International Journal of Mental Health Systems

International Journal of Mental
Health Systems BioMed Central
Research Open Access

Collective trauma in northern Sri Lanka: a qualitative
psychosocial-ecological study
Daya 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 - dayanandan.somasundaram@adelaide.edu.au
Published: 4 October 2007 Received: 16 March 2007

Accepted: 4 October 2007
International Journal of Mental Health Systems 2007, 1:5 doi:10.1186/1752-4458-1-5
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.
Abstract
Background: Complex situations that follow war and natural disasters have a psychosocial impact
on not only the individual but also on the family, community and society. Just as the mental health
effects on the individual psyche can result in non pathological distress as well as a variety of
psychiatric disorders; massive and widespread trauma and loss can impact on family and social
processes causing changes at the family, community and societal levels.
Method: This qualitative, ecological study is a naturalistic, psychosocial ethnography in Northern
Sri Lanka, while actively involved in psychosocial and community mental health programmes among
the Tamil community. Participatory observation, key informant interviews and focus group
discussion 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 war
and 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 more
fundamental social transformations. At the family level, the dynamics of single parent families, lack
of trust among members, and changes in significant relationships, and child rearing practices were
seen. 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 of
community level interventions were tried.
Conclusion: Exposure to conflict, war and disaster situations impact on fundamental family and
community dynamics resulting in changes at a collective level. Relief, rehabilitation and development
programmes to be effective will need to address the problem of collective trauma, particularly using
integrated multi-level approaches.
Background sequelae. These could range from adaptive and construc-

Disasters, whether natural or man made, are now well tive coping responses in the face of catastrophic events to
known to cause a variety of psychological and psychiatric understandable non-pathological distress as well as a
Page 1 of 27
(page number not for citation purposes)
International Journal of Mental Health Systems 2007, 1:5 http://www.ijmhs.com/content/1/1/5
number of recognizable psychiatric disorders. Conditions [7,11]. Collective events and consequences may have
like Acute Stress Reaction (ASR, the old disaster syn- more significance in collectivistic communities than in
drome), Posttraumatic Stress Disorder (PTSD), depres- individualistic societies like the US and Australia. It may
sion, anxiety, somatoform disorders, alcohol and drug also be important to bear in mind that societies are in flux,
abuse [1,2], and in the long term, complex PTSD [3], changing. With modernization and globalization, collec-
enduring personality changes or Disorders of Extreme tivistic societies are also increasingly becoming individu-
Stress Not Otherwise Specified (DESNOS) have been alistic and consumer oriented. There may also be
shown to occur after disasters [4]. Evidence based and traditional subcultures within the bigger, individualistic
effective, modern treatments like Cognitive Behaviour culture. In collectivist societies, The individual becomes
Therapy (CBT) and pharmacotherapy for PTSD to help embedded within the family and community so much so
individuals affected by the trauma of disasters to recover that traumatic events are experienced through the larger
are now available in western countries [5]. unit and the impact will also manifest at that level. The
family and community are part of the self, their identity
However, there is less recognition or understanding of the and consciousness. The demarcation or boundary
effects disasters have at the supra-individual levels as well between the individual self and the outside becomes
as about appropriate interventions at these levels. There blurred. For example Tamil families, due to close and
are many reasons for this relative deficiency. First, the field strong bonds and cohesiveness in nuclear and extended
of disaster studies is itself rather recent. For example the families, tend to function and respond to external threat
diagnosis of PTSD was accepted only in 1980 with the or trauma as a unit rather than as individual members.
American DSM III [6]. They share the experience and perceive the event in a par-
ticular way. During times of traumatic experiences, the
Secondly, modern psychology and psychiatry have had a family will come together with solidarity to face the threat
western medical illness model perspective that is prima- as a unit and provide mutual support and protection. In
rily individualistic in orientation[7]. Geertz describes the time the family will act to define and interpret the trau-
Western concept of self as "...a bounded, unique, more or less matic event, give it structure and assign a common mean-
integrated motivational and cognitive universe, a dynamic cen- ing, as well as evolve strategies to cope with the stress.
tre of awareness, emotion, judgement, and action organized Thus it may be more appropriate to talk in terms of family
into a distinctive whole and set contrastively both against other dynamics rather than of individual personalities. There
such wholes and against its social and cultural background....is maybe some individual variation in manifestation,
a peculiar idea within the context of world cultures" [8]. The depending on their responsibilities and roles within the
'Kantian concept of an autonomous self' [9] and 'Enlight- family and personal characteristics, while some may
enment values of individualism' [10] has come to mould become the scapegoat in the family dynamics that ensues
western ways of experiencing the self, the world and (see family case histories [12]). Similarly, in the Tamil
events. PTSD is clearly a condition that exclusively afflicts communities, the village and its people, way of life and
the individual self, the traumatic event impacting on the environment provided organic roots, a sustaining support
individual psyche to produce the PTSD. However, it is system, nourishing environment and network of relation-
being increasingly recognized generally that we need to go ships. The village traditions, structures and institutions
beyond to the family, group, village, community and were the foundations and framework for their daily life. In
social levels if we are to more fully understand what is the Tamil tradition, a person's identity was defined to a
going on in the individual, whether it be his/her develop- large extent by their village or uur of origin [13]. Their uur
ment, behaviour, emotion, cognition or responses to more or less placed the person in a particular socio-cul-
stress and trauma as well as design effective interventions tural matrix.
to help in the recovery and rehabilitation of not only the
affected individuals but also their families and commu- A word of caution is necessary in trying to romanticize or
nity. For when the family and/or community regained idealize the family, neighbourhood, village, collective and
their healthy functioning, there was often improvement community which in reality are vague, amorphous terms,
in the individual member's wellbeing as well. The sense of and which include within it considerable variation among
community appears to be a vital protective factor for the members as well as negative dynamics like scapegoating,
individual and their families and important in their recov- marginalization, exclusion, ostracism and hegemonic ten-
ery. dencies. It would also prove very difficult to define com-
munity and collective very precisely, as the borders will
This broader, holistic perspective becomes paramount in invariably breakdown [14]. However for this paper, the
non-western, 'collectivist' cultures which have tradition- discussion addresses cataclysmic forces impacting on
ally been family and community oriented, the individual these structures and as such consideration of some of
tending to become submerged in the wider concerns
Page 2 of 27
these important internal difficulties can be temporarily arose among family members as children were made
postponed till the overarching issues are clearer. report on their parents. The essential unity, trust and secu-
rity within the family system, the basic unit of society, was
A better understanding of the supraindividual reality can broken. Similar changes at the family and community lev-
be sought through the ecological model of Bronfenbren- els became discernable in the Northern Sri Lanka as the
ner [15] with the micro, meso, exo and macro systems or conflict continued.
the individual nested in the family nested in the commu-
nity [16,17]. The Bronfenbrenner model fits the WHO From a conservative society caught up in the world wide
definition of health which also emphasises the need to modernization and globalization, the minority Tamil
look beyond the micro or individual level (see Table 1): society in Sri Lanka became increasingly embroideled in a
civil, ethnic war from 1983 onwards. Developing as a defi-
"Health is a state of complete physical, mental, (family), social ant reaction to increasing majority Sinhala dominated
and (spiritual) well-being, and not merely an absence of disease state policies of discrimination; the youth rebellion took
or infirmity". an increasing violent form in opposition to increasing
state oppression. The North and East of the country, home
- World Health Organisation (WHO) to the minority Tamils, bore the brunt of the chronic vio-
lence that followed [12]. The state, including the Indian
The family unit has been included as it is paramount in state briefly in the late 1980's, various paramilitaries and
most parts of the traditional world. When the family is Tamil militants have been involved in in cycles of vio-
affected, the members too are affected, while if the family lence, counter violence, terror and counter terror [20].
is healthy the individual is either healthy or recovers During a lengthy period of ceasefire, the island was struck
within the family setting. The spiritual dimension has by the Asian Tsunami in December, 2004 that affected
been put forward at various WHO fora but has not been over 200, 000 people again mainly in the coastal commu-
formally accepted yet. nities of the North and East but also the South. The author
was put in charge of addressing the psychosocial needs in
This reflexive study grew out of the experience of working the North (see Fig. 1).
in disaster, post-disaster contexts: the man made disaster
of war and the 2004 Asian Tsunami in Northern Sri Lanka The impact of catastrophic events on the individual has
(see Fig. 1). The phenomena of collective trauma first been well established internationally [6,21] and was quite
became very obvious to the author when working in the clear in Northern Sri Lanka [12]. There have been some
post war recovery and rehabilitation context in Cambodia observations on the family level too in Northern Sri Lanka
[18]. During the Khmer Rouge regime, all social struc- [22]. However, it was when it came to addressing mental
tures, institutions, family, educational and religious health problems that the impact on the community
orders were razed to 'ground zero' deliberately (so as to became evident. Simple interventions at the individual
rebuild a just society anew!) [19]. Mistrust and suspicion level were not sufficient. The problems at the community
Table 1: Dimensions of health
Dimensions Causes Symptoms Diagnosis Interventions

of Health
Physical Physical injury Pain, fever, Somatization Physical illness, Psychosomatic, Drugs treatment,
Infections Somatoform disorders Physiotherapy, Relaxation
Epidemics techniques, massage
Psychological Shock Tension, fear, sadness, learned ASR, PTSD, Anxiety, Psychological First aid,
Stress helplessness Depression, Alcohol & Drug Psychotherapy, Counselling,
Fear-Terror abuse Relaxation techniques, CBT
Loss Trauma
Family Death Vacuum Family Pathology, Scapegoating Family Therapy
Separation Disharmony Marital Therapy
Disability Violence Family Support
Social Unemployment, Poverty, war conflict, suicidal ideation, Parasuicide, Suicide, Violence, Group Therapy,
anomie, alienation, loss of collective trauma Rehabilitation, community
communality mobilization, Social
Engineering
Spiritual Misfortune, bad period, spirits, Despair, Demoralization, Loss Possession Logotherapy, rituals,
angry gods, evil spells, Karma of belief, Loss of hope traditional healing, Meditation,
Contemplation, Mindfulness
Page 3 of 27
80° 80°30' 81°
SRI LANKA KaraKankesanturai

t
iti
Point Pedro National capital
Provincial capital
ai
vu
Jaffna
.I
Kayts Jaffna Peninsula Town, village
r
St
Kayts I.
Ja f
Airports
fna
k
Punkudutivu I. L ag o Elephant Pass Provincial boundary
Pa l
on
9°30'
Devipattinam Delft I. Main road
N Secondary road
I
DIA Pa l k B a y Kilinochchi
Puthukkudiyiruppu
- Nanthi Kadal Railroad
Rameswaram Iranaitivu Is. Mullaittivu
Pamban I. Vellankulam 81°30' 82°
Ferr y
Dhanushkodi Talaimannar Mankulam Nayaru Lagoon
Ad
am
's B
r id g e N O RT H E R N Nedunkeni Kokkilai
Mannar Lagoon
9° Puliyankulam 9°
Island Mannar Pulmoddai
Madhu Road
Vavuniya
Bay of Bengal
Gulf of Mannar Silavatturai
Kebitigollewa Pankulam Nilaveli
Medawachchiya Horuwupotana Trincomalee

A r u vi
Bay
iyar
8°30' dd 8°30'
Hamillewa
Ko
ru
A
Karaitivu I. Mutur
a
Yan Oy
Pomparippu Anuradhapura Kantalai
Kalpitiya NORTH CENTRAL Kathiraveli

P u t t a l a m L ag o o n
Maragahewa
Ka
la O
ya
Kekirawa Habarane
Puttalam Galgamuwa
8° 8°
Polonnaruwa
NORTH Valachchenai
M adura Oya
Mundal L. Anamaduwa Maho Dambulla Chenkaladi
WESTERN Naula Batticaloa
u Oya
dur EASTERN
Mahaweli Ganga
De Ganewatta
Chilaw Madura Oya
Reservoir
Maha Oya Paddiruppu
7°30' Kurunegala 7°30'
Matale
Kuliyapitiya Kehelula
CENTRAL Uhana Kalmunai
Pannala Kandy
Mahiyangana Amparai
y a Randenigale
M a ha O a
Negombo Kegalla
Res. Tirrukkovil
y
lO
Ga
Negombo Victoria Falls Senanayake
Lagoon Gampaha Reservoir Bibile Samudra
Ja-Ela Nuwara
7° Eliya Badulla 7°
Kelani nga Avissawella
Ga
Colombo
Sri Jayewardenepura Kotte U VA
Mount Lavinia Pottuvil
Moratuwa Monaragala
Haputale
Laccadive Sea WESTERN Ratnapura Buttala
Panadura Horana lu Ganga Balangoda
Ka
Okanda
K ir i n
SABARAGAMUWA
a n ga
Kalutara
di Oya
Matugama Pelmadulla Rakwana Telulla

G
Kumana
Walawe
6°30' 6°30'
Beruwala Kataragama
Embilipitiya
SRI LANKA Deniyaya Tissamaharama
Ambalangoda INDIAN
Udugama Kirinda
SOUTHERN OCEAN
Akuressa Hambantota
Galle 0 25 50 75 km
The boundaries and names shown and the designations Tangalla 6°
used on this map do not imply official endorsement or
acceptance by the United Nations.
Matara Dondra Head 0 25 50 mi
79° 79°30' 80° 80 30'
° 81° 81°30' 82°
Map No. 4172 Rev. 1 UNITED NATIONS Department of Peacekeeping Operations

January 2004 Cartographic Section
Figure
Map of Sri
1 Lanka (from UN-OHCHR)
Map of Sri Lanka (from UN-OHCHR).
Page 4 of 27
level too had to be understood and addressed if the indi- group therapies as well as rehabilitation, NGO network-
viduals were to be helped. Further, families and commu- ing, occupational therapy and vocational training can be
nities had to recover if any meaningful socio-economic considered social forms of therapy. Likewise, it is said that
rehabilitation programmes were to succeed. In fact, in spiritual meaning, hope and strengths will produce resil-
time most long-term programmes, as in other post disas- ience and improvement at all the above levels. Viktor
ter settings arond the world [23-25], began to include a Frankl [32] pioneered this form of treatment which he
community based psychosocial component within the called logotherapy after surviving the Nazi concentration
larger socio-economic rehabilitation and reconstruction camps during World War II.
efforts, [26,27].
Previous workers had already drawn attention to the com-
In these complex (post) disaster situations, the multi-level munity level problems caused by disasters. Kai Erikson
WHO definition of health is useful in conceptualizing the [33,34] gives a graphic account of Collective Trauma as
causes, effects and interventions for psychosocial and 'loss of communality' following the Buffalo Creek disaster
mental health problems found in these devastated com- in the US. He and colleagues described the 'broken cul-
munities (Table 1). In reality, these dimensions are inter- tures' in North American Indians and 'destruction of the
acting systems which are interrelated, each level having entire fabric of their culture' due to the forced displace-
effects at other levels so that a holistic approach that inte- ments and dispossession from traditional lands into reser-
grates all these levels becomes necessary. vations, separations, massacres, loss of their way of life,
relationships and spiritual beliefs [35]. Similar tearing of
For example, physical illnesses like injuries, epidemics the 'social fabric' has been described in Australian aborig-
and malnutrition resulting from war conditions [28,29], inal populations [36]:
will have direct physical causes, physical symptoms and
physical treatment. But it could also have psychological, "...it implies things have to be woven together properly for
social and spiritual causes, symptoms and treatment. strength, what a shame our fabric was torn to shreds through
Physical diseases, in addition to the familiar physical signs invasion, what we have left now is in tatters, repairing fabric
& symptoms, also manifest with psychological, social and can make it weak or sometimes stronger depending on how it is
spiritual symptomatology. At the same time, psychologi- done. It is important to repair the holes and not just cover them
cal factors can cause or contribute to physical diseases like over so that when some tension is applied it doesn't fall apart.
Bronchial Asthma, Hypertension, Eczema, and Colitis. What kept our fabric strong was spirituality, the invisible
Mental illnesses can manifest with physical symptoms thread that binds us all"
such as the common Somatoform Disorders or Somatiza-
tion. A global perspective shows that mental health prob- The National Strategic Framework for Aboriginal and
lems the world over produces a major proportion of the Torres Strait Islander Health [37] states:
Global Burden of Disease (GBD), including death, disa-
bility and injury due to behavior related problems such as "The sense of grief and loss experienced by generations of Abo-
adverse life style, alcohol and drug use, road traffic acci- riginal and Torres Strait Islander peoples in relation to dispos-
dents, war and violence, exploitation, and AIDS [30]. session, to the disruption of culture, family and community and
However, the contribution to GBD from disasters is yet to to the legislated removal of children has contributed to ongoing
be mapped out [28,29]. Physical and mental illness have problems in emotional, spiritual, cultural and social well-
social repercussions. Epidemics of physical illnesses like being for Aboriginal and Torres Strait Islander individuals,
the current HIV/AIDS pandemic has severe socioeco- families and communities."
nomic implications nationally and internationally. Men-
tal illnesses can cause problems in the family, community O'Donoghue [38] describes the collective trauma,
and work place due to irritability, paranoia, relationship
conflicts, alcoholism and/or drug abuse, domestic vio- "Aboriginal culture has been subjected to the most profound
lence, morbid jealousy and social withdrawal. In a like shocks and changes. It is a history of brutality and bloodshed.
manner, social problems like unemployment, poverty, The assault on Aboriginal people includes massacres, diseases,
war, and displacement can cause psychosomatic diseases, dispossession and dispersal from the land... I cannot overstate
mental illnesses like depression and suicide [31]. When the traumatic consequences of policy and the destruction of
considering treatment one can also have interventions at Aboriginal and community life that resulted."
all these levels, either alone or in combination. Thus phar-
macotherapy or treatment with drugs is the prototype of Nadew [39] in his survey of psychosocial and mental
physical treatment. Psychotherapy, counselling, behav- health problems among the aboriginal population found
ioural and cognitive therapies are some common psycho- a very high prevalence of conditions like PTSD (55 %),
logical forms of treatment. While marital, family and depression (22%), alcohol abuse (73 %), and violence.
Page 5 of 27
He linked it to the long-term and massive trauma suffered post Dec. 2004 Tsunami recovery effort in Northern Sri
by the aboriginal population. O'Shane identifies the loss Lanka. The ecological study follows Bronfenbrenner [11]:
of pride, identity, self respect, language, songs, laughter,
spirituality, relationships, traditional knowledge and "...an effort to investigate the progressive accommodation
skills in the group as a whole [40]. The consequences are between the growing human organism and its environment
trans-generational, being passed onto later generations as through systematic contrast between two or more environmen-
was found with World War II holocaust survivors [41]. tal systems or their structural components, with a careful
attempt to control other sources of influence either by random
The high incidence of mental health problems, alcohol assignment (planned experiment) or by matching (natural
and drug abuse, physical and sexual violence, child abuse experiment).... There are instances in which a design exploiting
and family disharmony found among indigenous popula- an experiment of nature proves a more critical contrast, insures
tions around the world can be the result of the break up of greater objectivity, and permits more precise and theoretically
traditional culture, way of life and belief systems. Instead significant inferences- in short, is more elegant and constitutes
of the usual response of incarceration, exclusion and sup- "harder" science- than the best possible contrived experiment
pressive measures, significantly, there are now attempts to addressed to the same research question."
repair the torn social fabric. The Dulwich centre in
Adelaide has used narrative therapy to 'reclaim commu- Participant Observation, in depth case studies [53], key
nity' [42]. By sharing stories at community gatherings informant interviews and focus group discussions as well
relationships, connection and links are re-established, tra- as several quantitative, individualistic psychosocial and
ditional values, beliefs, knowledge, skills and hope are re- mental health surveys published elsewhere [12,54,55]
kindled, giving rise to community solidarity and support. provided the data for the study. The focus group discus-
The method has been expanded to other indigenous pop- sions have included groups from the community, village,
ulations around the world. local government (G.S.-village headman, teachers, social
workers, priests); displaced camp and relief workers; Dis-
There was a description of 'cultural bereavement' due to trict (GA-District Authority, Non-Governmental Organi-
the loss of cultural traditions and rituals in Indochinese zation (NGO), militant) committees; National (Health
refugees in the US [43] and collective trauma due to the Ministry, Presidential Task force); and International NGO
chronic effects of war [44]. More recently, a number of dis- (INGO's, UN) groups that discussed and debated mental
cerning workers in the field have been drawing attention health and psychosocial issues. The author had the
to the importance of looking at the family [26,27,45,46] unique experience of working as a mental health profes-
and cultural dimension [7,45,47-49] following disasters. sional in these settings. Though being an Asian, ethnic
Finally, Abramowitz [50] has given a moving picture of Tamil, the author had most of his education and profes-
'collective trauma' in six Guinean communities exposed to sional training abroad, particularly in the west, providing
war. both an 'insiders' and 'outsiders' view point.
Borrowing from the individual psychopathological The main purpose of this study is an attempt to phenom-
descriptions, the term collective trauma is being intro- enologically describe and understand the familial and
duced in this study in a metaphorical sense to represent societal factors involved so as to better design and imple-
the negative impact at the collective level, that is on the ment more effective, appropriate and workable interven-
social processes, networks, relationships, institutions, tions, policies and programmes in a post-disaster context.
functions, dynamics, practices, capital and resources; to In addition there is a plea for prevention of such disasters
the wounding and injury to the social fabric. The long last- and the consequences they entail by documenting and
ing impact at the collective level or some have called it describing the devastating effects of war and disasters on
tearing in the social fabric would then result in the social families and communities.
transformation [51], of a sociopathic nature that can be
called collective trauma. This study attempts to describe Results and Discussion
the phenomena of collective trauma, to delineate the Individual
symptoms and community level interventions that can be Several surveys of individual level trauma and its effects in
used in such contexts. the contexts of war and post tsunami in North Sri Lanka
have shown widespread traumatization and considerable
Methods psychosocial sequelae in the different population groups
This qualitative, ecological study is a naturalistic, psycho- [12,54,55]. In depth case studies show the variety of psy-
social ethnography [52] in two contexts: The main focus chopathological responses [53]. An epidemiological sur-
is on the ongoing chronic civil war situation from 1983 vey using the UCLA PTSD Child Reaction Index with
onwards contrasted to the pre-war conditions and the expert validation (Kappa .80) [56] carried out in the
Page 6 of 27
Vanni, an area in the North of Sri Lanka, found that 92% also helped their families, communities or refugee camps
of primary school children had been exposed to poten- where they lived. In addition, the conventional psychotic
tially terrorizing experiences including combat, shelling, illnesses like Schizophrenia and Bipolar disorders needed
and witnessing the death of loved ones. In 57% of the continued medical treatment. However, due to the disas-
children, the effects of these experiences were interfering ters much of the health infrastructure and resources were
considerably with their daily life (e.g., social withdrawal destroyed or depleted and did not function adequately.
and weakening school performance). About 25% were Mental health services using essential psychotropic medi-
found to suffer from PTSD. Our epidemiological survey of cation, out reach clinics in the periphery and badly
school children in the North and East found that 47% of affected areas, and training of primary health care workers
those who had been exposed directly to the tsunami and enabled minimum cover. The generous post tsunami
15% of children not exposed had PTSD (all living in a war international support facilitated the introduction of
context). decentralized mental health services at the district level
(Fig. 2). Indeed, community mental health programmes
Apart for the individual suffering and disability, such a that do not include the possibility of addressing the prob-
large prevalence of psychiatric disorders in a population lems of those with severe mental disorders would fail in
would lead to a cumulative effect that would cause consid- the eyes of the community and cause a breakdown in the
erable social pathology and dysfunction. However, in this smooth functioning of the setting where they were. Nev-
abnormal situation many of the reactions, which would ertheless, it was not feasible to treat the large numbers
be considered pathological in normal times, would affected with minor mental health problems due to the
become the norm – a normal reaction to an abnormal sit- disasters with western psychiatric treatment. Rather, a
uation. For example, startle reactions to sudden loud community based programme to rebuild the damaged
noises like backfiring of motorcycles, banging doors or family units and social structures, networks, resources and
firecrackers and nightmares of war events, which are char- relationships encourage re-establishment of helpful tradi-
acteristic symptoms of PTSD, were widely prevalent and tional healing rituals and practices; group meetings and
not considered abnormal. Thus many with so-called diag- functions, in short to start the community working again
nosable psychiatric disorder like those who would be appeared to be more judicious. Training a variety of grass
identified in population surveys may not seek help, at
least western psychiatric help. This is clearly shown in the
low percentage of PTSD and similar post trauma syn-
dromes in psychiatric out patient services (approximately
5%). Some were seeking help through other avenues such
as the traditional sector or general health care facilities
with somatic complaints [57] or more traditional idioms
Psychiatric care
of distress like Perumuchu (Deep sighing breathing signify- at District Level
ing worries and emotional burdens) in the Tamil commu- Psychiatrist, Psychiatric Nurses
& Multi Disciplinary Team for
nity. An important contentious issue is whether those Psychiatric Care of severe cases.
diagnosed as having psychiatric disorder using western

categories are in fact having a mental illness, the categori-
cal fallacy [58]. The person, his/her family and commu-
Primary Health Care
nity often did not recognize or accept a psychiatric
Primary Health Worker (eg. Doctors,, PHW's, Nurses, PHI)
disorder. To manage the effects of mild mental health disorders
(PTSD, anxiety, depression)
A further problem is how effective or appropriate are west-

ern treatments such as psychopharmacotherapy or state of Community
the art CBT even in those with manifest dysfunction. In Community level workers ( eg. Teachers, G.S, NGO, etc. ) and people in basic
Mental Health methods.
Northern Sri Lanka, CBT was not possible as there were no
clinical psychologists. Even the recommended psychop-
harmacological agents in the west, SSRI's, were not avail-
x Multi disciplinary team - Psychiatric social worker, Clinical Psychologist, Counsellor,
able (In the post tsunami period these treatments did Child therapist
( includes art, play, drama ), Relaxation therapist and Occupational therapist.
become briefly available thanks to the international good- Referral
will). Our experience in Northern Sri Lanka in these differ-
ent contexts has been that a small minority with more Figure
lems
Referral
(at 2District
structureLevel)
for management of mental health prob-
severe dysfunction do benefit from psychiatric treatment Referral structure for management of mental health prob-
which could also include cultural techniques like yogic lems (at District Level).
relaxation methods [59]. When individuals improved it
Page 7 of 27
root workers in basic mental health and psychosocial tested area between the Sri Lanka Navy and the Tamil mil-
skills was the most effective way to accomplish this [60] itants. Altogether there are 19,090 female headed
When the family and community regained their function, households in Jaffna. A great number are widows who
individuals recovered their confidence, motivation, capac- have lost their husbands due to the war. The effect on the
ity and skills. family, the widow [61], and the children has been
immense. The loss of one member of the household, par-
Family ticularly the breadwinner has a marked impact on the
The war and the tsunami had a major impact on the func- family dynamics. Absence of members of the family due
tioning family system. From the loss of one or both par- to death, injury or displacement will create immense gaps
ents, separations and traumatization in one member, in the functioning of the family unit. The uncertainty or
pathological family dynamics adversely affected individ- grief about the missing member will add to the maladap-
ual family members, particularly the children. tive family dynamics that will ensue. The loss of the essen-
tial unifying role of the missing member can cause
The traditional family unit as the basic social institution disruption and disharmony within the family. A common
has barely survived but its function has been irrevocably situation is where the father has been detained, 'disap-
changed by the chronic conflict. The cohesiveness and tra- peared' or killed but the family members are not sure of
ditional relationships are no longer the same. Compared his fate. They are caught in a 'conspiracy of silence' where
to before the war, it is a common complaint that children further inquiries may lead to more problems for the father
no longer respect or listen to their elders, including teach- were he still alive and the mother may not be able to share
ers. These changes, attitudes and perceptions, like many the truth with the child. The child then presents with
others, may have antedated the war but could have been behavioural problems. The mother has to adapt to all the
accelerated by it. A seniour British INGO (SCF) worker negative implications of being a 'widow' in this society.
who had served in Jaffna for a long period made the obser- The role of the mother has undergone momentous change
vation of the common day to day occurrence at the perva- with increasing non-traditional responsibilities, activities
sive check points in the North and East. Tamil parents and "liberation" [62].
quickly change their behaviour and tone (in contrast to
what the child has seen at home or elsewhere) when deal- A more tragic situation happens when the disappearing is
ing with the security forces. They, perhaps unconsciously done by a local Tamil militant group. Here the conspiracy
and with the best of intentions (to safeguard their chil- of silence is much deeper. A disappearance by the army or
dren and to avoid unnecessary hassle), assume a submis- security forces is acceptable within the community. But
sive posture (removal of hat, bent head and body, low and disappearance by the Tamil militants is something the
almost pleading tone of voice, pleasing manner with a widow and her children cannot talk about even in the
smile) when accosted by the security forces (e.g. at check community or inner family circle. Apart from the danger
points). The children will observe this change without and risk of repercussions, the disappeared is made into an
comprehending the full purpose (perhaps to avoid the undesirable, a traitor. The family itself often becomes
child being detained), comparing it to their demeanour at ostracized by society. The widow cannot express her emo-
home and in time loose faith in his or her parents. A tions at all, even to herself; the deception thus goes much
strong influence has been the contemptuous way elders deeper into oneself. In a case that I was seeing, the widow
and community leaders have been treated by the authori- was suppressing the memory of her husband and in time
ties and the submissive way they have responded. Elders he disappeared from her consciousness as well as from his
are perceived as being powerless and incompetent in deal- children and society.
ing with war and its consequences, a point often made by
the young militants. Parents were careful about what they In 1996 there were reported to have been 600 disappear-
discussed in front of their children as the child could inad- ances in Jaffna [63] and in the current period from Dec.
vertently let this out in school or during play, particularly 2005, there have already been 1300 Island wide [64]. A
if it was something against the Tamil militants. Elders study by Shantiaham [65] involved the follow-up of the
have also been traumatized by the war, affecting their families of the disappeared, assessment of needs and psy-
functioning, relationships and parenting skills. chosocial support. When entering the homes of the disap-
peared, the atmosphere was akin to a funeral house, even
Due to the peculiarities of the war, males were more often years after the disappearance. The mildest of conversa-
targeted and were at high risk to be killed, arrested, tions linked to the disappeared, would set off tears and
detained, disappeared, join the militancy or to migrate. crying. The house was not lively, it was quiet and moody.
For example in the small fishing village of Chavatkaddu, In the case of the disappeared there is no closure of the
where we set up a widow's group, there were 180 widows, death, no certainty about the fate of the person. It would
many of whose husbands were killed at sea, a highly con-
Page 8 of 27
be disloyal to even consider that the person could have In the case of the tsunami, there were more women who
been killed. died compared to men as elsewhere [68]. Perhaps the
women were less capable of surviving, not having the
A study assessed the impact of displacement in the North skills in the sea. Women may also have been home when
on functioning of the family system [22]. Psychological the tsunami struck. This left many male widows who
disturbances particularly depressive symptoms were found it difficult to cope with the remaining families, not
much more common in displaced families than in those having the skills to look after children, prepare food or do
living in their own homes. In displaced children, separa- routine household chores. Some took to alcoholism. Sui-
tion anxiety was common as were cognitive impairment, cidal ideation, attempts and suicide was reported to be
conduct disorders and sleep disturbances. Disturbances in high. In time some re-married creating problems for the
family dynamics particularly disputes and quarrelling children. Often the children were given to other relations
between father and mother were attributed to economic to look after. Cases of child abuse were reported in some
stress, lack of privacy and interference of others in over of these arrangements. The attempts to adopt children
crowded camps. Other war related trauma like torture and who lost one or both parents or to put them in institu-
loss of a limb due to landmine injury had a direct impact tions were resisted by child protection authorities. Ini-
on families [66]. The loss of a limb led to feelings of infe- tially there had been reports of abduction of orphans, so
riority and shame that made family life difficult. In some called tsunami babies as well as interest from people
cases, husbands left their wives. Torture survivors who abroad to adopt tsunami orphans. Thus in many ways the
returned to their families often were not able to function impact of the tsunami on the family was unique.
as before. They were socially withdrawn, had difficulties
with intimate relationships, they were irritable and not Community
motivated to work or be active [67]. These situations Disasters have an effect not only on individuals [12], but
changed the family dynamics. In one case referred to the also on their family, extended family, group, community,
psychiatric unit, there was a role reversal with the wife village and wider society. During civil conflicts, arbitrary
going to work and the husband trying to cope with house- detention, torture, massacres, extrajudicial killings, disap-
hold chores. Due to his feelings of inadequacy, he pearances, rape, forced displacements, bombing and
attempted suicide. He had clear PTSD symptoms, yet the shelling became common (see Tables 2).
family refused to accept mental health help. When a fam-
ily member develops a psychiatric disorder like PTSD, Whole communities or villages were targeted for total
depression or substance abuse due to traumatization, the destruction, including their way of life and their environ-
symptoms and social dysfunction had an adverse effect on ment. According to a Save the Children, UK publication
the family as well. [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 stress
Death 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 stress
Economic 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
Page 9 of 27
"Civilians are no longer 'incidental' casualties but the direct lage on the northern coast, from early 1990's. The dis-
targets of violence.Mass terror becomes a deliberate strategy. placed families from these communities can be found
Destruction of schools, houses, religious buildings, fields and dispersed in a number of refugee camps or where several
crops as well as torture, rape and interment, become common- families occupy makeshift accommodation in abandoned
place. Modern warfare is concerned not only to destroy life, but homes. Inter and intra family conflict is rife with the once
also ways of life. It targets social and cultural institutions and active fishing folk observed to be despondent and hope-
deliberately aims to undermine the means whereby people less. Fishermen are at increased risk of death, disappear-
endure and recover from the suffering of war....." ance, detention, and injury due to the war in the sea. As a
result the highest number of widows come from this com-
"A key element of modern political violence is the creation of munity. This has had a terrible toll on this community.
states of terror to penetrate the entire fabric of economic, socio- Many have shifted to other occupations, some are still
cultural and political relations as a means of social control" unemployed living off government rations, others have
[70]. left the area. They have lost their way of life and culture.
Many yearn for the days when they were able to fish freely
It maybe more accurate to say that the nature of war has and lead a fisherman's life in their village. They often
changed. Instead of the old fashioned wars between states report dreams of living in their old homes and going fish-
for control of territory, where sides will fight each other on ing in the sea. Before 1983, fishing was a very fruitful
battlefields till one emerges as a victor, modern wars have occupation, the catch was good off the long North East
now become internal, civil wars, where the conflict is coast, and a considerable part of the fish was transported
more psychological for control of loyalties through intim- to Colombo and other areas in the Island. In the whole
idation and terror, the fighting occurs within civilian pop- island the North East was a leading area for fishing. The
ulations, where 90% of casualties are civilians [71]. Apart coastal communities were thriving hives of activity.
from wars for complete extermination, that is genocide,
the goal of modern warfare is more for absorption and With the ceasefire in 2002, many of the fishing families
assimilation in to one dominant culture and way of life. returned to their coastal villages and restarted their fishing
The minority is expected to forgo its own culture and iden- activities step by step. When the tsunami struck in Decem-
tity and merge with the or become subservient to the ber 2004, all this was again destroyed. The sea had been a
dominant culture. Whey they try to resist the process eth- vital and intimate part of their lives. The sea was called the
nic or civil conflict erupts. 'mother' in Tamil in their folk songs, narratives, literature
and common parlance. When the sea rose up and struck
In this way, the civil war in Sri Lanka began as an ethnic with such destructive furore, a fundamental, organic bond
confrontation between the majority Sinhalese and Tamil was broken. In the early days after the Tsunami most of
minorities, where the majority sought to impose their lan- the fisherman vowed never to go back to the sea. Many of
guage and religion. The resultant conflict has had a pro- their songs and discourse of this time expressed this loss,
found impact on Tamil village traditions, structures and grief and feelings of being abandoned by the mother,
institutions that had been the foundations and framework rebuked and punished. The slow mending of this organic
for the their daily life causing fundamental, irrevocable relationship took time. Eventually most fisherman
change in these processes [72,73]. Good examples are the returned to fishing, families slowly moved closer the sea
systemic attacks on all the Tamil villages in the Trincoma- from where they had initially been displaced and then
lee District which eventually displaced all of them into the feared returning to. Community mental health pro-
city or to other districts. Another example is the LTTE's grammes worked on reducing this fear (by various desen-
forced eviction in the early 1990's of the Moslems of the sitisation techniques) and encouraged the return to
North with 48 hours notice, many of whom still languish fishing. The resumption of conflict has displaced many of
in refugee camps in the South. these communities again. Significantly, the recent disap-
pearances and extrajudicial killings have targeted the lead-
Apart from direct attacks, whole villages of all three com- ers of the fishing organizations who had become effective
munities, Sinhala, Tamil and Muslim, have been dis- socio-politically in working for the betterment of their
rupted, displaced and uprooted due to the ongoing community.
conflict. Examples are the fishing community and farm-
ers: From the beginning, for alleged security reasons, fish- It has been a similar tale with farmers, many of whom
ing in the North and East has been restricted. This has have been displaced from their traditional lands, and have
included bans on fishing in large areas, restrictions on the lost all their equipment. Some are unable to cultivate their
distance where fishing can be done (usually restricted to land, as it is located in restricted 'security zones' or is
short distances offshore). Whole fishing communities mined. Some have abandoned their traditional occupa-
have been displaced, such as from Myeliddy, a fishing vil- tion as it no longer profitable, given unavailability or cost
Page 10 of 27
of agricultural inputs like fertilizers, insecticides and fuel, almost everyone at one time or another, have forced the
or lack of access to markets for their product. The ubiqui- Tamils to abandon their homes. People who returned to
tous presence of buried landmines creates a pervasive their homes after displacement, felt there was a change in
apprehension in the back of the minds of people, making the organic bond. They could not re-establish the relation-
them ever vigilant, cautious about walking freely on the ship with their homes. Many have left their homes in a
land, afraid of putting a wrong foot somewhere. Some state of disrepair, occupying a part of the home with
developed nightmares of being the victim of an exploding makeshift arrangement, ever in the ready with an emer-
landmine. The once beloved land itself becomes polluted, gency bag ready to move.
a source of terror [66].
Some catastrophic events were of such a scale that it left an
Other traditional trades like carpenters, masons and bak- imprint on everyone, on the 'groupmind', on thinking pat-
ers have been affected similarly. The Moslems, many of terns and memory. It changed the lives of individuals,
whom were part of a very prosperous business commu- their families and their communities in fundamental
nity, or specialized in other occupations like tailoring, ways, it transformed society [51] and the experience
tinkering, leather work and commercial entrepreneurship passed on into the collective memory to be recounted in
have lost their occupations and way of life due to their stories, narratives and folklore, songs, poetry and dramas;
forced eviction. They had tried tentatively to return after to influence future generations through subtle social proc-
the 2002 ceasefire but never felt secure or reassured that esses, so that it may be appropriate to speak of an impact
abductions for ransoms and eviction would not be on the collective unconscious. The mass exodus of 1996
repeated. With the resumption of hostilities, they have was one such experience [74]. Apart from the forced
again fled. The Sinhalese were well known bakers in the breaking of the bonds with their homes and village, the
North and East, but have now all left. trek of over 400,000 people in the middle of night with
rain and shells changed everyone. They left in terror and
As already mentioned, in these various rural communi- not by choice, with few possessions, roads clogged with
ties, the village or uur, was the secure and familiar envi- crowds moving slowly, step by step, the less able, the eld-
ronment with traditional way of life, supportive social erly, falling by the wayside; and finally arriving in make-
structures, institutions and functioning. With the disas- shift, inadequate accommodation with very poor facilities
ters, both the war and tsunami, many villages have ceased or none at all. People lost their identity, pride, dignity and
to exist. Due to dislocation villagers have been separated hope.
so that the sustaining network of relationships, structures
and institutions have been lost. Even when people have Other major events having an impact on the collective
returned, the village was not the same. Many were com- unconscious were the so-called July 1983 ethnic holo-
plete newcomers. The old structures and institutions were caust; the burning of the Jaffna public library with its irre-
no longer functioning. Thus the protective environment, placeable old Tamil manuscripts and books (sometimes
the social fabric, provided by the uur is no longer there. referred to as cultural genocide); the Indian military oper-
ation to capture Jaffna in October 1987 (rupturing a bond
Similarly, in the life of Tamils, their home (veedu) is very with another traditional mother); and the tsunami of
important. There will be a history of the home. The ances- December 2004. Some widespread phenomena seen dur-
tral relations who have died, will continue to have con- ing the war like 'disappearances', torture and landmines,
nections with the home. They will be remembered and also had a long-term effect on the collective unconscious.
considered as if they were present in the home, especially
when rituals are performed in the home. There is a Tamil Noteworthy, in our community survey [54] is the finding
tradition of being loyal to the home. If one makes a big that 1% of the study population had been tortured, but
mistake, he feels guilty of having betrayed his home. the figure reached 8% in the OPD patients [57]. Torture
There is a biological link between the home and the peo- was used as a routine procedure carried out on all those
ple who are dwelling in the home. When one is in the detained [67]. It was developed into a physical and psy-
home, or when he or she come from outside into the chosocial tool to break the individual personalities of
home or when they are away from the home and think of those who tried to resist, as well as an encompassing
the home, they feel security and peace (like a baby in the method to coerce a community into submission. Many
womb). When they area forced to leave the home sud- individuals did not survive torture, but those who did
denly with the whole household for long periods, this were released in a broken condition; or when dead, their
biological link breaks. This affects the mental condition in maimed bodies were conspicuously exhibited to act as a
several ways. People believe that ghosts or demons will warning to others. It became one aspect of institutional-
occupy the homes which are left alone, unoccupied for a ized violence and laws were passed, such as the Preven-
long time. Repeated displacements, which have affected tion of Terrorism Act and Emergency Regulations, which
Page 11 of 27
facilitate prolonged incommunicado detention without build up between the state, the military and civil society.
charges or trial, in locations at the discretion of the Secu- Any positive developments in that direction were dealt
rity Forces, and allowed for the disposal of bodies of vic- with harshly. Public relations exercises were often ill con-
tims without judicial inquiry. These legislations ceived. There were some belated attempts by the security
legitimized the use of torture and death in custody [75]. forces to learn the local language, Tamil.
Thus torture became institutionalised as an aspect of state
terror. It was similarly used by the militants but without The loss of leadership and the talented, skillful, resource-
the legal veneer. The Istanbul Protocol for the investiga- ful persons, the professional, technocrats, and entrepre-
tion and documentation of torture project team speak of neurs from the community has had devastating
community trauma by the creation of a 'repressive ecology' consequences. Many left over the years due to increasing
based on imminent, pervasive threat, terror and inhibi- difficulties, traumatic experiences and social pressure
tion that causes a state of generalized insecurity, terror and from family and colleagues, the so called 'brain drain'.
rupture of the social fabric [76]. Those who remained have been targeted by those aspiring
to rule the community. The various authorities vying for
The chronic climate of terror, insecurity and uncertainty the loyalty and subservience of the community have ruth-
was a prominent cause of the collective trauma due to the lessly eliminated what they have perceived as obstruction
war [77], but was not seen with the tsunami. The natural to their power and control. Apart from the extrajudicial
disaster was a one off catastrophic event that left a trail of killings of the state and its allied paramilitary forces, the
destruction and loss but did not continue to exert a pro- internecine warfare among various Tamil militant organi-
longed effect. As a result the severity of the collective zations competing for the loyalty of the community have
trauma was much less. That war was man made also resulted in the elimination of many of its own ethnic,
appeared to add to severity of the traumatic effect. The tsu- more able, civilians- a process of self-destruction, auto
nami on the other hand was attributed to an act of nature genocide. Those with leadership qualities, those willing to
or the wrath of God for some wrong doing, karma, often challenge and argue, the intellectuals, the dissenters and
of a collective nature. In N. Sri Lanka, people had been those with social motivation have been weeded out ('Pullu
exposed to multiple traumatic events (in N. SL the average Kalaithal'- those eliminated are labeled as anti social ele-
was over 6 events) so much so that the condition of ments or traitors). They have either been intimidated into
chronic traumatic stress maybe a better description [78]. leaving, killed or made to fall silent. At these shifts in
The Tsunami was an additional traumatic event on top of power, recriminations, false accusations, revenge and ret-
many more. One study found that there was a building ribution were very common. It happened in 1987 (IPKF,
block effect, those who had been already traumatized by the Indian intervention); in 1990 (LTTE takeover), in1996
war were at an increased risk to re-traumatization by the (SLA control) and is currently happening as a free-for-all
tsunami [55]. Further such indirect effects of disasters currently after 2005 with the collapse of the ceasefire.
(Table 1) like displacement, unemployment, poverty, ill
health, malnutrition and socio-economic hardships could Bronfenbrenner [15] warns of the destructive conse-
be as debilitating and traumatic in its long term effect. quences to a society which experiences the systematic
degrading and debilitation of its richly talented members.
Another ecological factor that was a cause of collective This is the loss of vital resources [16], the destruction of
trauma was the breakdown in intersetting communica- social capital, the nodal points of vibrant relationships
tion and knowledge [15] between the mesosystem of the and essential networks which is a prominent cause of Col-
community and the macrosystem of those in authority. lective Trauma. Without leadership and organization,
Those in authority, the military, militants and the state, vital networks and working relationships have collapsed,
held all the power and failed to communicate essential leaving the community easy prey to competing propa-
information. Apart from the language barrier between the ganda, authoritarian control and suppression. Many have
Sinhala (and briefly Indian) state and the Tamil commu- observed that ordinary people in Jaffna have become pas-
nity, decisions and actions appeared arbitrary and dictato- sive and submissive. These qualities have become part of
rial. There was no genuine relationships or attempts to the socialization process, where children are taught to
communicate except for competing versions, rumours keep quiet, not to question or challenge, accept the situa-
and propaganda exercises through the media that were tion, as assertive behaviour carries considerable risk. The
more confusing to civil society [12]. Accurate and helpful creative spirit, the vital capacity to rebuild and recover is
information is considered essential for maintaining and being suppressed.
promoting mental health in disaster situations. Access to
essential information and awareness programmes are An important ingredient in the social recovery process is
basic mental health strategies. The Tamil militants were resource gain cycles [16]. Unfortunately, after extreme
also careful not to allow any congenial relationships to stress the opposite occurs – rapid and turbulent loss cycles
Page 12 of 27
[16]. Vicious spirals of loss are set in motion due to cas- social experiment of simulating prison conditions were
cading patterns of multiple stressors where the loss of one carried out by Zimbardo and colleagues [81]. The power
resource triggers other losses [17]. Hobfoll [16] points out differential between the guards who held and exercised
that 'major trauma cycles not only spirals (downwards) for the arbitrary control over the prison population and the inter-
individual in a personal sense with anxiety, depression and personal dynamics between the two groups soon mani-
loneliness, but also often result in reduced social involvement, fested in the guards increasing aggressive, brutal,
diminished interest in life and family feelings of social detach- dehumanizing and hostile behaviour. On the other hand
ment and a sense of alienation... Moreover, PTSD has a stress- the prison population showed a syndrome of passivity,
contagion influence producing psychological distress in loved dependence, depression, helplessness, loss of identity and
ones...' For example in the context of war in N.S.L., dis- submissiveness. In addition, as seen in real prison systems
placed communities had to first face the traumatic loss of by powerful group networks within the prisoners, in the
loved ones, their homes, village structures and relation- Jaffna situation too there was the more pervasive 'counter-
ships, witnessing horrifying events before being com- control' by the Tamil militants through social pressure,
pelled to flee to perceived safer havens but ending up in intimidation, killings, abductions and internal terror trap-
crowded, refugee camps with inadequate facilities. Here ping the civil population between the two forces.
stressors of unemployment, malnutrition, illness, socio-
economic difficulties within an atmosphere of uncertainty A pernicious element in the collective traumatization of
and insecurity compound their already precarious plight. this ethnic war was the systemic nature, the institutional-
The uprooting from the familiar village environment ization of the violence, the terror and counter terror. It
often meant loss of social support networks, traditional became structural, becoming entrenched in the laws of the
leadership, rituals and practices. For community healing land, in the way the state treated the minorities, pervading
and recovery, this vicious cycle has to be broken and a all relationships and activity. Beginning with discrimina-
resource gain cycle instituted. Psychosocial and multisec- tion and inequity, the emergency and anti-terror legisla-
torial interventions will have to address these various tion, to total militarization of society and targeting of
problems simultaneously in parallel, in an integrated and Tamils, youth in particular, in mass arrests, detention, dis-
holistic way if these negative processes are to be reversed. appearances and killings to the counter violence of the
However, the most effect way to the stop the downward Tamil militants to control the populations; a fluid and
spiral and break the vicious cycle would be to stop the shifting terror was there just below the surface, subtle and
war! covert but an important part of the ecological context. A
photographic record of this terror can be seen in the faces
A unique context of the military situation in Jaffna was of the 'Army I.D. cards' issued to those returning to Jaffna
geographical in that it was a peninsula, connected to after the Army took control in 1996.
mainland Sri Lanka by a narrow isthmus, a thin causeway
called Elephant Pass, blocking of which would effectively The change in the dynamics and social transformation
cut off Jaffna from the rest of Sri Lanka and the world (see that arise from ecological transitions or shifts [15] from
Fig. 1). This happened several times during the two dec- the civil, peace context to a war context would result in
ades of war, sometimes lasting for years. Communications change at cognitive, emotional and social levels. In N.S.L.,
including telecommunications and postal services, elec- with the vicious spirals of resource loss, there was regres-
tricity, transport and travel were all blocked except for very sion to constriction of consciousness, narrowing of out-
limited air and sea travel. They were attendant shortage of look and world views, and reduced social cohesion with
food, fuel, medicine and other essential items. Travel was suspicion, mistrust and ennui. Studies of adolescents [12],
allowed only after an elaborate pass and permit system. showed a marked impairment in cognitive functioning.
During these times, Jaffna was often under what was per- These can be discerned in adults also. Particularly, there
ceived as 'foreign' occupation with conspicuous security was a constriction or narrowing of cognition, thinking in
arrangements consisting of armed guards, weapons of all general had become very restrictive, petty, mundane,
types, check points, regular patrolling, frequent search rigid, fixed on survival and self-interest. A characteristic
operations, arrests, detention, abduction, disappearances, feature of traumatization is loss of concern about the
skirmishes, guerilla attacks, ambushes and counter kill- future, lack of planning (DSM IV). People learned to sur-
ings by the militants, all this hidden from the eyes of the vive from day to day. A marked preoccupation with death
media, the rest of the island and the world. The atmos- as seen in popular media (death announcements, condo-
phere created a feeling of entrapment, of being besieged. lence messages, posters commemorating the dead) and
The conditions were compared to being in an 'open less concern with the future was noticeable. The constric-
prison' by some of the community leaders, the Bishop of tion in cognition and the domination of negative emo-
Jaffna [79] and Surgeon of the Jaffna Hospital, Dr. Thaya- tions led to stereotypic ideas of other groups, paranoia,
lan Ambalavanar [80] among them. An illuminating hatred and revenge. Self-perpetuating cycles of violence
Page 13 of 27
and counter violence, terror and counter terror kept a all the vital items to live rough and essential documents,
whole young generation growing up in this atmosphere, ready to leave at a moments notice. When displaced to a
and society locked into a mind set of violence and war. camp, they are very systematic in getting themselves
Non violent solutions to problems were not seen to work. organized. They immediately find a corner, hang up
Well intended peace building programmes failed to break screens with sarees, and start arranging their belongings
this cycle as the fixated minds of decision makers or lead- for a stay. It should be also mentioned they are now very
ers were not addressed nor were the fundamental inequi- adamant in obtaining, even demanding dry rations and
ties fueling the conflict. An attempt at recovery and other relief items. This 'previous training' came in handy
reconciliation programmes will have to reverse these per- after the Tsunami, where the displaced from the Tamil
nicious cognitive changes and repair the socioeconomic community were found to cope much better than their
and political causes. Southern counterparts. Many of the Tamil psychosocial
training manuals that had been developed over the years
Social Justice were translated into Sinhalese after the tsunami.
Another important casualty in this war has been the
implicit faith in the world order and justice in particular. However, some coping strategies that may have had sur-
The overriding experience of Tamils has been a discrimi- vival value during intense conflict may become maladap-
natory system and injustice. Those responsible for what tive during reconstruction and peace (see Table 3). For
may be called war crimes and the worst types of human example, the Tamil community had learned to be silent,
rights abuses have never been punished. The few cases of uninvolved and to stay in the background which would
massacres, disappearances, torture, rape, custodial kill- have helped in survival. They have developed a deep suspi-
ings, mass graves that have been investigated and brought cion and mistrust. For example the Tamil people no longer
to light have not resulted in justice being done. Impunity trust the security forces, including the police. Their recent
prevails. Though perpetrators have been identified, and in experiences have taught them otherwise. Thus instead of
some rare cases arrested and court cases instituted, none trust, respect for Police, and a belief in their legitimacy;
have been sentenced (the sole exemption being the highly there is fear, even terror. Thus when someone breaks the
publicized Krishanthy case which was taken up by many law, or there is a robbery or some other illegal activity, no
women's and other human rights organizations), or pun- Tamil would naturally report it to the Police. A recent
ished [82]. The perpetrators are promoted (such as diplo- example was the UNDP mine awareness programme
matic posts overseas), or they are transferred elsewhere. In where the UNDP naively asked people, when they dis-
the case of abuse and injustices committed by the Tamil cover a mine, to report it to the local security forces. Peo-
militants, there is no social mechanism for redress; the ple protested and the UNDP changed its policy. Similar
victims usually have to bear it in silence, a silence that is paranoid attitudes were found after the Sept. 9/11 attack
often individual as well as collective. in New York [83]. Trust is the basic binding glue that
keeps communities and societies together. Trust in rela-
Consequences of collective trauma tionships, that they will not be betrayed, that others will
The cumulative effect of all these devastating events and fulfill their obligations, responsibilities and undertakings,
ecological contexts on the community can be described as that their intentions are benign; trust in social structures
collective trauma. In addition to the sum total of individ- and institutions, justice, law, values and cultural beliefs,
ual traumas, which can in itself be substantial given the the future and finally a trust in themselves, their family
widespread nature of the traumatization due to disas- and kin. Trust is gradually destroyed by war. This cohesive
ter(s), there are impacts at the supra-individual family, force is progressively weakened setting in motion a
community and social levels that produce systemic
changes in social dynamics, processes, structures and
functioning. In fact, the psychosocial reactions in the indi- Table 3: Consequences of collective trauma
vidual may have come to be accepted as a normal part of
life. Thus being tense, ever vigilant, readily startled, irrita- Mistrust
ble, having nightmares and poor sleep and experiencing Suspicion
"Conspiracy of Silence"
multiple somatic complaints would not be considered
Brutalization
unusual. But at the community level, manifestations of Deterioration in morals and values
extreme experiences can, for example, be seen in the pre- Poor leadership
vailing coping strategies. People have learned to survive Dependency
under extraordinarily stressful conditions. A UNHCR offi- Passiveness
cial observed that in Jaffna people have become profes- Despair
sional in dealing with complex emergencies from Superficial and short term goals
previous experiences. Every family has a bag packed with
Page 14 of 27
vicious self fulfilling cycle, spiraling downwards of One worrying development identified in many commu-
increasing suspicion and mistrust. nity focus group discussions is the anti-social personality
development in male adolescents and youth. It was
People have learned to simply attend to their immediate noticeable after the Tsunami, where the adolescents and
needs and survive to the next day. Any involvement or youth in displaced camps seemed to drift into anti-social
participation carried considerable risk, particularly at the groups and activities. Initially, during the Tsunami they
frequent changes in those in power. The repeated dis- had behaved heroically saving many and actively helping
placements, disruption of livelihood have made people in the rescue efforts. In the camps too they were in the
dependent on handouts and relief rations. Similar to forefront in organizing activities, programmes and serv-
Seligman's 'learned helplessness' [84], this dependence ices. However, many of them had lost a parent or sibling.
hampers rehabilitation and development efforts. People Grief seemed to soon overwhelm them. Further, in some
have lost their self-reliance, earlier a hallmark of Tamil families the family dynamics soon worked to blaming the
society. They have lost their motivation for advancement, youth for some of the deaths, not acting appropriately to
progress or betterment. There is a general sense of resigna- save a sibling for example. Thus guilt complicated the grief
tion to fate. People no longer feel motivated to work, or reactions. Further, no ongoing, constructive activities or
better their lots. Many prefer to continue to live in refugee programmes were designed and implemented for adoles-
camps refusing resettlement plans. After the recent cessa- cents and youth. They were left out of the school based
tion of hostilities in 2002, there were concerted efforts to programmes or those for children. Unemployed and at a
resettle displaced families by Governmental and Non loose ends, they drifted into groups and antisocial activi-
Governmental Organizations. But many refused to move. ties. Some left to join armed militant groups. Others
In hindsight, this may have been a wise instinct born of started abusing alcohol. Alcohol abuse also increased
previous experiences (the conflict restarted in 2006 and among widowed men and became a major problem in the
people were re-displaced once again). But even within ref- camps. Attempts by camp and community officials to
ugee camps, people did not show interest in self-help pro- restrict the availability of alcohol or control its abuse were
grammes like vocational training and income generating not successful.
projects. Outside camps, people appear to have resigned
themselves to just surviving. Similar to what Lifton [85] Similar antisocial personality development, particularly
found in Hiroshima survivors, "a pervasive tendency to slug- in male adolescents and youths, was seen in post war set-
gish despair....." They seemed to live a half life, as though tings (long-term ceasefires, cessation of hostilities). Par-
they were 'walking corpses' or the living dead. Many farm- ents and elders in the community who had traditionally
lands remain uncultivated, houses un-repaired. been respected no longer had control. These youths were
immersed in an atmosphere of extreme violence. Many
Brutalization had witnessed horrifying deaths of relations, the destruc-
Another conspicuous collective phenomenon due to the tion of their homes and social institutions. They were sur-
war has been the brutalization of society. Apart from the rounded by war equipment and paraphernalia. They had
militarization of all aspects of life (with the ubiquitous personally experienced bombings, shelling, extrajudicial
check points, armed men, weapons, checking, barbed killings and displacement. With no avenues for advance-
wire) and the pervasiveness of the 'gun culture', is the ment or hope for the future, knowing only camp life,
long-term effect on thinking and behaviour patterns. Wit- unemployment, and poverty, adolescents and youths
nessing the horrifying deaths (including killings) of loved formed into violent groups and criminal gangs. Inter-
ones, friends or strangers, seeing many mutilated or dis- group rivalry, violence and clashes developed to an alarm-
membered bodies, decaying and bloated remains have ing degree unseen in conservative Jaffna before.
saturated the consciousness with death as evidenced by
drawings, dreams, and poetry. Similarly, watching the There were inter-gang conflicts and violent fights, spilling
destruction of what had been a permanent structure, like over into their communities. Thefts and other antisocial
a home, or having to abandon ones' home under forced activities like abduction and sexual assault of females, har-
circumstances appeared to result in the perceived collapse assment and abuse became common. Parents, teachers
of everything secure and strong, particularly in children and community members expressed difficulties and fear
who lost the hopes for a future With time people have in handling adolescents and youth. This was the age
become habituated to such scenes and experiences. In a group, which in normal times would have been involved
way they were immunized to the worst aspects of the war, in constructive social activities, advancing and nurturing
able to carry on nevertheless, attend to immediate survival society with youthful exuberance and altruism [12,86].
needs in the midst of the destruction and death, a form of
resilience. At workshops and meetings with adolescents and youth,
it was clear that there was considerable pent up anger and
Page 15 of 27
resentment against the military, which was seen as an age abortions and child sexual abuse This has also been
occupying force, responsible for atrocities and violence. attributed to the reduction of privacy in cases of displace-
The emotions and hostility were just beneath the surface, ment, to increased alcoholism and to the inability of par-
when given an opportunity to express and ventilate their ents to keep an eye on their children in camps. Robberies
feelings within the secure but somewhat suggestive and of the houses and property of those displaced is common-
encouraging atmosphere of the workshops, the aggression place. Widespread looting by the public (indulged in even
came out clearly. When asked to hit out (at objects like a by socially respectable teachers and others highly placed
pillow) if they felt like it, invariably the pillow was imag- members of society) was seen for example in the wake of
ined to be a soldier, and considerable aggression was many army operations such as after the Indian interven-
vented in these group settings. Some discerning workers tion in 1987 and in Thenmarachi in April 1996 when the
and INGO's expressed concern at the manipulation of this army allowed people to return to Jaffna. There is currently
anger by pro-militant organizations used for recruitment a dramatic increase in the number of child abuse cases,
and propaganda purposes. including sexual abuse, being reported in Jaffna to the
District Child Protection Committee showing an increase
Social deterioration during periods of war and a decrease during the cease-
The signs of collective trauma can be discerned in many fire[87]. A recent survey found that 96% of children had
fundamental social processes. Compared to pre-war experienced violence at home, with 52% indicating more
times, there seems to be a general ennui. People have left than 5 violent events, and that most violence was ongoing
their homes and property in disrepair, not taking the [88].
effort to start repairs. In offices and organizations, the
work output was reported to have declined considerably. This apparent increase in child abuse could be due to
Once a work ethic dominated this hard working society, increased awareness of the problem (child abuse has
now one often hears the complaint that most people are always being there in our society, as has teenage preg-
not inclined to work hard, but merely sign their names in nancy, but it is only now coming to light) but it is also due
the work register and take the day off for the slightest rea- to the new stresses due to the war. Many families are dis-
son. More effort and interest is seen to be spent on obtain- placed from their familiar surroundings and natural hab-
ing relief items, rations, incentive payments, risk itat where there was the support and protection of others
allowances and such like. At times, difficulties have from the village, their extended family and friends. They
resulted in people fighting over limited resources or facil- now have to live in crowded camps or accommodation in
ities, for example in the queues for rations, or seats on the strange and new places. Parents too have to go out to
ship to Trincomalee. attend to various urgent requirements like obtaining
relief, rations, and meeting authorities. Some families are
There appears to be a crisis of leadership. People are reluc- separated without their men. In some families, the father
tant to take leadership positions like chairmanships or and/or mother has started another relationship leaving
presidencies (unlike before, there is no active campaign- the children vulnerable to abuse.
ing or canvassing, though there was a brief increase in
interest during the ceasefire). The considerable threat to There has also been noticeable increase in violence against
those aspiring to leadership roles, many having been women as evidenced by the number of battered women
killed or intimidated into subjugation, has meant that few seen through the Kavasam (Women protection) pro-
would take the risk nor would their family or community gramme at General Hospital Jaffna [62].
allow it. Most positions go by default. There is a noticea-
ble lack of quality in civil society, partly due to the crip- An example of deterioration in morale and loss of sensi-
pling brain drain, but also due to the devastating effect of tivity in being human is from the health sector where,
the war. until recently, there was a spirit of service [89]. Medical
staff would stay with their patients, sometimes sacrificing
There is also widely reported perception in northern Sri their own well-being for the interests of the patient. The
Lanka that there has been a marked deterioration in social collective experience of what happened at General Hospi-
values evidenced by changing sexual and social behav- tal, Jaffna on Theepavali day in 1987 has made most staff
iours. Although there has been considerable changes in lose their altruism. During that fateful period, staff
society due to modernization and globalization, but war decided to stick to the hospital and patients despite con-
and displacement may have accelerated these changes so siderable risk. When the Indian Army entered and massa-
much so that people attribute the perceived changes to cred both patients and staff, this last bit of service ideal
recent events. For example, in the refugee camps in Vavu- died, too. Staff now look after their self-interest first. At
niya and in general society in northern Sri Lanka, medical the slightest hint of trouble, they abandon the hospital,
personnel report increased unwanted pregnancies, teen-
Page 16 of 27
their responsibilities, and patients, as happened during As described the greatest impact of the structural violence
the intensification of the conflict in May 2000. and oppression is on the younger generation. A more per-
manent solution to the phenomena of child soldiers
Child soldiers would be to bring pressure on the state to dismantle the
It is in this context of psychological, social, economical socioeconomic and political oppression the children face
and political deprivation that the phenomenon of child to prevent them becoming soldiers.
soldiers becomes possible. A whole generation of Tamil
children has been lost, who in the normal run of things, On the other hand, examining the pull factors, it becomes
should become the energetic developers of their society. It clear that the LTTE and more recently, state backed para-
may not be enough to just merely condemn the recruit- military groups have turned to children and females to do
ment of children, but to ask the deeper question, "Why do their fighting as the older males are no longer joining. The
children join the militants"? It is as important to understand older youths have matured enough to see through the
the context under which children become soldiers and propaganda. Children because of their age, immaturity,
work to improve these conditions if this practice is to be curiosity and love for adventure still remain susceptible to
effectively prevented [90]. They can be divided into push 'Pied Piper" enticements through a variety of psychologi-
and pull factors (see Fig. 3). Some of the push factors cal methods. Recruiters have used public displays of war
include death of one or both parents or relations; separa- paraphernalia, funerals and posters of fallen heroes,
tions; destruction of home and belongings; displacement; speeches and videos, particularly shown in schools and
lack of adequate or nutritious food; ill health; economic temple festivals; heroic songs and stories to cleverly draw
difficulties, poverty; lack of access to education; not hav- out feelings of patriotism. The very strict restrictions on
ing any avenues for future employment and advance- leaving LTTE controlled areas, particularly in the recruita-
ment; social and political oppression of the group, and ble age group, both ensures that there is a continuing sup-
facing harassment, abductions, detention and death. ply of fighters and creating a feeling of being trapped and
Opportunities for and access to further education, sports, powerless in potential recruits. In addition the aforemen-
foreign scholarships or jobs in the state sector have been tioned actions of the Sri Lankan forces all have created a
progressively restricted by successive Sinhalese-domi- milieu where children are psychologically compelled to
nated governments, despite the lip service paid to main- join. When these have failed more coercive means, includ-
taining ethnic ratios. There is an alarming drop out rates ing threats to parents, abductions and press ganging have
and irregular attendance in schools in the Jaffna District, been employed. The LTTE has introduced compulsory
becoming the highest in the island [91] that had tradition- military type training for all eligible ages in areas under
ally given pre-eminence to education. Ironically the Tamil their influence. This instills a military thinking and lead to
rebellion that started out as a protest against standardiza- more joining.
tion, a strategy by the state to restrict Tamil admission to
Universities on merit, has deteriorated with the war to In this context, it is easy to understand why joining a pow-
Jaffna now having to claim disadvantaged area status with erful group can become an alluring alternative. Those
guaranteed admissions. responsible for the recruitment, training and deployment
of child soldiers as well as those perpetuating the socio-
economic and politically oppressive conditions should be
considered 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 appropriate
psychological, socio-economic and educational opportu-
nities for rehabilitation as is being attempted currently by
the UNICEF. The tragic occurrence at Bindunewava where
captured child soldiers were later massacred is a poignant
reminder how hypocritical towards the actual welfare of
(Tamil) children the state really is.
In these circumstances of recruitment of children, Tamil

sociocultural and religious institutions have failed to pro-
test. Apart from functioning as apologists, no Tamil lead-
Figure 3child soldiers – push and pull factors
Creating ers have not dared to comment, let alone condemn. This
Creating child soldiers – push and pull factors. paralysis may be partly due to the severe human rights
violations that have been perpetrated by the Sri Lankan
Page 17 of 27
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.
Levels of Intervention
Only a few affected parents have made muted protests.
Thus the Tamil militants have been allowed to function
SOCIETAL
freely within society to attract and pull children through Public Public
Safety Policy
their propaganda and psychological pressure in the vac- Public COMMUNITY Service
Education Coordination
uum left by the abdication of social institutions. Capacity Building Village Training/Education
Family, Self-Help
Networks FAMILY Family Education
Although not the focus of this paper, there were some pos-
Traditional Healing Clinical Treatment
itive, constructive changes in society that could be INDIVIDUAL
observed which could be useful in attempts in designing
programmes to address the collective trauma. There were
the emergence of new community organizations, particu- Types of Intervention
larly with active female participation, enhanced female
role and leadership [62], breakdown in caste barriers and
hierarchical structures [92] and a decrease in suicide rates
Figure
Conceptual
and humanitarian
4 modelcrises
for psychosocial
[1] interventions in social
during active periods of conflict [93]. Together with the
Conceptual model for psychosocial interventions in social
resilience gained from surviving decades of war and the and humanitarian crises [1].
potential post traumatic growth, these positive develop-
ments need to be utilized in the recovery process and start
the resource gain cycle [16].
nity level interventions which include public education,
Collective strategies support for community leaders, development of social
Traditionally, disaster interventions have been catego- infrastructure, empowerment, cultural rituals and ceremo-
rized into rescue, relief, rehabilitation, reconstruction and nies, service coordination, training and education of grass
development depending primarily on time course after root workers, and capacity building. The fourth layer is
the disaster. Apart from attending to the immediate basic family interventions that focus both on the individual
needs and other acute problems in the rescue and relief within a family context and on strategies to promote well-
phases after a major disaster, rehabilitation, reconstruc- being of the family as a whole. The bottom layer of the
tion and development strategies need to include collective pyramid concerns interventions designed for the individ-
level interventions [23-25]. Indeed, it has been our expe- ual with psychological symptoms or psychiatric disorders.
rience that many long-term programmes do not reap the These include psychiatric, medical and psychological
expected benefits if they do not take into consideration treatments which are the most expensive and labour
collective issues and ways of addressing them. In fact, intensive approaches that require highly trained profes-
many individual oriented interventions appear to fair sional staff. Therefore, they should be reserved, particu-
much better when undertaken within an overall collective larly in the poor, developing world settings, for the small
level design. minority of individuals who cannot benefit from the
larger scale interventions at higher levels of the pyramid.
Models of mental health interventions Theoretical, practical, empirical and treatment considera-
One approach is to use the WHO definition of health tions suggests a holistic, integrated, multiple levels of
already mentioned to address the physical and psychoso- interventions, an expanded psychosocial synthetic
cial needs of the survivors through physical and psychoso- approach [93].
cial interventions (Table 1). Another more comprehensive
and useful conceptual model (Fig. 4) for psychosocial and Community approaches
mental health interventions is an inverted pyramid with The wide spread problem of collective traumatization and
five overlapping and interrelated levels of intervention 'loss of communality' following disasters is best approached
prepared for UN and other Disaster workers by the United through community level interventions. Community
Nations and International Society for Traumatic Stress based approaches will enable one to reach a larger target
Studies [2]. As shown in Figure 3, at the top of the pyra- population as well as undertake preventive and promo-
mid are societal interventions designed for an entire pop- tional public mental health activities at the same time. In
ulation, such as laws, public safety, public policy, these circumstances it may be more meaningful to look at
programmes, social justice, and a free press. Descending how the community as a whole has responded, how the
the pyramid, interventions target progressively smaller community coped, and what we can do at the collective
groups of people. The next two layers concerns commu- level. For example, it may be more beneficial to consider
Page 18 of 27
strengthening and rebuilding the family and village struc- 1999 which resulted in increased numbers being reported
tures, as well as finding a common meaning for the (see above) and being helped.
immense suffering than to treat only individual traumati-
zation. For this purpose, the protocol developed by the Training
Transcultural Psychosocial Organization, a WHO collabo- Training of grass root community level workers in basic
rating centre, working around the world to relieve the psy- mental health knowledge and skills is the easiest way of
chosocial problems of people affected by internal conflict reaching a large population [97]. They in turn would
and war [95] was very effectively adapted to the situation increase general awareness and disseminate the knowl-
in Cambodia [96] and in northern Sri Lanka [89]. The edge as well as do preventive and promotional work. Thus
main principles of community level approaches (Table 4) there would be a multiplication effect where the informa-
are to empower the community to look after their own tion would spread to the general population. The majority
problems by not only through psychoeducation to trans- of minor mental health problems following disasters
fer basic psychosocial knowledge and skills but also could be managed by community level workers and oth-
through encouragement, support, affirmation and re- ers referred to the appropriate level. A referral system
establishing community processes, traditional practices, where more severe problems are referred for more special-
rituals, resources and relationships. ized treatment was established (Fig. 2). Primary Health
Workers including doctors, medical assistants, nurses,
General awareness Family Health Workers; school teachers; village resources
Basic information about what has happened, what to do like the village headman, elders, traditional healers,
and not to do and where help can be obtained were done priests, monks and nuns; Governmental, Non Govern-
through the media, pamphlets and popular lectures. One mental Organization (NGO), volunteer relief and refugee
such popular programme was carried out through the camp workers were community level workers who were
Extra Mural Studies unit of the University of Jaffna where trained. A manual based on the WHO/UNHCR [98]
batches of around 100 participants were taken through a booklet, "Mental Health of Refugees", was adapted to the
basic introduction to psychosocial issues over a five week cultural context for this purpose [60]. A Training of Train-
period. Five such courses were completed. Another major ers (TOT's) in community mental health using this man-
psychoeducational effort was carried out immediately ual was done under a UNICEF programme. They in turn
after the Tsunami by Mental Health Task Force in Jaffna trained a variety of community level workers from the
using the media, pamphlets and lectures. The Mental North and East and have followed them up regularly in
Health Task Force (MHTF) was formed spontaneously the field (for example, after the Tsunami, there were 36
after the Tsunami by most of the organizations involved different training programmes for 11 agencies with a total
in psychosocial work in the Jaffna peninsula which then of 732 participants over a 9 month period in 2005).
met regularly and attempted to organize and coordinate
the psychosocial work after the tsunami. MHTF now con- A systematic training programme for teachers in basic
tinues as the Psychosocial Coordination Forum under the mental health for a period of six months with assessments
Deputy Director of Health Services, Jaffna. After the Tsu- and follow up were carried out with the German sup-
nami the MHTF carried out 18 awareness programmes for ported GTZ-BECAre programmes and Ministry of Educa-
568 relief workers and others. Similarly the committees tion, University of Jaffna and Shantiaham, a local NGO
involved in Child abuse and Domestic violence carried working in the psychosocial field. Altogether around 151
out considerable to public education programmes from primary school teachers from all three communities
selected from the North and East were trained in the
period 2002–2005 using a manual, Child Mental Health,
Table 4: Community approaches
developed locally for this purpose [99]. They then
Community Approaches received further extensive training in Narrative Exposure
Therapy (NET) [100] by a German team for the University
Awareness of Konstanz (Vivo) and a manual for NET made available
Training of community workers in Tamil. An impact study [101] found that there had
Public mental health promotive activities been considerable change in the attitude and skills of the
Encourage indigenous coping strategies
teachers who now interacted more with their students,
Cultural rituals and ceremonies
Community interventions parents and colleagues, avoided punishment and created
- Family a more caring, participatory and democratic class atmos-
- Groups phere apart from carrying out a variety of psychosocial
- Expressive methods interventions for affected students. They were then
- Rehabilitation involved in the training of around 1030 'Befriender' teach-
Prevention ers from the same region in simple psychosocial issues
Page 19 of 27
over a 5 day course using a manual, 'Joyful Living', pre- which in time should develop its own healing and caring
pared for this purpose [102]. Regular follow-up and processes. A widows' support programme funded by the
supervision locally was carried out. Yet, the whole pro- Government of Finland was started in a particularly badly
gramme faltered after the German GTZ changed its pro- affected fishing village, Chavatkaddu, which had a high
gramme focus from 2005. One advantage of all this number of war widows. The widows met as a group to
training that had been done during the war period became support each other, exchange their stories and recount
apparent when the tsunami struck in 2004. The trained experiences. Coping strategies used by one person could
teachers were mobilized to assist the affected students be tried by another. The widows were able to organize
throughout the North East. The benefits of this pro- themselves into a powerful group to overcome stigma and
gramme became evident nationally and the manual was exclusion in their village, undertake joint economic ven-
translated into Sinhalese. Copies in Sinhala and Tamil tures, obtain relief and rehabilitation projects, arrange for
were made available in all the schools in the Island education and tuition for their children, go on tours
through the efforts of PLAN International, and psychoso- together, celebrate religious and cultural festivals and
cial training for teachers in the Tsunami affected areas was observe death anniversaries. In time they were able to
done. expand their programmes to other villages, training their
counterparts and helping them to organize themselves.
Traditional coping strategies
Indigenous coping strategies that had helped the local Family support
population to survive were encouraged. Culturally medi- In our cultures where the family bonds are very strong, the
ated protective factors like rituals and ceremonies were family is an essential resource that can be used for healing.
promoted and arranged. For example funerals and anni- Efforts were taken to keep the family together and func-
versaries, were very powerful ways to help in grieving and tioning. For example, attempts to separate orphans into
finding comfort. They were a source of strength, support institutions were resisted through the District Child Pro-
and meaning. tection Committee (DCPC), and efforts were made to
keep and support the child with their near relations. In
Teaching of the culturally appropriate relaxation exercises time this principle was accepted and adopted by the
to large groups in the community and to students in National Child Protection Authority after the issue arose
schools was carried out as both preventive and promotive after the Tsunami. Other agencies like the ICRC were con-
mental health. The benefits of these originally spiritual tacted to trace missing relations and unite the family.
practices were not confined to producing relaxation. Family cohesion was strengthened. The principles of fam-
When methods are culturally familiar, they tap into past ily dynamics were used to facilitate supportive and heal-
childhood, community and religious roots and thus ing relationships while counteracting damaging and
release a rich source of associations that can be helpful in maladaptive interactions. Communication of individual
the healing process. It became clear that traditionally problems leading to an awareness of each other, one's role
relaxation methods exemplify a holistic approach work- and encouragement towards mutually interdependent
ing at the physical, mental, social and spiritual levels; pre- functioning were used to build up family unity. Tradi-
venting, maintaining, promoting well being as well as tional roles had to be re-established. These considerations
being therapeutic when needed [59]. We found that peo- were used for the extended family as well. When individ-
ple naturally turned to traditional practices when under uals, particularly children, presented with problems due
stress and found relief in them. For example, in Sri Lanka to pathological family dynamics, it was the family that
we found religious practices such as ana pana sati, repeti- had to be managed if the individual was to recover [12].
tion of meaningful phrases such as Buddham saranam gac-
chami, mindfulness, and vipassana meditation among Village level psychosocial interventions
Buddhists; rosary or telling prayer beads and contemplation Badly affected villages by the war and later, by the tsu-
among Catholic Christians; thikir among Muslims; and nami, were selected for psychosocial work. The steps in
Japa mala, repetition of a mantra such as om, shanthi the intervention programme in each village are given in
asanam, yoga, pranayamam and meditation among Hindus Table 5 and the psychosocial interventions in Table 6.
were powerful methods known to the people and priests. Although broken up as steps, they were in reality all ongo-
ing processes, with the monitoring evaluation and assess-
Community interventions ment fedback into the programme to adjust and modify
Group support the design and implementation based on lessons learnt
The formation of groups for survivors, affected families, and contextual factors. For example, after the tsunami the
widows, ex-detainees, torture survivors, landmine victims interventions had to be made more appropriate for the
and other groupings can be very helpful. A therapist male widows or some areas or aspects of programmes
would facilitate the interactions within these groups, changed due to developing security concerns.
Page 20 of 27
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 village
7 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 area
8 Data collection & documentation Basic Demographic data about the village
9 Social Mapping Ecosystem of society, places where collective trauma occurred, the house of the
community leader, temples, CBO's, Traditional leaders
10 Identifying and analysing the problems Through Key informant interviews, Focus group interviews
11 Planning Based on the abovementioned identified problems and their priorities
12 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 6
17 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
professionals
19 Networking Working with GO's and NGO's for socio-economic and other needs
20 Monitoring and evaluation Feedback into modify Planning stage and programme implementation. Design of
new programmes.
-Vijayashankar, PSW Trainer, Shantiaham
Consequent to the Tsunami of Dec. 2004, the WHO Expressive methods

developed a strategy of training Community Support Structured play activity for children were arranged to
Officers (CSO's) to address the mental health needs of the enhance recovery in post-disaster situations. Children's
affected families throughout the areas devastated by the time was usefully structured and physical energy chan-
Tsunami in Northern Sri Lanka. In pursuance of this aim, nelled in a healthy manner. More important, it helped
CSO's were selected from Primary Health and other com- organize community or camp activity, build friendships
munity level workers from Vadamarachy East, Maru- and peer relationships and give an opportunity for the
thenkerny, Killinochi and Mullaithivu (see Fig. 1) and child to bring out his or her emotions and creative
given a basic training in basic mental health and psycho- impulses.
social work. They then visited each family affected by the
Tsunami and identified families and individuals needing In a collaborative programme involving the Ministry of
help. They attended to simple problems using a variety of Education, Danish and Sri Lanka Red Cross and Shantia-
psychosocial interventions (Table 6) and referred more ham, 150 teachers and 118 volunteers were trained during
difficult cases to the local mental health clinic. Commu- 2004–5, to implement structured activity in badly affected
nity interventions were also carried out. There was regular schools in the Jaffna peninsula using a manual, "We are
supervision and follow-up. little children", prepared for this purpose. The aim was to
Page 21 of 27
Table 6: Essential psychosocial interventions
Individual Family Social
Case identification Psycho education Awareness

Psycho education Family counselling Training
Counselling Strengthening the family dynamics e.g. Intervention for special groups (children, widows, widower,
Talking and eating together youths etc)
Other Psychotherapy Family Reunification Encourage to do religious and ritual activities
Yoga and Relaxation Social support Encourage to do cultural activities
Family & social support Capacity Building and Income Forming and reactivating CBO's.
generation
Referral and net work Follow up Re-establishing relationships, social networks
Capacity Building and Income generation Network with other NGOs
Rehabilitation Encouraging networking with other communities.
Follow up Follow up
-Vijayashankar, PSW Trainer, Shantiaham
promote psychosocial well being through play, art, danc- Rehabilitation programmes were encouraged to include
ing, stories, yoga, creative and emotional expression and education, vocational training, income generating
involvement of the parents. A total of 2,800 children from projects, loans and housing that is tailored to the needs of
19 schools and 4,000 parents were expected to take part in the survivors and post disaster situation. Close liaison, co-
the activities in 2005 and 2006. With the acceptance of operation and networking with governmental and NGO's
this methodology by the National Institute of Education involved in relief, rehabilitation, reconstruction and
in the aftermath of the tsunami, the manual was then development work was attempted (Fig. 5). The network
translated into Sinhalese and distributed to all schools was used to refer needy survivors for relief, socio-eco-
nationally. However, the whole programme collapsed nomic rehabilitation, legal aid, shelter, nutrition, water
when the Danish Red Cross decided to pull out of Jaffna and sanitation, human rights, protection and other assist-
after the resurgence of the war in 2005–6. A similar Class ance (For recommended guidelines see IASC [25]).
Based Intervention (CBI) developed by Robert Macy and
colleagues at the Centre for Trauma Psychology, Boston A holistic integrated approach was advocated with Gov-
using structured play activityover 5 weeks for15 sessions ernmental and Non Governmental aid agencies empha-
where 1455 students from 30 schools underwent this pro- sising the need for planning that included due
gramme from 2004 to 2007. consideration for the psychological processes that pro-
mote individual, family and social healing, recovery and
Psychological and socio-dramas can go a long way in cre-
ating awareness about trauma among the public and help
traumatized individuals to ventilate their emotions or
seek treatment. A few such dramas were produced in the Governmental
Non-Governmental
Organizations Community Based
Northern Sri Lanka. There were also attempts in the north Organizations
(GO)
1.
(NGO)
(I)NGO
Organizations
(CBO)
to use drama and street plays as well as art to work with Educational sector
School, Teacher,
2. (L)NGO
Private institutions
children affected by the tsunami [103].
Religious &
Spiritual
Sector
Rehabilitation Health Sector
Primary Health care
Attempts were made to rebuild social networks and sense Disaster Survivors
Traditional
of community by encouraging and facilitating formation Healing
of organizations, rural societies, schools and the like. Judicial System

Social mobilization was promoted by tapping local Human Rights
External
Family
resources, re-establishing traditional relationships, prac-
Village
Family
tices and engendering leadership from among the com- Resources
Village Leader,
Father, Mother, Media
Information
Non-State
Actors
Sister, Brother
munity. For example, a local widow from Chavatkadu Elders, Midwife
who was trained as a psychosocial worker became the

head of the their widow's organization, Tharaka, and was Figureorganizations
Networking
mental 5 – working with governmental and non-govern-
later nominated for the Nobel prize in 1985 with 1000 Networking – working with governmental and non-govern-
other leading women worldwide for their services by an mental organizations.
international women's group [104].
Page 22 of 27
integration. Such programmes were encouraged to take as the one doing the construction, channelling the aid,
into account the wishes of the local population con- receiving credit and legitimacy. Co-operation with the
cerned, that they be given an active and deciding role political forces on the ground was the only realistic option
rather than a dependent, 'victims' role, as it promotes their available and the route taken by the GO's, NGO's and
overall sense of participation and thus their eventual psy- INGO's. But, ultimately political and military priorities
chological recovery. To avoid this, emergent self-help such as recruitment took precedence. Independent social
groups and local leadership were encouraged to resume activity, particularly beyond a critical, effective level car-
traditional and habitual patterns of behaviour, re-estab- ried an intrinsic risk. Thus, in such situations, workers
lish social networks and community functioning at the need in addition to cultural competency, political compe-
grass root level [105]. The local skills and resources were tency as well. Every act takes on a political significance.
tapped and utilized, which gave the community a sense of Tragically, even the post Tsunami rehabilitation process
accomplishment and fulfilment in the recovery process. and programmes became political. Unlike in Aceh, an
Provision for the non-partisan cultural working through opportunity for addressing a humanitarian need in an
of the shared traumatic experience in the form of periodic equitable, neutral way to build trust and faith in peaceful
reminders of the loss and reiteration of its meaning, and rehabilitation to bring warring parties together was lost.
of the heroism of those who suffered expressed in media,
arts, public works, monuments, and occasions of public Prevention, policy, planning
mourning were encouraged as they have been found to be Tragically, much of the deaths and destruction caused by
useful in post disaster situations [106]. For example, after natural disasters can be avoided. This is even truer for the
the tsunami, affected schools were encouraged to have man made disaster that is war. Ahimsa, peaceful coexist-
regular ceremonies to commemorate those who died, to ence, conflict resolution, reconciliation and other values
have pictures, flowers and candles for the students who were advocated and passed on wherever possible. How-
had died and support was sought for communities which ever, it is sobering that despite all this effort and training,
sought to build memorial structures at sites of mass buri- the country has once again returned to full scale hostilities
als where public gatherings, meetings and religious cere- since December of 2005.
monies will allow for communal release of feeling, review
and coming to terms with the collective trauma; socially Just as the consequences of disasters must be addressed on
define and interpret their experiences, as well as re-estab- both community and family levels, so must plans for pre-
lishing social relationships and planning for the future. It venting or mitigating their impact. In fact, there should be
has been found that sites where mass trauma has occurred plans at the local, district, provincial, national, regional
become sacred, imbibed with community meaning [107]. and international levels for disaster preparedness and
However this was not always allowed in the charged polit- emergency response because many disasters affect multi-
ical situation that prevailed in these areas. For example, in ple communities, nations or regions. Such plans are typi-
the coastal villages of Maruthernkerny where 901 people cally formulated by committees at the appropriate level
out of a local population of 16,153 died due to the tsu- and may involve collaborative efforts between formal
nami, there had been hasty burials in mass graves. As a emergency management agencies, public health and other
method of consoling the traumatic grief of the surviving agencies, and citizen groups. Small steps were taken in for-
family members, attempts to build memorials at these mulating disaster plans.
sites where people could visit, grieve, remember and per-
form rituals were consistently blocked. Another area of intervention was at the national, regional
and district levels by influencing policy making, rehabili-
In the polarized and totalitarian political situation with tation and international aid programmes. Memberships
competing loci of power and parallel governments, com- at various committees at the local, district, regional and
munity organization, mobilization and empowering was national levels provided the opportunity to make some
only allowed to proceed up to a point. When the organi- contribution towards prevention and alleviation of the
zation or mobilization started to become effective, politi- effects of individual and collective trauma. The problems
cal forces took over, infiltrated or interfered in the process. of putting psychosocial and mental health concerns on
In the Tamil areas no independent large scale organiza- the agenda and the general stigma associated with mental
tion or activity was allowed. Perhaps it was taken as a chal- health were quite evident at these committees. Although
lenge to the existing social arrangements, control, there was wide acceptance of psychosocial problems due
dispensation, and loyalties. More than the state, it was the to the Tsunami and there were considerable effort to
Tamil militants who were very sensitive to such activity address these by the state, militants, NGO and INGO sec-
and became very efficient in organizing and implement- tors; the state is still to accept or take responsibility for the
ing relief, rehabilitation and development programmes. psychosocial problems arising from the war. As such it
There was a need for the political organization to be seen was left to INGO and local NGO's to carry out psychoso-
Page 23 of 27
cial interventions and programmes. Unfortunately many DSM – Diagnostic and Statistical Manual
of these internationally supported programmes and struc-
tures tended to collapse when the funding stopped or G.A. – Government Agent (District Administrator)
INGO's pulled out. The local partners and government
were not able to maintain the momentum. This raises the G.O. – Governmental Organization
question of long term sustainability. The national dis-
crimination, inequity in distribution of resources and pro- G.S. – Gramma Sevaka (Village Headman)
grammes, and exclusion of the North and East continued
to be insurmountable hurdles [108]. GTZ – German Technical Cooperation
Conclusion IASC – Inter Agency Standing Committee

The effects of disasters, particularly massive, chronic trau-
mas go beyond the individual to the family, community INGO – International Non-Governmental Organization
and wider society. Social processes, dynamics and func-
tioning can be changed fundamentally by disasters. In the LTTE – Liberation Tigers of Tamil Eelam (dominant Tamil
aftermath of war some of the community level changes militant group)
included mistrust, suspicion, silence, brutalization, deteri-
oration in morals and values, poor leadership, depend- N.S.L – Northern Sri Lanka
ency, passiveness and despair. It maybe important to
recognize the manifestations of collective trauma, so that NGO – Non-Governmental Organization
effective interventions that is effective at the community
level can be used in these complex situations. Community PTSD – Posttraumatic Stress Disorder
approaches that were found useful in rebuilding commu-
nities in Northern Sri Lanka were creating public aware- SCF – Save the Children Fund
ness, training of grass root workers, encouraging
traditional practices and rituals, promoting positive fam- SSRI – Selective Serotonin Reuptake Inhibitor (Anti
ily and community relationships and processes, rehabili- depressant)
tation and networking with other organizations.
UNDP – United Nations Development Program
Limitations
This was only a phenomenological study of collective UNHCR – United Nations High Commission for Refugees
trauma. There are obvious limitations to dispassionate sci-
entific study due to the ongoing war situation. The case for UNICEF – United Nations International Children Emer-
collective trauma was merely described, no random con- gency Fund
trolled trials were conducted nor the outcome of the com-
munity interventions collected in a systemic way. The WHO – World Health Organization
evidence base for the efficacy of psychosocial interven-
tions in a post disaster situation is still lacking and only Competing interests
guidelines have emerged from humanitarian work carried In terms of conflict of interest, the author subscribes to a
out so far [25]. Operational criteria for the syndrome of pacifist persuasion, contrasting with the militant/military
collective trauma and the evidence for best practice in fervour of the authorities in power. This has added a con-
these complex situations will need to be established siderable targeted risk factor, particularly in Northern Sri
through further studies. Lanka, apart from the general uncertainties (terror) of
these contexts. The author has been the originator and
Abbreviations organizer of various social and humanistic programmes in
APA – American Psychiatric Association the region including child rights, women affected by
domestic violence, human rights and traditional yoga.
BECAre – Basic Education for Children in Disadvantaged This has involved considerable public advocacy and cam-
Areas paigns, the tone of which colours much of the author's
writings. The author believes with many other health
CBO – Community Based Organization workers [3,28,29] that there can be no neutral position in
these extreme situations.
CBT – Cognitive Behavioural Therapy
CSO – Community Support Office
Page 24 of 27
Authors' contributions 14. Van de Put WACM, Eisenbruch M: The Cambodian Experience.
In Trauma, War and violence: Public mental health in sociocultural context
The author was directly involved in all aspects of this Edited by: de Jong JTVM. New York: Plenum-Kluwer; 2002:93-155.
study from the initial participatory observation, analysis 15. Bronfenbrenner U: The ecology of human development: experiments by
and documentation. He was either directly responsible for nature and design Cambridge, Mass.: Harvard University Press; 1979.
16. Hobfoll SE: Stress, culture, and community: the psychology and philosophy
the specific studies described or functioned in an advisory of stress New York: Plenum Press; 1998.
or supervisory capacity. The author takes responsibility for 17. Dalton JH, Elias MJ, Wandersman A: Community psychology: linking indi-
the conclusions and views expressed here. viduals and communities 2nd edition. Belmont, Calif.: Thomson
Wadsworth; 2007.
18. Somasundaram DJ, van de Put W, Eisenbruch M, de Jong Joop : Start-
Acknowledgements ing Mental Health Services in Cambodia. Soc Sci Med 1999,
I wish to acknowledge colleagues and co-workers for without them the 48:1029-1046.
19. Vickery M: Cambodia: 1975–1982 Boston, MA: South End Press; 1984.
ongoing work in Northern Sri Lanka would not have been possible nor the 20. Hoole MRR, Somasundaram DJ, Thiranagama R, Sritharan K: Broken
observations recorded here. Sivayokan and Canagarathanam always Palmyra 1990 [http://www.uthr.org/BP/Content.htm]. California: Sri
worked closely with the author as did the psychiatric units at Tellipallai, Lanka Studies Institute
Jaffna, Point Pedro, Killinochi, Vavuniya and Mannar. The Multidisciplinary 21. World Health Organization: Mental Disorders: Glossary and Guide to
their Classification in Accordance with the Ninth Revision of the Interna-
Team in these units and Shantiaham were the back bone of the psychosocial tional Classification of Diseases, Tenth revision (ICD-10) Geneva: WHO;
interventions in these disaster situations. Many colleagues around the globe 1992.
have been very supportive of our work and constructively commented on 22. Jeyanthy K, Loshani NA, Sivarajini G: A study of Psychological
earlier versions of this paper. They include Sambasivamooorthy Sivayokan, Consequences of Displacement on Family Members. In MBBS
thesis University of Jaffna, Dept. Of Community Medicine; 1993.
Rachel Tribe, Anula Nikapota, Mark van Ommeren, Willem van de Put, 23. Sphere Project: Sphere Handbook-Humanitarian Charter and Minimum
Joop de Jong, Ken Miller, the late Robert Barrett, Michael Roberts, Helen Standards in Disaster Response, Revised Edition 2004 [http://
Herrman, Norman James, Harry Hustig, Beverley Raphael, Derrick Silove, www.sphereproject.org/handbook]. Oxford, Oxfam Publishing
Johan Schioldann, Rajan Hoole, Ted Lo, Arun Ravindran, Jack Saul, Nancy 24. Department of Mental Health and Substance Dependence, World
Health Organization: Disaster Mental Health-Mental and Social Aspects
Baron, Jeannine Guthrie, Gaithri Fernando, Ananda Gallapati, Wietse Tol,
of Health of Populations Exposed to Extreme Stressors Geneva: WHO;
Clare Pain, Elisabeth Schauer, Thomas Elbert and many others. 2003.
Naguleswaran (Babu) drew Fig. 3, Creating Child Soldiers, Vijeyashankar 25. Inter-Agency Standing Committee: IASC Guidelines on Mental Health
prepared Tables 5 and 6, Rathakrishnan the figures and Anavarathan was and Psychosocial Support in Emergency Settings Author: Geneva; 2007.
helpful in the analysis of the post-tsunami data. Institutionally, the University 26. Tribe R: A Critical Review of the Evolution of a Multi-level
Community-based Children's Play Activity Programme Run
of Jaffna and Shantiaham provided the base and facilities for carrying out this by the Family Rehabilitation centre (FRC) Throughout Sri
study. The University of Adelaide, particularly the Glenside Campus and Lanka. Journal of Refugee studies 2004, 17:114-135.
Barr-Smith Library, provided the visiting Fellowship and excellent facilities 27. Tribe R, Family Rehabilitation Centre Staff: Internally Displaced
to carry out the literature survey and collaborative work to produce the Sri Lankan War Widows: The Women's Empowerment Pro-
gramme. In The Mental Health of Refugees: Ecological approaches to
paper. The Scholar Rescue Fund based in New York bestowed the Fellow- Healing and Adapt ion Edited by: Miller K, Rasco L. New York: Law-
ship and timely assistance to leave the disturbed northern province on my rence Earlbaum; 2004:161-168.
sabbatical leave to Adelaide in Australia. 28. Armenian HK: Perceptions from Epidemiological Research in
an Endemic War. Soc Sci Med 1989, 28:643-647.
29. Zwi A, Ugalde A: Towards an Epidemiology of Political Vio-
References lence in the Third World. Soc Sci Med 1989, 28:633-646. See also
1. Green BL, Friedman MJ, de Jong JTVM, (eds): Trauma interventions in whole special issue of Soc Sci Med 1989, 28 (7): 631–767.
war and peace: prevention, practice and policy New York: Kluwer/Ple- 30. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL: Global
num Press; 2003. and regional burden of disease and risk factors, 2001: sys-
2. Green BL: Psychosocial Research in Traumatic Stress: An tematic analysis of population health data. Lancet
Update. J Trauma Stress 1994, 7:341-362. 2006:1747-1757.
3. Herman JL: Trauma and Recovery London: Pandora; 1992. 31. Durkheim E: Suicide Trans Edited by: Spaulding JA, Simpson G. Illinois:
4. De Jong JTVM, Komproe IH, Spinazzola J, van der Kolk B, van Free Press; 1951.
Ommeren M: DESNOS in four post conflict settings: cross-cul- 32. Frankl V: Man's search for meaning: An introduction to logotherapy Bos-
tural construct equivalence. J Trauma Stress 2005, 18:13-23. ton: Beacon Press; 1959.
5. Nutt D, Davidson JRT, Zohar J, (Eds.): Post-traumatic Stress Disorder: 33. Erikson KT: In the Wake of the Flood London: Allen Unwin; 1979.
Diagnosis, Management and Treatment London: Martin Dunitz; 2000. 34. Erikson KT: Disaster at Buffalo Creek. Loss of communality at
6. American Psychiatric Association: Diagnostic and Statistical Manual of Buffalo Creek. Am J Psychiatry 1976, 133(3):302-305.
Mental Disorders (3rd Ed., DSM-111),(4 Ed., DSM IV), Washington: 35. Erikson KT, Vecsey C: A report to the People of Grassy Nar-
Author; 1980 1994. rows. In American Indian Environments-Ecological Issues in Native Amer-
7. De Jong JTVM: Public Mental Health and Culture: Disasters as ican History Edited by: Vecsey C, Venables RW. New York: Syracuse
a Challenge to Western Mental Health Care Models, the University Press; 1980:152-161.
Self, and PTSD. In Broken Spirits: The Treatment of Asylum Seekers 36. Milroy H: Australian Indigenous Doctors' Association (AIDA)
and Refugees with PTSD Edited by: John P Wilson, Boris Drozdek. submissions on the consultative document: Preventative
Brunner/Routledge Press, New York,; 2004:159-179. Healthcare and Strengthening Australia's Social and Economic
8. Geertz C: Local Knowledge New York: Basic Books; 1983. Fabric. 2005 [http://www.nhmrc.gov.au/consult/submissions/_files/
9. Flood G: The Tantric Body London: I.B. Tauris; 2006. 52.pdf].
10. Kostelny K: A Culture-Based, Integrative Approach. In A World 37. National Aboriginal and Torres Strait Islander Health Council:
Turned Upside Down-Social Ecological Approaches to Chilsren in War National strategic framework for Aboriginal and Torres Strait Islander
Zones Edited by: Boothby N, Strang A, Wessells M. CT, USA: Kumar- health context Canberra: National Aboriginal and Torres Strait
ian Press; 2006:19-37. Islander Health Council; 2003.
11. Hofstede G: Cultures and organizations: software of the mind 2nd edi- 38. O'Donoghue L: Aboriginal families and ATSIC. Family Matters
tion. New York : McGraw-Hill; 2005. 1993, 35:14-15.
12. Somasundaram DJ: Scarred Minds New Delhi: Sage Publications; 1998. 39. Nadew G: An epidemiological study of the relationship
13. Daniel VE: Fluid Signs-Being a Person the Tamil Way Berkeley: University between exposure to traumatic Events, Prevalence of Post-
of California Press; 1984. traumatic Stress Disorder and Alcohol Abuse in Remote
Page 25 of 27
Aboriginal Communities. In PhD thesis, Department of Psychiatry, 62. Somasundaram DJ: Addressing of Psychosocial Problems of Women in a
School of Medicine, Faculty of Health Science The University of Adelaide; war ravaged Society. People's Forum-Integration of Women in the Peace
2005. Process, University Of Jaffna, 8th – 9th Feb., 2003 [http://www.lines-
40. O'Shane P: The Psychological Impact of White settlement on magazine.org/Art_Feb03/Daya.htm]. University of Jaffna
Aboriginal People. Aboriginal and Islander Health Worker Journal 63. Human Rights Commission: Report of the Committee on Disappearances
1995, 19:24-29. in the Jaffna Region Colombo: Author; 2003.
41. Rosenbeck R: Impact of Posttraumatic Stress Disorder of 64. Jeyaraj DBS: An Overview of the "Enforced Disappearances" Phenomenon.
World War II on the Next Generation. J Nerv Ment Dis 1986, TamilWeek 2007 [http://transcurrents.com/tamiliana/archives/311].
174:319-327. 65. Shantiaham: Families of the Disappeared Jaffna: Association for Health
42. Denborough D, Koolmatrie C, Mununggirritj D, Marika D, Dhurrkay and Counselling, Jaffna; 2001.
W, Yunupingu M: Linking Stories and Initiatives: A narrative 66. Gunaratnam HR, Gunaratnam S, Somasundaram DJ: The Psychoso-
approach to working with the skills and knowledge of com- cial Effects of Landmines in Jaffna. Med Confl Surviv 2003,
munities. The International Journal of Narrative Therapy and Commu- 19(3):223-234.
nity Work 2006, 2:19-51. 67. Doney A: The Psychological After-Effects of Torture: a Survey of
43. Eisenbruch M: From Post-Traumatic Stress Disorder to cul- Sri Lankan Ex-Detainees. In Scarred Minds Edited by: Somasunda-
tural bereavement: Diagnosis of Southeast Asian Refugees. ram DJ. New Delhi: SAGE; 1998.
Soc Sci Med 1991, 33:673-680. 68. Oxfam: The tsunami's impact on women 2005 [http://www.oxfam.org/
44. Somasundaram DJ: Post Traumatic Responses to Aerial Bomb- en/files/bn050326_tsunami_women]. Oxfam Briefing Note. Oxfam
ing. Soc Sci Med 1996, 42:1465-1471. International
45. Landau L, Saul J: Facilitating Family and Community Resilence 69. Save the Children Fund: Rethinking the Trauma of War Edited by:
in Response to Major Disaster. In Living Beyond Loss Edited by: Bracken PJ, Petty C. London: Free Association Books; 1998.
Walsh F, McGoldrick M. New York: Norton; 2006. 70. Summerfield D: The Impact of War and Atrocity on Civilian
46. Ager A: What is Family? In A World Turned Upside Down-Social Eco- Populations: Basic Principles for NGO Interventions and a
logical Approaches to Children in War Zones Edited by: Boothby N, critique of Psychosocial Trauma Projects. In Relief and Rehabil-
Strang A, Wessells M. CT, USA: Kumarian Press; 2006:38-62. itation Network, Network paper 14 London: Overseas Development
47. De Jong Joop TVM: Public Mental Health, Traumatic stress and Institute; 1996.
Human Rights Violations in Low-income Countries: A Cul- 71. Machel G: Impact of armed conflict on children New York: United
turally Appropriate Model in Times of Conflict, Disaster and Nations; 1996.
Peace. In Trauma, War and violence: Public mental health in sociocultural 72. Council of NGO's Jaffna District: Socio Economic Degradation-Jaffna
context Edited by: Jong de Joop TVM. New York: Plenum-Kluwer; Peninsula, Author, Jaffna 1999.
2002:1-91. 73. National Peace Council, MARGA: Cost of the War. Colombo:
48. Miller K, Rasco L: An Ecological Framework for Addressing the National Peace Council; 2001.
Mental Health Needs of Refugee Communities. In The Mental 74. University Teachers for Human Rights (Jaffna): Exodus from Jaffna
Health of Refugees: Ecological Approaches to Refugee Mental Health 1995 [http://www.uthr.org/SpecialReports/spreport6.htm].
Edited by: Miller K, Lisa Rasco L. New York: Lawrence Erlbaum; Colombo: Author
2005:1-64. 75. Amnesty International: Sri Lanka Disappearances AI Index: ASA 37/08/
49. Silove D, Steel Z, Psychol M: Understanding community psycho- 86, London; 1986.
social needs after disasters: Implications for mental health 76. Baykai T, Schlar C, Kapken E: International Training Manual on Psycho-
services. J Postgrad Med 2006, 52:121-125. logical Evidence of Torture Istanbul: Human Rights Foundation of Tur-
50. Abramowitz SA: The poor have become rich, and the rich have key; 2004.
become poor: collective trauma in the Guinean Languette. 77. Somasundaram DJ: Short- and Long- Term Effects on the Victims
Soc Sci Med 2005, 61:2106-18. of Terror in Sri Lanka. Journal of Aggression, Maltreatment & Trauma
51. Bloom SL: By the crowd they have been broken, by the crowd 2004, 9:215-228.
they shall be healed: The social transformation of trauma. In 78. Straker G, Sanctuaries Team: The continuous traumatic stress
Posttraumatic growth: Positive changes in the aftermath of crisis Edited by: syndrome. The single/therapeutic interview. Psych Soc 1986,
Tedeschi RG, Park CL, Calhoun LG. Mahwah, NJ: Lawrence Erlbaum 8:48.
Associates, Inc; 1998:179-213. 79. Savundaranayagam T: Bishop of Jaffna urges Co-Chairs to pre-
52. Osterman J, de Jong JTVM: Cultural issues. PTSD: Science & Practice vail upon GoSL to open A9, implement CFA. TamilNet [http:/
– A Comprehensive Handbook in press. /www.tamilnet.com/art.html?catid=13&artid=20324]. 19 November
53. Somasundaram DJ: Psychiatric Morbidity Due to the War in Northern Sri 2006
Lanka, In International Handbook of Traumatic Stress Syndromes Edited 80. Partners: Sri Lanka: the Forgotten War. In World Mission Partners
by: Wilson JP, Raphael B. New York: Plenumm Publishing Corpora- Volume 11. Uniting Church, Australia; 1999:1, 14.
tion; 1993:205-258. 81. Haney C, Banks C, Zimardo P: Interpersonal dynamics in a sim-
54. Somasundaram DJ, Sivayokan S: War Trauma in a Civilian Popula- ulated Prison. International Journal of Criminology and Penology 1973,
tion. Br J Psychiatry 1994, 165:524-527. 1:69-97.
55. Neuner F, Schauer E, Catani C, Ruf M, Elbert T: Post-tsunami 82. University Teachers for Human Rights-Jaffna: Disappearances &
Stress: a Study of Posttraumatic Stress Disorder in Children Accountability 1999 [http://www.uthr.org/]. Colombo: author
Living in Three Severely Affected Regions in Sri Lanka. J 83. Aber JL, Gershoff ET, Ware A, Kotler JA: Estimating the Effects
Trauma Stress 2006, 19:339-347. of September 11th and other Forms of Violence on the Men-
56. VIVO [Victims' Voice]: Epidemiological survey of children's mental health tal Health and Social Development of New York City's
in the Vanni region Colombo: German Technical Cooperation; 2003. Youth: a Matter of Context. Applied Development Science 2004,
57. Somasundaram DJ: War Trauma and Psychosocial Problems: 8:111-129.
Patient Attendees in Jaffna. International Medical Journal 2001, 84. Seligman ME, Groves DP: Nontransient learnt helplessness. Psy-
8:193-197. chonomic Science 1970, 19:191-192.
58. Kleinman A: The Illness narratives: Suffering, healing and the human con- 85. Lifton RJ: Death in Life: Survivors of Hiroshima New York: Random
dition New York: Basic Books; 1977. House; 1967.
59. Somasundaram DJ: Using traditional relaxation techniques in 86. Erikson EH: Identity, Youth and Crisis London: Faber & Faber; 1968.
minor mental health disorders. International Medical Journal 2002, 87. Senthuran G, Somasundaram D: Child Abuse in the Context of War.
9:191-198. International Conference on Children Affected by Armed Conflict. Save the
60. Somasundaram DJ, Sovayokan S: Mental Health in the Tamil Community, Children, 1st-3rd October 2002. Colombo, Sri Lanka .
in English and Tamil, Jaffna: Shantiam 2001. 88. Catani C, Jacob N, Schauer E, Kohila M, Elbert T, Neuner F: War, Tsu-
61. Kumerandran B, Pavani A, Kalpana T, Nagapraba S, Kalamgagal T, nami and Domestic Violence – a dose effect of traumatic stress in Tamil
Thayanithi S, Sivashankar R, Somasundaram DJ: A Preliminary Sur- school children in Northern Sri Lanka European Conference on Trau-
vey of Psychosocial Problems of Widowhood and Separation matic Stress Studies, Croatia; 2007.
among Women in Jaffna. In Jaffna Medical Association 10th Annual 89. Somasundaram DJ: Abandoning Jaffna Hospital-Ethical and
Sessions [abstract] Jaffna. Sept. 4–6, 1998 Moral Dilemmas. Medicine, Conflict and Survival 1997, 13:333-347.
Page 26 of 27
90. Somasundaram DJ: Child Soldiers – Understanding the Con-

text. BMJ 2002, 324(7348):1268-71.
91. Save the Children: Situation report: Children affected by armed conflict in
North and East Sri Lanka Colombo: SCF; 1998.
92. Somasundaram DJ, Jamunanantha CS: Psychosocial consequences
of war – Northern Sri Lankan Experience. In Trauma, War and
Violence-Public Mental Health in Socio-cultural Context Edited by: De Jong
Joop TVM. New York: Plemum Press; 2002:205-258.
93. Somasundaram DJ, Rajadurai S: War and Suicide. Acta Psychiatr
Scand 1995, 91:1-4.
94. Assagioli M: Psychosynthesis, A Manual of Principles and Techniques New
York: 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 victims
of organized violence within primary health care of adults and children The
Netherlands: 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 1995–1995
Phnom Penh, Cambodia: Transcultural Psychosocial Organization;
1997.
97. Somasundaram DJ, van de Put W: Putting mental health in per-
spective. Bulletin of the World Health Organization 1999, 77:275-277.
98. World Health Organization, UNHCR: Mental Health of refugees.
Edited by: De Jong J, Clarke L. Geneva: WHO; 1996.
99. Sivayokan S, Mahendran K, Somasundaram D, (eds.): Child Mental
Health, Revised edition, In English, Tamil and Sinhalese, Colombo: GTZ-Plan
International 2005.
100. Schauer M, Neuner F, Elbert T: Narrative Exposure Therapy (NET). A
Short-Term Intervention for Traumatic Stress Disorders after War, Terror,
or Torture Gottingen: Hogrefe & Huber; 2005.
101. Basic Education for Children in Disadvantaged Areas: Impact Study of
Counsellor Training Vavuniya: Author; 2003.
102. Mahendran K, Somasundaram D, (eds.): Joyful Living, In Tamil, English &
Sinhalese, Trincomalee: GTZ/Becare-Shantiam 2003.
103. Sivathas S: Nalamudan (Tamil) Colombo: Nihari; 2005.
104. 1000 peace women [http://www.1000peacewomen.org/typo/
index.php?id=14&L=1&WomenID=1046]
105. Raphael B: When Disaster Strikes Hutchinson, Australia; 1986.
106. Kinston W, Rosser R: Disaster: Effects on Mental and physical
state. J Psychosom Res 1974, 18(6):437-456.
107. Tumarkin M: Traumascapes. Melbourne: Melbourne University
Press; 2005.
108. Somasundaram DJ: Health and Human Rights in the Jaffna Peninsula.
Report for the Regional Committee in Jaffna, Human Rights Commission of
Sri Lanka, Colombo 2005.
Publish with Bio Med Central and every

scientist can read your work free of charge
"BioMed Central will be the most significant development for
disseminating the results of biomedical researc h in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:

available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central
yours — you keep the copyright
Submit your manuscript here: BioMedcentral

http://www.biomedcentral.com/info/publishing_adv.asp
Page 27 of 27

International Journal of Mental Health Systems

Uploaded by

Copyright:

Available Formats

International Journal of Mental Health Systems

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

International Journal of Mental Health Systems

Uploaded by

Copyright:

Available Formats

How does the study characterize the effects of war on families and communities in Northern Sri Lanka?

How does the study characterize the effects of war on families and communities in Northern Sri Lanka?

What community level interventions were tried to address the effects of the war?

What community level interventions were tried to address the effects of the war?

International Journal of Mental

Health Systems BioMed Central

Research Open Access

Published: 4 October 2007 Received: 16 March 2007

Background sequelae. These could range from adaptive and construc-

Dimensions Causes Symptoms Diagnosis Interventions

80° 80°30' 81°

SRI LANKA KaraKankesanturai

Medawachchiya Horuwupotana Trincomalee

Kalpitiya NORTH CENTRAL Kathiraveli

Matugama Pelmadulla Rakwana Telulla

Map No. 4172 Rev. 1 UNITED NATIONS Department of Peacekeeping Operations

diagnosed as having psychiatric disorder using western

A further problem is how effective or appropriate are west-

Table 2: Distribution of war stress in the community

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

In these circumstances of recruitment of children, Tamil

State, and partly because of the general social deteriora-

Table 5: Steps for community based psychosocial work

Step Title Description

-Vijayashankar, PSW Trainer, Shantiaham

Consequent to the Tsunami of Dec. 2004, the WHO Expressive methods

Table 6: Essential psychosocial interventions

Individual Family Social

Case identification Psycho education Awareness

-Vijayashankar, PSW Trainer, Shantiaham

of organizations, rural societies, schools and the like. Judicial System

who was trained as a psychosocial worker became the

Conclusion IASC – Inter Agency Standing Committee

CSO – Community Support Office

90. Somasundaram DJ: Child Soldiers – Understanding the Con-

Publish with Bio Med Central and every

Your research papers will be:

Submit your manuscript here: BioMedcentral

You might also like