The heinous and inexplicable acts of violence that shook the country on Easter Sunday have inflicted a heavy psychological toll on Sri Lankan society. Though the resulting scars will inevitably be slow to fade, it is our collective responsibility to attend to the emotional injuries borne by those who have been most deeply affected; to help people deal with both grief and trauma, and to prevent the compounding of their suffering as psychological wounds begin to fester.
ne crucial aspect of any attempt at collective healing is the provision of psychosocial support to those who are in need of it. Institutionally speaking, the provision of this support involves different interventions by a multi-disciplinary team of mental health experts at various junctures in the period following a traumatic event. The methods by which these professionals provide help, as well as their advice to the public, can impart lessons on how we as members of our community can also assist in this process of helping those who continue to suffer.
The Daily News spoke to mental health professionals involved in providing support at each of these junctures to tell us how they go about treating the trauma and grief that accompanies tragedies such as that which we witnessed on Easter Sunday, as well as to offer their expertise as to how members of the public can also help those who are in distress.
Who is on hand to Help?
UNICEF describes psychosocial support as a process by which individuals and communities are helped to heal psychological wounds and rebuild social structures after an emergency or critical event, the ultimate aim of which is to transform people into active survivors rather than passive victims.
Providing psychosocial support involves a multi-disciplinary approach, in which a whole range of professionals is involved. In Sri Lanka, this involves tireless work from a team of social workers, psychiatric nurses (both in hospitals and in the community), occupational therapists and psychiatrists.
Registrar in psychiatry at NIMH Dr. Jayantha Herath explains, “When someone calls us, we have to see if they fit into a particular diagnosis, for instance, we go about checking for early symptoms of post-traumatic stress disorder (PTSD). If so, they can be referred to a clinic so that we will see them at the clinic if it is convenient for them, if not they can come anytime to the hospital, our services are available. Our nurses are trained to identify acute problems. For example, someone might call with an idea of suicide, that’s an emergency, so the nurses will identify it and react appropriately.’
In addition to being contactable via this helpline, there is a network of community psychiatric nurses, as well as psychiatric social workers all over the country, who can provide follow up visits to survivors after a tragedy if making a hospital visit proves too challenging.
Having dealt with the immediate acute symptoms that affect victims and families in the immediate aftermath of a traumatic event, community psychiatric nurses also deal with the more long-term psychological problems that may arise when victims or those otherwise affected try to reintegrate themselves back into normal life. W.L.D.G. Samanthi, a community psychiatric nurse notes, “After we have dealt with the acute state, people need service from the mental health team once they’re in the community, so we have to follow up.”
With regard to how one goes about providing this support psychiatric social worker, Sanjeewani Hettiarachi highlights that “It’s about listening empathetically, with reference to their situation.” In terms of the role of social workers in contributing to the process of providing psychosocial support she noted, “We are involved in implementing awareness programmes about early identification of mental health problems in the community. We are also involved with fund coordination, making sure the clients receive the funds from the government and NGOs.”
Psychological First Aid
Consultant psychiatrist at NIMH Dr. Pushpa Ranasinghe has been involved extensively in the provision of psychosocial support after traumatic events, having supported survivors and bereaved families in tragedies such as the 2004 tsunami.
With regard to assisting survivors of the Easter Sunday attacks, she noted: “We have to protect them and make them feel safe, some people were worried that there was going to be a bomb blast again in the hospital, we have to ensure their safety. We also have to give them accurate information about what’s going on, otherwise, you won’t be able to reassure the person. Sometimes they want to get in contact with their relatives, we can try and get a phone call to allow them to make a connection. We also had a list, which allowed us to know if family members (who were also survivors) are in another ward for instance. People who didn’t have their immediate families with them were showing more distress compared to other people. They were getting panic attacks, and sometimes medications had to be given. Some people who had PTSD symptoms said that they were okay with someone with them, but when they were alone the symptoms appeared again. We made sure that we inform the relatives that it is better if you can keep someone with them. Luckily everybody had mobile phones so that they can keep in contact with us if they have any problems.”
With regard to the issue of trauma and how mental health professionals may respond to someone displaying distressing symptoms, Ranasinghe notes, “We have to reassure them that this is something you can get after a stressful event or a disaster, this is a normal reaction when it persists is when you need the intervention. They know they can call us at any time. Normally PTSD develops after three months or so, suddenly you may get images or start reliving the experience, you’ll feel severe distress and your personality can change and you may start to feel suicidal or homicidal. We educate the relatives about this; that they (the victim) may be normal for a time and develop it later. So, they know about this and can detect it early and contact us to get any information they need, whether that be any treatment or social support. We have to identify people who are particularly at risk, single parents, children, people who have a history of psychiatric illness, people who are isolated, the financially disadvantaged. We have to follow up on them.”
Role of mutual understanding
Dr. Ranasinghe highlights the role of mutual understanding and strong community bonds in helping those affected by a traumatic event, “You have to make sure people don’t feel neglected or abandoned, we have to make the social network very strong. Our team had people who spoke Tamil, when they (the survivors) spoke to someone in their mother tongue, their eyes were a lot brighter and they connected very much. We have to take this into consideration when making a support group, we have to show that we are one of them.”
In terms of the ways we may go about providing support, Dr. Ranasinghe points out that though venting can be helpful for a survivor, this must only be encouraged if the individual feels able to do so, “Don’t force them to tell their story. Allow them to talk but if they don’t want to talk don’t force them. Previously there was a treatment method called debriefing, where we ask them to tell it again and again, they’ve done studies and found out that this is much more traumatising, we just listen non-judgementally. We’re not going to put our value system onto them, we must provide support without challenging patients.”
Dr. Herath reiterates the importance of psychological support from members of the community, noting that “The victims are more in the community than with us. There is no shortage of people willing to help in Sri Lanka. They should understand what these people are going through and they should be educated on how to deal with these situations. Share the sorrow, be with them, let them vent if they need to, the stresses will be relieved whilst doing so, don’t be judgemental during this time.”
Occupational Therapy
The work of mental health professionals does not end after the immediate symptoms following a traumatic event are over. Another important aspect of psychosocial support is the work that needs to be done in order to help survivors and those who are grieving to carry on with their lives.
The occupational therapist at NIMH Pradeep Gunarathne is part of a team whose role is to encourage those affected to recapture a sense of normalcy in their lives and to make it as easy as possible for them to do so.
“Our role is to help people to restore their skills and routine of life. We believe that engaging in normal routines that they had before the incident is essential for recovery. We start with little things like sleeping routines and general day to day personal care”, he notes.
“We listen to them and do basic counselling, but we mainly concentrate on personal care, work and leisure. I’ve seen some people who lie in bed all day, and some people who don’t sleep at all, what we try to do is to help people engage in their personal routines. Later, with time, when they get used to this, we have to let them go to work. This is important because engaging in their previous routines reduces the acute reactions of distress. Most importantly what we have to promote is leisure. Maybe they used to go on picnics with family, but maybe one family member is gone now. They may then stop it for their life. But that shouldn’t happen, we have to encourage them to do what they did earlier. We must encourage people to carry on, not letting them be neglected in the community.”
Gunarathne mentions that people must be made more aware that such a service exists for anyone who is in need of it, with help available not just for those suffering from severe disorders such as PTSD but also for anyone who is struggling to get back on their feet in the aftermath of the tragedy. “We need communities to be aware that there is a service like this. If you have a psychiatric illness after the incident then psychiatrists are available to help you, but for the majority who don’t have a psychiatric illness but need a little bit of support to adjust to going back to normal life, they must be made aware that this service is available.”
Gunarathne, having highlighted the importance of those affected eventually returning to work and their previous routines, also has some advice for employers regarding their responsibility to help their employees recover. “Employers should make sure, in any big company, that their employees have access to some sort of counselling. They should also provide them with a relaxing of some regulations, allow them to take some time off if necessary, they have to give these employees some exceptions. They must help them to recover and get involved with the work they were doing before. Also, there should be at least one person in the workplace to contact if they are having some trouble, if they find it difficult to work, employers should help them with that.”
Centring survivors and the bereaved
With the advice highlighted above in mind, there are a few key points to remember in your conversations with those affected.
* When speaking to someone who is in distress, let them know you are listening and don’t interrupt or rush them.
* Do not provide judgements or make comments such as ‘you are lucky to have survived’ or ‘it could have been worse’. Acknowledge their losses.
* Ask about their needs and concerns and help them access services they may be in need of.
* Be aware of the fact that severe distress may result in survivors and the bereaved reacting to you with anger or frustration. Be calm, recognize that this is normal and understandable, do not take it personally.
* Help people connect with friends and family. If they are religious, help them reconnect with their spiritual community.
* Try and avoid any potential triggers that may induce unwanted memories of the incident.
With all this in mind, as we move forward, attempting to repair the lacerations that have emerged in our social fabric, we must make sure we centre those of us most affected by the tragedy. Though indeed political lessons must be learned and such questions must not be avoided, we must ensure that the suffering of victims and the discourse surrounding the tragedy are not reduced to a theatre for the performance of political dramas. Providing genuine support involves not losing sight of the lived human experience that ultimately justifies all political action; it involves holding at the forefront of our minds our responsibility as a community to engage with those affected with sensitivity and empathy, to stand by them in genuine solidarity.
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