Tsunami wreaks mental health havoc
Survivors are likely to spend years wrestling with the mental health impact of the Asian tsunami and the earthquake off the Indonesian coast. Aid programmes will quickly reconstruct homes, schools and hospitals, but rebuilding the shattered lives and minds of the people who lost friends, family, homes and their livelihoods will take much longer.
Countries were also advised to provide social and psychological support, such re-opening schools, reuniting families, organizing child-friendly services and fostering economic development as well as simple psychological interventions, such as training community health workers in basic counseling skills.
One problem that concerned WHO was programmes focusing solely on PTSD, which the agency believes has been wrongly considered to be the biggest mental disorder after a disaster. It warned other agencies not to waste precious time in building PTSD-focused services that might miss survivors with other mental health problems.
Delivering any sort of health care was compromised by the massive destruction of infrastructure and difficulties of coordinating responses when so many agencies were involved, said Professor Harry Minas, a WHO consultant and Director of the Centre for International Mental Health at the University of Melbourne, Australia.
A more complex problem for Western aid agencies was adapting their clinical and psychological support services to the cultural specifics of the tsunami-affected population. Many interventions required understanding of the socio-cultural context which meant that local mental health professionals had to play a lead role.
“In Sri Lanka, concepts like ‘mental health’ or ‘psychological problems’ are not part of the lexicon of the population. They expressed emotional distress through the body, e.g. headaches or bodily pain,” said Sales, adding that western clinical responses to acute stress disorder, PTSD and similar conditions were probably inadequate.
One solution in Sri Lanka was to ask local social organizations to help provide support to the affected population. “Culturally adequate support seemed to come, in many cases, from the community”, said Sales. A traumatic event causes a breakdown in basic assumptions around oneself, the world and the role we have in it, said Sales.
Therefore “religion had a decisive role in the cultural processing of traumatic situations … not necessarily in active practising, but as the cultural matrix from where trauma is understood”, Sales said.
Somasundaram said that in Jaffna “we are encouraging the use of traditional practices like mourning and funeral rituals for the dead and use of traditional relaxation like yoga”.
WHO mental health expert Dr Mark Van Ommeren said it was important to install long-term programmes: “We advised governments against one-off ventures”.
Minas, who has been working in Aceh, Indonesia, with WHO’s Department of Mental Health and Substance Abuse, and the Indonesian Ministry of Health, said projects had to be sustainable so they could be taken over by local health workers.
“This is an opportunity to develop more effective mental health services,” Minas said.
Dr Sales said his agency’s priorities after the tsunami struck were health care in refugee camps focusing on psychosocial issues; community mobilization; health education and nutritional assessment; and rehabilitation of infrastructures, such as hospitals.
“For psychosocial attendance, it seemed clear to MdM-E that a short-term crisis-focused model … where no mental health facilities were available in most areas of the country seemed inadequate,” Sales said.
For example in Trincomalee in north-eastern Sri Lanka, WHO and national health authorities developed a national mental health plan based on a 12-bed mental health unit in a general hospital and a training programme of community and psychosocial workers for outreach work.
MdM-E suggested a slightly different programme that would make better use of current resources and would be better in the long term: a 12-bed inpatient unit in the general hospital with outpatient consultations, occupational therapy, a full-time psychiatrist and auxiliary personnel.
“We changed an emergency short-term view for a developmental long-term view … instead of a narrow trauma-focused perspective,” said Sales.
Haroon Ashraf, London.