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International Journal of Mental Health Systems

Open AccessResearchCollective trauma in northern Sri Lanka: a qualitative psychosocial-ecological studyDaya Somasundaram1,2,3

Address: 1Department of Psychiatry, University of Adelaide, Australia, 2Scholar Rescue Fund, Institute of International Education, New York, USA and 3University of Jaffna, Sri Lanka

Email: Daya Somasundaram - [email protected]

AbstractBackground: Complex situations that follow war and natural disasters have a psychosocial impacton not only the individual but also on the family, community and society. Just as the mental healtheffects on the individual psyche can result in non pathological distress as well as a variety ofpsychiatric disorders; massive and widespread trauma and loss can impact on family and socialprocesses causing changes at the family, community and societal levels.

Method: This qualitative, ecological study is a naturalistic, psychosocial ethnography in NorthernSri Lanka, while actively involved in psychosocial and community mental health programmes amongthe Tamil community. Participatory observation, key informant interviews and focus groupdiscussion with community level relief and rehabilitation workers and government and non-governmental officials were used to gather data. The effects on the community of the chronic, man-made disaster, war, in Northern Sri Lanka were compared with the contexts found before the warand after the tsunami.

Results: Fundamental changes in the functioning of the family and the community were observed.While the changes after the tsunami were not so prominent, the chronic war situation caused morefundamental social transformations. At the family level, the dynamics of single parent families, lackof trust among members, and changes in significant relationships, and child rearing practices wereseen. Communities tended to be more dependent, passive, silent, without leadership, mistrustful,and suspicious. Additional adverse effects included the breakdown in traditional structures,institutions and familiar ways of life, and deterioration in social norms and ethics. A variety ofcommunity level interventions were tried.

Conclusion: Exposure to conflict, war and disaster situations impact on fundamental family andcommunity dynamics resulting in changes at a collective level. Relief, rehabilitation and developmentprogrammes to be effective will need to address the problem of collective trauma, particularly usingintegrated multi-level approaches.

BackgroundDisasters, whether natural or man made, are now wellknown to cause a variety of psychological and psychiatric

sequelae. These could range from adaptive and construc-tive coping responses in the face of catastrophic events tounderstandable non-pathological distress as well as a

Published: 4 October 2007

International Journal of Mental Health Systems 2007, 1:5 doi:10.1186/1752-4458-1-5

Received: 16 March 2007Accepted: 4 October 2007

This article is available from: http://www.ijmhs.com/content/1/1/5

© 2007 Somasundaram; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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number of recognizable psychiatric disorders. Conditionslike Acute Stress Reaction (ASR, the old disaster syn-drome), Posttraumatic Stress Disorder (PTSD), depres-sion, anxiety, somatoform disorders, alcohol and drugabuse [1,2], and in the long term, complex PTSD [3],enduring personality changes or Disorders of ExtremeStress Not Otherwise Specified (DESNOS) have beenshown to occur after disasters [4]. Evidence based andeffective, modern treatments like Cognitive BehaviourTherapy (CBT) and pharmacotherapy for PTSD to helpindividuals affected by the trauma of disasters to recoverare now available in western countries [5].

However, there is less recognition or understanding of theeffects disasters have at the supra-individual levels as wellas about appropriate interventions at these levels. Thereare many reasons for this relative deficiency. First, the fieldof disaster studies is itself rather recent. For example thediagnosis of PTSD was accepted only in 1980 with theAmerican DSM III [6].

Secondly, modern psychology and psychiatry have had awestern medical illness model perspective that is prima-rily individualistic in orientation[7]. Geertz describes theWestern concept of self as "...a bounded, unique, more or lessintegrated motivational and cognitive universe, a dynamic cen-tre of awareness, emotion, judgement, and action organizedinto a distinctive whole and set contrastively both against othersuch wholes and against its social and cultural background....isa peculiar idea within the context of world cultures" [8]. The'Kantian concept of an autonomous self' [9] and 'Enlight-enment values of individualism' [10] has come to mouldwestern ways of experiencing the self, the world andevents. PTSD is clearly a condition that exclusively afflictsthe individual self, the traumatic event impacting on theindividual psyche to produce the PTSD. However, it isbeing increasingly recognized generally that we need to gobeyond to the family, group, village, community andsocial levels if we are to more fully understand what isgoing on in the individual, whether it be his/her develop-ment, behaviour, emotion, cognition or responses tostress and trauma as well as design effective interventionsto help in the recovery and rehabilitation of not only theaffected individuals but also their families and commu-nity. For when the family and/or community regainedtheir healthy functioning, there was often improvementin the individual member's wellbeing as well. The sense ofcommunity appears to be a vital protective factor for theindividual and their families and important in their recov-ery.

This broader, holistic perspective becomes paramount innon-western, 'collectivist' cultures which have tradition-ally been family and community oriented, the individualtending to become submerged in the wider concerns

[7,11]. Collective events and consequences may havemore significance in collectivistic communities than inindividualistic societies like the US and Australia. It mayalso be important to bear in mind that societies are in flux,changing. With modernization and globalization, collec-tivistic societies are also increasingly becoming individu-alistic and consumer oriented. There may also betraditional subcultures within the bigger, individualisticculture. In collectivist societies, The individual becomesembedded within the family and community so much sothat traumatic events are experienced through the largerunit and the impact will also manifest at that level. Thefamily and community are part of the self, their identityand consciousness. The demarcation or boundarybetween the individual self and the outside becomesblurred. For example Tamil families, due to close andstrong bonds and cohesiveness in nuclear and extendedfamilies, tend to function and respond to external threator trauma as a unit rather than as individual members.They share the experience and perceive the event in a par-ticular way. During times of traumatic experiences, thefamily will come together with solidarity to face the threatas a unit and provide mutual support and protection. Intime the family will act to define and interpret the trau-matic event, give it structure and assign a common mean-ing, as well as evolve strategies to cope with the stress.Thus it may be more appropriate to talk in terms of familydynamics rather than of individual personalities. Theremaybe some individual variation in manifestation,depending on their responsibilities and roles within thefamily and personal characteristics, while some maybecome the scapegoat in the family dynamics that ensues(see family case histories [12]). Similarly, in the Tamilcommunities, the village and its people, way of life andenvironment provided organic roots, a sustaining supportsystem, nourishing environment and network of relation-ships. The village traditions, structures and institutionswere the foundations and framework for their daily life. Inthe Tamil tradition, a person's identity was defined to alarge extent by their village or uur of origin [13]. Their uurmore or less placed the person in a particular socio-cul-tural matrix.

A word of caution is necessary in trying to romanticize oridealize the family, neighbourhood, village, collective andcommunity which in reality are vague, amorphous terms,and which include within it considerable variation amongmembers as well as negative dynamics like scapegoating,marginalization, exclusion, ostracism and hegemonic ten-dencies. It would also prove very difficult to define com-munity and collective very precisely, as the borders willinvariably breakdown [14]. However for this paper, thediscussion addresses cataclysmic forces impacting onthese structures and as such consideration of some of


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these important internal difficulties can be temporarilypostponed till the overarching issues are clearer.

A better understanding of the supraindividual reality canbe sought through the ecological model of Bronfenbren-ner [15] with the micro, meso, exo and macro systems orthe individual nested in the family nested in the commu-nity [16,17]. The Bronfenbrenner model fits the WHOdefinition of health which also emphasises the need tolook beyond the micro or individual level (see Table 1):

"Health is a state of complete physical, mental, (family), socialand (spiritual) well-being, and not merely an absence of diseaseor infirmity".

- World Health Organisation (WHO)

The family unit has been included as it is paramount inmost parts of the traditional world. When the family isaffected, the members too are affected, while if the familyis healthy the individual is either healthy or recoverswithin the family setting. The spiritual dimension hasbeen put forward at various WHO fora but has not beenformally accepted yet.

This reflexive study grew out of the experience of workingin disaster, post-disaster contexts: the man made disasterof war and the 2004 Asian Tsunami in Northern Sri Lanka(see Fig. 1). The phenomena of collective trauma firstbecame very obvious to the author when working in thepost war recovery and rehabilitation context in Cambodia[18]. During the Khmer Rouge regime, all social struc-tures, institutions, family, educational and religiousorders were razed to 'ground zero' deliberately (so as torebuild a just society anew!) [19]. Mistrust and suspicion

arose among family members as children were madereport on their parents. The essential unity, trust and secu-rity within the family system, the basic unit of society, wasbroken. Similar changes at the family and community lev-els became discernable in the Northern Sri Lanka as theconflict continued.

From a conservative society caught up in the world widemodernization and globalization, the minority Tamilsociety in Sri Lanka became increasingly embroideled in acivil, ethnic war from 1983 onwards. Developing as a defi-ant reaction to increasing majority Sinhala dominatedstate policies of discrimination; the youth rebellion tookan increasing violent form in opposition to increasingstate oppression. The North and East of the country, hometo the minority Tamils, bore the brunt of the chronic vio-lence that followed [12]. The state, including the Indianstate briefly in the late 1980's, various paramilitaries andTamil militants have been involved in in cycles of vio-lence, counter violence, terror and counter terror [20].During a lengthy period of ceasefire, the island was struckby the Asian Tsunami in December, 2004 that affectedover 200, 000 people again mainly in the coastal commu-nities of the North and East but also the South. The authorwas put in charge of addressing the psychosocial needs inthe North (see Fig. 1).

The impact of catastrophic events on the individual hasbeen well established internationally [6,21] and was quiteclear in Northern Sri Lanka [12]. There have been someobservations on the family level too in Northern Sri Lanka[22]. However, it was when it came to addressing mentalhealth problems that the impact on the communitybecame evident. Simple interventions at the individuallevel were not sufficient. The problems at the community

Table 1: Dimensions of health

Dimensions of Health

Causes Symptoms Diagnosis Interventions

Physical Physical injuryInfectionsEpidemics

Pain, fever, Somatization Physical illness, Psychosomatic, Somatoform disorders

Drugs treatment, Physiotherapy, Relaxation techniques, massage

Psychological ShockStressFear-TerrorLoss Trauma

Tension, fear, sadness, learned helplessness

ASR, PTSD, Anxiety, Depression, Alcohol & Drug abuse

Psychological First aid, Psychotherapy, Counselling, Relaxation techniques, CBT

Family DeathSeparationDisability

VacuumDisharmonyViolence

Family Pathology, Scapegoating Family TherapyMarital TherapyFamily Support

Social Unemployment, Poverty, war conflict, suicidal ideation, anomie, alienation, loss of communality

Parasuicide, Suicide, Violence, collective trauma

Group Therapy, Rehabilitation, community mobilization, Social Engineering

Spiritual Misfortune, bad period, spirits, angry gods, evil spells, Karma

Despair, Demoralization, Loss of belief, Loss of hope

Possession Logotherapy, rituals, traditional healing, Meditation, Contemplation, Mindfulness


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Map of Sri Lanka (from UN-OHCHR)Figure 1Map of Sri Lanka (from UN-OHCHR).

Ferry

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SABARAGAMUWA

National capital

Provincial capital

Town, village

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Main road

Secondary road

Railroad

SRI LANKA

Map No. 4172 Rev. 1 UNITED NATIONSJanuary 2004

Department of Peacekeeping OperationsCartographic Section

The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations.

SRI LANKA

0 25 50 75 km

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80° 80°30'

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level too had to be understood and addressed if the indi-viduals were to be helped. Further, families and commu-nities had to recover if any meaningful socio-economicrehabilitation programmes were to succeed. In fact, intime most long-term programmes, as in other post disas-ter settings arond the world [23-25], began to include acommunity based psychosocial component within thelarger socio-economic rehabilitation and reconstructionefforts, [26,27].

In these complex (post) disaster situations, the multi-levelWHO definition of health is useful in conceptualizing thecauses, effects and interventions for psychosocial andmental health problems found in these devastated com-munities (Table 1). In reality, these dimensions are inter-acting systems which are interrelated, each level havingeffects at other levels so that a holistic approach that inte-grates all these levels becomes necessary.

For example, physical illnesses like injuries, epidemicsand malnutrition resulting from war conditions [28,29],will have direct physical causes, physical symptoms andphysical treatment. But it could also have psychological,social and spiritual causes, symptoms and treatment.Physical diseases, in addition to the familiar physical signs& symptoms, also manifest with psychological, social andspiritual symptomatology. At the same time, psychologi-cal factors can cause or contribute to physical diseases likeBronchial Asthma, Hypertension, Eczema, and Colitis.Mental illnesses can manifest with physical symptomssuch as the common Somatoform Disorders or Somatiza-tion. A global perspective shows that mental health prob-lems the world over produces a major proportion of theGlobal Burden of Disease (GBD), including death, disa-bility and injury due to behavior related problems such asadverse life style, alcohol and drug use, road traffic acci-dents, war and violence, exploitation, and AIDS [30].However, the contribution to GBD from disasters is yet tobe mapped out [28,29]. Physical and mental illness havesocial repercussions. Epidemics of physical illnesses likethe current HIV/AIDS pandemic has severe socioeco-nomic implications nationally and internationally. Men-tal illnesses can cause problems in the family, communityand work place due to irritability, paranoia, relationshipconflicts, alcoholism and/or drug abuse, domestic vio-lence, morbid jealousy and social withdrawal. In a likemanner, social problems like unemployment, poverty,war, and displacement can cause psychosomatic diseases,mental illnesses like depression and suicide [31]. Whenconsidering treatment one can also have interventions atall these levels, either alone or in combination. Thus phar-macotherapy or treatment with drugs is the prototype ofphysical treatment. Psychotherapy, counselling, behav-ioural and cognitive therapies are some common psycho-logical forms of treatment. While marital, family and

group therapies as well as rehabilitation, NGO network-ing, occupational therapy and vocational training can beconsidered social forms of therapy. Likewise, it is said thatspiritual meaning, hope and strengths will produce resil-ience and improvement at all the above levels. ViktorFrankl [32] pioneered this form of treatment which hecalled logotherapy after surviving the Nazi concentrationcamps during World War II.

Previous workers had already drawn attention to the com-munity level problems caused by disasters. Kai Erikson[33,34] gives a graphic account of Collective Trauma as'loss of communality' following the Buffalo Creek disasterin the US. He and colleagues described the 'broken cul-tures' in North American Indians and 'destruction of theentire fabric of their culture' due to the forced displace-ments and dispossession from traditional lands into reser-vations, separations, massacres, loss of their way of life,relationships and spiritual beliefs [35]. Similar tearing ofthe 'social fabric' has been described in Australian aborig-inal populations [36]:

"...it implies things have to be woven together properly forstrength, what a shame our fabric was torn to shreds throughinvasion, what we have left now is in tatters, repairing fabriccan make it weak or sometimes stronger depending on how it isdone. It is important to repair the holes and not just cover themover so that when some tension is applied it doesn't fall apart.What kept our fabric strong was spirituality, the invisiblethread that binds us all"

The National Strategic Framework for Aboriginal andTorres Strait Islander Health [37] states:

"The sense of grief and loss experienced by generations of Abo-riginal and Torres Strait Islander peoples in relation to dispos-session, to the disruption of culture, family and community andto the legislated removal of children has contributed to ongoingproblems in emotional, spiritual, cultural and social well-being for Aboriginal and Torres Strait Islander individuals,families and communities."

O'Donoghue [38] describes the collective trauma,

"Aboriginal culture has been subjected to the most profoundshocks and changes. It is a history of brutality and bloodshed.The assault on Aboriginal people includes massacres, diseases,dispossession and dispersal from the land... I cannot overstatethe traumatic consequences of policy and the destruction ofAboriginal and community life that resulted."

Nadew [39] in his survey of psychosocial and mentalhealth problems among the aboriginal population founda very high prevalence of conditions like PTSD (55 %),depression (22%), alcohol abuse (73 %), and violence.


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He linked it to the long-term and massive trauma sufferedby the aboriginal population. O'Shane identifies the lossof pride, identity, self respect, language, songs, laughter,spirituality, relationships, traditional knowledge andskills in the group as a whole [40]. The consequences aretrans-generational, being passed onto later generations aswas found with World War II holocaust survivors [41].

The high incidence of mental health problems, alcoholand drug abuse, physical and sexual violence, child abuseand family disharmony found among indigenous popula-tions around the world can be the result of the break up oftraditional culture, way of life and belief systems. Insteadof the usual response of incarceration, exclusion and sup-pressive measures, significantly, there are now attempts torepair the torn social fabric. The Dulwich centre inAdelaide has used narrative therapy to 'reclaim commu-nity' [42]. By sharing stories at community gatheringsrelationships, connection and links are re-established, tra-ditional values, beliefs, knowledge, skills and hope are re-kindled, giving rise to community solidarity and support.The method has been expanded to other indigenous pop-ulations around the world.

There was a description of 'cultural bereavement' due tothe loss of cultural traditions and rituals in Indochineserefugees in the US [43] and collective trauma due to thechronic effects of war [44]. More recently, a number of dis-cerning workers in the field have been drawing attentionto the importance of looking at the family [26,27,45,46]and cultural dimension [7,45,47-49] following disasters.Finally, Abramowitz [50] has given a moving picture of'collective trauma' in six Guinean communities exposed towar.

Borrowing from the individual psychopathologicaldescriptions, the term collective trauma is being intro-duced in this study in a metaphorical sense to representthe negative impact at the collective level, that is on thesocial processes, networks, relationships, institutions,functions, dynamics, practices, capital and resources; tothe wounding and injury to the social fabric. The long last-ing impact at the collective level or some have called ittearing in the social fabric would then result in the socialtransformation [51], of a sociopathic nature that can becalled collective trauma. This study attempts to describethe phenomena of collective trauma, to delineate thesymptoms and community level interventions that can beused in such contexts.

MethodsThis qualitative, ecological study is a naturalistic, psycho-social ethnography [52] in two contexts: The main focusis on the ongoing chronic civil war situation from 1983onwards contrasted to the pre-war conditions and the

post Dec. 2004 Tsunami recovery effort in Northern SriLanka. The ecological study follows Bronfenbrenner [11]:

"...an effort to investigate the progressive accommodationbetween the growing human organism and its environmentthrough systematic contrast between two or more environmen-tal systems or their structural components, with a carefulattempt to control other sources of influence either by randomassignment (planned experiment) or by matching (naturalexperiment).... There are instances in which a design exploitingan experiment of nature proves a more critical contrast, insuresgreater objectivity, and permits more precise and theoreticallysignificant inferences- in short, is more elegant and constitutes"harder" science- than the best possible contrived experimentaddressed to the same research question."

Participant Observation, in depth case studies [53], keyinformant interviews and focus group discussions as wellas several quantitative, individualistic psychosocial andmental health surveys published elsewhere [12,54,55]provided the data for the study. The focus group discus-sions have included groups from the community, village,local government (G.S.-village headman, teachers, socialworkers, priests); displaced camp and relief workers; Dis-trict (GA-District Authority, Non-Governmental Organi-zation (NGO), militant) committees; National (HealthMinistry, Presidential Task force); and International NGO(INGO's, UN) groups that discussed and debated mentalhealth and psychosocial issues. The author had theunique experience of working as a mental health profes-sional in these settings. Though being an Asian, ethnicTamil, the author had most of his education and profes-sional training abroad, particularly in the west, providingboth an 'insiders' and 'outsiders' view point.

The main purpose of this study is an attempt to phenom-enologically describe and understand the familial andsocietal factors involved so as to better design and imple-ment more effective, appropriate and workable interven-tions, policies and programmes in a post-disaster context.In addition there is a plea for prevention of such disastersand the consequences they entail by documenting anddescribing the devastating effects of war and disasters onfamilies and communities.

Results and DiscussionIndividualSeveral surveys of individual level trauma and its effects inthe contexts of war and post tsunami in North Sri Lankahave shown widespread traumatization and considerablepsychosocial sequelae in the different population groups[12,54,55]. In depth case studies show the variety of psy-chopathological responses [53]. An epidemiological sur-vey using the UCLA PTSD Child Reaction Index withexpert validation (Kappa .80) [56] carried out in the


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Vanni, an area in the North of Sri Lanka, found that 92%of primary school children had been exposed to poten-tially terrorizing experiences including combat, shelling,and witnessing the death of loved ones. In 57% of thechildren, the effects of these experiences were interferingconsiderably with their daily life (e.g., social withdrawaland weakening school performance). About 25% werefound to suffer from PTSD. Our epidemiological survey ofschool children in the North and East found that 47% ofthose who had been exposed directly to the tsunami and15% of children not exposed had PTSD (all living in a warcontext).

Apart for the individual suffering and disability, such alarge prevalence of psychiatric disorders in a populationwould lead to a cumulative effect that would cause consid-erable social pathology and dysfunction. However, in thisabnormal situation many of the reactions, which wouldbe considered pathological in normal times, wouldbecome the norm – a normal reaction to an abnormal sit-uation. For example, startle reactions to sudden loudnoises like backfiring of motorcycles, banging doors orfirecrackers and nightmares of war events, which are char-acteristic symptoms of PTSD, were widely prevalent andnot considered abnormal. Thus many with so-called diag-nosable psychiatric disorder like those who would beidentified in population surveys may not seek help, atleast western psychiatric help. This is clearly shown in thelow percentage of PTSD and similar post trauma syn-dromes in psychiatric out patient services (approximately5%). Some were seeking help through other avenues suchas the traditional sector or general health care facilitieswith somatic complaints [57] or more traditional idiomsof distress like Perumuchu (Deep sighing breathing signify-ing worries and emotional burdens) in the Tamil commu-nity. An important contentious issue is whether thosediagnosed as having psychiatric disorder using westerncategories are in fact having a mental illness, the categori-cal fallacy [58]. The person, his/her family and commu-nity often did not recognize or accept a psychiatricdisorder.

A further problem is how effective or appropriate are west-ern treatments such as psychopharmacotherapy or state ofthe art CBT even in those with manifest dysfunction. InNorthern Sri Lanka, CBT was not possible as there were noclinical psychologists. Even the recommended psychop-harmacological agents in the west, SSRI's, were not avail-able (In the post tsunami period these treatments didbecome briefly available thanks to the international good-will). Our experience in Northern Sri Lanka in these differ-ent contexts has been that a small minority with moresevere dysfunction do benefit from psychiatric treatmentwhich could also include cultural techniques like yogicrelaxation methods [59]. When individuals improved it

also helped their families, communities or refugee campswhere they lived. In addition, the conventional psychoticillnesses like Schizophrenia and Bipolar disorders neededcontinued medical treatment. However, due to the disas-ters much of the health infrastructure and resources weredestroyed or depleted and did not function adequately.Mental health services using essential psychotropic medi-cation, out reach clinics in the periphery and badlyaffected areas, and training of primary health care workersenabled minimum cover. The generous post tsunamiinternational support facilitated the introduction ofdecentralized mental health services at the district level(Fig. 2). Indeed, community mental health programmesthat do not include the possibility of addressing the prob-lems of those with severe mental disorders would fail inthe eyes of the community and cause a breakdown in thesmooth functioning of the setting where they were. Nev-ertheless, it was not feasible to treat the large numbersaffected with minor mental health problems due to thedisasters with western psychiatric treatment. Rather, acommunity based programme to rebuild the damagedfamily units and social structures, networks, resources andrelationships encourage re-establishment of helpful tradi-tional healing rituals and practices; group meetings andfunctions, in short to start the community working againappeared to be more judicious. Training a variety of grass

Referral structure for management of mental health prob-lems (at District Level)Figure 2Referral structure for management of mental health prob-lems (at District Level).

Community

Community level workers ( eg. Teachers, G.S, NGO, etc. ) and people in basic Mental Health methods.

Psychiatric careat District Level

Psychiatrist, Psychiatric Nurses & Multi Disciplinary Team for

Psychiatric Care of severe cases.

Primary Health Care

Primary Health Worker (eg. Doctors,, PHW's, Nurses, PHI)To manage the effects of mild mental health disorders

(PTSD, anxiety, depression)

Multi disciplinary team - Psychiatric social worker, Clinical Psychologist, Counsellor,Child therapist( includes art, play, drama ), Relaxation therapist and Occupational therapist.

Referral


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root workers in basic mental health and psychosocialskills was the most effective way to accomplish this [60]When the family and community regained their function,individuals recovered their confidence, motivation, capac-ity and skills.

FamilyThe war and the tsunami had a major impact on the func-tioning family system. From the loss of one or both par-ents, separations and traumatization in one member,pathological family dynamics adversely affected individ-ual family members, particularly the children.

The traditional family unit as the basic social institutionhas barely survived but its function has been irrevocablychanged by the chronic conflict. The cohesiveness and tra-ditional relationships are no longer the same. Comparedto before the war, it is a common complaint that childrenno longer respect or listen to their elders, including teach-ers. These changes, attitudes and perceptions, like manyothers, may have antedated the war but could have beenaccelerated by it. A seniour British INGO (SCF) workerwho had served in Jaffna for a long period made the obser-vation of the common day to day occurrence at the perva-sive check points in the North and East. Tamil parentsquickly change their behaviour and tone (in contrast towhat the child has seen at home or elsewhere) when deal-ing with the security forces. They, perhaps unconsciouslyand with the best of intentions (to safeguard their chil-dren and to avoid unnecessary hassle), assume a submis-sive posture (removal of hat, bent head and body, low andalmost pleading tone of voice, pleasing manner with asmile) when accosted by the security forces (e.g. at checkpoints). The children will observe this change withoutcomprehending the full purpose (perhaps to avoid thechild being detained), comparing it to their demeanour athome and in time loose faith in his or her parents. Astrong influence has been the contemptuous way eldersand community leaders have been treated by the authori-ties and the submissive way they have responded. Eldersare perceived as being powerless and incompetent in deal-ing with war and its consequences, a point often made bythe young militants. Parents were careful about what theydiscussed in front of their children as the child could inad-vertently let this out in school or during play, particularlyif it was something against the Tamil militants. Eldershave also been traumatized by the war, affecting theirfunctioning, relationships and parenting skills.

Due to the peculiarities of the war, males were more oftentargeted and were at high risk to be killed, arrested,detained, disappeared, join the militancy or to migrate.For example in the small fishing village of Chavatkaddu,where we set up a widow's group, there were 180 widows,many of whose husbands were killed at sea, a highly con-

tested area between the Sri Lanka Navy and the Tamil mil-itants. Altogether there are 19,090 female headedhouseholds in Jaffna. A great number are widows whohave lost their husbands due to the war. The effect on thefamily, the widow [61], and the children has beenimmense. The loss of one member of the household, par-ticularly the breadwinner has a marked impact on thefamily dynamics. Absence of members of the family dueto death, injury or displacement will create immense gapsin the functioning of the family unit. The uncertainty orgrief about the missing member will add to the maladap-tive family dynamics that will ensue. The loss of the essen-tial unifying role of the missing member can causedisruption and disharmony within the family. A commonsituation is where the father has been detained, 'disap-peared' or killed but the family members are not sure ofhis fate. They are caught in a 'conspiracy of silence' wherefurther inquiries may lead to more problems for the fatherwere he still alive and the mother may not be able to sharethe truth with the child. The child then presents withbehavioural problems. The mother has to adapt to all thenegative implications of being a 'widow' in this society.The role of the mother has undergone momentous changewith increasing non-traditional responsibilities, activitiesand "liberation" [62].

A more tragic situation happens when the disappearing isdone by a local Tamil militant group. Here the conspiracyof silence is much deeper. A disappearance by the army orsecurity forces is acceptable within the community. Butdisappearance by the Tamil militants is something thewidow and her children cannot talk about even in thecommunity or inner family circle. Apart from the dangerand risk of repercussions, the disappeared is made into anundesirable, a traitor. The family itself often becomesostracized by society. The widow cannot express her emo-tions at all, even to herself; the deception thus goes muchdeeper into oneself. In a case that I was seeing, the widowwas suppressing the memory of her husband and in timehe disappeared from her consciousness as well as from hischildren and society.

In 1996 there were reported to have been 600 disappear-ances in Jaffna [63] and in the current period from Dec.2005, there have already been 1300 Island wide [64]. Astudy by Shantiaham [65] involved the follow-up of thefamilies of the disappeared, assessment of needs and psy-chosocial support. When entering the homes of the disap-peared, the atmosphere was akin to a funeral house, evenyears after the disappearance. The mildest of conversa-tions linked to the disappeared, would set off tears andcrying. The house was not lively, it was quiet and moody.In the case of the disappeared there is no closure of thedeath, no certainty about the fate of the person. It would


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be disloyal to even consider that the person could havebeen killed.

A study assessed the impact of displacement in the Northon functioning of the family system [22]. Psychologicaldisturbances particularly depressive symptoms weremuch more common in displaced families than in thoseliving in their own homes. In displaced children, separa-tion anxiety was common as were cognitive impairment,conduct disorders and sleep disturbances. Disturbances infamily dynamics particularly disputes and quarrellingbetween father and mother were attributed to economicstress, lack of privacy and interference of others in overcrowded camps. Other war related trauma like torture andloss of a limb due to landmine injury had a direct impacton families [66]. The loss of a limb led to feelings of infe-riority and shame that made family life difficult. In somecases, husbands left their wives. Torture survivors whoreturned to their families often were not able to functionas before. They were socially withdrawn, had difficultieswith intimate relationships, they were irritable and notmotivated to work or be active [67]. These situationschanged the family dynamics. In one case referred to thepsychiatric unit, there was a role reversal with the wifegoing to work and the husband trying to cope with house-hold chores. Due to his feelings of inadequacy, heattempted suicide. He had clear PTSD symptoms, yet thefamily refused to accept mental health help. When a fam-ily member develops a psychiatric disorder like PTSD,depression or substance abuse due to traumatization, thesymptoms and social dysfunction had an adverse effect onthe family as well.

In the case of the tsunami, there were more women whodied compared to men as elsewhere [68]. Perhaps thewomen were less capable of surviving, not having theskills in the sea. Women may also have been home whenthe tsunami struck. This left many male widows whofound it difficult to cope with the remaining families, nothaving the skills to look after children, prepare food or doroutine household chores. Some took to alcoholism. Sui-cidal ideation, attempts and suicide was reported to behigh. In time some re-married creating problems for thechildren. Often the children were given to other relationsto look after. Cases of child abuse were reported in someof these arrangements. The attempts to adopt childrenwho lost one or both parents or to put them in institu-tions were resisted by child protection authorities. Ini-tially there had been reports of abduction of orphans, socalled tsunami babies as well as interest from peopleabroad to adopt tsunami orphans. Thus in many ways theimpact of the tsunami on the family was unique.

CommunityDisasters have an effect not only on individuals [12], butalso on their family, extended family, group, community,village and wider society. During civil conflicts, arbitrarydetention, torture, massacres, extrajudicial killings, disap-pearances, rape, forced displacements, bombing andshelling became common (see Tables 2).

Whole communities or villages were targeted for totaldestruction, including their way of life and their environ-ment. According to a Save the Children, UK publication[69] on the nature of current conflicts:

Table 2: Distribution of war stress in the community

Stress factors Community [44] (n = 98) OPDc [47] (n = 65)

Direct stressDeath of friend/relation 50% 46%Loss to property 46% 55%Injury to friend/relation 39% 48%Experience of bombing/shelling/gunfire 37% 29%Witness violence 26% 36%Detention 15% 26%Injury to body 10% 9%Assault 10% 23%Torture 1% 8%Indirect stressEconomic difficulties 78% 85%Displacementa 70% 69%Lack of food 56% 68%Unemployment 45% 55%Ill healthb 14% 29%

aBefore the 1995 mass displacement when the figure would have reached almost 100%bIll health due to war related injuries including amputations due to landmine blasts, epidemics like malaria, reduced resistance to infections (due to stress and malnutrition), septicemia etc. had debilitating mental effects.cOut Patient Department (OPD) at General Hospital, Jaffna


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"Civilians are no longer 'incidental' casualties but the directtargets of violence.Mass terror becomes a deliberate strategy.Destruction of schools, houses, religious buildings, fields andcrops as well as torture, rape and interment, become common-place. Modern warfare is concerned not only to destroy life, butalso ways of life. It targets social and cultural institutions anddeliberately aims to undermine the means whereby peopleendure and recover from the suffering of war....."

"A key element of modern political violence is the creation ofstates of terror to penetrate the entire fabric of economic, socio-cultural and political relations as a means of social control"[70].

It maybe more accurate to say that the nature of war haschanged. Instead of the old fashioned wars between statesfor control of territory, where sides will fight each other onbattlefields till one emerges as a victor, modern wars havenow become internal, civil wars, where the conflict ismore psychological for control of loyalties through intim-idation and terror, the fighting occurs within civilian pop-ulations, where 90% of casualties are civilians [71]. Apartfrom wars for complete extermination, that is genocide,the goal of modern warfare is more for absorption andassimilation in to one dominant culture and way of life.The minority is expected to forgo its own culture and iden-tity and merge with the or become subservient to thedominant culture. Whey they try to resist the process eth-nic or civil conflict erupts.

In this way, the civil war in Sri Lanka began as an ethnicconfrontation between the majority Sinhalese and Tamilminorities, where the majority sought to impose their lan-guage and religion. The resultant conflict has had a pro-found impact on Tamil village traditions, structures andinstitutions that had been the foundations and frameworkfor the their daily life causing fundamental, irrevocablechange in these processes [72,73]. Good examples are thesystemic attacks on all the Tamil villages in the Trincoma-lee District which eventually displaced all of them into thecity or to other districts. Another example is the LTTE'sforced eviction in the early 1990's of the Moslems of theNorth with 48 hours notice, many of whom still languishin refugee camps in the South.

Apart from direct attacks, whole villages of all three com-munities, Sinhala, Tamil and Muslim, have been dis-rupted, displaced and uprooted due to the ongoingconflict. Examples are the fishing community and farm-ers: From the beginning, for alleged security reasons, fish-ing in the North and East has been restricted. This hasincluded bans on fishing in large areas, restrictions on thedistance where fishing can be done (usually restricted toshort distances offshore). Whole fishing communitieshave been displaced, such as from Myeliddy, a fishing vil-

lage on the northern coast, from early 1990's. The dis-placed families from these communities can be founddispersed in a number of refugee camps or where severalfamilies occupy makeshift accommodation in abandonedhomes. Inter and intra family conflict is rife with the onceactive fishing folk observed to be despondent and hope-less. Fishermen are at increased risk of death, disappear-ance, detention, and injury due to the war in the sea. As aresult the highest number of widows come from this com-munity. This has had a terrible toll on this community.Many have shifted to other occupations, some are stillunemployed living off government rations, others haveleft the area. They have lost their way of life and culture.Many yearn for the days when they were able to fish freelyand lead a fisherman's life in their village. They oftenreport dreams of living in their old homes and going fish-ing in the sea. Before 1983, fishing was a very fruitfuloccupation, the catch was good off the long North Eastcoast, and a considerable part of the fish was transportedto Colombo and other areas in the Island. In the wholeisland the North East was a leading area for fishing. Thecoastal communities were thriving hives of activity.

With the ceasefire in 2002, many of the fishing familiesreturned to their coastal villages and restarted their fishingactivities step by step. When the tsunami struck in Decem-ber 2004, all this was again destroyed. The sea had been avital and intimate part of their lives. The sea was called the'mother' in Tamil in their folk songs, narratives, literatureand common parlance. When the sea rose up and struckwith such destructive furore, a fundamental, organic bondwas broken. In the early days after the Tsunami most ofthe fisherman vowed never to go back to the sea. Many oftheir songs and discourse of this time expressed this loss,grief and feelings of being abandoned by the mother,rebuked and punished. The slow mending of this organicrelationship took time. Eventually most fishermanreturned to fishing, families slowly moved closer the seafrom where they had initially been displaced and thenfeared returning to. Community mental health pro-grammes worked on reducing this fear (by various desen-sitisation techniques) and encouraged the return tofishing. The resumption of conflict has displaced many ofthese communities again. Significantly, the recent disap-pearances and extrajudicial killings have targeted the lead-ers of the fishing organizations who had become effectivesocio-politically in working for the betterment of theircommunity.

It has been a similar tale with farmers, many of whomhave been displaced from their traditional lands, and havelost all their equipment. Some are unable to cultivate theirland, as it is located in restricted 'security zones' or ismined. Some have abandoned their traditional occupa-tion as it no longer profitable, given unavailability or cost


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of agricultural inputs like fertilizers, insecticides and fuel,or lack of access to markets for their product. The ubiqui-tous presence of buried landmines creates a pervasiveapprehension in the back of the minds of people, makingthem ever vigilant, cautious about walking freely on theland, afraid of putting a wrong foot somewhere. Somedeveloped nightmares of being the victim of an explodinglandmine. The once beloved land itself becomes polluted,a source of terror [66].

Other traditional trades like carpenters, masons and bak-ers have been affected similarly. The Moslems, many ofwhom were part of a very prosperous business commu-nity, or specialized in other occupations like tailoring,tinkering, leather work and commercial entrepreneurshiphave lost their occupations and way of life due to theirforced eviction. They had tried tentatively to return afterthe 2002 ceasefire but never felt secure or reassured thatabductions for ransoms and eviction would not berepeated. With the resumption of hostilities, they haveagain fled. The Sinhalese were well known bakers in theNorth and East, but have now all left.

As already mentioned, in these various rural communi-ties, the village or uur, was the secure and familiar envi-ronment with traditional way of life, supportive socialstructures, institutions and functioning. With the disas-ters, both the war and tsunami, many villages have ceasedto exist. Due to dislocation villagers have been separatedso that the sustaining network of relationships, structuresand institutions have been lost. Even when people havereturned, the village was not the same. Many were com-plete newcomers. The old structures and institutions wereno longer functioning. Thus the protective environment,the social fabric, provided by the uur is no longer there.

Similarly, in the life of Tamils, their home (veedu) is veryimportant. There will be a history of the home. The ances-tral relations who have died, will continue to have con-nections with the home. They will be remembered andconsidered as if they were present in the home, especiallywhen rituals are performed in the home. There is a Tamiltradition of being loyal to the home. If one makes a bigmistake, he feels guilty of having betrayed his home.There is a biological link between the home and the peo-ple who are dwelling in the home. When one is in thehome, or when he or she come from outside into thehome or when they are away from the home and think ofthe home, they feel security and peace (like a baby in thewomb). When they area forced to leave the home sud-denly with the whole household for long periods, thisbiological link breaks. This affects the mental condition inseveral ways. People believe that ghosts or demons willoccupy the homes which are left alone, unoccupied for along time. Repeated displacements, which have affected

almost everyone at one time or another, have forced theTamils to abandon their homes. People who returned totheir homes after displacement, felt there was a change inthe organic bond. They could not re-establish the relation-ship with their homes. Many have left their homes in astate of disrepair, occupying a part of the home withmakeshift arrangement, ever in the ready with an emer-gency bag ready to move.

Some catastrophic events were of such a scale that it left animprint on everyone, on the 'groupmind', on thinking pat-terns and memory. It changed the lives of individuals,their families and their communities in fundamentalways, it transformed society [51] and the experiencepassed on into the collective memory to be recounted instories, narratives and folklore, songs, poetry and dramas;to influence future generations through subtle social proc-esses, so that it may be appropriate to speak of an impacton the collective unconscious. The mass exodus of 1996was one such experience [74]. Apart from the forcedbreaking of the bonds with their homes and village, thetrek of over 400,000 people in the middle of night withrain and shells changed everyone. They left in terror andnot by choice, with few possessions, roads clogged withcrowds moving slowly, step by step, the less able, the eld-erly, falling by the wayside; and finally arriving in make-shift, inadequate accommodation with very poor facilitiesor none at all. People lost their identity, pride, dignity andhope.

Other major events having an impact on the collectiveunconscious were the so-called July 1983 ethnic holo-caust; the burning of the Jaffna public library with its irre-placeable old Tamil manuscripts and books (sometimesreferred to as cultural genocide); the Indian military oper-ation to capture Jaffna in October 1987 (rupturing a bondwith another traditional mother); and the tsunami ofDecember 2004. Some widespread phenomena seen dur-ing the war like 'disappearances', torture and landmines,also had a long-term effect on the collective unconscious.

Noteworthy, in our community survey [54] is the findingthat 1% of the study population had been tortured, butthe figure reached 8% in the OPD patients [57]. Torturewas used as a routine procedure carried out on all thosedetained [67]. It was developed into a physical and psy-chosocial tool to break the individual personalities ofthose who tried to resist, as well as an encompassingmethod to coerce a community into submission. Manyindividuals did not survive torture, but those who didwere released in a broken condition; or when dead, theirmaimed bodies were conspicuously exhibited to act as awarning to others. It became one aspect of institutional-ized violence and laws were passed, such as the Preven-tion of Terrorism Act and Emergency Regulations, which


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facilitate prolonged incommunicado detention withoutcharges or trial, in locations at the discretion of the Secu-rity Forces, and allowed for the disposal of bodies of vic-tims without judicial inquiry. These legislationslegitimized the use of torture and death in custody [75].Thus torture became institutionalised as an aspect of stateterror. It was similarly used by the militants but withoutthe legal veneer. The Istanbul Protocol for the investiga-tion and documentation of torture project team speak ofcommunity trauma by the creation of a 'repressive ecology'based on imminent, pervasive threat, terror and inhibi-tion that causes a state of generalized insecurity, terror andrupture of the social fabric [76].

The chronic climate of terror, insecurity and uncertaintywas a prominent cause of the collective trauma due to thewar [77], but was not seen with the tsunami. The naturaldisaster was a one off catastrophic event that left a trail ofdestruction and loss but did not continue to exert a pro-longed effect. As a result the severity of the collectivetrauma was much less. That war was man made alsoappeared to add to severity of the traumatic effect. The tsu-nami on the other hand was attributed to an act of natureor the wrath of God for some wrong doing, karma, oftenof a collective nature. In N. Sri Lanka, people had beenexposed to multiple traumatic events (in N. SL the averagewas over 6 events) so much so that the condition ofchronic traumatic stress maybe a better description [78].The Tsunami was an additional traumatic event on top ofmany more. One study found that there was a buildingblock effect, those who had been already traumatized bywar were at an increased risk to re-traumatization by thetsunami [55]. Further such indirect effects of disasters(Table 1) like displacement, unemployment, poverty, illhealth, malnutrition and socio-economic hardships couldbe as debilitating and traumatic in its long term effect.

Another ecological factor that was a cause of collectivetrauma was the breakdown in intersetting communica-tion and knowledge [15] between the mesosystem of thecommunity and the macrosystem of those in authority.Those in authority, the military, militants and the state,held all the power and failed to communicate essentialinformation. Apart from the language barrier between theSinhala (and briefly Indian) state and the Tamil commu-nity, decisions and actions appeared arbitrary and dictato-rial. There was no genuine relationships or attempts tocommunicate except for competing versions, rumoursand propaganda exercises through the media that weremore confusing to civil society [12]. Accurate and helpfulinformation is considered essential for maintaining andpromoting mental health in disaster situations. Access toessential information and awareness programmes arebasic mental health strategies. The Tamil militants werealso careful not to allow any congenial relationships to

build up between the state, the military and civil society.Any positive developments in that direction were dealtwith harshly. Public relations exercises were often ill con-ceived. There were some belated attempts by the securityforces to learn the local language, Tamil.

The loss of leadership and the talented, skillful, resource-ful persons, the professional, technocrats, and entrepre-neurs from the community has had devastatingconsequences. Many left over the years due to increasingdifficulties, traumatic experiences and social pressurefrom family and colleagues, the so called 'brain drain'.Those who remained have been targeted by those aspiringto rule the community. The various authorities vying forthe loyalty and subservience of the community have ruth-lessly eliminated what they have perceived as obstructionto their power and control. Apart from the extrajudicialkillings of the state and its allied paramilitary forces, theinternecine warfare among various Tamil militant organi-zations competing for the loyalty of the community haveresulted in the elimination of many of its own ethnic,more able, civilians- a process of self-destruction, autogenocide. Those with leadership qualities, those willing tochallenge and argue, the intellectuals, the dissenters andthose with social motivation have been weeded out ('PulluKalaithal'- those eliminated are labeled as anti social ele-ments or traitors). They have either been intimidated intoleaving, killed or made to fall silent. At these shifts inpower, recriminations, false accusations, revenge and ret-ribution were very common. It happened in 1987 (IPKF,the Indian intervention); in 1990 (LTTE takeover), in1996(SLA control) and is currently happening as a free-for-allcurrently after 2005 with the collapse of the ceasefire.

Bronfenbrenner [15] warns of the destructive conse-quences to a society which experiences the systematicdegrading and debilitation of its richly talented members.This is the loss of vital resources [16], the destruction ofsocial capital, the nodal points of vibrant relationshipsand essential networks which is a prominent cause of Col-lective Trauma. Without leadership and organization,vital networks and working relationships have collapsed,leaving the community easy prey to competing propa-ganda, authoritarian control and suppression. Many haveobserved that ordinary people in Jaffna have become pas-sive and submissive. These qualities have become part ofthe socialization process, where children are taught tokeep quiet, not to question or challenge, accept the situa-tion, as assertive behaviour carries considerable risk. Thecreative spirit, the vital capacity to rebuild and recover isbeing suppressed.

An important ingredient in the social recovery process isresource gain cycles [16]. Unfortunately, after extremestress the opposite occurs – rapid and turbulent loss cycles


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[16]. Vicious spirals of loss are set in motion due to cas-cading patterns of multiple stressors where the loss of oneresource triggers other losses [17]. Hobfoll [16] points outthat 'major trauma cycles not only spirals (downwards) for theindividual in a personal sense with anxiety, depression andloneliness, but also often result in reduced social involvement,diminished interest in life and family feelings of social detach-ment and a sense of alienation... Moreover, PTSD has a stress-contagion influence producing psychological distress in lovedones...' For example in the context of war in N.S.L., dis-placed communities had to first face the traumatic loss ofloved ones, their homes, village structures and relation-ships, witnessing horrifying events before being com-pelled to flee to perceived safer havens but ending up incrowded, refugee camps with inadequate facilities. Herestressors of unemployment, malnutrition, illness, socio-economic difficulties within an atmosphere of uncertaintyand insecurity compound their already precarious plight.The uprooting from the familiar village environmentoften meant loss of social support networks, traditionalleadership, rituals and practices. For community healingand recovery, this vicious cycle has to be broken and aresource gain cycle instituted. Psychosocial and multisec-torial interventions will have to address these variousproblems simultaneously in parallel, in an integrated andholistic way if these negative processes are to be reversed.However, the most effect way to the stop the downwardspiral and break the vicious cycle would be to stop thewar!

A unique context of the military situation in Jaffna wasgeographical in that it was a peninsula, connected tomainland Sri Lanka by a narrow isthmus, a thin causewaycalled Elephant Pass, blocking of which would effectivelycut off Jaffna from the rest of Sri Lanka and the world (seeFig. 1). This happened several times during the two dec-ades of war, sometimes lasting for years. Communicationsincluding telecommunications and postal services, elec-tricity, transport and travel were all blocked except for verylimited air and sea travel. They were attendant shortage offood, fuel, medicine and other essential items. Travel wasallowed only after an elaborate pass and permit system.During these times, Jaffna was often under what was per-ceived as 'foreign' occupation with conspicuous securityarrangements consisting of armed guards, weapons of alltypes, check points, regular patrolling, frequent searchoperations, arrests, detention, abduction, disappearances,skirmishes, guerilla attacks, ambushes and counter kill-ings by the militants, all this hidden from the eyes of themedia, the rest of the island and the world. The atmos-phere created a feeling of entrapment, of being besieged.The conditions were compared to being in an 'openprison' by some of the community leaders, the Bishop ofJaffna [79] and Surgeon of the Jaffna Hospital, Dr. Thaya-lan Ambalavanar [80] among them. An illuminating

social experiment of simulating prison conditions werecarried out by Zimbardo and colleagues [81]. The powerdifferential between the guards who held and exercisedarbitrary control over the prison population and the inter-personal dynamics between the two groups soon mani-fested in the guards increasing aggressive, brutal,dehumanizing and hostile behaviour. On the other handthe prison population showed a syndrome of passivity,dependence, depression, helplessness, loss of identity andsubmissiveness. In addition, as seen in real prison systemsby powerful group networks within the prisoners, in theJaffna situation too there was the more pervasive 'counter-control' by the Tamil militants through social pressure,intimidation, killings, abductions and internal terror trap-ping the civil population between the two forces.

A pernicious element in the collective traumatization ofthis ethnic war was the systemic nature, the institutional-ization of the violence, the terror and counter terror. Itbecame structural, becoming entrenched in the laws of theland, in the way the state treated the minorities, pervadingall relationships and activity. Beginning with discrimina-tion and inequity, the emergency and anti-terror legisla-tion, to total militarization of society and targeting ofTamils, youth in particular, in mass arrests, detention, dis-appearances and killings to the counter violence of theTamil militants to control the populations; a fluid andshifting terror was there just below the surface, subtle andcovert but an important part of the ecological context. Aphotographic record of this terror can be seen in the facesof the 'Army I.D. cards' issued to those returning to Jaffnaafter the Army took control in 1996.

The change in the dynamics and social transformationthat arise from ecological transitions or shifts [15] fromthe civil, peace context to a war context would result inchange at cognitive, emotional and social levels. In N.S.L.,with the vicious spirals of resource loss, there was regres-sion to constriction of consciousness, narrowing of out-look and world views, and reduced social cohesion withsuspicion, mistrust and ennui. Studies of adolescents [12],showed a marked impairment in cognitive functioning.These can be discerned in adults also. Particularly, therewas a constriction or narrowing of cognition, thinking ingeneral had become very restrictive, petty, mundane,rigid, fixed on survival and self-interest. A characteristicfeature of traumatization is loss of concern about thefuture, lack of planning (DSM IV). People learned to sur-vive from day to day. A marked preoccupation with deathas seen in popular media (death announcements, condo-lence messages, posters commemorating the dead) andless concern with the future was noticeable. The constric-tion in cognition and the domination of negative emo-tions led to stereotypic ideas of other groups, paranoia,hatred and revenge. Self-perpetuating cycles of violence


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and counter violence, terror and counter terror kept awhole young generation growing up in this atmosphere,and society locked into a mind set of violence and war.Non violent solutions to problems were not seen to work.Well intended peace building programmes failed to breakthis cycle as the fixated minds of decision makers or lead-ers were not addressed nor were the fundamental inequi-ties fueling the conflict. An attempt at recovery andreconciliation programmes will have to reverse these per-nicious cognitive changes and repair the socioeconomicand political causes.

Social JusticeAnother important casualty in this war has been theimplicit faith in the world order and justice in particular.The overriding experience of Tamils has been a discrimi-natory system and injustice. Those responsible for whatmay be called war crimes and the worst types of humanrights abuses have never been punished. The few cases ofmassacres, disappearances, torture, rape, custodial kill-ings, mass graves that have been investigated and broughtto light have not resulted in justice being done. Impunityprevails. Though perpetrators have been identified, and insome rare cases arrested and court cases instituted, nonehave been sentenced (the sole exemption being the highlypublicized Krishanthy case which was taken up by manywomen's and other human rights organizations), or pun-ished [82]. The perpetrators are promoted (such as diplo-matic posts overseas), or they are transferred elsewhere. Inthe case of abuse and injustices committed by the Tamilmilitants, there is no social mechanism for redress; thevictims usually have to bear it in silence, a silence that isoften individual as well as collective.

Consequences of collective traumaThe cumulative effect of all these devastating events andecological contexts on the community can be described ascollective trauma. In addition to the sum total of individ-ual traumas, which can in itself be substantial given thewidespread nature of the traumatization due to disas-ter(s), there are impacts at the supra-individual family,community and social levels that produce systemicchanges in social dynamics, processes, structures andfunctioning. In fact, the psychosocial reactions in the indi-vidual may have come to be accepted as a normal part oflife. Thus being tense, ever vigilant, readily startled, irrita-ble, having nightmares and poor sleep and experiencingmultiple somatic complaints would not be consideredunusual. But at the community level, manifestations ofextreme experiences can, for example, be seen in the pre-vailing coping strategies. People have learned to surviveunder extraordinarily stressful conditions. A UNHCR offi-cial observed that in Jaffna people have become profes-sional in dealing with complex emergencies fromprevious experiences. Every family has a bag packed with

all the vital items to live rough and essential documents,ready to leave at a moments notice. When displaced to acamp, they are very systematic in getting themselvesorganized. They immediately find a corner, hang upscreens with sarees, and start arranging their belongingsfor a stay. It should be also mentioned they are now veryadamant in obtaining, even demanding dry rations andother relief items. This 'previous training' came in handyafter the Tsunami, where the displaced from the Tamilcommunity were found to cope much better than theirSouthern counterparts. Many of the Tamil psychosocialtraining manuals that had been developed over the yearswere translated into Sinhalese after the tsunami.

However, some coping strategies that may have had sur-vival value during intense conflict may become maladap-tive during reconstruction and peace (see Table 3). Forexample, the Tamil community had learned to be silent,uninvolved and to stay in the background which wouldhave helped in survival. They have developed a deep suspi-cion and mistrust. For example the Tamil people no longertrust the security forces, including the police. Their recentexperiences have taught them otherwise. Thus instead oftrust, respect for Police, and a belief in their legitimacy;there is fear, even terror. Thus when someone breaks thelaw, or there is a robbery or some other illegal activity, noTamil would naturally report it to the Police. A recentexample was the UNDP mine awareness programmewhere the UNDP naively asked people, when they dis-cover a mine, to report it to the local security forces. Peo-ple protested and the UNDP changed its policy. Similarparanoid attitudes were found after the Sept. 9/11 attackin New York [83]. Trust is the basic binding glue thatkeeps communities and societies together. Trust in rela-tionships, that they will not be betrayed, that others willfulfill their obligations, responsibilities and undertakings,that their intentions are benign; trust in social structuresand institutions, justice, law, values and cultural beliefs,the future and finally a trust in themselves, their familyand kin. Trust is gradually destroyed by war. This cohesiveforce is progressively weakened setting in motion a

Table 3: Consequences of collective trauma

MistrustSuspicion"Conspiracy of Silence"BrutalizationDeterioration in morals and valuesPoor leadershipDependencyPassivenessDespairSuperficial and short term goals


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vicious self fulfilling cycle, spiraling downwards ofincreasing suspicion and mistrust.

People have learned to simply attend to their immediateneeds and survive to the next day. Any involvement orparticipation carried considerable risk, particularly at thefrequent changes in those in power. The repeated dis-placements, disruption of livelihood have made peopledependent on handouts and relief rations. Similar toSeligman's 'learned helplessness' [84], this dependencehampers rehabilitation and development efforts. Peoplehave lost their self-reliance, earlier a hallmark of Tamilsociety. They have lost their motivation for advancement,progress or betterment. There is a general sense of resigna-tion to fate. People no longer feel motivated to work, orbetter their lots. Many prefer to continue to live in refugeecamps refusing resettlement plans. After the recent cessa-tion of hostilities in 2002, there were concerted efforts toresettle displaced families by Governmental and NonGovernmental Organizations. But many refused to move.In hindsight, this may have been a wise instinct born ofprevious experiences (the conflict restarted in 2006 andpeople were re-displaced once again). But even within ref-ugee camps, people did not show interest in self-help pro-grammes like vocational training and income generatingprojects. Outside camps, people appear to have resignedthemselves to just surviving. Similar to what Lifton [85]found in Hiroshima survivors, "a pervasive tendency to slug-gish despair....." They seemed to live a half life, as thoughthey were 'walking corpses' or the living dead. Many farm-lands remain uncultivated, houses un-repaired.

BrutalizationAnother conspicuous collective phenomenon due to thewar has been the brutalization of society. Apart from themilitarization of all aspects of life (with the ubiquitouscheck points, armed men, weapons, checking, barbedwire) and the pervasiveness of the 'gun culture', is thelong-term effect on thinking and behaviour patterns. Wit-nessing the horrifying deaths (including killings) of lovedones, friends or strangers, seeing many mutilated or dis-membered bodies, decaying and bloated remains havesaturated the consciousness with death as evidenced bydrawings, dreams, and poetry. Similarly, watching thedestruction of what had been a permanent structure, likea home, or having to abandon ones' home under forcedcircumstances appeared to result in the perceived collapseof everything secure and strong, particularly in childrenwho lost the hopes for a future With time people havebecome habituated to such scenes and experiences. In away they were immunized to the worst aspects of the war,able to carry on nevertheless, attend to immediate survivalneeds in the midst of the destruction and death, a form ofresilience.

One worrying development identified in many commu-nity focus group discussions is the anti-social personalitydevelopment in male adolescents and youth. It wasnoticeable after the Tsunami, where the adolescents andyouth in displaced camps seemed to drift into anti-socialgroups and activities. Initially, during the Tsunami theyhad behaved heroically saving many and actively helpingin the rescue efforts. In the camps too they were in theforefront in organizing activities, programmes and serv-ices. However, many of them had lost a parent or sibling.Grief seemed to soon overwhelm them. Further, in somefamilies the family dynamics soon worked to blaming theyouth for some of the deaths, not acting appropriately tosave a sibling for example. Thus guilt complicated the griefreactions. Further, no ongoing, constructive activities orprogrammes were designed and implemented for adoles-cents and youth. They were left out of the school basedprogrammes or those for children. Unemployed and at aloose ends, they drifted into groups and antisocial activi-ties. Some left to join armed militant groups. Othersstarted abusing alcohol. Alcohol abuse also increasedamong widowed men and became a major problem in thecamps. Attempts by camp and community officials torestrict the availability of alcohol or control its abuse werenot successful.

Similar antisocial personality development, particularlyin male adolescents and youths, was seen in post war set-tings (long-term ceasefires, cessation of hostilities). Par-ents and elders in the community who had traditionallybeen respected no longer had control. These youths wereimmersed in an atmosphere of extreme violence. Manyhad witnessed horrifying deaths of relations, the destruc-tion of their homes and social institutions. They were sur-rounded by war equipment and paraphernalia. They hadpersonally experienced bombings, shelling, extrajudicialkillings and displacement. With no avenues for advance-ment or hope for the future, knowing only camp life,unemployment, and poverty, adolescents and youthsformed into violent groups and criminal gangs. Inter-group rivalry, violence and clashes developed to an alarm-ing degree unseen in conservative Jaffna before.

There were inter-gang conflicts and violent fights, spillingover into their communities. Thefts and other antisocialactivities like abduction and sexual assault of females, har-assment and abuse became common. Parents, teachersand community members expressed difficulties and fearin handling adolescents and youth. This was the agegroup, which in normal times would have been involvedin constructive social activities, advancing and nurturingsociety with youthful exuberance and altruism [12,86].

At workshops and meetings with adolescents and youth,it was clear that there was considerable pent up anger and


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resentment against the military, which was seen as anoccupying force, responsible for atrocities and violence.The emotions and hostility were just beneath the surface,when given an opportunity to express and ventilate theirfeelings within the secure but somewhat suggestive andencouraging atmosphere of the workshops, the aggressioncame out clearly. When asked to hit out (at objects like apillow) if they felt like it, invariably the pillow was imag-ined to be a soldier, and considerable aggression wasvented in these group settings. Some discerning workersand INGO's expressed concern at the manipulation of thisanger by pro-militant organizations used for recruitmentand propaganda purposes.

Social deteriorationThe signs of collective trauma can be discerned in manyfundamental social processes. Compared to pre-wartimes, there seems to be a general ennui. People have lefttheir homes and property in disrepair, not taking theeffort to start repairs. In offices and organizations, thework output was reported to have declined considerably.Once a work ethic dominated this hard working society,now one often hears the complaint that most people arenot inclined to work hard, but merely sign their names inthe work register and take the day off for the slightest rea-son. More effort and interest is seen to be spent on obtain-ing relief items, rations, incentive payments, riskallowances and such like. At times, difficulties haveresulted in people fighting over limited resources or facil-ities, for example in the queues for rations, or seats on theship to Trincomalee.

There appears to be a crisis of leadership. People are reluc-tant to take leadership positions like chairmanships orpresidencies (unlike before, there is no active campaign-ing or canvassing, though there was a brief increase ininterest during the ceasefire). The considerable threat tothose aspiring to leadership roles, many having beenkilled or intimidated into subjugation, has meant that fewwould take the risk nor would their family or communityallow it. Most positions go by default. There is a noticea-ble lack of quality in civil society, partly due to the crip-pling brain drain, but also due to the devastating effect ofthe war.

There is also widely reported perception in northern SriLanka that there has been a marked deterioration in socialvalues evidenced by changing sexual and social behav-iours. Although there has been considerable changes insociety due to modernization and globalization, but warand displacement may have accelerated these changes somuch so that people attribute the perceived changes torecent events. For example, in the refugee camps in Vavu-niya and in general society in northern Sri Lanka, medicalpersonnel report increased unwanted pregnancies, teen-

age abortions and child sexual abuse This has also beenattributed to the reduction of privacy in cases of displace-ment, to increased alcoholism and to the inability of par-ents to keep an eye on their children in camps. Robberiesof the houses and property of those displaced is common-place. Widespread looting by the public (indulged in evenby socially respectable teachers and others highly placedmembers of society) was seen for example in the wake ofmany army operations such as after the Indian interven-tion in 1987 and in Thenmarachi in April 1996 when thearmy allowed people to return to Jaffna. There is currentlya dramatic increase in the number of child abuse cases,including sexual abuse, being reported in Jaffna to theDistrict Child Protection Committee showing an increaseduring periods of war and a decrease during the cease-fire[87]. A recent survey found that 96% of children hadexperienced violence at home, with 52% indicating morethan 5 violent events, and that most violence was ongoing[88].

This apparent increase in child abuse could be due toincreased awareness of the problem (child abuse hasalways being there in our society, as has teenage preg-nancy, but it is only now coming to light) but it is also dueto the new stresses due to the war. Many families are dis-placed from their familiar surroundings and natural hab-itat where there was the support and protection of othersfrom the village, their extended family and friends. Theynow have to live in crowded camps or accommodation instrange and new places. Parents too have to go out toattend to various urgent requirements like obtainingrelief, rations, and meeting authorities. Some families areseparated without their men. In some families, the fatherand/or mother has started another relationship leavingthe children vulnerable to abuse.

There has also been noticeable increase in violence againstwomen as evidenced by the number of battered womenseen through the Kavasam (Women protection) pro-gramme at General Hospital Jaffna [62].

An example of deterioration in morale and loss of sensi-tivity in being human is from the health sector where,until recently, there was a spirit of service [89]. Medicalstaff would stay with their patients, sometimes sacrificingtheir own well-being for the interests of the patient. Thecollective experience of what happened at General Hospi-tal, Jaffna on Theepavali day in 1987 has made most stafflose their altruism. During that fateful period, staffdecided to stick to the hospital and patients despite con-siderable risk. When the Indian Army entered and massa-cred both patients and staff, this last bit of service idealdied, too. Staff now look after their self-interest first. Atthe slightest hint of trouble, they abandon the hospital,


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their responsibilities, and patients, as happened duringthe intensification of the conflict in May 2000.

Child soldiersIt is in this context of psychological, social, economicaland political deprivation that the phenomenon of childsoldiers becomes possible. A whole generation of Tamilchildren has been lost, who in the normal run of things,should become the energetic developers of their society. Itmay not be enough to just merely condemn the recruit-ment of children, but to ask the deeper question, "Why dochildren join the militants"? It is as important to understandthe context under which children become soldiers andwork to improve these conditions if this practice is to beeffectively prevented [90]. They can be divided into pushand pull factors (see Fig. 3). Some of the push factorsinclude death of one or both parents or relations; separa-tions; destruction of home and belongings; displacement;lack of adequate or nutritious food; ill health; economicdifficulties, poverty; lack of access to education; not hav-ing any avenues for future employment and advance-ment; social and political oppression of the group, andfacing harassment, abductions, detention and death.Opportunities for and access to further education, sports,foreign scholarships or jobs in the state sector have beenprogressively restricted by successive Sinhalese-domi-nated governments, despite the lip service paid to main-taining ethnic ratios. There is an alarming drop out ratesand irregular attendance in schools in the Jaffna District,becoming the highest in the island [91] that had tradition-ally given pre-eminence to education. Ironically the Tamilrebellion that started out as a protest against standardiza-tion, a strategy by the state to restrict Tamil admission toUniversities on merit, has deteriorated with the war toJaffna now having to claim disadvantaged area status withguaranteed admissions.

As described the greatest impact of the structural violenceand oppression is on the younger generation. A more per-manent solution to the phenomena of child soldierswould be to bring pressure on the state to dismantle thesocioeconomic and political oppression the children faceto prevent them becoming soldiers.

On the other hand, examining the pull factors, it becomesclear that the LTTE and more recently, state backed para-military groups have turned to children and females to dotheir fighting as the older males are no longer joining. Theolder youths have matured enough to see through thepropaganda. Children because of their age, immaturity,curiosity and love for adventure still remain susceptible to'Pied Piper" enticements through a variety of psychologi-cal methods. Recruiters have used public displays of warparaphernalia, funerals and posters of fallen heroes,speeches and videos, particularly shown in schools andtemple festivals; heroic songs and stories to cleverly drawout feelings of patriotism. The very strict restrictions onleaving LTTE controlled areas, particularly in the recruita-ble age group, both ensures that there is a continuing sup-ply of fighters and creating a feeling of being trapped andpowerless in potential recruits. In addition the aforemen-tioned actions of the Sri Lankan forces all have created amilieu where children are psychologically compelled tojoin. When these have failed more coercive means, includ-ing threats to parents, abductions and press ganging havebeen employed. The LTTE has introduced compulsorymilitary type training for all eligible ages in areas undertheir influence. This instills a military thinking and lead tomore joining.

In this context, it is easy to understand why joining a pow-erful group can become an alluring alternative. Thoseresponsible for the recruitment, training and deploymentof child soldiers as well as those perpetuating the socio-economic and politically oppressive conditions should beconsidered as war criminals while the child soldiers them-selves should not be treated as criminals or juvenile delin-quents as they are now. They are but victims of the system,the ecological context and should be offered appropriatepsychological, socio-economic and educational opportu-nities for rehabilitation as is being attempted currently bythe UNICEF. The tragic occurrence at Bindunewava wherecaptured child soldiers were later massacred is a poignantreminder how hypocritical towards the actual welfare of(Tamil) children the state really is.

In these circumstances of recruitment of children, Tamilsociocultural and religious institutions have failed to pro-test. Apart from functioning as apologists, no Tamil lead-ers have not dared to comment, let alone condemn. Thisparalysis may be partly due to the severe human rightsviolations that have been perpetrated by the Sri Lankan

Creating child soldiers – push and pull factorsFigure 3Creating child soldiers – push and pull factors.


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State, and partly because of the general social deteriora-tion caused by the war. But it is also the silence of a com-munity under totalitarian control by the Tamil militants.Only a few affected parents have made muted protests.Thus the Tamil militants have been allowed to functionfreely within society to attract and pull children throughtheir propaganda and psychological pressure in the vac-uum left by the abdication of social institutions.

Although not the focus of this paper, there were some pos-itive, constructive changes in society that could beobserved which could be useful in attempts in designingprogrammes to address the collective trauma. There werethe emergence of new community organizations, particu-larly with active female participation, enhanced femalerole and leadership [62], breakdown in caste barriers andhierarchical structures [92] and a decrease in suicide ratesduring active periods of conflict [93]. Together with theresilience gained from surviving decades of war and thepotential post traumatic growth, these positive develop-ments need to be utilized in the recovery process and startthe resource gain cycle [16].

Collective strategiesTraditionally, disaster interventions have been catego-rized into rescue, relief, rehabilitation, reconstruction anddevelopment depending primarily on time course afterthe disaster. Apart from attending to the immediate basicneeds and other acute problems in the rescue and reliefphases after a major disaster, rehabilitation, reconstruc-tion and development strategies need to include collectivelevel interventions [23-25]. Indeed, it has been our expe-rience that many long-term programmes do not reap theexpected benefits if they do not take into considerationcollective issues and ways of addressing them. In fact,many individual oriented interventions appear to fairmuch better when undertaken within an overall collectivelevel design.

Models of mental health interventionsOne approach is to use the WHO definition of healthalready mentioned to address the physical and psychoso-cial needs of the survivors through physical and psychoso-cial interventions (Table 1). Another more comprehensiveand useful conceptual model (Fig. 4) for psychosocial andmental health interventions is an inverted pyramid withfive overlapping and interrelated levels of interventionprepared for UN and other Disaster workers by the UnitedNations and International Society for Traumatic StressStudies [2]. As shown in Figure 3, at the top of the pyra-mid are societal interventions designed for an entire pop-ulation, such as laws, public safety, public policy,programmes, social justice, and a free press. Descendingthe pyramid, interventions target progressively smallergroups of people. The next two layers concerns commu-

nity level interventions which include public education,support for community leaders, development of socialinfrastructure, empowerment, cultural rituals and ceremo-nies, service coordination, training and education of grassroot workers, and capacity building. The fourth layer isfamily interventions that focus both on the individualwithin a family context and on strategies to promote well-being of the family as a whole. The bottom layer of thepyramid concerns interventions designed for the individ-ual with psychological symptoms or psychiatric disorders.These include psychiatric, medical and psychologicaltreatments which are the most expensive and labourintensive approaches that require highly trained profes-sional staff. Therefore, they should be reserved, particu-larly in the poor, developing world settings, for the smallminority of individuals who cannot benefit from thelarger scale interventions at higher levels of the pyramid.Theoretical, practical, empirical and treatment considera-tions suggests a holistic, integrated, multiple levels ofinterventions, an expanded psychosocial syntheticapproach [93].

Community approachesThe wide spread problem of collective traumatization and'loss of communality' following disasters is best approachedthrough community level interventions. Communitybased approaches will enable one to reach a larger targetpopulation as well as undertake preventive and promo-tional public mental health activities at the same time. Inthese circumstances it may be more meaningful to look athow the community as a whole has responded, how thecommunity coped, and what we can do at the collectivelevel. For example, it may be more beneficial to consider

Conceptual model for psychosocial interventions in social and humanitarian crises [1]Figure 4Conceptual model for psychosocial interventions in social and humanitarian crises [1].

Public Safety

Public Policy

Public Education

Service Coordination

Training/Education

Family Education

Clinical TreatmentTraditional Healing

Capacity Building

Family, Self-Help Networks

SOCIETAL

COMMUNITY

Village

FAMILY

INDIVIDUAL

Types of Intervention

Levels of Intervention


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strengthening and rebuilding the family and village struc-tures, as well as finding a common meaning for theimmense suffering than to treat only individual traumati-zation. For this purpose, the protocol developed by theTranscultural Psychosocial Organization, a WHO collabo-rating centre, working around the world to relieve the psy-chosocial problems of people affected by internal conflictand war [95] was very effectively adapted to the situationin Cambodia [96] and in northern Sri Lanka [89]. Themain principles of community level approaches (Table 4)are to empower the community to look after their ownproblems by not only through psychoeducation to trans-fer basic psychosocial knowledge and skills but alsothrough encouragement, support, affirmation and re-establishing community processes, traditional practices,rituals, resources and relationships.

General awarenessBasic information about what has happened, what to doand not to do and where help can be obtained were donethrough the media, pamphlets and popular lectures. Onesuch popular programme was carried out through theExtra Mural Studies unit of the University of Jaffna wherebatches of around 100 participants were taken through abasic introduction to psychosocial issues over a five weekperiod. Five such courses were completed. Another majorpsychoeducational effort was carried out immediatelyafter the Tsunami by Mental Health Task Force in Jaffnausing the media, pamphlets and lectures. The MentalHealth Task Force (MHTF) was formed spontaneouslyafter the Tsunami by most of the organizations involvedin psychosocial work in the Jaffna peninsula which thenmet regularly and attempted to organize and coordinatethe psychosocial work after the tsunami. MHTF now con-tinues as the Psychosocial Coordination Forum under theDeputy Director of Health Services, Jaffna. After the Tsu-nami the MHTF carried out 18 awareness programmes for568 relief workers and others. Similarly the committeesinvolved in Child abuse and Domestic violence carriedout considerable to public education programmes from

1999 which resulted in increased numbers being reported(see above) and being helped.

TrainingTraining of grass root community level workers in basicmental health knowledge and skills is the easiest way ofreaching a large population [97]. They in turn wouldincrease general awareness and disseminate the knowl-edge as well as do preventive and promotional work. Thusthere would be a multiplication effect where the informa-tion would spread to the general population. The majorityof minor mental health problems following disasterscould be managed by community level workers and oth-ers referred to the appropriate level. A referral systemwhere more severe problems are referred for more special-ized treatment was established (Fig. 2). Primary HealthWorkers including doctors, medical assistants, nurses,Family Health Workers; school teachers; village resourceslike the village headman, elders, traditional healers,priests, monks and nuns; Governmental, Non Govern-mental Organization (NGO), volunteer relief and refugeecamp workers were community level workers who weretrained. A manual based on the WHO/UNHCR [98]booklet, "Mental Health of Refugees", was adapted to thecultural context for this purpose [60]. A Training of Train-ers (TOT's) in community mental health using this man-ual was done under a UNICEF programme. They in turntrained a variety of community level workers from theNorth and East and have followed them up regularly inthe field (for example, after the Tsunami, there were 36different training programmes for 11 agencies with a totalof 732 participants over a 9 month period in 2005).

A systematic training programme for teachers in basicmental health for a period of six months with assessmentsand follow up were carried out with the German sup-ported GTZ-BECAre programmes and Ministry of Educa-tion, University of Jaffna and Shantiaham, a local NGOworking in the psychosocial field. Altogether around 151primary school teachers from all three communitiesselected from the North and East were trained in theperiod 2002–2005 using a manual, Child Mental Health,developed locally for this purpose [99]. They thenreceived further extensive training in Narrative ExposureTherapy (NET) [100] by a German team for the Universityof Konstanz (Vivo) and a manual for NET made availablein Tamil. An impact study [101] found that there hadbeen considerable change in the attitude and skills of theteachers who now interacted more with their students,parents and colleagues, avoided punishment and createda more caring, participatory and democratic class atmos-phere apart from carrying out a variety of psychosocialinterventions for affected students. They were theninvolved in the training of around 1030 'Befriender' teach-ers from the same region in simple psychosocial issues

Table 4: Community approaches

Community Approaches

AwarenessTraining of community workersPublic mental health promotive activitiesEncourage indigenous coping strategiesCultural rituals and ceremoniesCommunity interventions

- Family- Groups- Expressive methods- Rehabilitation

Prevention


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over a 5 day course using a manual, 'Joyful Living', pre-pared for this purpose [102]. Regular follow-up andsupervision locally was carried out. Yet, the whole pro-gramme faltered after the German GTZ changed its pro-gramme focus from 2005. One advantage of all thistraining that had been done during the war period becameapparent when the tsunami struck in 2004. The trainedteachers were mobilized to assist the affected studentsthroughout the North East. The benefits of this pro-gramme became evident nationally and the manual wastranslated into Sinhalese. Copies in Sinhala and Tamilwere made available in all the schools in the Islandthrough the efforts of PLAN International, and psychoso-cial training for teachers in the Tsunami affected areas wasdone.

Traditional coping strategiesIndigenous coping strategies that had helped the localpopulation to survive were encouraged. Culturally medi-ated protective factors like rituals and ceremonies werepromoted and arranged. For example funerals and anni-versaries, were very powerful ways to help in grieving andfinding comfort. They were a source of strength, supportand meaning.

Teaching of the culturally appropriate relaxation exercisesto large groups in the community and to students inschools was carried out as both preventive and promotivemental health. The benefits of these originally spiritualpractices were not confined to producing relaxation.When methods are culturally familiar, they tap into pastchildhood, community and religious roots and thusrelease a rich source of associations that can be helpful inthe healing process. It became clear that traditionallyrelaxation methods exemplify a holistic approach work-ing at the physical, mental, social and spiritual levels; pre-venting, maintaining, promoting well being as well asbeing therapeutic when needed [59]. We found that peo-ple naturally turned to traditional practices when understress and found relief in them. For example, in Sri Lankawe found religious practices such as ana pana sati, repeti-tion of meaningful phrases such as Buddham saranam gac-chami, mindfulness, and vipassana meditation amongBuddhists; rosary or telling prayer beads and contemplationamong Catholic Christians; thikir among Muslims; andJapa mala, repetition of a mantra such as om, shanthiasanam, yoga, pranayamam and meditation among Hinduswere powerful methods known to the people and priests.

Community interventionsGroup supportThe formation of groups for survivors, affected families,widows, ex-detainees, torture survivors, landmine victimsand other groupings can be very helpful. A therapistwould facilitate the interactions within these groups,

which in time should develop its own healing and caringprocesses. A widows' support programme funded by theGovernment of Finland was started in a particularly badlyaffected fishing village, Chavatkaddu, which had a highnumber of war widows. The widows met as a group tosupport each other, exchange their stories and recountexperiences. Coping strategies used by one person couldbe tried by another. The widows were able to organizethemselves into a powerful group to overcome stigma andexclusion in their village, undertake joint economic ven-tures, obtain relief and rehabilitation projects, arrange foreducation and tuition for their children, go on tourstogether, celebrate religious and cultural festivals andobserve death anniversaries. In time they were able toexpand their programmes to other villages, training theircounterparts and helping them to organize themselves.

Family supportIn our cultures where the family bonds are very strong, thefamily is an essential resource that can be used for healing.Efforts were taken to keep the family together and func-tioning. For example, attempts to separate orphans intoinstitutions were resisted through the District Child Pro-tection Committee (DCPC), and efforts were made tokeep and support the child with their near relations. Intime this principle was accepted and adopted by theNational Child Protection Authority after the issue aroseafter the Tsunami. Other agencies like the ICRC were con-tacted to trace missing relations and unite the family.Family cohesion was strengthened. The principles of fam-ily dynamics were used to facilitate supportive and heal-ing relationships while counteracting damaging andmaladaptive interactions. Communication of individualproblems leading to an awareness of each other, one's roleand encouragement towards mutually interdependentfunctioning were used to build up family unity. Tradi-tional roles had to be re-established. These considerationswere used for the extended family as well. When individ-uals, particularly children, presented with problems dueto pathological family dynamics, it was the family thathad to be managed if the individual was to recover [12].

Village level psychosocial interventionsBadly affected villages by the war and later, by the tsu-nami, were selected for psychosocial work. The steps inthe intervention programme in each village are given inTable 5 and the psychosocial interventions in Table 6.Although broken up as steps, they were in reality all ongo-ing processes, with the monitoring evaluation and assess-ment fedback into the programme to adjust and modifythe design and implementation based on lessons learntand contextual factors. For example, after the tsunami theinterventions had to be made more appropriate for themale widows or some areas or aspects of programmeschanged due to developing security concerns.


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Consequent to the Tsunami of Dec. 2004, the WHOdeveloped a strategy of training Community SupportOfficers (CSO's) to address the mental health needs of theaffected families throughout the areas devastated by theTsunami in Northern Sri Lanka. In pursuance of this aim,CSO's were selected from Primary Health and other com-munity level workers from Vadamarachy East, Maru-thenkerny, Killinochi and Mullaithivu (see Fig. 1) andgiven a basic training in basic mental health and psycho-social work. They then visited each family affected by theTsunami and identified families and individuals needinghelp. They attended to simple problems using a variety ofpsychosocial interventions (Table 6) and referred moredifficult cases to the local mental health clinic. Commu-nity interventions were also carried out. There was regularsupervision and follow-up.

Expressive methodsStructured play activity for children were arranged toenhance recovery in post-disaster situations. Children'stime was usefully structured and physical energy chan-nelled in a healthy manner. More important, it helpedorganize community or camp activity, build friendshipsand peer relationships and give an opportunity for thechild to bring out his or her emotions and creativeimpulses.

In a collaborative programme involving the Ministry ofEducation, Danish and Sri Lanka Red Cross and Shantia-ham, 150 teachers and 118 volunteers were trained during2004–5, to implement structured activity in badly affectedschools in the Jaffna peninsula using a manual, "We arelittle children", prepared for this purpose. The aim was to

Table 5: Steps for community based psychosocial work

Step Title Description

1 Village assessment information from GA, DS, GS, psychiatrists, counsellors, psychiatric social workers, health workers, psychosocial workers and the representatives of the organisations from that region (statistical data)

2 Selection of the villages Based on Poverty, Affected by war (death, injured, missing), Displacement, Resettlement, Socioeconomic problems, Domestic violence, Alcohol and drug abuse, Natural Disasters (e.g. Tsunami), Child abuse

3 Obtaining permission Permission will be obtained from the government authorities to work in the selected villages. E.g. Divisional Secretariat, Grama Sevaka Officers

4 Integration with people introduction to Villages about the worker, organisation and intention of the activities

5 Meeting with resources discuss with the most important resources from the village to get their whole support

6 Cross walk Looking around all the nook and corners of the village7 Learning about the society Getting to know the language, culture, traditions, rituals and occupations with the

help of the important resources who are living in that area8 Data collection & documentation Basic Demographic data about the village9 Social Mapping Ecosystem of society, places where collective trauma occurred, the house of the

community leader, temples, CBO's, Traditional leaders10 Identifying and analysing the problems Through Key informant interviews, Focus group interviews11 Planning Based on the abovementioned identified problems and their priorities12 Community meetings and creating awareness First with the key resources, then for the whole community, explain about plans,

benefits, psychosocial wellbeing, prioritised problems of the community. E.g. Alcohol awareness, awareness of child abuse, domestic violence etc.

13 Selection of the Core Group (CG) A local group which is made up of teachers, university students, farmers, villagers and contains 15 – 20 people with gender balance

14 Core Group training Focused on psychosocial well being and psychosocial problems in the village level, referral and networking.

15 Working with Core Group Trainer works with CG in Social mobilization, community awareness, children group activities, Identification of psychosocial problems in the community, psychosocial interventions for individuals, families and community, facilitate women groups, following up the past cases, doing referral and network for new cases etc.

16 Psychosocial Interventions See Table 617 Core Group follow up After handing over the village to the Core Group, they will continue work in

village. Supervision and further training in particular.18 Referral Problems which the CG is unable to handle would be referred to mental health

professionals19 Networking Working with GO's and NGO's for socio-economic and other needs20 Monitoring and evaluation Feedback into modify Planning stage and programme implementation. Design of

new programmes.

-Vijayashankar, PSW Trainer, Shantiaham


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promote psychosocial well being through play, art, danc-ing, stories, yoga, creative and emotional expression andinvolvement of the parents. A total of 2,800 children from19 schools and 4,000 parents were expected to take part inthe activities in 2005 and 2006. With the acceptance ofthis methodology by the National Institute of Educationin the aftermath of the tsunami, the manual was thentranslated into Sinhalese and distributed to all schoolsnationally. However, the whole programme collapsedwhen the Danish Red Cross decided to pull out of Jaffnaafter the resurgence of the war in 2005–6. A similar ClassBased Intervention (CBI) developed by Robert Macy andcolleagues at the Centre for Trauma Psychology, Bostonusing structured play activityover 5 weeks for15 sessionswhere 1455 students from 30 schools underwent this pro-gramme from 2004 to 2007.

Psychological and socio-dramas can go a long way in cre-ating awareness about trauma among the public and helptraumatized individuals to ventilate their emotions orseek treatment. A few such dramas were produced in theNorthern Sri Lanka. There were also attempts in the northto use drama and street plays as well as art to work withchildren affected by the tsunami [103].

RehabilitationAttempts were made to rebuild social networks and senseof community by encouraging and facilitating formationof organizations, rural societies, schools and the like.Social mobilization was promoted by tapping localresources, re-establishing traditional relationships, prac-tices and engendering leadership from among the com-munity. For example, a local widow from Chavatkaduwho was trained as a psychosocial worker became thehead of the their widow's organization, Tharaka, and waslater nominated for the Nobel prize in 1985 with 1000other leading women worldwide for their services by aninternational women's group [104].

Rehabilitation programmes were encouraged to includeeducation, vocational training, income generatingprojects, loans and housing that is tailored to the needs ofthe survivors and post disaster situation. Close liaison, co-operation and networking with governmental and NGO'sinvolved in relief, rehabilitation, reconstruction anddevelopment work was attempted (Fig. 5). The networkwas used to refer needy survivors for relief, socio-eco-nomic rehabilitation, legal aid, shelter, nutrition, waterand sanitation, human rights, protection and other assist-ance (For recommended guidelines see IASC [25]).

A holistic integrated approach was advocated with Gov-ernmental and Non Governmental aid agencies empha-sising the need for planning that included dueconsideration for the psychological processes that pro-mote individual, family and social healing, recovery and

Networking – working with governmental and non-govern-mental organizationsFigure 5Networking – working with governmental and non-govern-mental organizations.

Educational sectorSchool, Teacher,

Private institutions

Governmental Organizations

(GO)

Non-Governmental Organizations

(NGO)1. (I)NGO2. (L)NGO

Community Based Organizations

(CBO)

Religious &Spiritual

Sector

Traditional Healing

External Family

Non-State Actors

FamilyFather, Mother,Sister, Brother

Village Resources

Village Leader,Elders, Midwife

Judicial SystemHuman Rights

Health SectorPrimary Health care

MediaInformation

Disaster Survivors

Table 6: Essential psychosocial interventions

Individual Family Social

Case identification Psycho education AwarenessPsycho education Family counselling TrainingCounselling Strengthening the family dynamics e.g.

Talking and eating togetherIntervention for special groups (children, widows, widower, youths etc)

Other Psychotherapy Family Reunification Encourage to do religious and ritual activitiesYoga and Relaxation Social support Encourage to do cultural activitiesFamily & social support Capacity Building and Income

generationForming and reactivating CBO's.

Referral and net work Follow up Re-establishing relationships, social networksCapacity Building and Income generation Network with other NGOsRehabilitation Encouraging networking with other communities.Follow up Follow up

-Vijayashankar, PSW Trainer, Shantiaham


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integration. Such programmes were encouraged to takeinto account the wishes of the local population con-cerned, that they be given an active and deciding rolerather than a dependent, 'victims' role, as it promotes theiroverall sense of participation and thus their eventual psy-chological recovery. To avoid this, emergent self-helpgroups and local leadership were encouraged to resumetraditional and habitual patterns of behaviour, re-estab-lish social networks and community functioning at thegrass root level [105]. The local skills and resources weretapped and utilized, which gave the community a sense ofaccomplishment and fulfilment in the recovery process.Provision for the non-partisan cultural working throughof the shared traumatic experience in the form of periodicreminders of the loss and reiteration of its meaning, andof the heroism of those who suffered expressed in media,arts, public works, monuments, and occasions of publicmourning were encouraged as they have been found to beuseful in post disaster situations [106]. For example, afterthe tsunami, affected schools were encouraged to haveregular ceremonies to commemorate those who died, tohave pictures, flowers and candles for the students whohad died and support was sought for communities whichsought to build memorial structures at sites of mass buri-als where public gatherings, meetings and religious cere-monies will allow for communal release of feeling, reviewand coming to terms with the collective trauma; sociallydefine and interpret their experiences, as well as re-estab-lishing social relationships and planning for the future. Ithas been found that sites where mass trauma has occurredbecome sacred, imbibed with community meaning [107].However this was not always allowed in the charged polit-ical situation that prevailed in these areas. For example, inthe coastal villages of Maruthernkerny where 901 peopleout of a local population of 16,153 died due to the tsu-nami, there had been hasty burials in mass graves. As amethod of consoling the traumatic grief of the survivingfamily members, attempts to build memorials at thesesites where people could visit, grieve, remember and per-form rituals were consistently blocked.

In the polarized and totalitarian political situation withcompeting loci of power and parallel governments, com-munity organization, mobilization and empowering wasonly allowed to proceed up to a point. When the organi-zation or mobilization started to become effective, politi-cal forces took over, infiltrated or interfered in the process.In the Tamil areas no independent large scale organiza-tion or activity was allowed. Perhaps it was taken as a chal-lenge to the existing social arrangements, control,dispensation, and loyalties. More than the state, it was theTamil militants who were very sensitive to such activityand became very efficient in organizing and implement-ing relief, rehabilitation and development programmes.There was a need for the political organization to be seen

as the one doing the construction, channelling the aid,receiving credit and legitimacy. Co-operation with thepolitical forces on the ground was the only realistic optionavailable and the route taken by the GO's, NGO's andINGO's. But, ultimately political and military prioritiessuch as recruitment took precedence. Independent socialactivity, particularly beyond a critical, effective level car-ried an intrinsic risk. Thus, in such situations, workersneed in addition to cultural competency, political compe-tency as well. Every act takes on a political significance.Tragically, even the post Tsunami rehabilitation processand programmes became political. Unlike in Aceh, anopportunity for addressing a humanitarian need in anequitable, neutral way to build trust and faith in peacefulrehabilitation to bring warring parties together was lost.

Prevention, policy, planningTragically, much of the deaths and destruction caused bynatural disasters can be avoided. This is even truer for theman made disaster that is war. Ahimsa, peaceful coexist-ence, conflict resolution, reconciliation and other valueswere advocated and passed on wherever possible. How-ever, it is sobering that despite all this effort and training,the country has once again returned to full scale hostilitiessince December of 2005.

Just as the consequences of disasters must be addressed onboth community and family levels, so must plans for pre-venting or mitigating their impact. In fact, there should beplans at the local, district, provincial, national, regionaland international levels for disaster preparedness andemergency response because many disasters affect multi-ple communities, nations or regions. Such plans are typi-cally formulated by committees at the appropriate leveland may involve collaborative efforts between formalemergency management agencies, public health and otheragencies, and citizen groups. Small steps were taken in for-mulating disaster plans.

Another area of intervention was at the national, regionaland district levels by influencing policy making, rehabili-tation and international aid programmes. Membershipsat various committees at the local, district, regional andnational levels provided the opportunity to make somecontribution towards prevention and alleviation of theeffects of individual and collective trauma. The problemsof putting psychosocial and mental health concerns onthe agenda and the general stigma associated with mentalhealth were quite evident at these committees. Althoughthere was wide acceptance of psychosocial problems dueto the Tsunami and there were considerable effort toaddress these by the state, militants, NGO and INGO sec-tors; the state is still to accept or take responsibility for thepsychosocial problems arising from the war. As such itwas left to INGO and local NGO's to carry out psychoso-


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cial interventions and programmes. Unfortunately manyof these internationally supported programmes and struc-tures tended to collapse when the funding stopped orINGO's pulled out. The local partners and governmentwere not able to maintain the momentum. This raises thequestion of long term sustainability. The national dis-crimination, inequity in distribution of resources and pro-grammes, and exclusion of the North and East continuedto be insurmountable hurdles [108].

ConclusionThe effects of disasters, particularly massive, chronic trau-mas go beyond the individual to the family, communityand wider society. Social processes, dynamics and func-tioning can be changed fundamentally by disasters. In theaftermath of war some of the community level changesincluded mistrust, suspicion, silence, brutalization, deteri-oration in morals and values, poor leadership, depend-ency, passiveness and despair. It maybe important torecognize the manifestations of collective trauma, so thateffective interventions that is effective at the communitylevel can be used in these complex situations. Communityapproaches that were found useful in rebuilding commu-nities in Northern Sri Lanka were creating public aware-ness, training of grass root workers, encouragingtraditional practices and rituals, promoting positive fam-ily and community relationships and processes, rehabili-tation and networking with other organizations.

LimitationsThis was only a phenomenological study of collectivetrauma. There are obvious limitations to dispassionate sci-entific study due to the ongoing war situation. The case forcollective trauma was merely described, no random con-trolled trials were conducted nor the outcome of the com-munity interventions collected in a systemic way. Theevidence base for the efficacy of psychosocial interven-tions in a post disaster situation is still lacking and onlyguidelines have emerged from humanitarian work carriedout so far [25]. Operational criteria for the syndrome ofcollective trauma and the evidence for best practice inthese complex situations will need to be establishedthrough further studies.

AbbreviationsAPA – American Psychiatric Association

BECAre – Basic Education for Children in DisadvantagedAreas

CBO – Community Based Organization

CBT – Cognitive Behavioural Therapy

CSO – Community Support Office

DSM – Diagnostic and Statistical Manual

G.A. – Government Agent (District Administrator)

G.O. – Governmental Organization

G.S. – Gramma Sevaka (Village Headman)

GTZ – German Technical Cooperation

IASC – Inter Agency Standing Committee

INGO – International Non-Governmental Organization

LTTE – Liberation Tigers of Tamil Eelam (dominant Tamilmilitant group)

N.S.L – Northern Sri Lanka

NGO – Non-Governmental Organization

PTSD – Posttraumatic Stress Disorder

SCF – Save the Children Fund

SSRI – Selective Serotonin Reuptake Inhibitor (Antidepressant)

UNDP – United Nations Development Program

UNHCR – United Nations High Commission for Refugees

UNICEF – United Nations International Children Emer-gency Fund

WHO – World Health Organization

Competing interestsIn terms of conflict of interest, the author subscribes to apacifist persuasion, contrasting with the militant/militaryfervour of the authorities in power. This has added a con-siderable targeted risk factor, particularly in Northern SriLanka, apart from the general uncertainties (terror) ofthese contexts. The author has been the originator andorganizer of various social and humanistic programmes inthe region including child rights, women affected bydomestic violence, human rights and traditional yoga.This has involved considerable public advocacy and cam-paigns, the tone of which colours much of the author'swritings. The author believes with many other healthworkers [3,28,29] that there can be no neutral position inthese extreme situations.


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Authors' contributionsThe author was directly involved in all aspects of thisstudy from the initial participatory observation, analysisand documentation. He was either directly responsible forthe specific studies described or functioned in an advisoryor supervisory capacity. The author takes responsibility forthe conclusions and views expressed here.

AcknowledgementsI wish to acknowledge colleagues and co-workers for without them the ongoing work in Northern Sri Lanka would not have been possible nor the observations recorded here. Sivayokan and Canagarathanam always worked closely with the author as did the psychiatric units at Tellipallai, Jaffna, Point Pedro, Killinochi, Vavuniya and Mannar. The Multidisciplinary Team in these units and Shantiaham were the back bone of the psychosocial interventions in these disaster situations. Many colleagues around the globe have been very supportive of our work and constructively commented on earlier versions of this paper. They include Sambasivamooorthy Sivayokan, Rachel Tribe, Anula Nikapota, Mark van Ommeren, Willem van de Put, Joop de Jong, Ken Miller, the late Robert Barrett, Michael Roberts, Helen Herrman, Norman James, Harry Hustig, Beverley Raphael, Derrick Silove, Johan Schioldann, Rajan Hoole, Ted Lo, Arun Ravindran, Jack Saul, Nancy Baron, Jeannine Guthrie, Gaithri Fernando, Ananda Gallapati, Wietse Tol, Clare Pain, Elisabeth Schauer, Thomas Elbert and many others. Naguleswaran (Babu) drew Fig. 3, Creating Child Soldiers, Vijeyashankar prepared Tables 5 and 6, Rathakrishnan the figures and Anavarathan was helpful in the analysis of the post-tsunami data. Institutionally, the University of Jaffna and Shantiaham provided the base and facilities for carrying out this study. The University of Adelaide, particularly the Glenside Campus and Barr-Smith Library, provided the visiting Fellowship and excellent facilities to carry out the literature survey and collaborative work to produce the paper. The Scholar Rescue Fund based in New York bestowed the Fellow-ship and timely assistance to leave the disturbed northern province on my sabbatical leave to Adelaide in Australia.

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94. Assagioli M: Psychosynthesis, A Manual of Principles and Techniques NewYork: Viking Press; 1975.

95. De Jong JTVM: TPO Program for the identification, management, and pre-vention of psychosocial and mental health problems of refugees and victimsof organized violence within primary health care of adults and children TheNetherlands: TPO; 1997.

96. Van de Put WACM, Somasundaram D, Eisenbruch IM, Kall K, Soom-ers R, Thomassen L: Facts and thoughts on the first years 1995–1995Phnom Penh, Cambodia: Transcultural Psychosocial Organization;1997.

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98. World Health Organization, UNHCR: Mental Health of refugees.Edited by: De Jong J, Clarke L. Geneva: WHO; 1996.

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