude." Although volunteers said that they were good listeners and nonjudgmental, in discussions and role-plays, they conveyed impatience with the grieving and mourning process and an eagerness to move quickly into problem solving. They then felt frustrated when their problem-solving efforts did not seem to have the desired effect. Almost all the volunteers were directly affected by the tsunami, and there was recognition of their own sacrifices and willingness to help others without expecting anything in return; service to the village was highly valued.
The psychosocial part of the workshops stressed basic techniques and approaches, which were discussed and demonstrated. Again, there was ample discussion about whether or not these were culturally appropriate. The main areas that we covered are listed in Appendix D. We emphasized the importance of relationships; the need to allow people space to grieve and mourn; the importance of a strengths-based, empowerment-oriented approach; and the value of mutual aid and support. The volunteers reported that the approaches were either building on techniques they were already using or culturally compatible. However, in discussions and role-plays, it was consistently difficult for the volunteers to be patient and present when a person was grieving and mourning or was depressed and despondent.
What Volunteers Reported
The volunteers in the Eastern villages all lived in the villages they were serving, and the vast majority of them were directly affected by the tsunami. Some of the volunteers from Mediha in the South were actually from the village, whereas others were from more inland communities and were not directly affected by the tsunami. In the East, the description of the tsunami was that there was shouting on December 26 at about 8:30 a.m., as people noticed a wave that was 2–3 feet high. Many men were already at work or on their way to work either going out in fishing boats or moving further inland to jobs. Most women and children who lived on the coast were home. The first wave attracted attention and drew people toward the water. About 45 min later, there was a huge wave, as high as the tops of palm trees, followed by another huge wave within 5 min. These waves were thick, fast moving and very muddy, and as they moved inland were saturated with debris and bodies.
In some areas, there were nearby lagoons that experienced storm surges and where people were deposited. One man described saving 45 people who had been washed into a lagoon. He was still angry that more people had not assisted him in his rescue efforts and felt guilty that he had not saved more people. He was haunted by the vision of a woman whom he had saved but had failed to rescue her children. She kept her arm crooked where she had held her lost child. There were many other tragic stories shared by the volunteers. One was of a man who had lost his wife and six children. One day he just walked into the sea in front of a Hindu temple and never returned.
Reactions to the Tsunami
As noted earlier, in each village the volunteers were divided into six workgroups: children, youth, women, men, elderly and disabled, and the environment.
General Themes.
There was widespread fear about future tsunamis. In contrast to the civil war, which has been persistent and long-standing, the tsunami was sudden, unanticipated, and shocking. Part of the psychological trauma of the tsunami was that it came from the sea, the source of economic livelihood for so many, whereas beaches were a place of recreation and relaxation. The sudden turning of the sea against people was frightening and confusing, as well as leading to a loss of faith and trust. Six months after the tsunami, people were still on high alert and hypervigilant. People were easily startled or frightened by what previously were benign occurrences—a rainstorm, loud noises, or people shouting. Volunteers reported people found it difficult to fall asleep because they were wary of letting their guard down. Many people of all ages were still having nightmares. Volunteers were skeptical about scientific pronouncements about the unlikelihood of a tsunami recurring in the near future being sufficient to reassure villagers.
Fear and watchfulness was related to a loss of faith and meaning. Three of the four villages reported significant numbers of people questioning their faith and religious beliefs. The one major exception to this was the predominantly Muslim village. Volunteers in this village were incredulous that the tsunami might cause people to question their religious beliefs. They reported that to the contrary, the tsunami has strengthened the religious convictions of people in their village. However, volunteers in this village also reported that there was a belief that families who had suffered a great deal during the tsunami had not been as devout in their religious faith as those who were spared significant losses.
Regression, depression, listlessness, apathy, confusion, anger and resentment, and flashbacks were reported for all age groups in all villages. Although this was often in response to losses from the tsunami, it was also related to ongoing sources of stress and tension. A major contributor was that many people were still living in refugee camps and temporary shelters. Nearly 0.5 million people were displaced by the tsunami, and there was a need for 100,000 homes to resettle them (BBC News, 2005). The camps lacked adequate water, sanitation, and privacy. There were few organized activities or social services being offered. Youth, women, and men lacked the tools and equipment to pursue their livelihoods, many of which were home based, such as cultivating a garden, fishing, delivering goods by bicycle, and sewing and crafting things to be sold. Many people had to rely on NGOs for nearly everything—shelter, food, water, sanitation, and clothing, leading to ambivalent feelings. Along with gratitude were feelings of resentment over dependency and perceptions of unfair treatment when goods and services were distributed.
Children.
There were many reports of children being neglected. Surviving caretakers were often too depressed or distracted to offer their usual standard of parental care and those children who lost caretakers were often falling through the cracks. A number of villages reported that orphans were exploited, being made to do work, and treated "like slaves." Orphans were stigmatized and scapegoated by other children. Volunteers reported that children were fearful, crying excessively, having nightmares, waking suddenly at night, and in many instances regressing. Not surprisingly, they were having difficulty concentrating, studying, reading, remembering, and playing. Routines had been disrupted and many were attending new schools with longer commutes. Some children resisted attending school.
Children had not only lost parents, siblings, and homes but also lost their favorite toys and belongings. Volunteers described children as being listless, depressed, and neglecting their self-care. There were reports of higher levels of misbehavior and angry outbursts. There was also more lying and stealing. Some children were hurting themselves and there were even reports of suicide attempts by children as young as 3 years.
Youth.
Like children, there were many reports of regression, low motivation, poor school attendance, falling grades, lack of motivation to work and "negative attitudes" among adolescents and young adults. Youth were viewed as engaging in socially proscribed activities at much higher rates, particularly drinking, using drugs, and engaging in casual sex. Many young women were concerned that they would not be able to marry due to lost dowries. Volunteers reported men breaking off engagements when dowries were destroyed or seeking partners who could offer higher dowries.
Youth seemed to have a particularly complex relationship with NGOs. Volunteers were concerned that many had become dependent on NGOs and expected to be taken care of by them. If the expected level of care failed to materialize, or if others were viewed as receiving more help, youth were often angry and resentful.
Elderly and Disabled.
Although each village had workgroups focusing on these populations, they are distinct groups often with very different needs. Both groups had experienced profound social isolation since the tsunami. There were few services, such as senior and day care centers and service programs, available before the tsunami, but after the disaster there was also less support and attention from family members who had served as caretakers and support systems. As a consequence, self-care was suffering. Volunteers reported that elders were receiving little respect. Those elderly and disabled who had been able to provide for themselves were, like other groups, bereft of tools and other resources to help support themselves. People found their disabilities magnified since the tsunami, as routines were dislocated, transportation disrupted, prosthetic implements and accessories enhancing mobility lost or damaged, and caretakers less available. The environment was also more hazardous, with more illnesses circulating due to overcrowding in refugee camps and poor sanitary conditions and less medical attention and medicines available.
Not surprisingly, there were many reports of both the elderly and disabled feeling sad, worthless, despondent, and angry. There were constant fears about their future ability to care for themselves and survive. Alcohol and illicit drug use rates were elevated.
Men.
Among all three ethnic groups, men are viewed as the primary economic providers for their families. Fishermen had lost their boats and carpenters their tools. Transportation was hampered by lost bicycles and motorbikes. In addition to struggling materially, men were grappling with their diminished ability to support their families, which led to low self-esteem and fractured social roles. There was regression, depression, angry outbursts, higher rates of drinking, as well as increased suicide attempts. There were elevated levels of domestic violence. Both men and women struggled over diminished opportunities for "intimacy" while living in crowded refugee camps.
Women.
Women lost their ability to pursue home-based work, such as sewing, making coconut art, growing flowers, doing laundry, baking, and making sweets due to lost and destroyed equipment. They also found it more difficult to care for their children and husbands as they had less ability to cook, wash clothing, and keep their living areas clean. Young women lost their dowries and widows were particularly vulnerable as their chances of being cared for had severely declined. The tsunami disrupted other social relationships as well, through loss of life and dislocations, resulting in less available social support.
As with youth and men, many women were depressed, angry, despondent, and isolated. There was less interest and motivation in pursing education by those who had been in school. Volunteers described many as still mourning their losses.
Environment.
In all four villages, volunteers focusing on the environment reported similar findings. Many trees had been destroyed, and there was less shade to protect people from the heat. Herb and vegetable gardens were also destroyed; so many people were no longer able to grow their own produce.
As a result of the tsunami, there were sanitation problems and pollution had increased. Due to the destruction of many wells and the presence of many relief workers, a great deal of bottled water was being used, leaving tons of plastic bottles to be disposed of. As there is no recycling program and very limited sanitation—refuse facilities, the bottles were poorly disposed of and often burned, creating noxious fumes. It was also more difficult for people to care for their personal hygiene, and living in overcrowded, temporary conditions increased the risks of contagious and infectious diseases. Many hospitals and medical facilities were damaged or destroyed.
The social fabric of community life was torn by the tsunami, and it was more difficult for people to support themselves and one another. There was greater economic and social dependency on the government and NGOs.
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Discussion |
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It will take many years to assess and grasp the long-term consequences of the tsunami on Sri Lanka. These consequences will be mitigated by how the country rebuilds and attends to the psychosocial needs of survivors. It may never be possible to extract the impact of the tsunami from the war, long-term interethnic conflict, and other sociopolitical dynamics. The trainings described in this paper were minimal interventions and, if anything, raised many questions rather than offer answers and solutions.
Despite the plethora of nations and NGOs offering tsunami relief, villagers received little or no attention for their psychosocial needs. There were few Sri Lankan mental health workers to begin with, and the war and tsunami have severely overtaxed their capacity to respond. Workers and volunteers from other countries encountered similar linguistic and cultural challenges described in this paper. Many would arrive for short stints and then return to their countries. There was little consistency or follow-up and no strategic plan to comprehensively respond to all affected people or to triage or target those with the most severe problems. These issues point to the need for a clear follow-up plan and exit strategy before even beginning to offer relief.
The four villages described in this paper were fortunate to have the services of the young adults who served as volunteers. They were from the community, understood local cultural and social practices, and were richly linked to social and neighborhood connections. They were also tsunami and war survivors and were struggling to regain their footing, including many unmet psychosocial needs of their own. They had little or no training in psychosocial responses to disasters. There was no systematic follow-up to the trainings described in this paper. There were also no formal evaluation procedures.
The expression of mourning, grief, and sadness is mediated by cultural beliefs and practices. It is unclear about whether the assumptions mentioned earlier—particularly that it helps to talk about one's experiences and to share feelings, as well as being present with a person while they grieve and mourn, without hurrying them—are culturally compatible with Sri Lankan society. There are cultural and religious traditions that are thousands of years old in Sri Lanka, modified by modernization, affected by ethnic conflict and war, and overwhelmed by the tsunami. How well these traditions and practices sustain hope and support recovery and healing is unclear, just as the efficacy of Western-based disaster mental health practices in an Eastern culture and society is uncertain. It is also possible that the Western relief workers have inadvertently undermined indigenous healers and spiritual leaders having been elevated to a privileged a position of "experts."
A commonly shared belief was that there is no point being sad and that it does not get you anywhere. Volunteers would smile while relating sad and tragic stories about the tsunami. The volunteers, as well as the people they were seeking to help, were often reluctant to share their feelings with others out of concern for "burdening" other people with their problems. It was as if sharing sadness publicly carried the risk of depleting a person of a vital life force (Wikan, 1989). A common response in role-plays where a widow or youth was crying or expressing sadness was for the volunteer to say, "Come on now, many people lost a lot." The volunteer would then try and refocus the affected person toward having a more positive attitude and identifying concrete steps they could take to improve their situation. There was a low tolerance for staying with an affected person's pain or helping them to grieve and mourn—this was seen as being counterproductive and contributing to a "negative attitude." And yet much of the literature on disaster mental health and response stresses the importance of this stance (Gist & Lubin, 1999; Rosenfeld et al., 2005; Zinner and Williams, 1999). As the Asian tsunami-affected Eastern cultures, it will be important to evaluate the relevance and value of these approaches and to understand culturally responsive ways of helping people recover from a major natural disaster.
Although there is international research about how people from different cultures and countries respond to disasters (Nader, Dubrow, & Stamm, 1999; Rosenfeld et al., 2005; Zinner & Williams, 1999), the disaster relief literature still relies on many Western suppositions about how people react, grieve and mourn, and recover. These assumptions are in turn based on a Western notion of an autonomous, independent self. Such assumptions clearly need to be examined and scrutinized when helping people to recover in cultures with collective orientations and different worldviews and value systems.
As there was no formal evaluation of the workshops, it is difficult to ascertain their long-term impact. The only feedback mechanisms were verbal reports about what was helpful, shared by volunteers at the close of each workshop, as well as the observations of the coordinators and project directors. Volunteers reported that they were helped by having concepts that rendered meaningful the reactions and behaviors of affected people and that normalized many responses to the disaster. Volunteers also reported that information about stages of child development, risk factors for suicide, and models for understanding drug and alcohol abuse were also of value. Despite discomfort with sharing problems and feeling, the volunteers responded positively to strategies for engaging people and forming relationships.
Volunteers were intrigued with the potential for utilizing groups as a means for helping people to recover. The workshops introduced the concept of mutual support groups and activity groups (Gitterman & Schulman, 1986), as well as groups where there was discussion and processing of what happened during and after the tsunami, in a similar vein to debriefings and defusings (Miller, 2003). However, the idea of bringing affected people together for ongoing, intentional groups, where feelings were expressed, caused discomfort. The volunteers were more at ease with trainings where information is presented or with experiential learning within the framework of a focused workshop. Psychoeducational groups may be the best way to bridge this disjuncture.
As most of the volunteers in the workshops were tsunami survivors, the trainings offered them an opportunity to have space to discuss their own reactions and to think about what has been helpful to them. This meant that the help-givers also had the opportunity to process their own experiences. Hopefully, this deepened their capacity to help others.
Although workshops such as these might be of some value, a "training of trainers" model may have greater long-term utility. If two to four of the most motivated and experienced volunteers from each village received intensive training, they could in turn train and supervise their fellow volunteers. There would then be indigenous "experts" and "consultants" available to supervise and teach volunteers on an ongoing basis. They in turn would benefit from ongoing consultation and training to deepen and enhance their skills, as well as offering support for their work. It would be difficult to offer a group for all the indigenous supervisor/trainers, as the distance between the southern village and the Eastern villages is great, the expense of transportation prohibitive, and telecommunications are insufficient for long-distance learning. However, the three Eastern villages are close enough to each other so that there could be regular contact between the volunteer leaders. Another barrier to this proposal is ongoing funding for volunteers.
A social ecology model of response recognizes the inextricable interaction between Sri Lanka's history, sociopolitical context, civil war, multiple ethnic groups, and the tsunami. What is considered "normal" and "pathological" cannot be understood from a transplanted, Eurocentric lens. Helping people recover from their psychosocial wounds necessitates a macroperspective as well as clinical insights; tsunami trauma relief will be futile if the civil war escalates. At best, helpers from the outside can be resources for local people and should avoid assuming the mantle of expert. Whenever possible, local citizens should be fully engaged in the planning and execution of trainings and not be treated as passive consumers. Limited local resources, many of which have been devastated by civil war and natural disaster pose a challenge to this ideal, but the vision of empowering indigenous peoples while doing no harm must be maintained.
The model of having local people help their own villages to recover is empowering and the dedication, energy, and commitment of the volunteers inspiring. However, looming over all the recovery efforts like a dark cloud is the slowly simmering civil war, the unresolved conditions which spawned it and the potential for it to explode again into a full-scale conflict. Although Sri Lankans have endured a great deal of pain and suffering from this conflagration, the tsunami stands out as a sudden catastrophic event which shattered communities and lives, many already injured by the war. The war in turn has hampered and limited rebuilding and recovery efforts. Should it escalate, it will surely weaken what tsunami relief efforts have been offered thus far, exacerbate the many wounds and scars inflicted by the tsunami, and inhibit future psychosocial recovery initiatives. However, the Sri Lankan people have been slowly recovering from the tsunami, and thus far, the work of rebuilding has helped to keep the hounds of war at bay.
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Appendix A. Workshop Components |
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- I. Intro/icebreaker.
- II. What they are seeing?
- III. What are their concerns?
- IV. What are their questions?
- V. Disasters and their psychosocial consequences: cognitive, emotional, behavioral, spiritual, interpersonal, physical.
- VI. Impact of Tsunami on special populations: children, youth, disabled/elderly, women, men, environment.
- VII. Two goals of recovery—grieving and coping.
- VIII. How to help people with specific symptoms or problems—which we took from the examples that they gave.
- IX. Assessing risk— particularly suicide and alcoholism.
- X. Survivor guilt.
- XI. Community timeline for recovery from a disaster.
- XII. Coping and strengths in individuals, family, groups, community.
- XIII. Mutual aid and group strategies.
- XIV. Memoralizing.
- XV. Self—care and mutual care of helpers.
- XVI. Follow-up strategies.
- II. What they are seeing?
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Appendix B. Reactions to Tsunami |
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- Normal reactions to abnormal events.
- Mourning and recovery both important—need to find balance.
- It helps to share and relationships help us to heal.
- Notion of bearing witness, being present and available—not pulling or pushing too hard—deep listening.
- People will heal over time.
- People have strengths and resources they can draw upon.
- Value of mutual aid and support.
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Appendix C. Reports from Volunteers about what they Saw as their Strengths |
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- Collecting data.
- Good observation skills, recognizing people's "body language".
- Being respectful and polite.
- Responding to people in a soft and gentle fashion.
- Listening and understanding people's problems.
- Giving people information, educating them.
- Giving to others without expecting anything in return for themselves.
- Sacrificing their own needs to help others.
- Remaining neutral and being tolerant.
- Retaining self–control, remaining calm.
- Being able to let go of other people's problems.
- Expressing views to people, setting goals and helping them to take action.
- Conveying a positive attitude to people.
- Respecting themselves and knowing themselves.
- Respecting confidentiality—not sharing people's "secrets".
- Helping people to have more positive beliefs and attitudes.
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Appendix D. Basic Psychosocial Principles |
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- Observing.
- Listening non-judgmentally and with patience.
- Working to build a relationship and establish trust.
- How to ask questions which were validating as well as providing data.
- Being present and empathic with the "affected person".
- Staying with the "affected person's" feelings.
- Being able to tolerate the "affected person's" pain.
- Finding a balance between allowing people to mourn and helping people to access their strengths.
- Conveying caring and compassion.
- Respecting confidentiality.
- Connecting people with one another.
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Acknowledgments |
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The author wishes to thank Alisa Ainbinder, David Burton, Joanne Corbin, Dishani Jayaweera, Yoosun Park, and Jayantha Seneviratne for their helpful comments on earlier drafts of this paper. Conflict of Interest: None declared.
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