Nearly a month has passed by since the tragedy of the Easter Sunday bomb blasts. As the communities affected directly attempt to limp back to normalcy and the country as a whole tries to come to grips with what hit Sri Lanka on that fateful day, Senior Consultant Psychiatrist Dr. Athula Sumathipala keeps stressing the need to be cautious on how we handle the survivors.

Restoring law and order and bringing the culprits to book will be the best intervention by the authorities to bring back peace of mind and reconciliation, says Dr. Sumathipala.

With regard to those directly affected by the blasts, he points out that “we need to acknowledge that what we see is a ‘normal’ reaction to an ‘abnormal’ event. We should not ‘medicalize’ or ‘psychologise’ the normal reactions of the victims”.

Here are specific Do’s and Don’ts
Dr. Sumathipala urges that Sri Lanka follow:

• Acknowledge what you see is a normal reaction to an abnormal event.
• Do not ‘medicalize’ or ‘psychologize’ the normal reactions of the victims.
• Express grief in a culturally appropriate way. Use of cultural and religious beliefs to manage it, even though the challenge is that this incident happened at religious places. Therefore, people especially the youth, may question religious faith which needs to be handled carefully.
• Acknowledge that there may be wider grief and bereavement aspects involved in coming to terms with the losses and shock.
• To alert people to a dose effect (amount of exposure to trauma) and, therefore, directly affected communities need more psychosocial support/comfort.
• Every possible attempt should be made not to separate children from left-behind families and relatives.
• Use existing social networks and friends to support them.
• Counselling or direct psychological interventions are not indicated in the immediate aftermath and may even do more harm than good.
• Open schools as soon as possible, with heightened security.
• Restrict TV access of children (disaster coverage).
• Organise any kind of play or activity for children.
• Teachers should meet regularly to share concerns and ideas and take advice from experts, if there are doubts. There are more than 100 consultant psychiatrists and 100 public health consultants in the country who can provide advice on mental health issues.

Only a minority of people may get a mental illness which needs medication or psychological treatment such as cognitive behaviour therapy that needs to be administered by a properly trained professional.

Anti-depressant and anxiolytic medication should not be used routinely. There is a limited role for the use of anxiolytics such as Diazepam or hypnotics, which should only be used when symptoms are acute and only on the advice of experts. Prescription should not be for periods longer than about 10 days and their use in children should be avoided.

Delving deep into the subject, Dr. Sumathipala says that this is a catastrophic situation, which will result in expressions of grief and shock and could manifest in a variety of ways and with varied symptomatology.  “Sleeplessness, nightmares, tremors, chest pain and other somatic symptoms will be commonplace. These should be considered as natural reactions to an abnormal traumatic event.”

Abnormal grief reactions and depression will not manifest until very much later. Tranquillisers and anti-depressants are generally not indicated in the acute phase of post-trauma unless for people who have a previous history of depression or major mental illness, according to him.

Urging that it is important to reassure people who consult medical professionals, he suggests that they use ways of dealing with grief, which are usual for them – seeking support from the clergy or talking to friends. “Encourage them to express their grief, fear and anger in a non-destructive manner.”

Where children are concerned, says Dr. Sumathipala, it is important for medical professionals to:

• Allow children to talk about their feelings or express them through drawings.
• Ensure, if possible, that children are protected from endless repetition of the events. Eg. Watching TV news coverages (there is evidence that such viewing has been damaging to children after the 9/11 incident).
• Children should be given other activities – such as playing, reading, drawing etc.

Providing guidance to policy planners, he says that the aim should be to help people normalise their lives as far as possible within this terrible situation so that the need and use of psychological help and/or other treatment is minimised and made available only for those who require it.

Measures that will help this approach are:

Immediate –

• Coordination of efforts – Encourage networking and also remain in touch with a central source within the Ministry of Disaster Management and Ministry of Health.
• Public information – Make use of the mass media to emphasise that in this situation, grief is NORMAL as are all the symptoms of grief and should be expressed. Feeling guilty for being spared is also NORMAL. Reinforce the use of traditional ways of grieving and seeking solace.

Sensationalised reporting should not be encouraged. Seemingly helpful information may be damaging, generating more fear, anger and hatred.

• Children require special thought and specific planning – Children need to be protected from an endless review of events which maximises the impact of trauma. Schools should reopen as a means of helping these children to normalise.

Requests for donations should include requests for simple toys e.g. balls and writing and drawing materials

Children must, as far as possible, be left with family/familiar adults in the aftermath and not taken away from family/familiar people.

• Awareness of high-risk groups – Local administrators should make a note in each area of high-risk groups such as workers involved in the disposal of bodies; those bereaved; those rendered homeless; and some volunteers. This information will help in monitoring those that may later require more help.

Subsequent action –

• This action should focus on targeted inputs to minimise sequelae of the trauma and requires:
• Development of resource groups with appropriate skills. Use must be made of available resources in the country particularly of groups already trained in counselling techniques
• A programme of training which will strengthen the existing skills of teachers and supervision of core groups of trainers which would then extend skills to other groups through a planned cascading of training
• Make available resource materials. This will include manuals on working with traumatised groups including children.
• Implementation of therapeutic help which includes networking with local administrators, identification of high-risk groups, involvement of specialist professionals to provide support and supervision.

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