In south India 's shattered coastal communities, tsunami survivors are just beginning to pick up the pieces of their lives. Psychological trauma is common, but India 's new army of support workers is providing solace, counselling, and encouragement.  - Patralekha Chatterjee reports.

More than 2 months after the sea swallowed her husband and destroyed her home, Chellamma sits quietly, thinking about the future for her three unmarried daughters. The 50 year-old widow and mother of seven from Muzhukuthurai, in tsunami-battered Cuddalore, Tamil Nadu, southern India , is only now starting to pick up the pieces of her life. "I used to sell fish. Now, there is nothing to sell, [because] no one is going to sea . . . My husband is gone. Who will look after my children and me?", she asks.

All around is sand, a torn fishing net, and the remains of a thatched hut--once her home. But there is a glimmer of hope. Chellamma is one of 20 women in and around Muzhukuthurai who have formed a self-help group. The first step is a savings kitty, with each woman contributing Rs50 (around US$1). The savings, the women hope, will help them start income-generating enterprises and cope with future emergencies. The idea came from efforts by community-level workers recently trained in psychosocial counselling.

Psychosocial care can be just as valuable as material assistance in disaster situations. And there is growing evidence to show that early diagnosis and timely interventions can make a significant difference to the recovery process. But few people who have experienced natural disasters view themselves as in need of mental health care, and are therefore unlikely to seek help. To help address the unique needs of such individuals, WHO recommends that health workers set aside traditional methods, avoid use of mental health labels, and use an active outreach approach.

In India , psychosocial care has changed a great deal since the Bhopal Gas Leak tragedy in December 1984. This disaster--the worst industrial disaster ever seen--left not only a trail of death and life-long illnesses, but also numerous mental disorders among survivors. Mental health workers were slow to respond, however: it was 6-8 weeks before psychiatrists became involved in the relief effort, a delay attributed to the fact that none of the five regional medical colleges had a psychiatrist on their faculty.

By contrast, psychosocial care was a key concern for local and national government immediately after the tsunamis hit India in Dec 2004. One reason the situation is so different from that seen 20 years ago is the new generation of politicians. In Cuddalore, for example, Gagandeep Singh Bedi, Cuddalore district's top government administrator admits that the "young generation of bureaucrats" like him are more responsive to new ideas. In Bedi's district, the Department of Medical and Rural Health Services and Family Welfare brings out a daily report about mental-health outreach sessions in different areas.

V Sabeetha, a government psychiatrist who is overseeing mental-health outreach in the district says counselling services are gratefully received. "My team and I have held counselling sessions in relief camps in all the 52 villages in the district . . . Most people we met appreciated being counselled on typical symptoms following any disaster--eg, sleep disorders, nightmares, etc. No one had alerted them earlier about these symptoms", he says.

These sessions helped abate disaster stress in the early days. But with most people now back in their villages, the big issue is follow-up, says Sabeetha.

Gauri, a community worker trained in psychosocial counselling by CREED, a local NGO affiliated with the Tamil Nadu Social Welfare Board, is trying to reintroduce some semblance of normality to the people of Muzhukuthurai.

He says active listening was the most valuable intervention immediately after the tsunamis. "We did not push [survivors] to speak if they did not want to. But we would ask them if they had eaten or bathed . . . With the man, the family breadwinner, gone, and with children to support, widows were nervous about the new, unfamiliar roles they had been pushed into."

Many whose homes were destroyed have been allotted temporary sheds. But most families prefer to stay with relatives. The women cook together and after the meal they sit around talking to each other. In many ways, the community bond compensates for the loss of the family support structure, explains Gauri.

"Though counselling is very important, we must be careful about not overdoing it. When we find someone can cope, then we have no role", says Koteshwar Rao, a psychiatric social worker with the Chennai-based Schizophrenia Research Foundation (SCARF), one of several agencies offering training in mental-health counselling for southern India.

Many of the psychosocial interventions being used were instigated by the WHO regional office. "Within 2 weeks of the tsunamis, WHO alerted medical schools and WHO collaborating centres. A group of people were identified to act as master trainers. Then, talks were initiated with the state governments to drive the return to normalcy and mental health", says WHO official Cherian Varghese. He says the idea was to operate on a three-tier structure consisting of master trainers who would train local NGOs, and trainers at the district level who would, in turn, train community-level workers.

"The primary need is not an overmedicalised approach. What most survivors need is empathetic listening and someone to show them a roadmap to the future", he adds.

A typical psychosocial counselling training session for NGOs and community volunteers, for instance, contains a lot of practical tools with which community level workers can assist tsunami survivors. SCARF trainer Koteshwar Rao stresses the importance of being up to date with latest government schemes and knowing details of agencies that are providing free services to tsunami-affected individuals. Other tools include innovative suggestions about income generation, such as those adopted by Chellamma and her community.

Given that most of those who come for training know little about mental-health counselling, the sessions are designed to be entertaining and interactive, with lots of games and opportunities to express ones creativity and concern. Most trainees also need a briefing about common symptoms of post-traumatic stress disorder and basic dos and don'ts of psychosocial counselling. "The idea is to expand the choices and options of the affected community so that they focus on the future", says Rao.

The Academy for Disaster Management, Education, Planning, and Training, an NGO helping to educate community workers, has trained nearly 200 elementary school teachers in tsunami-affected villages in southern India in providing psychological first-aid to children. Government school teachers who have undergone training are now experimenting with new ways of interacting with their students.

One government school teacher who had failed in her attempts to get a traumatised 6-year-old boy from a tsunami-affected village to open up took her class to a nearby nursery. There, the child's interest was sparked by the plants and he began to ask questions. Taking the cue, the teacher bought him a few saplings. Since then, the boy and the teacher discuss the plants' progress every day and the teacher has been reading stories about flora and fauna surviving adversity.

For the trainers, much of the work goes beyond classroom-style sessions. In the past few weeks, SCARF's Rao and his colleagues have travelled to villages to check whether the new community counsellors have taken on board the key principles of emergency psychosocial support. The cascade effect of the three-tier approach sometimes leads to partial comprehension of key principles--a Chinese whisper effect.

A key concern is monitoring vulnerable groups in the affected communities. This means not only children and widows but also widowers. A case in point is 60-year-old tsunami survivor Kuppuswamy, who lost his wife and is now a single parent. Unfamiliar with domestic chores, the distressed man wonders who will cook for him when he moves out of the relief camp, and about the complexities of arranging a suitable bride for his 23-year-old son.

Today, the immediate challenge is to extend counselling services to remote villages and reach those who have been neglected so far. But in the long-term, the challenge is to provide adequate mental health care with only small numbers of mental-health professionals. There are less than 4000 trained psychiatrists in India , and even fewer clinical psychologists. Predictably, most are located in major cities. As a result, the majority of people living in rural areas have virtually no access to mental-health facilities, so for them recovery is likely to be long and slow.

«Top»