Sunday Times 2
Psychosocial rehabilitation in north in a post-war context
Rehabilitation usually means reversing the debilitating effects of an injury. Injury would encompass physical, psychological and social trauma. The aim of rehabilitation would be restore health and wellbeing that has been lost or injured by the war and earlier, by the tsunami. Psychotherapy, counselling, behavioural and cognitive therapies are some common psychological forms of treatment that could be used in psychosocial rehabilitation. Marital, family and group therapies as well as rehabilitation, NGO networking, occupational therapy and vocational training can be considered social forms of therapy. Likewise, it is said that spiritual meaning, hope and strength will produce resilience and improvement at all the above levels.
Years of trauma after decades of war: A qualitative assessment of the current post-war situation in the north showed widespread exposure to traumatic events that were multiple and chronic.
Individuals, families and communities in Sri Lanka, particularly in the North, the East and so called border areas of Sri Lanka, have undergone twenty five years of war trauma, multiple displacements, injury, detentions, torture, and loss of family, kin, friends, homes, employment and other valued resources. There are widespread individual mental health consequences as shown in more recent study done by officials from the Ministry of Health, UNICEF and other organizations reported in the Journal of American Medical Association. They found PTSD (13%), anxiety (49%) and depression (42%) in the recent Vanni IDP’s. Muslim communities that were displaced forcefully continue to suffer with a variety of psychosocial problems. A study among the displaced Muslim community in Puttalam by Siriwardhana, Adikari, Sumathipala and others described a prevalence of Common Mental Disorders (CMD) of 18.8%, with somatoform disorder 14.0%, anxiety disorder 1.3%, major depression 5.1%, other depressive syndromes 7.3%, and PTSD 2.4%. Another study in the Sri Lanka military who had been in active combat by Fernando and Jayatunge found that 6.7% had PTSD, 15.7% with Depressive Disorder, 9.5% with psychosis like Schizophrenia, Bipolar Affective Disorder and Acute Transient Psychotic Disorder, 7.9% with Somatoform Disorder, 10.8% with Dissociative Disorder, 3.3% with Traumatic Brain Injury and 3.5% with Alcohol Abuse and Dependence and Substance Abuse Disorder in addition to complex PTSD, suicide and attempted suicide and other psychosocial problems like Domestic Violence. Exposure to combat was significantly greater among those who were deployed in the North and East of Sri Lanka who showed significantly higher mental health and psychosocial problems. All these members of different communities affected by the war are in need of psychosocial rehabilitation. Studies among military and militants who are demobilized have highlighted the psychosocial problems families and society will face such as strained relationships, domestic violence, alcohol and drug abuse, antisocial activities, and suicide if the returning veterans do not go through proper psychosocial rehabilitation processes.
Families too have been affected with pathological family dynamics due to displacement; separations; death, disappearance or injury to bread winner with female headed households. Whole communities have been uprooted from familiar and traditional ecological contexts such as ways of life, villages, relationships, connectedness, social capital, structures and institutions. The results are termed collective trauma which has resulted in tearing of the social fabric, lack of social cohesion, disconnection, mistrust, hopelessness, dependency, lack of motivation, powerlessness and despondency.
Yael Danieli has written eloquently about the transgenerational transmission of trauma: ‘massive trauma shapes the internal representation of reality of several generations, becoming an unconscious organizing principle passed on by parents and internalized by their children’… ‘the multigenerational, collective, historical, and cumulative psychic wounding or “soul wound” over time, both in their victims’ life span and across generations’. The trauma can be transmitted epigenetically, or through parent child interactions, family dynamics, sociocultural perpetuation of a persecuted ethnic identity based on selective, communal memories or ‘chosen traumas’; and through narratives, songs, drama, language, political ideologies and institutional structures. The long lasting impact at the collective level would then result in the social transformation, of a sociopathic nature that can be called collective trauma. Hoshmand described the systemic nature of traumatogenic forces and their impact on family, community and societal systems using a cultural-ecological perspective. Families and communities cope with the disaster in a multitude of adaptive and non-adaptive ways that can result in a variety of psychosocial problems or in positive resilience and growth. Community level interventions, particularly Mental Health and Psychosocial Support (MHPSS), can be used to help communities affected by disasters.
The impact of mass trauma at the level of the community became evident when it came to addressing mental health problems during the war and after the tsunami. Conventional interventions at the individual level were inadequate. The problems at the community level too had to be understood and addressed if the individuals were to be fully helped. Further, families and communities had to recover if any meaningful socio-economic rehabilitation programmes were to succeed. In fact, in time most long-term programmes in other post disaster settings around the world began to include a community based psychosocial component, what is now being termed MHPSS, within the larger socio-economic rehabilitation and reconstruction efforts.
Social Capital
Disasters such as a massive natural catastrophe or a chronic civil war can lead to depletion of social capital. According to Bracken and Petty, strategies used in modern warfare (sometimes called counter-insurgency) deliberately destroy social capital assets to control communities. The covert goals may become elimination or co-option of leaders as well as control and coercion of groups, media, governance structures and institutions and in the final analysis, the minds of ordinary people.
In fact, understanding the destruction of social capital by long term civil conflict is crucial for describing collective trauma. However, contemporary social analysts such as Goodhand, Hulme and others caution against a simplistic or superficial view of social capital and call for a deeper, detailed, fine grain analysis of social transformation at the community level to look for positive, negative and ‘perverse’ changes. Social capital encompasses community networks, relationships, civic engagement with norms of reciprocity and trust in others that facilitate cooperation and coordination for mutual benefit. Fundamentally it looks at social institutions, structures, functions, dynamics, and the quality and quantity of social interactions. It is a reflection of social cohesion, the glue that holds society together. Theoretically, positive social capital would increase the community’s resilience, capacity to withstand disasters and to respond constructively.
Although traditional Sri Lankan communities had high levels of social capital, this was mainly in the form of social, family and intra-ethnic bonding. The root cause of civil conflict would stem from the lack of bridging social capital due to competitive and antagonistic inter-ethnic relations resulting from polarized and exclusive ethnocentric perceptions. This could arise from a myriad of further sub-causes like Stewart’s ‘horizontal inequalities’ in opportunity; income and economic resources (poor linking social capital); ethnic suspicions and tensions (poor bridging social capital); group exclusion; disparities in political access and participation; weak civic engagement with the government leading to weak community links with the state; polarization between ethnic communities and experiencing ethnic based discrimination and humiliation. The driving force for the conflict would have been polarized ethnic identities and consciousness. The insecurity, fear and strong feelings aroused when a group’s identity, culture and way of life, its’ access to land, resources and survival are perceived as being threatened are mobilized into collective actions, defiance, resistance, militancy and violence. The sources of growing frustrations and rebellion can be traced to 1) Power differentials between the rulers and the governed in a hierarchical, authoritarian society; 2) The poor or absent access to sources of power, decision makers, control over opportunity structures and resource distribution; and 3) Discrimination as a group showing the lack of vital vertical or linking social capital among the minority.
As a consequence of the long drawn out conflict, the ‘common community coping strategy’ according to Goodhand and others ‘was to fall back on group based networks and family ties. The most resilient sources of social capital are socially embedded networks and institutions’. This resulted in strengthening social bonding within each ethnic group while weakening bridging social capital between the different ethnic groups. The goal of psychosocial rehabilitation and national reconciliation would be to rebuild these interdependent, community bridges that were once there between the ethnic groups.
Conflict entrepreneurs, that is, social actors with vested interest in maintaining ethnic tensions, had socially engineered ‘perverse’ social capital gaining power, legitimacy and social control. The resulting social transformation had, according to Nordstrom, ‘led to the emergence of authoritarian leadership, it had altered gender and generational hierarchies and created a ‘new rich’ entrepreneurial class in a ‘dirty war’ context. However, in the long term with competing regimes of control and terror, even the bonding social capital has been eroded, bridging social capital between groups consistently undermined and people have lost trust in social institutions, structures and governance. Civil conflict causes community trauma by the creation of a ‘repressive ecology’ based on imminent, pervasive threat, terror and inhibition that causes a state of generalized insecurity, terror and rupture of the social fabric. Colletta and Cullen say that civil conflict and war, “weakens social fabric. It divides the population by undermining interpersonal and communal trust, destroying the norms and values that underlie cooperation and collective action….This damage to a nation’s social capital-the norms, values, and social relations that bond communities together, as well as the bridges between communal groups (civil society) and the state-impedes the ability of either communal groups or the state to recover after hostilities cease. …economic and social development will be hindered unless social capital stocks are restored… Such an understanding could enhance the abilities of international actors and policymakers to more effectively carry out peacebuilding- relief, reconstruction, reconciliation, and development”. A key element of post-war rehabilitation, and reconciliation would be rebuild trust, the basic glue that holds society and nations together. Trust in her institutions like those for law and order, justice, governance structures, between authorities and the ruled, between the different members of society themselves. In the recent post Punguduthivu incidents, civil society reacted in the way they did as they had lost trust in the mechanisms and those responsible for law, order and justice due to their tragic experiences before, during and after last few decades of ethnic conflict. But the opportunity to react and show their dissatisfaction was a healthy development that was not available under the previous repressive regime.
Post-war context
For a qualitative assessment of the current post-war situation in Northern Sri Lanka, we conceptualize the functioning of the community in the context of different levels: individual, family, community and sociocultural, as these maybe affected in different ways, positively, negatively or in varying combination of both. The findings were divided into expected ordinary reactions to human suffering, more distressful psychological suffering which would benefit from community and family support and diagnosable psychiatric disorders needing professional help. These could be understood as a continuum and not discrete categories with rigid boundaries of exclusion. Positive effects included resilience and beneficial transformative or adaptive change. The identified changes were located as belonging to the individual, family, community or sociocultural levels. Some responses overlapped, saddling several levels; for example, grief which manifested at the individual level as normal, prolonged or pathological grief but also at the family and community levels when members of the family or important community leaders were killed in traumatic circumstances.
There was widespread exposure to potentially traumatizing events that under normal conditions would be considered extreme and would cause distress in most people. Commonly these traumatic events had been multiple and chronic. For example, a University of Jaffna Community Medicine Research study of medical faculty students from the Vanni in 2010, found 82% had been directly exposed to the war situation, 67% had barely escaped death, 63% had lost family or friend, 43% had witnessed killing, 27% had been imprisoned, 23% kidnapped or abducted, and 18% had been tortured or beaten. Using the Harvard Trauma Questionnaire, thirty eight percent of the students had experienced 1-3 traumatic events, 28% had experienced 4-7 traumatic events and 10% had experienced 8-11 traumatic events. And with all these, these students had been expected to continue with their studies with no psychosocial help. It would be no surprise that some ended up committing suicide.
In our qualitative study, forced displacement in extreme situations among the Vanni population was universal and commonly multiple (up to 10 or more displacements in many cases). The unexpected and sudden death of a close family member(s), relation(s), and friend(s) in distressing ways was again almost universal experiences. Experiencing injuries, disappearances, separations, internment, arrests, detentions, beatings, bombings, shelling’s, and shootings as well as witnessing these events were common. Undergoing extraordinary physical hardships like thirst, hunger, long marches, and lack of medical attention or shelter were experienced by most families and communities. As such these experiences were considered for the purpose of this study as norms for the population and placed under ‘Ordinary human suffering’. When these experiences caused observable behaviour or complaints of a psychosocial nature amounting to distress they were placed under ‘Distressing psychosocial reactions’. When the signs and symptoms met criteria for a diagnosable condition, they were categorized as ‘Psychiatric disorders’.
The social disorganization led to unpredictability, low efficacy, absent social control of anti-social behavior patterns and high emigration, particularly a crippling brain drain, which in turn causes breakdown of social norms, anomie, learned helplessness, thwarted aspirations, low self-esteem, and insecurity. Social pathologies like alcohol (Fig 1) and substance abuse; violence, gender based- and child- abuse (Fig. 2); female headed households; elder abuse and neglect; suicide and attempted suicide (Fig. 3) have increased. Child abuse, particularly child sexual abuse, in 2011 compared to 2007 have increased (Fig. 2). A worrying post-war development has been the increasing corporeal punishment in schools that was brought under control during the war years by concerted efforts under the District Child Protection Committee functioning under the NCPA. Some teachers rationalize by blaming increasing student violence. This is an area of public concern that the civil society organizations can take a lead role in addressing through health education and awareness programmes. Other wide-spread, chronic post-war consequences with psychosocial repercussions that need addressing would include large numbers of disabled survivors with loss of limbs needing prosthesis like Jaipur foot and other orthopaedic and spinal problems. Fortuitously, landmine injures in the north are on the decline. The intense landmine clearing operations are bearing fruit and we must be thankful for their dedicated work. Some have been injured and killed while at work.
Various behavioural manifestations of risk taking such as Road Traffic Accidents (RTA’s), partly due to lack of diligence for safety, discipline and respect for others commonly under the influence of alcohol; and disinhibition of social constraints for example, unwanted and teenage pregnancies, legal and illegal abortions, extramarital affairs indicate wider post-war psychosocial issues. Alcohol consumption can be linked to RTA’s, crime, DV and child abuse. One concern raised in the qualitative study above was the increasing alcohol use or experimentation by youth and student population. One positive post-war development has been the dramatic decrease in Kassippu brewing and consumption (except perhaps in some areas), possibly due to wide availability of legal alcohol including arrack, beer and foreign liquor. Obviously, Kassippu brewing has become a less profitable income generating activity for desperate families. Toxic consequences of Kassippu to the liver and other organs used to fill up the medical and other wards during the war years.
Generally, except for child abuse, particularly child sexual abuse, there appears to be a slight improvement or stabilization in the projected figures compared to previous post-war years as far as the psychosocial problems discussed here. This may be an indication that the worst post-war consequences are over, that time is a healer and some interventions are working.
2013 figures projected from data up to July
Source: Excise Department, Jaffna District
Kassippu figures not available
Fig. 3 Suicide rates in Jaffna (1979-2013)
Source: Jaffna District Courts
1990-97 data from Registrar Generals Department
2013 figures projected from data up to July
Resilience
In our qualitative study, individuals, families or communities showing any positive response, coping, adaptation or growth, were placed under ‘Resilience’ or ‘Adversity Activated Development (ADD)’. Under the circumstances, the lack of adverse reactions to these extraordinary experiences, termed here as ‘Ordinary human suffering’ could be considered positive coping. Papadopoulos advises to keep in mind that communities may find ‘meaning in their suffering and are able to transmute their negative experiences in a positive way, finding new strengths and experiencing transformative renewal’. These categorizations have public mental health implications. Programmes and interventions should promote positive adaptations, resilience, Post Traumatic Growth and effective strategies that people have used to cope with human loss and suffering. Distressful psychosocial reactions and psychiatric disorders would need appropriate support, treatment and rehabilitation measures, particularly in a resource poor setting, community level approaches.
Important characteristics of resilient communities are functioning family, extended and neighbourhood support systems and networks. Public mental health strategies should promote where available or help rebuild bonding social capital. These would include community resources like respected elders, traditional healers, religious leaders and organizations, institutions like schools, health facilities, governmental and non-governmental organizations; cultural practices; community level conflict resolving mechanisms and functioning structures like judicial system, democratic practices and access to authorities, free media, and reliable information. Weerackody and Fernando warn that ‘economic recovery will not be sufficient, people need ‘to reconstruct communities, re-establishing social norms and values’. Economic and income stability, employment, occupations and traditional vocations, food, shelter, security, and other essential needs being met would help communities cope with adversities and shocks to the system. Well-functioning communities have the capacity, resources and skills within the community to act together, cooperatively and effectively, to meet challenges. Unfortunately in post-disaster situations, particularly chronic war contexts some or many of these resources and support systems would be affected, dysfunctional or not available. Community responses and coping may thus become compromised. A vicious resource loss cycle where breakdown of social support, networks, leadership, economic resources and material goods will create a downward spiral of a deteriorating situation of increasing needs and dysfunction, one lack feeding the other deprivation.
Yet, critical challenges and adversity may just provide the impetus, catalytic stimulus for change and social transformation. Thus the breakdown of traditional forms of oppression and rigid hierarchical structures like caste, feudal ownership and patriarchal female suppression could lead to more positive emancipation and development. New organizations, networks, relationships, friendships, forgetting of old quarrels and conflicts, shared memories and experiences could lead to community growth. Motivated and vibrant leadership may emerge while older, ineffective and anachronistic methods are shed. Collective consciousness can be awakened leading to more awareness and knowledge. According to the Social Policy Analysis and Research Centre (SPARC) of the Faculty of Arts, University of Colombo, the breakdown in social structures and institutions creates an opportunity for empowerment, collective transformation and re-alignment of social dynamics, “challenging existing structures of power and achieving a shift in power relations, ultimately resulting in the transformation of the existing social order”.
International law recognizes the Principle of Restitutio ad integrum for the redress of victims of armed conflict to help them reconstitute their destroyed ‘life plan’. This justifies the need for rehabilitation as a form of reparation clarified by the UN ‘Basic Principles and Guidelines on the Right to a Remedy and Reparations for Victims’ as taking five forms: restitution, compensation, rehabilitation, satisfaction and guarantees of non-repetition and passed by the UN General Assembly in 2005. This should necessarily include psychosocial rehabilitation at the individual, family and community levels.
Significant advances have taken place in recognizing universal human rights, in particular the right to health that is now enshrined in international human rights law, humanitarian law and criminal law. Many of these relevant treaties have been ratified by states, including Sri Lanka, and found their way into domestic law. Having established human rights, the need to translate consequences of breaches, the right to reparations for serious violations and the state’s responsibility to provide remedy is slowly attaining consensus and customary status.
Disregard for the rights of victims to reparations is common in most transitional justice initiatives that aim primarily at establishing criminal accountability of perpetrators. Ordinary citizens should generally benefit from normal development efforts but victims have a special right to reparation measures. Christine Evans of the UN Human Rights Commission uses the examples of Guatemala, Sierra Leone, East Timor and Colombia to illustrate reparation measures for victims undertaken in post conflict situations as a result of domestic truth commissions with varying degrees of engagement and support from the international community and UN along tempered by geopolitical factors. Gameela Samarasinghe from the University of Colombo interprets the spirit of the report from the Sri Lanka Lessons Learnt and Reconciliation Commission (LLRC) “as a whole acknowledges trauma and the prolonged suffering people have faced. The commission recognizes that the suffering that people have faced needs to be addressed through counselling, justice mechanisms, compensation and acknowledgment if reconciliation is to take place. The commission also noted that reconciliation and peace can only be achieved through systemic changes in law and state structures and though a process of integration”.
In Sri Lanka, the most cost-effective remedy for state responsibility to provide redress to victims would be a community based approach that would benefit the largest number of victims, due to the systemic nature of collective trauma as well as the state’s financial and judicial constraints. Unless victims of serious human rights violations receive reparations, they are likely to continue to suffer loss of dignity, social exclusion and stigma. They should be given an opportunity to participate in society on an equal footing to others which would be the first step towards national reconciliation. Rehabilitation is a substantive right that does not depend on who was responsible or who was the perpetuator.
Due to the widespread nature of the impact of war trauma, those affected in a collectivistic society would be best addressed through a community based approach that would reach the largest population. Further, community based approaches will enable one to undertake preventive, promotional and long-term public mental health activities at the same time. The Opportunity provided by post war context could be utilized to develop a comprehensive community based programme as envisioned in the Sri Lanka Mental Health Policy as well as ‘building back better’ as was done after the Tsunami in Sri Lanka. The post-war rehabilitation should be done with the same commitment and effort as was seen after the Tsunami as the impact and consequences are similar if not worse. Tragically, Psychosocial rehabilitation was neglected, and even prohibited in the militarized post-war context under the previous regime. With the change in the political situation, it now becomes possible to address some of these urgent needs. Individuals and families can be expected to recover and cope when communities become functional, activating healing mechanisms within the community itself.
Community level Rehabilitation
A comprehensive and practical conceptual model for psychosocial rehabilitation is an inverted pyramid with five overlapping and interrelated levels of interventions prepared for UN and other Disaster workers by the United Nations and International Society for Traumatic Stress Studies. At a broader level are societal interventions designed for an entire population, such as laws, public safety, public policy, programmes, social justice, and a free press. Descending the pyramid, interventions target progressively smaller groups of people. The next two layers concern community level interventions which include public education, support for community leaders, development of social infrastructure, empowerment, cultural rituals and ceremonies, service coordination, training and education of grass root workers, and capacity building. The fourth layer is family interventions that focus both on the individual within a family context and on strategies to promote wellbeing of the family as a whole. The bottom layer of the pyramid concerns interventions designed for the individual with psychological symptoms or psychiatric disorders. These include psychiatric, medical and psychological treatments which are the most expensive and labour intensive approaches that require highly trained professional staff. Many of these different levels of psychosocial interventions had been used in the North, particularly after the Tsunami but even during the war. Tragically, psychosocial work was blocked for various political reasons in the immediate post war context. Psychosocial interventions can now be used for the post war rehabilitation to help individuals, families and communities recover:
Psychoeducation
Basic information should be provided to individuals and to the community about what has happened, where help can be obtained, instructions about available programmes and assistance. Psychoeducation about trauma for the general public, what to do and not to do, can be done through the media, pamphlets, posters and popular lectures. Culturally, the Tamil community have been receptive to health messages through drama, especially street drama.
Training
Training of grass root community level workers in basic mental health knowledge and skills is the easiest way of reaching a large population. They in turn would increase general awareness and disseminate the knowledge as well as do preventive and promotional work. The majority of minor mental health problems could be managed by community level workers and others needing more specialized care referred to appropriate professionals. It is important that primary level or community level workers adopt a holistic approach, incorporating the different aspects of physical, mental, family, culture, community, societal health in a horizontal integration rather than as vertical programmes as practiced in Sri Lanka today. Primary Health Workers including doctors, medical assistants, nurses, Family Health Workers; health volunteers and other grass-root resources like teachers, Gramma Sevakas, elders, traditional healers, priests, monks and nuns; government servants, particularly Divisional (AGA) level officers like Social Workers, Samurdhi Officers, Child Probation and Rights Officers, Women Development Officers, Rural Development Officers, Cultural Officers, Youth officers, and Sports Officers; Non-Governmental Organization (NGO) staff, volunteer relief and refugee camp workers are ideal community level workers for training. Trauma and mental health should become part of the normal curricula of all health staff and teachers. Because of the strong stigma associated with ‘mental’ conditions, it may be prudent to deal with psychosocial problems and minor mental health issues themselves outside a psychiatric facility by frontline workers.
A manual based on the WHO/UNHCR booklet, “Mental Health of Refugees”, was adapted to the Tamil cultural context and is now in its 3rd edition. As was done after the tsunami and during the war’ a Training of Trainers (TOT’s) in community mental health using this manual could be done. They in turn can train the variety of community level workers mentioned above. In this way the necessary knowledge and skill can be disseminated to a wider population. Community workers will have to aim to create a sense of agency and control in the community, that they can determine their own future and faith in collective efficacy. It is only by creating a strong sense of community, collective efficacy and confidence, that social capital can be increased, leading to a gain cycle where trust, motivation and hope are re-established. Linking social capital where communities have access to power, decision making and resources are vital for building resilience. Negative post-war conditions such as fear, lack of trust and uncertainty must be addressed. Efforts must be directed at rebuilding social capital through community networks, relationships, responsibilities, roles and processes.
At the same time, the community workers have to work towards creating opportunity structures for education, vocational and skill training, and capacity building particularly for youth and income generating programmes. It is by establishing some economic stability, livelihood and access to resources that families and communities will regain their dignity, faith and hope. Improvement in mental health and psychosocial wellbeing motivates the population and enables increased participation in rehabilitation and development programmes.
Expressive methods
Artistic expression of emotions and trauma can be cathartic for individuals, groups and the community as a whole. Art, drama, storytelling, writing poetry or novels (testimony), singing, dancing, clay modelling, and sculpturing are very useful emotive methods in trauma therapy. The traumatized individual or group is able to externalize the traumatic experience through a medium and thereby handle and manipulate the working through outside without the associated internal distress. Children in particular, who are usually unable to express their thoughts or emotions verbally, will benefit from the above mentioned expressive methods and play therapy.
Community monuments that would help focus and express emotions after mass trauma have been called traumascapes. For example, a civil monument at Mullivaikal to all who died there (military, militant, civilian) by a sensitive sculptor and national ceremonies to be observed there annually as recommended by the LLRC would support reconciliation.
Traditional Coping Strategies
Indigenous coping strategies that have helped the local population to survive should be encouraged. Culturally mediated protective factors like rituals and ceremonies should be strengthened. In traditional cultures, funerals and anniversaries can be very powerful ways to help in grieving and finding comfort. Funeral rites like eddu chelavu, anthyetty, andu thuvasam, thuvasam and similar anniversary observance are powerful social mechanisms to deal with grief and loss. The gathering together of relations, friends and the community is an important social process to share, work through and release deep emotions, define and come to terms with what has happened and finally integrate the traumatic experience into social reality. Sadly, grieving and observance of traditional funeral rites was banned by the previous regime. For the first time, remembrance ceremonies were allowed this year and this provided a welcome relief and impetus towards a recovery process.
In addition to funerals, religious and temple rites, cultural festivals, dramas, musical concerts, exhibitions and other programs, meetings and social gatherings provide the opportunity for people to discuss, construct meaning, share and assimilate traumatic events. In the context of active warfare, these rituals are not possible or may be improperly performed; thus, the trauma is never fully accepted or put to rest, as in the cases of “disappearances” where there is no finality about death. Patricia Lawrence has brought out the psychosocial value of the traditional oracle practice of “vakuu choluthal” in Batticaloa, particularly in cases of disappearances, where the families are told what has happened to the disappeared person in a socially supportive environment. In cases of detention by the security forces the relatives may take vows (nethi kadan) at Temples to various Gods which they will fulfill if the person is released. The practice of Thuukkukkaavadi, a propitiatory ritual involving hanging from hooks, have increased dramatically after the war and maybe especially useful after detention and torture according to Degres. After resettlement, Kovalan Koothu (a popular folk drama) was performed all over the Vanni with large attendances and community participation. In the traditional folk form of Opari (lament), recent experiences and losses from the Vanni war was incorporated in to community grief performances. Religious festivals, folk singing and dancing as well as leisure activities like sports can be ways of meeting, finding support and expressing emotions. Koothu, other dramatic forms, laments, poetry, writings and drawing should be encouraged and promoted.
Ideally the social processes should work to promote feelings of belonging and participation, where the group is able to give meaning to what has happened, adapt to the new situation, and determine their future. It is noteworthy that the worldwide panel of trauma experts identified restoring connectedness, social support and a sense of collective efficacy as essential elements in interventions after mass trauma. Cultural rituals and practices are well suited to do just that.
Teaching of the culturally familiar relaxation exercises like jappa, dhikir, anna pana sati, rosaries or yoga (see Box ) to families, large groups in the community and as part of the curricula in schools can be both preventive and promotes of well-being. Their traditional approaches can produce the calming, sense of collective efficacy, social and cultural connectedness that the trauma experts recommended . Although these techniques do no formal psychotherapy, they may accomplish what psychotherapy attempts to do by releasing cultural and spiritual restorative processes and mobilize social support.
Psychosocial Rehabilitation
Attempts can be made to rebuild social networks and sense of community by encouraging and facilitating formation of organizations (e.g. for widows), rural societies (CBO’s), schools and other groupings and promote inter-sectorial cooperation. Rehabilitation programmes should include education, vocational training, income generating projects, loans and housing that is tailored to the needs of the survivors and post disaster situation. Close liaison, co-operation, collaboration and networking with Governmental and NGO’s involved in relief, rehabilitation, reconstruction and development work will be very productive. The network can be used to refer needy survivors for socio-economic and rehabilitation assistance.
What needs to be stressed here is that such a design includes due consideration for the psychological processes that promote individual, family and social healing, recovery and integration. It is important that programmes take into account the wishes of the local population concerned, that they are given active and deciding roles rather than dependent, ‘victims’ roles, to promote full participation and thus their eventual psychological recovery. Emergent self-help groups and local leadership should be encouraged to resume traditional and habitual patterns of behaviour, re-establish social networks and community functioning at the grass root level. Local skills and resources must be utilized so the community gains a sense of accomplishment and fulfilment in the recovery process. In rebuilding community resilience it is important to promote the reestablishment of trust between members of the community and social institutions in order to strengthen hope for the future and a sense of collective efficacy.
Prevention
Wars and conflict can be prevented and psychosocial well-being ensured by appropriate conflict resolution mechanisms, equitable access to resources, power sharing arrangements, social justice and respect for human and social rights. Techniques such as torture and disappearances violating basic human rights cause long-term sequelae in individuals, families and communities which can be prevented if international conventions, humanitarian law and treaties are observed.
It is worthwhile planning beforehand to prevent or mitigate the impact of disasters at the community and family levels. There should be regional and international mechanisms to protect – civilians in times of conflict and/or when powerful leaders and states overstep boundaries of good governance and observation of basic rights. In the long term, there is a need to create a “culture of peace” by social peace building.
If we can only raise one consistent voice for peace! Reports, documentation and publications are avenues to raise awareness. Or, in our day to day dealings and contacts, we can take principled stands on issues and express our concerns; for example, on such issues as disappearances, child abuse, domestic violence and torture. Another area of intervention, both for prevention and reconciliation is at the national level by influencing policy making, rehabilitation and international aid programmes.
` The UNICEF Education for Conflict Resolution will be a very effective programme for introduction into schools. The UNICEF developed “peace education as the process of promoting the knowledge, skills, attitudes and values needed to bring about behaviour changes that will enable children, youth and adults to prevent conflict and violence, both overt and structural; to resolve conflict peacefully; and to create the conditions conducive to peace, whether at an intrapersonal, interpersonal, intergroup, national or international level.” Their publication edited by Bush & Saltarelli, “The Two Faces of Education in Ethnic Conflict” is a powerful critique of the way education can be an aggravating factor in ethnic conflict and how it can be used more positively for solving such problems.
(Dr Daya Domasundaram is a senior professor of Psychiatry at the Faculty if Medicine, University of Jaffna and a Consultant Psychiatrist. He is a Commonwealth scholar and has received the fellowship of the Scholar Rescue Fund (Institute of International Education, USA). He is a Fellow of the Royal College of Psychiatrists (UK), the Royal Australian and New Zealand College of Psychiatrists and Sri Lanka Vollege of Psychiatrists and taught recently at the University of Southern Australia, Adelaide. He lives currently in Jaffna.)