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INFORMATION MANUAL 2

PSYCHOSOCIAL CARE by COMMUNITY LEVEL HELPERS for SURVIVORS
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INFORMATION MANUAL 2

RIOTS
PSYCHOSOCIAL CARE by COMMUNITY LEVEL HELPERS for SURVIVORS

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INFORMATION MANUAL 2

RIOTS
PSYCHOSOCIAL CARE by COMMUNITY LEVEL HELPERS for SURVIVORS
Prepared by: Dr K Sekar – M A, PhD* Senior Consultant Ms Antara Sen Dave – M S W, M.Ed* Consultant Mr Subhashis Bhadra – M S W, M Phil.,** Psycho Social Programme Co-ordinator Mr G P Rajashekar – M A** Social Worker Dr K V Kishore Kumar – DPM*** Senior Psychiatrist Dr R Srinivasa Murthy – M D*** Professor of Psychiatry

*ACTIONAID INDIA, **OXFAM INDIA, ***NIMHANS

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INFORMATION MANUAL 2

RIOTS
PSYCHOSOCIAL CARE by COMMUNITY LEVEL HELPERS for SURVIVORS

Published by BOOKS for CHANGE (A Unit of ActionAid Karnataka Projects) 139, Richmond Road Bangalore – 560 025 Ph: 080-5586682 e-mail: bfc@actionaidindia.org

Edition: First, 2002

Copyright © Aman Samudhay

www.actionaidindia.org www.oxfamindia.org www.indiadisaster.com

This document may be freely reviewed, abstracted, reproduced or translated, in part or in whole, purely on a non-profit basis. We welcome receiving information of its adaptation or use. The opinions, analysis and recommendations expressed in this document are solely the responsibility of the authors.

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CONTENTS
Preface Acknowledgements Events in Gujarat Impact on the People Psychosocial Support Understanding Psychosocial Needs Role of a Community Level Helper Psychosocial Interventions Principles Individual Family Community Special Groups Referral Self Care Riots and the Community vii viii 1 4 8 11 24 27

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Dedicated to the Survivors of the 2002 Gujarat Riots

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PREFA PREFACE
Riots pose a monumental challenge to the total community. Everyone who is exposed to the riots experience disruption of their life to varying degrees. Among the survivors, the most affected are people whose lives are disrupted more severely by the disaster. This includes those who have lost their home, experienced violence, lost their family members and community. For too long, psychosocial consequences have been neglected as a part of relief, rehabilitation and reconstruction. In India, starting with the Bhopal disaster in 1984, there has been a gradual acceptance of the need for psychosocial care. Long-term studies of psychological problems of disaster were studied in the Bhopal population as well as the survivors of Marathwarda earthquake. Both of them demonstrated that there is higher emotional illnesses even years after the disaster. For the first time, following the Orissa Super cyclone a programme of psychosocial care with community level workers (Snehakarmis) was implemented. This intervention demonstrated the nature of the needs of the vulnerable groups, the possibility of community level workers to provide care and the effectiveness of such care. In a way, the Orissa experience established a new approach to psychosocial care. Every disaster is similar and different in a number of ways. The riots of Gujarat and what it means for the survivors and the approach to psychosocial care is the scope of the current manual. This manual differs from earlier efforts. It outlines the anger, anguish and betrayal felt by the survivors and normalisation of their emotions. The approaches outlined are totally based on extensive field work, the initial experiences of the Aman Pathiks in providing care and the observations of the mental health professionals to provide support and supervision. The rebuilding of people, reconstruction of not only of shelters and livelihood but of the Human Spirit is the challenge. This Manual works towards that goal. We sincerely appreciate the contributions of all of the authors. The Aman Pathiks, the People of Gujarat who shared their personal lives and the Aman Samuday team in Gujarat. R Srinivasa Murthy Professor of Psychiatry NIMHANS Bangalore 560 029 Harsh Mander Country Director ActionAid India New Delhi 110 049 vii

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CKNOWLEDGEMENT ACKNOWLEDGEMENT
We would like to take this opportunity to thank all the people who helped to enrich this manual in varied ways. While it may not be possible to acknowledge them all here, we would like to start by extending our gratitude to the Aman Pathiks (their names have been listed in p. 56) without whom none of this would have been possible. They have been with us constantly through the entire process, right from the start during training to adding valuable insights from the field. They continue to be our learnings. We gratefully acknowledge the people and the organisations associated with the Citizens Initiative without whom the peace movement would not have been possible. Our special thanks to Aman Samudaya supporters, Fr Victor Moses r. j. of St Xavier’s Social Service Society, Mira Maleek of Centre for Development, Mishra of Kamdhar Swasthya Seva Mandal, Rajendar of SAATH who braved the riotous situation and brought in the volunteers to be shaped up as Aman Pathiks. A warm rememberance on the sensitivities of Brinda Nanavati of Shantikumar Trust and Sushma J Pucadyil of INTACH. Sonal of Eklavya Foundation and Wilfred of INSAF. Specific mention is to Amar Jyoti Naik and Supriya of ActionAid India and M G Sriramappa and Dr P V Unnikrishnan of Oxfam India for all their commitment to actualise psychosocial care component in the normalization process of the riot victims. There have been others who have given their time through discussions and review of our material and we would like to thank them too: Fr. Jimmy Dabhi, Prasad and Persie Ginwille of Behavioural Science Centre, Kiran Patel, Consultant/Trainer from Oakland, C. Balaji Singh of CARE, Binoy Acharya of Unnati, Swaroopaben of St. Xavier’s College, Dr Darshan Trivedi, Dr Chandraguptsanan and Prof. Vankar of Department of Psychiatry, Civil Hospital, Ahmedabad. We also place on record the service support provided by Dr Ajay Chauhan, Medical Superintendent, Institute of Mental Health and his team. We would like to acknowledge the support and guidance of our colleagues at Action Aid India, Gujarat Regional Office - Javeed, Mahesh, Hiren Gandhi, Bina Srinivasan, Beena Jadhav and Raju. From Action Aid India Country Office, Delhi - Sandeep Chachra, Damodaram Kuppuswami, Jeroninio Almedia, Anurag, Sunil Sharma and Shabir Ali from Action Aid, Bangalore office. Mr Bhurelal is specially remembered for his logistical support. Christy Abraham, Sunitha Singh, Sujatha and Seetharam of Bangalore Regional Office for facilitating the requirements. Special thanks are also due to all the volunteers from Andhra Pradesh, Rajasthan, Patna region who actively gave feedback about the psychosocial needs in various camps and the Aman Pathiks. Sriram and Somnath, the volunteers in action. The diligent and meticulous work of Shoba Ramachandran, Rajeev, Gokul, Shailaja of the Books for Change deserve special mention for the effort and time devoted to this work. We would like to thank Suresh for the excellent illustrations. July 2002. THE AUTHORS

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EVENTS IN GUJARAT
E VENTS AND CHALLENGES AHEAD
The state of Gujarat was torn apart by savage sectarian violence, possibly the most brutal since Independence. This carnage has convulsed the state of Gujarat in over four months since 27 February 2002 and left a trail of profound human tragedy. The violence has resulted in the death of nearly 1000 persons, many of them women and children. It targeted a large number of women and girls with rape and sexual violence. Many others were injured and disabled. Houses and commercial establishments were looted destroyed and charred to the ground across the state, resulting in mass destruction of livelihoods and displacement of people. Thousands of people, mostly from the minority community, were rendered homeless. Places of worship of the minority community were specifically targeted. In the immediate aftermath of the violence, there were at least 100,000 women, children and men in the 103 relief camps in Ahmedabad. An estimated 50,000 people were in similar such camps across the state in Gujarat. Having lost everything they once had, people were condemned to live as internal refugees on their own land, often in their own cities. The media has depicted very clearly that even after three months of their world being devastated, survivors subsist in makeshift camps in schools, darghas or graveyards. ‘The monumental pain, loss, betrayal and injustice suffered during the riots’, ‘the depth of anger and longing for revenge’ and ‘the wounds may not heal for generations’, document the intensity of the psychological scar in the minds of the survivors. Very little was done even to meet the basic survival needs of the people who were economically and socially displaced. There is also little evidence of significant state or civil society efforts for long-term rehabilitation of the survivors of mass violence. Currently there seems little hope visible even in the distant horizon for the survivors of the mass violence, including for those in the remaining camps. Communal hatred has been actively fostered in Gujarati society in recent decades, with ghettoisation in towns and cities, and deep distrust infecting the countryside.
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The media reports: ‘Trauma haunts children’, ‘crying need for the healing touch’, ‘practising meditation to come out of their mental depression’, ‘share the responsibility to assuage, heal and rebuild’, ‘social organisations bound together to heal’. These statements very clearly indicate that the impact of the recent riots in Gujarat on the affected people is not only a reality but also widely recognised.

C HALLENGES AHEAD
It is against this grim scenario that any strategy for relief, rehabilitation and reconciliation in Gujarat needs to be positively considered. Following are the main challenges that confront the government and indeed the entire nation:
q

Ensuring that people living in the relief camps have access to
x x x

x

x x q

Regular food supplies, especially for infants and children Additional sets of clothes and allowance for daily expenses Sanitation, drainage, toilets and clean drinking water, all vital to protect public health, are especially endangered during the monsoons Public health interventions like immunisation, preventive health care in terms of monitoring expectant mothers and people suffering from tuberculosis Heat and rainproof shelters Child care and education facilities and support.

Ensuring access to basic entitlements in terms of their compensation, government schemes and credit institutions so that they can rebuild their homes and livelihood back to the same levels as before the riot
x

There are hurdles in the way of families accessing the special welfare schemes meant for them in terms of relief grants, compensation, housing, livelihood, etc. By now the Gujarat Government has issued at least ten Government Orders. However, information on these orders is not accessible to the survivors since it is either not readily available, or complicated in explaining procedures and not survivor friendly. Hence the urgency lies in the need for support to enable community groups to access compensation, relief and rehabilitation packages meant for them so that they can rebuild their homes and livelihood to a certain extent.

q

Ensuring livelihood reintegration
x

Majority of the riot victims living in the camps have no personal support base to fall back on. People have lost their jobs, their means of livelihood and their small investments. There is need to rebuild livelihoods of people based on their earlier vocations and their own choice. This would require the mobilisation of enormous resources of the government, financial institutions, aid agencies and private sector.
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Ensuring legal rights and social justice to the riot survivors, including filing of FIRs, investigation and contesting cases in the court.
x

Legal aid is essential for the riot victims because in many cases FIRs have not been registered. Also in several cases, entire families have been wiped out and no one or sometimes no responsible person is left to file the claims. All these make the riot victims feel very vulnerable and demoralised. They need a lot of moral support and confidence building. For them to even be able to think of taking legal action against the perpetrators is a big step.

q

Providing psychosocial counselling and support for dealing with loss, betrayal and anger.
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In the post-riot phase the victims are unable to come to terms with their loss, feelings of betrayal and anger. The fact is that whoever witnesses/experiences a riot is traumatised to various degrees. Also responses vary from one another and manifestations change with time. However, if any of these are unattended, it can lead to serious mental health problems. Thus preventive measures such as psychosocial support is needed. Psychosocial support to individuals, children and women in particular and communities in general enable them to relieve the trauma. It also helps and guides them to locate the various support systems available, along with rebuilding their hopes and self-esteem.

q

Community based care/rehabilitation for widows, orphans and those who are physically disabled by burns The specific population at risk subsequent to the riots is the women who were raped, persons with burn injuries, widows, orphans, physically handicapped and the uncared aged. Long-term community based care/rehabilitation activity needs to be initiated for these groups.

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Actively rebuilding a culture of communal harmony and trust There is a need for active resistance to communal violence and divisive ideology. Campaigns for communal harmony which are culturally relevant need to be carried out for the entire community with a long-term perspective to resist the prevailing social boycott of the minorities, such as not renting out houses to them, lawers refusing to fight their cause, not employing in their establishments and overcoming `borders’ in the mindset, like ‘their’ area and ‘our’ area.

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IMPACT ON THE PEOPLE
Any human-made disaster leaves people with a great sense of betrayal, ripping apart the social fabric that is essential for any person’s sense of well-being. The deep hurt and anguish caused by the loss of human life, as well as the disruption of daily living are far more difficult to overcome than when in a natural disaster. In riot affected areas, as in other major disasters, emotional reactions like anger, betrayal, irritability and revenge are common among the people living in camps or the people who are indirectly affected or living under threat. Along with relief, rehabilitation and care of physical health and injuries, emotional needs have to be given priority. This in the long run ensures rebuilding of confidence and peace. While rebuilding the affected areas will take a period of time and require sustained effort, what should be prioritised is essentially providing long-term wholistic care for the affected population. In order to take care of the emotional needs of the riot-affected people, five major challenges need to be considered:
q

q q q

q

Severe stress and trauma due to the riots. Sudden forced displacement. Difficulties of living in the camps. Uncertainty about the future and continuation of threat. Process of rebuilding personal, family and community life.

The socio-economic impact, like the lack of employment, homelessness, environmental destruction and disorganisation emerges as a consequence following the devastation. Disaster-affected people show various kinds of reactions. Emotional reactions immediately follow the event. The following page illustrates some of the responses of affected persons.

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Physical impact Stomach-aches, Diarrohea, Headaches, Body aches, Burns (heat, acid), Physical impairments (limbs, sight, voice, hearing), Injuries (bullet, sharp objects and others), Fever, Cough and Cold, Miscarriage, Physical Assault.

Emotional reactions Anger, Betrayal, Irritability, Revenge-seeking, Fear, Anxiety, Depression, Withdrawal, Grief, Addiction to pan masala, cigarette, beedi, Drug abuse.

Repeated thoughts about the disaster and related events

Worry

Socio-economic impact Loss of trust between communities, Lack of privacy, Single parent families, Widows, Orphan state with loss of both parents, Discontinuity in educational plans.
Loss of employment

Homelessness Loss of handcart Disorganisation of life routines Migration

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It is important to note that all these reactions are inter-linked to one another. For example, due to loss of livelihood opportunities an individual may get depressed and feel helpless, or a physical injury may prevent him/her from work, thereby resulting in the loss of his/her source of income. Hence, an impact on the socioeconomic front causes emotional reactions in the first case, whereas in the second case, an impact on the physical aspect influences the socio-economic front. This clearly indicates that all the three areas are inter-linked. For appropriate and effective interventions it is very important to have a clear understanding of the emotional reactions to disasters. It is now clear that these reactions:
q q q q q

Are normal responses to an abnormal situation. Are common and universal. Are experienced by anyone who witnesses a disaster. Manifest differently at different periods of time after the disaster. Require rehabilitation and rebuilding over a long-term process.

After a disaster, the emotional reactions among members of a community vary and usually also undergo change over time. Therefore, post-disaster psychological interventions should be flexible and based on an ongoing assessment of needs. The emotional reactions should be understood based on the manifestation of various stress reactions, level of individual effort invested by the people for their own reconstruction, the pattern and degree of disability as a result of these psychological stress, etc. Some factors that could influence the reactions among people are:
q q q q q q q q q

q

Nature and severity of the disaster. Amount of exposure to the disaster. Availability of adequate social support. Age. Gender. Status of the person (single/widowed/married). Separation/displacement from locality. Separation from family/primary support group. Personal losses of the survivor (loss of kith and kin, property, source of livelihood, personal injury). Poor pre-disaster mental adjustment.

These factors would influence the coping abilities of individuals who experience a sense of loss that is unique to them, for example:
q q

a lady widowed 6 months after marriage. an elderly couple losing all their life’s savings.

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q q

a youngster losing all his/her family members. a family whose sole earning member is disabled.

P OINTS TO REMEMBER
➢ Need to consider and care for the emotional needs of the population. ➢ Impact of the physical, emotional and socio-economic aspects on the individual. ➢ Emotional reactions need to be recognised.

¡
depresssion anxiety

¡ ¡

looking ahead

reaching out/networking

Emotional reactions undergo change over time.

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PSYCHOSOCIAL SUPPORT
C OPING WITH EMOTIONS
The emotional reactions of anger, irritability, panic attacks, sleeplessness, withdrawal from others, anxiety attacks in adults and nightmares in children are universal responses of people experiencing events beyond their coping capacity in disastrous events like riots. The level of depression varies with the kind of torment they were forced to experience. Women who witnessed brutal killings and sexual harassment have high level of trauma. The aged, women, children and disabled people experience greater degree of emotional reactions. These reactions reported by the people are a normal response to an abnormal experience. It is important to recognise this so that people experiencing emotional reactions are not made to feel that they are weak or unable to cope in any way.

C OPING WITH LOSS
Loss due to the death of a near and dear one, separation from loved ones and material losses are an inseparable part of human existence. Under normal circumstances, everyone goes through this process without much difficulty because the family and relatives come together to share the loss. Support from friends, relatives and neighbours occur automatically. Rituals are initiated soon after the death. For example, soon after a death in the family, arrangements are made for cremation, all the daily activities are temporarily suspended, prayers are offered to the deceased, and rituals are completed on a particular day by conducting the shradh / maiyat (rituals after a death) ceremony. All these help the individuals to understand the personal meaning of loss, come to terms with the changed situation and continue with their lives.

N EED FOR EXTERNAL SUPPORT SYSTEMS
As discussed above, after a traumatic incident, all acquaintances, friends, neighbours and relatives of the victims/survivors (both close and distant) have a definite role to help in recovery. However, in a disaster, the naturally available support systems and healing mechanisms are disrupted as most of the people are either themselves affected or incapable of providing such support. Hence, in a disaster situation, the existing social structure does not play the normal critical role in the healing process, because each individual in the area has been affected by the disaster. The family as a unit may no longer exist. For many this leads to a sense of isolation, helplessness and despair. The normal process of mourning and other related rituals do not occur automatically. In such cases, establishing a system of support by an external agency becomes important in order to help people who have been affected. 8
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Usually people who come from outside the community are doctors, lawyers, NGOs volunteers and such individuals, who in their own capacity contribute/donate food/ other basic essentials/money, and offer time and their skills and expertise. Along with them a group of volunteers, Community Level Helpers (CLHs), mostly from within the community come together and work towards rebuilding and rehabilitation in a comprehensive manner. Local Community Level Helpers (CLHs) have been seen to be more effective in providing psychosocial care and support to the affected people. Aman Samudaya is an example where the community level support system has been effective. The Aman Pathiks (CLHs) are part of a larger network of 30 NGOs, who have come together under the banner of ‘Aman Samudaya’ to work in the current situation. In the early stages following a disaster, most survivors are open and willing to talk about their experiences. As time goes by and with no help forthcoming, the survivors start withdrawing into a defensive, non-cooperative attitude. Therefore, it is of utmost importance that survivors are encouraged to seek help, share and talk about their emotional problems as early as possible, to prevent problems and development of further complications. In general, people do not readily/directly talk about their emotional problems. Even during visits to the health centres, they generally report physical problems. Emotional problems may be indirectly manifested as unidentifiable aches, pains, headaches, tiredness, etc. When given an opportunity, people do talk about themselves. It is important that the aid agencies be sensitive to the emotional needs of the affected population and provide them opportunities to talk and share their feelings. Rebuilding and Rehabilitation can take place with such sensitivity.

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MPORTANCE OF PSYCHOSOCIAL CARE

Emotional problems following disasters often tend to be neglected. This happens because they are relatively invisible when compared to the damage caused to life, physical health and property. It is important to remember that emotional problems occur very commonly. Distress is intense and leads to helplessness, isolation and apathy. Everyone who witnesses/experiences a disaster is affected by it. Hence, early identification of this problem, followed by intervention help the survivor to recover.

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It is important to realise that rebuilding of an individual’s life and reconstruction of the entire community following the disaster depend upon the survivor’s ability to accept the losses as early as possible. It will help him/her understand and emotionally accept the current reality and thereby work towards reconstruction of life both at the individual, family and community levels. An example: Let us take an analogy of a person with an injury. An injury to any part of the body will heal over a period of time because the body has the ability to repair the damage. The natural repair process takes some time. However, if the person gets immediate first aid for his injury (e.g., cleaning the wound with uncontaminated water and covering it with a sterile or clean cloth), the healing will be hastened, thereby gradually reducing the pain and discomfort. But on the other hand, imagine if the wound is unattended. The wound is likely to get infected and healing will be delayed, leaving a bad scar. This might even cause some limitation in the normal functioning of that part of the body. It is important to note that in both instances the scar remains.However, in the former, the scar is light and does not produce a limitation. In the latter, the scar is dense and produces a limitation for a long time. Similarly, any emotional reaction like anger, betrayal and pain due to loss and death requires help to facilitate ventilation or reliving. This works like the sterile cloth preventing infection, and allowing the body to work and heal. Non-availability of such help to release or share these emotions leaves a scar in the mind. Therefore, it is very important for people to share the pain, feelings and thoughts about personal losses.

P OINTS TO REMEMBER
➢ Proactive support and care is required to cope with loss. ➢ In a disaster, aid agencies need to play a supportive role in facilitating recovery among people. ➢ Psychosocial care is an important aspect of the rehabilitation process. ➢ Early recognition and intervention lead to better outcomes. 10
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UNDERSTANDING PSYCHOSOCIAL NEEDS
The need for community level helpers to take on the role of giving emotional support during such times becomes critical to help people in the recovery process. This section focuses on enabling the CLHs to understand the psychosocial needs of the people they would be working with in order to be able to give them emotional support.

P RINCIPLES FOR GIVING EMOTIONAL SUPPORT
The need for emotional support for riot-affected population is based on the following broad principles:
q

Everyone who witnesses/experiences the riots is touched by it. Disaster stress and grief reactions are normal responses to an abnormal situation. Anger, irritability, revenge, betrayal are very specific to riot situations. Disasters, depending on their nature and magnitude cause enormous loss to life, property and the environment of the area. Grief, sadness, anxiety and feelings of threat are common in such situations. Almost all individuals who are part of this event experience such reactions. Relief from stress, ability to talk about the experience and passage of time usually lead to the re-establishment of equilibrium. Individuals find comfort and reassurance when told that their reactions are understandable and very normal in such a situation. Public information about normal reactions, education on ways to handle them, and early attention to problematic symptoms can hasten recovery and prevent long-term problems. In this disaster a lot of anger outbursts and feelings of revenge were common, requiring special care and attention to reestablish peace and trust.

q

Disaster results in two types of trauma. The disaster-affected population has individual and collective trauma. Individual trauma manifests itself in stress and grief reactions, while collective trauma can severe the social ties of survivors with each other. These ties could provide important psychological support in times of stress. Hence, with the loss of these 11

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natural buffers in the community, mental health interventions, such as outreach, support groups and community organisations which seek to re-establish linkages between individuals and groups, become extremely essential.
q

Displaced living causes many problems Many emotional reactions of survivors stem from problems of living caused by the disaster. Disaster disrupts/displaces all aspects of daily life resulting in practical problems, like finding temporary housing, food, clothing, etc. Timely and appropriate relief and support measures are very vital to help survivors handle the disruption.

q

Disaster mental health services must be uniquely tailored to the communities they serve Mental health interventions should be based on the demography and characteristics of the population. It is also essential to consider the ethnic and cultural groups in the community so as to provide help in a manner which is culturally relevant, and in the language of the people. Hence, the emphasis is that such programmes are more effective when workers indigenous to the community and to its various ethnic and cultural groups are integrally involved.

q

Survivors respond to active interest and concern Survivors will usually be eager to talk about their experiences when approached with warmth and genuine interest. Workers should not hold back from talking with survivors out of any apprehension of intruding or invading their privacy.

q

Interventions must be appropriate to the phase of disaster It is of paramount importance to recognise different phases of the disaster, varying emotional reactions of each phase and the need for appropriate intervention strategies. In the initial phase, listening, supporting, ventilation, catharsis and grief resolution help, while in the latter phase handling frustration, anger and disillusionment becomes important.

q

Support systems are crucial for recovery The most essential support for individuals is the family. Attempts should be made to keep the family together and the members encouraged to be involved in each

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other’s recovery. For those who are orphaned or widowed or lone survivors, support from other groups are extremely important.
q

Attitude of the caregiver The caregiver (CLH) should avoid use of mental health labels like ‘neurotic’, ‘counselling’, ‘psychotic’, ‘psychotherapy’, etc., and use an active outreach approach to intervene successfully in the disaster. The caregivers need to be sensitive, non-judgemental and a confidante in all interactions with the survivors.

U NDERSTANDING THE EXPERIENCE OF STRESS
Survivor’s stress is the result of unpleasant experiences, inadequate living conditions, a sense of insecurity and a constant feeling of being under threat. Stress causes unhappiness and prevents people from doing useful work and may affect all areas of a person’s life. An individual suffering from stress and anxiety may not be able to talk about the stress directly but the existence of stress can be recognised through different symptoms such as:
q

Behavioural Symptoms Traumatic experiences cause a lot of stress, which is often beyond the coping capacity of an individual. The inability to cope effectively leads to symptoms in a person, some of which are manifested in his/her behaviour, such as:
x

Loss of interest in life Why should I be living anymore? What is the use of my life without my grandson and granddaughter? They should have killed me too.

x

Reduced activity, no energy There is nothing much to do here – just eat and then sit around. Now we are just living by name. It feels as if we have been reborn; the whole world has changed for us. My days just pass by. I do not know what to do. Earlier I used to do a lot of work. Now without doing much I feel very tired, my body aches, I cannot concentrate/focus on anything (‘mera maan nahin lagta’).

x

Overactivity and inability to rest (restlessness) I am not able to lie down for a minute. I need to do something or the other. My body is stiff. I am not able to sit or stand for a single minute.

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Difficulty in concentration Sitting in front of the kerosene stove reminds me of the fire. I am worried and preoccupied all the time. I keep making mistakes while cooking. I forget to put salt or chilly or other ingredients in the food.

x

Sleep disturbances and problem An aged man talks about his inability to have a restful sleep: If I start thinking about something, the whole night I lie awake.

x

Feel as though I cannot breathe The moment I enter my burnt house, I feel choking in the throat. I am not able to breathe at all inside my house.

x

Flashbacks A young boy saw his family members being killed and burnt alive in front of his eyes. Only his father was saved. At night he wakes up disturbed and crying and remembers the horrendous moment when he saw his mother trying to protect his brother from being killed and finally both of them were killed: I get up at night suddenly with the image of my mother throwing herself on my brother to save him, before they cut her up in two.

x

Taking intoxicants or drugs There is no work or any activity in the camp. Let me atleast keep munching paan masala. My child has also developed a liking for it.

q

Physical Symptoms Often people complain of bodily aches and pains, for which they visit a doctor. These symptoms do not have a physical cause. They are related to the emotional stress a person is undergoing. For instance, a headache can be due to both physical as well as emotional reasons. It is important to recognise and understand the kind of bodily symptoms that an individual experiences while under stress.
x

Headache My head aches all the time.

x

Tiredness I feel like just lying down.

x

Tense muscles My daughter is young and she got so scared that her whole body became stiff.

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x

Palpitation/irregular heartbeat Even now, if I hear some noise I get so alarmed as to what is happening. My heart starts racing (‘Mera dil tez dhadakta hai’).

x

Poor appetite, pain in abdomen, vomiting sensation I do not feel like eating; sometimes I do, otherwise I do not (‘Bhook nahin lagti, kabhi kha liya to khaya nahin to aise hi’).

x

Unidentifiable pain in arms, leg, chest or all over the body A woman who used to sell items on a handcart talks about her loss and the physical symptoms: I have lost everything; I do not know what will happen in future. I have an ache in my back and my arms. The medicines that the doctor has given do not seem to really help.

q

Emotional Symptoms A person who experiences stress will exhibit a lot of behavioural symptoms in his/her emotions. Emotional reactions are very apparent as they bring a distinct change in the survivor’s behaviour. It is important for us to identify and understand these manifestations as reactions to stress:
x

Anger We are not interested in your talk. You are the people who burnt our homes and now have come to soothe us. You are filling up forms; do you want us to get killed again? Why are you talking about peace to us? You need to talk to the people who committed these acts. Why do you come and what do you want to know? They could have killed all of us together rather than saying that they are taking us to a safe place and then hand us over to the killing mob. Next time this happens, either I will be in jail for having killed or I will be dead.

x

Irritability A mother beats her child for playing and running around: Why can’t you sit in one place, always running from here to there. A husband talks about his wife’s changed irritable behaviour: For small matters my wife gets very angry with the children.

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x

Revenge A teenage girl expresses her frustration and talks about revenge: You either get those policemen and I will take care of them or get me my mother back. A young boy talks of revenge: They killed my father; I will kill theirs. A woman expresses her thoughts about the situation: What do you think these children who have seen so much of killing will become when they grow up? Isn’t it natural that they will become terrorists.

x

Fear, vigilance and anxiety A young boy saw his entire family being killed by the rioters. Whenever he sees a group of people coming close to him, he believes they are coming to kill him: Let’s go from here, they are coming here. A woman used to earn her living by sewing. But now when she hears the whirr of the sewing machine, it reminds her of the rioters coming and closing in on her house. Loud voices or noises also really upset her: Oh god! Tell them to stop, I cannot take this. A mother talks about children in general: Children have started wetting their beds. A woman shares what happens in the camp: If there is any noise all of us go running out to see what has happened; even a slight sound makes us tense.

x

Helplessness, sadness and guilt An 18-year-old boy recounting what he feels at certain times: At times I cannot even cry, but also cannot hide the pain. I feel so miserable yet I cannot even explain this. My voice does not come out, I get so scared. Memories of what happened haunt my mind. A 30-year-old woman who was running with three children lost the younger one in the melee. She is not sure whether the child is alive or dead. She repeatedly keeps saying: I should have carried him on the back. This thought never occured to me. I am responsible for the loss. I am not able to get the scene out of my mind.

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A middle-aged lady talks about how helpless she felt when she came to the camp: Coming here I felt like a beggar, having to wait in line for tea, for food, etc. We often did not feel like eating. We were all here like orphans (lawaris), wearing whatever clothes we had worn at that time. A woman expresses her loss and feeling of helplessness: I lost my home; one son had got married and both homes have been looted. Now we have no support, only the camp people are there. A woman who witnessed other women being molested, raped and harassed but could not help, expresses her sadness and guilt: When the rioters (tola) came I was hiding with other women. They started cutting up people, burning homes and doing ugly things to women. We were watching but could not do anything. I really think about that time and feel bad. An old man expresses his guilt and helplessness about the situation: The girls in my colony used to call me ‘chacha’ uncle. I saw the same children being raped, they called out to me for help but I just hid and sat there, I could not do anything.
x

Repeated thoughts about the same thing A woman talks about what she witnessed during the riots: I saw the mob who tortured and harassed the women by stripping them naked, physically abusing them and then burning them alive. I do not know, I just feel very tired. I keep getting the same thought in my head again and again. Even now I remember those events (‘Abhi bhi yaad aata hai’).

x

Moods that keep changing frequently: Poor concentration, Forgetfulness and Suicidal thoughts All my family is gone; W hat do I have to live for?At times I feel I should go and hang myself.

q

Relational Changes When a person experiences stress, certain emotional reactions appear, as observed in the earlier examples. These reactions lower the quality of interpersonal relationships and interactions with others, and result in:
x

Disagreement and argument, unpleasantness My husband was ill and I used to repeatedly ask people around in my room to stop talking or lower their tone just for a few days while he needed rest. But they would not stop; they talked ceaselessly. I was in the toilet and a lady said, ‘Are you sleeping there?’ I had just gone in and when I came out I retorted, ‘Is this some place one would like to sleep?’
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Sometimes you are sitting down to have tea and someone will come and tell you rudely, ‘Get up, go and sit there’, you feel like just throwing things around and going away.
x

Lack of emotion Initially when Ms X came she was in a very bad condition; like a dead body. She used to just lie in one corner silently. That lady just sits in one corner, she lost her young son. A father talks about his loss in a very detached manner as if he has no pain or emotions associated with the event. I had two daughters, both were killed in these riots. They were raped and then burnt. I have not been able to get the postmortem report till now. I have not got my compensation money.

x

Too much dependence on others for decisions and support A wide range of symptoms such as amotivation, apathy, anger outbursts, deterioration in work performance etc., are common in survivors living in camps. Consequently, survivors tend to be dependent on care providers all the time. Effort should be made to encourage them to take decisions and support them to initiate activities.

U NDERSTANDING THE STAGES OF SYMPTOMS REACTIONS
Psychological reactions tend to change over time, it is essential to understand the different reactions in a phased manner. The reactions could be following a normal mode of occurrence or an abnormal mode:
q

Immediately after the event, i.e. within few hours to a few days These reactions are short lived and generally seen in all people:
x

Panic, tension, anxiety The event happens so suddenly that there is no time to think. The immediate reaction is to run for safety. Fear is predominant among everyone till they reach a safe place. We ran out without even wearing slippers (‘Aise bhage ki chappal bhi nahin pehne’). Shock or numbness Difficulty in accepting the reality of the event. Survivors behave as if nothing happened. A sense of being paralysed, distant, and removed from one’s feelings of grief is present. A person may be numb, or, like a robot, be able to go through the motions of life while actually feeling little. At the same time, physical symptoms such as confusion and loss of appetite are common.

x

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NORMAL REACTION OUTCRY (Fear, sadness and rage) DENIAL (Refusing to face the memory of the disaster) INTRUSION (Unbidden thoughts of the events) WORKING THROUGH (Facing the reality of what has happened)

ABNORMAL REACTION OVERWHELMED (Swept away by the immediate emotional reactions) PANIC/EXHAUSTION (From the escalated emotions) EXTREME AVOIDANCE (Drugs etc., to deny the pain) FLOODED STATES (Disturbing images and thoughts about the event) PSYCHOSOMATIC RESPONSES (Bodily complaints)

For a few days I did not even understand what happened. (‘Thode din to smaje mein bhi nahi aaya ki huya kya hai’). My daughter was so scared that she seemed a little lost for sometime (‘Yeh, ladki itna dar gai the ki iske hosh khoye hua se the’).
x

Relief, elation, euphoria among the survivors Some would feel a sense of joy to have escaped unharmed and have their family members safe.

x

Anger This reaction usually occurs when an individual feels helpless and powerless. It may result from feeling abandoned. Feelings of resentment may occur due to the injustice of this loss. Some survivors may ask questions, “What did we do?” “Why us?” “How could they do it?” Then slowly anger towards the people who have brought them to this state will emerge. It can be a mild feeling or a raging irrational emotion. People will talk of revenge. A woman while relating her experiences became very angry and started shouting: Tell me what would your situation be if you were in my position; what wrong did we do?

x

Survivor guilt Few survivors experience feelings of guilt and regret. “I should have done more”, “If only I had known”, are thoughts that haunt
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many people. The fact that they are alive may cause distress and discomfort. I could not do anything to save them (‘Mein kuch nahin kar paya unko bachane ke liye’). A woman talking about her daughter-in-law who had gone home for her delivery and got killed along with her entire family during the riots: I should have got her back to my home; at least she would have been alive.
x

Depression Experiencing a sense of great loss, mood fluctuations and feeling of wanting to be alone, may follow. Sleep and appetite disturbances, lack of energy and concentration, and crying spells are some of the typical symptoms. Feelings of loneliness, emptiness, isolation, and self-pity can also surface during this phase. After shock and denial have passed and anger has been exhausted, sadness and even hopelessness may set in. A person may have no energy even to do the simplest daily chores. Crying episodes may be experienced often. However, men do not cry often even though they are depressed. I remember how it was earlier (‘Sab yaad aata hai phele jaisa tha’). I have lost everything that I had saved (‘Mera to saab kuch lut gaya, sab joe banaya tha’). Restlessness, confusion, sleeplessness, repeated experiences of the events, nightmares, and arousal symptoms may come up.

q

As the days pass by (within 1 to 6 months) new reactions appear, these are seen in about 40–50%of the population in the form of
x x x x x

Grief Apathy Lack of response to others Inhibition of outward activity Physical symptoms of anxiety

q

Delayed reactions manifest after 6 months and may be seen as an intensification of the reactions seen earlier, in about 30% of the population. Grief

Grief occurs in response to the loss of someone or something. The loss may involve a loved one, a job, or some material possession. Grief is a normal and natural response to loss. There are a variety of ways the individuals respond to loss. Some are healthy coping mechanisms and some may hinder the grieving process. It is

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important to realise that acknowledging grief promotes the healing process. Spending quality time and giving support facilitate the individual’s grieving process, providing an opportunity to appropriately mourn the loss. Bereavement is a painful process and at times seems unbearable. It is a combination of many emotions that come and go, sometimes without warning. Grieving is the period during which the individual actively experiences these emotions. The duration and intensity of the grieving period vary from each individual. The length of time people grieve can be weeks, months, and even years but it gradually becomes less and less painful. Because it is so painful, some people try to ‘get over’ a loss by denying pain. When people do not deal with emotions of grief, the pain does not go away. Understanding the emotions of grief and its accompanying feelings and symptoms are important steps to heal and to help others who may be grieving. Some manifestations of this are:
x x x x x x x x x x x

Sadness Distress Depression Yearning for what has been lost Anger Guilt Sleeplessness Loss of appetite. Severe irritability Suicidal tendencies Being acutely upset and disturbed by anything, which reminds them of the loss.

A person can be helped to come out of his/her grief. What is absolutely essential is to help him/her share the feelings of loneliness, anger, and sadness openly and honestly. Next is to help them to understand that such feelings and reactions are absolutely normal in anyone coping with a personal loss. Practising relaxation, deep breathing exercises, listening to music and getting involved in other life activities will help in handling the symptoms of grief. Encouraging them to adopt a healthy routine, like good nutritious food, regular exercise, adequate sleep, etc., will help them cope with their reactions. Post-traumatic Stress Disorder (PTSD) Life never prepares people to face severe trauma. When people face an overwhelming event that is perceived as dangerous and beyond the normal coping capacity, the ability to respond adequately gets hampered. The symptoms that might develop in PTSD are understandable:
x

Reliving the trauma in intrusive memories or dreams which are painful, come uninvited.
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x x x

x x x

Avoidance of all activities and situations reminiscent of the traumatic event. Numbness, emotional blunting, and detachment from other people. Hypervigilance (i.e., inability to relax, being always tense), jumping at the slightest noise, fearfulness, palpitation. Inability to enjoy anything. Panic reactions. Acute outbursts of violence may also be present.

These symptoms develop because the person always seems to be in a state of arousal.

For example
14-year-old S belongs to a low socio-economic status family. She was witness to her mother being killed during the riots (Dhanga). She vividly recalls how the mob was rushing into the small by-lane where they lived and her family was running to safety. While trying to escape, the group caught up with her mother and slashed her throat. S was able to reunite with her father and brother at one of the camps. The father describes that most of the nights S gets up from her sleep and shouts, ‘The mob is coming’ (tola agaya) and subsequently her whole body shivers and she gasps for breath on some occasions. S reports that she is repeatedly haunted by the gory incident. She is unable to remove the scenes or the images from her mind. She very often re-experiences these memories. Returning from the camp to their house, she is scared of going near the theatre where the event occurred. She practically avoids going that side and even looking that side reminds her of the gory day and the events. Even a small cycle tyre burst in the road and she starts running away screaming, and is then found to be irritable for the next one or two hours. This sort of behaviour and response are increasing day by day. As can be seen from this vignette, PTSD is not a single symptom but a cluster of symptoms like re-experiencing, avoidance, hypervigilance, numbness and irritability in a person. A person can recover from PTSD on his or her own over a period of time through the combined actions of education, support, anxiety-management and lifestyle modification which can hasten the process of recovery:
x

Education, the first step, involves helping the person understand his/her condition and reassuring that the reactions are a result of the stress due to the traumatic event. Support from family, friends and anyone working with the person by letting the person know that he/she is not alone and is not responsible for the event, etc., helps in the recovery process.

x

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x

Teaching anxiety management strategies like relaxation, breathing techniques and diverting the individual’s mind through involvement in activities. Changes in their lifestyle is very important. This means following a healthy diet, avoiding stimulants or intoxicants, regular exercise and adequate sleep. In certain cases use of medication maybe recommended. All these help in the recovery process.

x

q

Other delayed reactions
x x x x x x

Loss of productivity Family problems Substance abuse Increased vulnerability to stress Poor physical health Suicidal thoughts.

P OINTS TO REMEMBER
➢ Use the principles for giving emotional support in your work. ➢ Identify different emotional reactions in people. ➢ Recognise the stage the person is going through on the basis of the symptoms.

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ROLE OF A COMMUNITY LEVEL HELPER
As mentioned earlier, the CLHs play a critical role in the rebuilding efforts after any community has experienced a disaster. In the Orissa cyclone disaster it was the Snehakarmis and in the Gujarat earthquake it was the Viklang Bandhus who provided psychosocial care. During the Gujarat riots, it has been the Aman Pathiks who are providing this care. The CLHs are a vital link between the affected population and the helping agencies (Individuals, Non-Governmental Organisations and Governmental Organisations) who come from outside the community. The CLHs, most often belong to the community, and are likely to know the area well and have close ties with several people in the locality. They will also be able to work in a more intense and sustained manner with the community. Emotional interventions can be provided to the family by daily visits. During such visits, time should be spent to talk about the survivor’s feelings and experiences, imparting health education, discussion of health problems, engaging in paralegal work, motivating individuals to hold group meetings, organising educational activities and maintaining a routine despite loss. The most important step in the psychosocial care and recovery process is to recognise that such care is essential for the entire population exposed to the catastrophic event. People differ only in terms of the degree of support needed. In other words, the care is wholistic rather than being limited to relief and support. Psychosocial care means not only emotional support but practical help, suggestions, guidance, information, education and so on. Under the spectrum of psychosocial care, seven basic issues will be addressed by the CLH (see box). The focus will be, identification of needs and attention to specific problems. Referrals would be made as and when required and there would be a commitment for long-term work. They would be working not only with the people who have been affected but also the larger society and others in the Aman Samudaya team.

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Spectrum of care would cover issues related to Rights and Justice

Compensation

Health Care

Paralegal Housing and Livelihood

Psychosocial

INDIVIDUAL
Self Help

Role of a CLH The foremost task of a CLH would be to meet and interact with many families at the camps. He/she should initiate interactions among the families using culturally appropriate greetings and gestures like, ‘salaam valikum’, ‘namasthe’, ‘aadhab’. In subsequent interactions, the CLH would help them with:
q

Understanding the changes that they experience in their body and mind. When people face any traumatic event, they experience both emotional and physical reactions. Helping them to understand that it is absolutely normal to feel this way is very important. It will make them feel more comfortable to deal with what they are experiencing. Knowing what they are experiencing currently is just a temporary phase and that over time they will be able to get back to their normal life, will benefit them.

q

Decreasing the physical and emotional effects by listening, relaxation, externalisation of interests and activities. Here the CLH would use the basic principles to extend emotional support and establish a relationship with individuals . This helps the survivors to relate what they have experienced, and share their feelings. By ventilating, the pressure of the strong emotions within them gets lighter and lighter over a period of time.

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q

Support and rebuild their shattered lives in the areas of housing, work, health and community. After establishing rapport, facilitating reliving and grief resolution, the CLH would go on to observe or enquire about any specific help a person may need. This could be in the form of
x

x

x x

x x

Guidance to get compensation, assistance in paralegal work, house damage assessment. Practical help like getting forms/accompanying survivors to the offices or helping the individual open a bank account, etc. Medical help if need be, specially going to the hospitals. Mobilising help from neighbours/relatives to support an orphan or an elderly survivor. Getting livelihood reorganised. Networking and coordinating with other agencies are also important for sourcing various other kinds of support.

The wholistic approach is more substantial not only in terms of meeting varied needs of an individual but also gives the CLH more entry points for intervention. Once the CLH has been able to establish rapport and built relationships with people, he/she would need to identify groups that need special attention and work closely with them. These groups are:
x x x x x x x

Widows Orphaned children. Single parent families. Families being run by older siblings. Aged people. People with disability. People who are economically devastated.

P OINTS TO REMEMBER
➢ CLHs are the appropriate people to work with the affected people, they are an important link. ➢ CLHs have critical roles to play. ➢ CLHs need to identify and give special attention to people who are vulnerable. 26

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PSYCHOSOCIAL INTERVENTIONS
Under normal circumstances, most people can take care of their problems. The riots being an abnormal situation, the people’s equilibrium is temporarily upset because of the emotional reactions they experience. Till the time they can develop successful coping strategies and handle their lives independently, they require emotional support. It is like extending help to a person who has fallen on the ground. Extend your hand to help the person sit, then slowly make him/her stand. Then walk a few paces with him/her and gradually he/she will walk independently. The following diagram would help understand at a glance the three areas of focus for psychosocial interventions: Can lead to DISTRESS AND DISABILITY

DISASTER

ROLE OF COMMUNITY LEVEL HELPERS

Help people understand the changes that they experience in their body and mind by
q q q

Decrease the physical and emotional effects by
q q

Support and rebuild their shattered lives through
q q

Ventilation Active listening Empathy

q q q q

Relaxation Externalisation of interests Lifestyle choices Social support Health care Spirituality

q q q

Help with housing Assistance for compensation Paralegal aid Educational help Employment

All the above three lead to

ADJUSTMENT AND MASTERY OVER EMOTIONAL DISTRESS


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P RINCIPLES
There are 7 principles that can be applied to give psychosocial support to any person in a post-disaster situation. Ventilation A person (i.e., in this case survivors of the riot) who has experienced trauma will have strong emotions which will very often be suppressed. The danger is that if there is no space or appropriate stimulus for release of these emotions, then the pressure will keep on building until one day the person can break down. Hence it is extremely important for the CLH to meet the people, interact with them and help them talk about (ventilate) what they have experienced and share their feelings and emotions.

For example
For instance, in a pressure cooker the safety valve is very important. It systematically and periodically takes the extra pressure out slowly and helps in getting the food cooked. The safety valve helps the extra pressure to be released or else the cooker could burst. Similarly, the CLH will have to work like the safety valve by getting the people he/ she is working with to slowly but constantly release their tensions, pain, anger or other emotions that they have supressed within them. This is an extremely important part of the role of a CLH. This process involves release of emotions and feelings. It is a very important intervention and should be used as soon as possible. People under stress find it difficult to relax and may have other symptoms. Even in crowded camps, people can be very lonely.

For example
Mr A whose daughters were raped and killed in front of him says, “I had two daughters both were killed in these riots. They were raped and then burnt. I have not been able to get the postmortem report till now. I have not got my compensation money.” When you talk with him, his conversation revolves around more practical issues like compensation, etc. He is not in touch with his feelings that relate to the loss of his children and the trauma he has experienced. He has managed to suppress those feelings; but they are simmering inside. If not given timely help, one day the pressure of those emotions can cause a break down in him. 28
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Empathy Often when we look at others we do not see their distress and everything appears very fine. But to understand another person’s feelings of loss and pain is very difficult. However, if we attempt to perceive things from the other person’s perspective it will give us a clearer picture of what that person is going through. This same goes for the CLH. The idea of being able to feel and experience the pain as your own by trying to be in the other person’s situation is the main idea of being able to empathise. While the person is sharing his/her thoughts and feeling, we have to be there, listening attentively as if his/her pain were our own. Then he/she will truly feel understood. In Hindi, the words, Mehsoos and Ehsaas express how we should be able to feel and experience the pain of the survivors while working with them. This will give them a great sense of relief of having been truly understood. As one Aman Pathik said Listening to her story and the way she was crying, even I had tears in my eyes. Active listening In a camp situation there will be lack of privacy when we are talking with people. There will be a lot of noise and distraction. But good listening is an important skill to provide emotional support and all the more in the camp situation. Practising some of the guidelines given below can help you work better:
x

Look into the eyes of the person while he/she is talking: This indicates being interested in what is being said. Respond occasionally while listening: The person speaking feels convinced that you understand and take him/her seriously Sometimes it helps to paraphrase what has been said, often giving the speaker another viewpoint. Avoid interruptions: Let the other person finish his/her thoughts. Do not interrupt unless there is confusion and the details are jumbled. Be accepting: Do not prejudge, moralise, condemn, or interpret how the other person should feel. Empathise: Share the experiences of the other person as if they are your own. You have to be sensitive and have the ability to recognise when the other person is going through certain feelings or emotional experiences.

x

x

x

x

Social support Everyone feels very comfortable with a certain level of emotional support that comes from others around. Social support networks are extremely important for feeling comfortable and secure. In a disaster situation these support systems get disrupted.
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For example
If we go to a new town for the first time and have to work or study there, we would feel, insecure, lonely, scared, and at times fearful. If we meet some people from our background (language, religion, region, etc.) then we would immediately feel a sense of happiness, and want to be with them, try to meet them and generally feel relieved. So it is essential in efforts like ours to provide some level of support through a bonding in terms of almost being like a family member. The losses during such riots are not only personal in terms of family members, belongings, etc., but also the loss of larger support systems like friends, neighbours, community, and so on, who/which otherwise could have been of help. The involvement of external agencies and CLHs specifically can play a great role in extending emotional support. Externalisation of interests The women at camps are engaging in community kitchens. They have something meaningful to do during some part of the day. Similarly, older children are seen transporting firewood from the truck to the storage area. All these, though small activities, give people a sense of being productive and help in enhancing their recovery process. The people are engaged in activities and their minds are meaningfully occupied. Also, any physical activity energises people and makes them feel better.

For example
One woman mentioned to the Aman Pathik that she would like to work with the children in the Bal Muskaan programme being run in the camp. It is important for this woman not only to be given an opportunity to work because she feels she has the skills, but also because it will help her personally to divert her thoughts from the traumatic experience she has experienced, to something which makes her regain her self-esteem and self-respect. In some camps, lists of women interested in sewing were drawn up and machines were provided to them. It is essential to identify vocational interests the person may exhibit and help him/her get involved in these activities. This was seen in the camps with the Bal Muskaan programme that was started for children. Here children spend time in non-formal activities, singing songs and playing games. Some books were also provided. Initially the children at camps used to while away their time. They did not have anything to look forward to and often sat with elders, listening repeatedly 30
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to horrific stories and negative messages. With the introduction of the Bal Muskaan programme, having their day filled with activities became a reality. The children now have something to divert their mind from the painful memories and emotions. This has made them feel releived. This helps in a healthy channelisation of their energy. Taking part in the Bal Muskaan programme as a facilitator or even taking part as an Aman Pathik has been healing for many. One lady said, My mind has become ‘fresh’ after I started working here (Aman Samudaya). Now I work with everyone and today the situation is such that I feel this camp is my home. This is a clear indication that if survivors are able to divert their mind and get interested in other activities, they feel better. The value of relaxation and recreation Getting back to a routine is a great way to divert one’s mind and deal with the stress of emotional reactions. The more the people engage in activities or recreational pursuits, the faster and greater will be the normalisation of their life. Some examples of how relaxation was occuring at the camps in Gujarat was seen among men in the camps who listened to the radio. In some camps, a loudspeaker played music and at the other camps movies were also shown. These helped in changing the atmosphere of the place. At one point of time, each camp had a street play performed by a cultural team from outside, which everyone watched and appreciated. The whole process of having a street play generated a lot of interest and energised the group. In some camps, people discussed their personal experiences, and identified themselves with the characters in the play. There were some people in the audience who started crying, leading to a form of mass ventilation and feeling of relief. During the mass wedding event, the whole camp resembled one big joint family preparing for a wedding. There was a lot of activity and everyone was doing something. Preparations were on right from discussing what presents to give, what food to be served and other arrangements to be made. There was music. During the Haldi ceremony everyone came out and there was some fun and laughter. Most women and young girls had put Mehndi on their hands. The act of encouraging people to undertake relaxation exercises regularly is greatly beneficial too. The person should sit in a squatting position with hands on the knees; then take a deep breath, hold it for a few seconds and slowly exhale. Do this for at least 5–10 minutes slowly. Repeat this twice a day. Another exercise could be to lie flat on the floor. Close your eyes. Take a deep breathe and exhale slowly. This should be done for 5 minutes several times a day. Concentrate on fresh air that is coming in and the warm stale air that is going out of your body. 31

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Spirituality In our country, religious beliefs or belief in a higher power greater than human beings is an integral part of our being and gives us great relief and support during testing times. We may question this power at times to ask why we are suffering and why we have to go through the pain, but at the same time we will again lean on the same power to get through any crisis we are facing. So it is important to reinforce this spirituality in anyone we are working with, because it has tremendous power to heal the pain and suffering. All the principles mentioned above can be used to work with people at three levels, i.e., The individual, the family and the community. The example which follows illustrates all these principles.

Example
S, a 14-year-old girl lived with her family of two brothers and her parents in Ahemadabad. During the recent riots her mother was killed in the police firing. Actually her mother was not someone who went out of the house but unfortunately this time on hearing something is happening in the next lane she became curious and went out to see. While running back she was killed in the police firing. Subsequently the family members were reacting to the incident of loss as all others did. The daughter who was very attached to the mother was very angry and disturbed. Anyone who went to provide her with help had to face a volley of questions like, “Can you bring back my mother? Or get the four policemen who killed her?” In their culture, when someone passes away, the members from the extended family invite the bereaved family members to stay with them. In S’s case, the extended family did not invite them over. So S and her brothers had to manage on their own. In addition, S’s family as such did not have very good relations with their immediate neighbours. In this case, the normal social support systems (family and friends) that usually help people recover from traumatic events were missing. Also, the loss took place in an unnatural manner and not as a natural death; so the level of pain and anger is very high. The Amanpathik of that area visited the home. What follows is the process of helping S to cope with her loss. The Amanpathik came to know about this family in the camp and on enquiry he found that the family had moved to their house in the neighbourhood. After identifying the family he visited them for the first time.

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First visit The Amanpathik, P who went to meet the family was greeted with hostility by the entire family. He was told that they had not done anything to the Hindu neighbours in the area. Although the other family members were angry, they talked to P but then S told him to leave saying, “You get back my mother or get the policemen who killed her and I will take care of them.” She refused to talk and left the room. She pulled the other family members into the house and closed the door. What is happening? As can be seen, the level of anger and resentment is immense. S has not even come to terms with her actual loss. She is at the stage of outrage right now. The family as an institution had been fostering her faulty coping methods rather than helping her normalise her reactions. What needs to be done? It was decided that a four-pronged approach would be taken to normalise the families reaction to the loss. Firstly, the local Clergy would approach the father. Secondly, a foster mother would be brought in to help S ventilate or share her feelings about the mother. Thirdly, work would be done through the elder brother by talking to his friends. Fourthly, an intra- referral to the support team working for children would be made. It was also decided that an Amanpathik, subsequent to the initial entry being achieved, would maintain a regular visit. It was also decided that a female Amanpathik would take charge of S since she may be identifying P with the policemen and her anger could be enhanced with his presence. Also, a female Amanpathik would be able to establish better rapport with S. Second visit G, the female Amanpathik who was put in touch with this family went over to the neighbourhood and was able to identify the opposite house lady who was willing to help the girl after long persuasion. This lady was requested to find out three basic answers from S: ‘What was the good thing in your mother?’ ‘Which was the best food you liked prepared by your mother?’ ‘Whom do you resemble – your mother or your father?’ These were questions which would help S open up and release the pent up emotions about her mother. What is happening? The process of creation of a neighborhood support system was initiated. Even though S made no attempts even to acknowledge this, the neighbour was motivated to continue to go over regularly and try and talk to S. This interaction is very critical because the neighbour is providing an empathetic bond, which will enable S to cope with her pain. As can be seen, it was a time-consuming process and a gradual one. However, these regular visits of the neighbour helped to establish trust and somewhere S was able to sense that the neighbour lady was genuinely concerned about her.

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Third visit The male Amanpathik met one of his elderly Muslim friends in the area and requested him to help to talk to the father of S. With some reluctance the old man agreed but the father did not heed his request. His friends, at the request of the Amanpathik, approached the elder brother of the girl. After severe argument about his sister’s welfare, the brother relented to the peer pressure but was unsure of how to help his own sister. What is happening? One can see that any situation of trying to support a family must have a multifaceted approach and at times you will meet with failures but one of the interventions will have the desired effect. Also in any situation the entire family needs to be worked with and not just one person. Fourth visit The coordinator of the children’s support team monitored the developments. She visited the house along with the brother and gained entry after sorting out the brother’s needs in terms of employment. The brother was very facilitative. The brother by now had understood the need for his sister to release her pent up feelings. During this visit he shared his concerns with his sister saying he would like her to start carrying on with her life. He talked to her saying he too missed their mother. While sharing some memories, S started to cry silently. The neighbour who had been reinforcing the same messages put her arm around S, comforting her as she cried. S expressed that she felt totally lost without her mother and now had no one to talk to. She felt totally frustrated that nothing had happened to punish those responsible for her mother’s death and she was very angry with the policemen. She felt that her mother had not deserved death. Everyone listened to her as she talked about her feelings about the event, her fears and worries. What is happening? This joint meeting was really beneficial in helping S feel comfortable to talk about her feelings and fears for the first time. It is the start of a process but demonstrates an acceptance as well as the importance of external support networks to come forward and help a family cope with its loss. The neighbour is continuing her work with S and ensures that she maintains her rapport and offers space for S to share her feelings and emotions. The Amanpathik, through regular visits, supports her. As of now, S is much better and is excited about her cousin’s marriage and is getting ready for the occasion mentally.

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Learning Points
x

x x x x

x

Initial entry was difficult – work to be done by a group than by individual Amanpathiks. Establish local support systems to provide guidance and assistance. Empathetic relations are critical and essential to the helping process. The entire family needs to be worked with rather than just one individual. It is a gradual process and ventilation is the key to opening of the channels for recovery to take place. Taking part in ceremonies/rituals is one example of how externalisation of interest helps in normalisation of the life for the survivor.

W ORK WITH INDIVIDUALS
q

For people who are willing to talk immediately:
x x x

x x

x x

x q

Listen attentively. Do not interrupt. Acknowledge that you understand the pain and distress by leaning forward. Look into their eyes. Console them by patting on the shoulders or touching or holding their hand as they cry. Caution: be sensitive to community norms about touching members of the opposite sex. Respect the silence during your interaction; do not try to fill it in by talking. Keep reminding them, “I am with you. Its good you are trying to release your distress by crying. It will make you feel better.” Do not ask them to stop crying.

For those unwilling to talk: Some people may be very angry or remain mute and silent.
x

x x

x

x

Do not get anxious or feel rejected that they are not communicating. Remain calm; tell them you are here to help them in the best possible way. Maintain regular contact and greet them. Ask them about their welfare. Maintain interaction by reminding them about the pain of separation, distress of being alone, helplessness, isolation, etc. This will help them to feel their pain and get it out of their system. Acknowledge that you understand their distress; the frustration, emptiness and also subsequent anger because of the vacuum created by the loss. Share their grief and console them that losing someone dear is terrible and unfortunate.

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x

x x

Make them understand they are not to blame for the tragedy and need not feel guilty Tell them you will return the next day or in a couple of days Tell them you are not upset or angry because he/she did not talk. Meanwhile ask him/her to think about whatever has been told. “Memories of good days you spent with each one must be alive in your memory and coming to your mind again and again. You must be tense inside! Try and let the steam out, that will make you feel better.”

Take the example of a father who was unwilling to talk after he lost his son. The CLH working with him was able to reach out to him and help him ventilate his pain and deal with his loss.

For example
In Orissa, during the cyclone, a father lost his children. For quite some time he was unable to accept the death of his youngest child and went into silence. If you talked about this child he would get very angry. The youngest child, a boy, had been very good looking with big round eyes and a mole on his face. Often at night, when everyone was asleep, the father would walk down to the place where the dead bodies had been burnt. This was noticed by the CLH (Sneh Karmi). One day the CLH followed him to the place. Standing behind the father, the CLH said, “Look there is the skull of your youngest child.” The father shouted very angrily and told him to go away, but the CLH continued telling him, “Look closely, the eyes are round just like your son’s; the face would have had a mole there.” The father stood for some time in silence and then suddenly broke down sobbing and crying. All the feelings he had been suppressing, suddenly came out in the form of tears. In this situation the CLH was able to use a ‘skull’ to help the father ventilate and bring out the feelings and emotions he had been suppressing within him. It helped the father accept his loss in entirety. This release was very healthy for the father and a very critical part of the recovery process. Once the person talks about the loss and personal grief, he/she feels better. It becomes easier to take stock of his/her life and understand the feeling of a vacuum, an emptiness created by the loss. This facilitates in rebuilding his/her life. Hence, the more he/she releases the pent up feelings, the lighter they will feel.
q

Once the person starts talking, maintain a conversation using the following queries:
x

How are you and how are your other family members?
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x x x x x x x

Give details of all the losses experienced by you and your family. How do you feel about the loss? – What is the personal meaning of loss to you? What is the support you received after the event from relatives, friends, relief workers, etc.? How have you been recovering? – How are you handling this situation? What are the effects of the event on health, like physical problems or problems like aches/pains, decreased sleep, decreased appetite, fear, and loss of interest? How do you visualise the future? What other help do you require?

Caution: Guide individuals to adopt healthy behaviours.
q

What can individuals do to recover?
x x x x x x x x x

x

Listen to authentic information about the situation; do not believe in rumours Stay with family members. Be with people from the same locality. Get back to daily routine/chores as soon as possible. Make it a point to share your experiences and feelings with your relatives or friends. This will help release your emotions. Take part in relief and rehabilitation operations. Work is a good tonic for healing. Avoid smoking, alcohol or other intoxicants. Sleep for 8 hours at least and eat well. Take time off everyday to relax and have a good time by playing games, reading, listening to music, singing, performing prayers and being with other people. Make time for yourself and acknowledge and admit that you will not always be functioning at your usual level of efficiency for a few weeks/months.

W ORK WITH FAMILIES
In addition to individual specific interventions, the family as a whole can also be helped simultaneously. This depends on the number of individuals surviving in the family. If some family members are present, encourage them to adopt the following activities:
x x

x

x

x

Share their experience of loss as a family. Contact relatives to mobilise support and facilitate recovery. Participate in rituals like prayers, keeping the dead persons photographs and preserving his/her belongings of the dead person. Make time for recreation using what is available like the radio, television, visiting religious places, playing with children and engaging in activities like sewing. Resume normal activities of the pre-disaster days with the family.
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x x

x

x

x

Try and do things together as a unit and support one another. Be together as family members. Do not send women, children and the aged to far off places for the sake of safety; separation in this case can cause a lot of anxiety to them and to you. Restart activities that are special to your family, like having meals together, praying, playing games, etc. Keep touching and comforting your parents, children, spouse and the aged in your family. This will not only make you feel good but also make the other person feel the same. Keep in constant touch in case of a member of the family having to be shifted to a far off hospital or residence. Update him/her about yourself as well as find out about him/herself. This gives a feeling of being cared for.

W ORK WITH THE COMMUNITY
The following activities help in rebuilding community life and setting up the social support systems, which are essential in the long-term rehabilitation process. Group mourning Grief resolution should occur at the personal, family and the community levels. Group mourning is a process of mass grieving. It expresses solidarity of the grief-stricken community and facilitates unity and collective action. Such activities should be initially organised on a weekly basis, gradually on a monthly basis, and later, annually. In Maharashtra there is a process wherein traditional coloured pastes (Haldi Kumkum) are applied to a widow before breaking her bangles. This process helps her to accept her loss and relate to her feelings. In Gujarat there is a traditional process ‘Iddath’ among the community, wherein the widow stays away from the rest of the people for some time before getting back to regular societal routines. Similarly in other communities, mass prayers with lighting of candles are done. All of these are traditional methods for people to come to terms with their loss and start their grieving process, which in turn helps them move ahead in their life.

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Group meetings Group meetings are important activities where the community as a whole participates. This stimulates the people to think, and brainstorm about various measures/initiatives for rebuilding the community. It not only helps the community to come to terms with the reality of loss and emptiness but also helps them to initiate collective action and rebuild their lives. An ‘Aman Bhojan’ (community meal) was organised where people from both the communities along with few prominent leaders came and ate together. This helped in establishing some faith and a feeling of normalcy among the people. It also showed people that others were with them. Coming together on occasions has taken place, like in the preparations for mass marriages. Supporting group initiatives The local community, on its own starts responding appropriately and effectively to the disaster by using healthy coping strategies. Hence, one important task of the Amanpatiks is to encourage, initiate, sustain and guide such local community action. The Amanpathiks can take the initiative to organise community-based actions specific to the local culture in order to alleviate mental suffering. At one place the camp was being run on the space provided by a cinema hall owner of another community. At another place, a local person had taken charge of running a certain camp. Cultural aspects There are things very specific to cultures that help in the recovery process. For instance, singing of folk songs helps people gather in a common place and share their grief. There is a sense of commonality in grief that increases the cohesiveness of the community. It was observed that putting Mehndi was an essential part of the pre-disaster life among this community and has returned even without a wedding taking place. Many are engaging in decorating their hands with mehndi. Such activities lead to faster recovery and normalisation of lives of the affected population. Rally Organise a rally to sensitise the administration regarding delays in implementation of action for restoration, rebuilding, relocation, compensation, etc. Rallies are also a powerful expression of solidarity. ‘All for one, one for all’, demonstrate strength and determination to fight for a just cause. Such rallies can also be used to sensitise groups, for instance to create awareness among students about issues around them and bring about a feeling of confidence and normalisation among them.
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A rally was taken out involving key members of the government and this was done in an area where there was great insecurity earlier. The rally helped in rebuilding the faith of the people in the government agency. It also helped sensitise the government officials about the reality of the situation. Group participation for rebuilding efforts Clearing rubble from broken homes and burnt residences, putting up temporary shelters and providing food for those who are the survivors or those who are disabled or dependent – all these actions help people to recognise that there are others around to help them and that they are not alone. A lot of people were engaged in community cooking, bringing in the raw material and storing it in the camps. Encourage people/survivors to share their success stories (recovering from the loss) with others during group meeting. This will make them feel good and also benefit those who need help to come to terms with reality. There are initiatives to mobilise support for community contribution towards rebuilding, (either in) cash or kind. Many groups have sponsored mass weddings, others have come forward to rebuild certain number of homes, etc. Sensitisation process Involve religious leaders and opinion leaders, in all community activities. Talk about re-education of the larger community, especially on ways to handle rumours. Also group discussions would help in expressing their feelings and extending support to each other and together being able to think about a future course of action. The cultural wing of the Aman Samudaya is holding street plays both within and outside the camps, and these are very popular among the survivors.

P OINTS TO REMEMBER
➢ There are seven basic aspects that a CLH can use as psychosocial interventions to work with people who have been affected. ➢ Rebuilding of life occurs at the level of individuals, the family and the community.

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SPECIAL GROUPS
‘No one who witnesses a disaster is untouched by it’. Although we understand this, it is also important to recognise that due to various factors (mentioned in the chapter on Impact of People, pp. 4-7), there are groups of people who are more vulnerable and need greater attention. We need to identify and work with such groups.

For example
There may be a child who has become an orphan. This child has not only been through the traumatic event but also lost the primary support unit and hence would require additional care to deal with both experiences. In this section we look at some of the vulnerable groups.

P EOPLE WHO HAVE BEEN RAPED AND THOSE WHO HAVE
WITNESSED RAPE
Women and girls are often discouraged by their culture and religion from reliving or talking about their experience of rape. This problem then remains hidden and creates psychological pain and suffering for the victim. It is essential to identify the rape victims by intensive interaction with the community, family and the individuals. Identifying emotional reactions or signs of physical violence is absolutely vital. Women/girls who have been raped often
x x x x x x x x x x x x

Feel ashamed and disgraced or humiliated (loss of face in the community). Feel dirty and soiled. Have guilt about having brought disgrace to the family. Are angry. Have a feeling of resignation to fate or destiny. Are constantly haunted by the incident and keep reliving it. Remain withdrawn or experience forced isolation by the family. Develop a fear of strangers. Have nightmares or are unable to sleep. Lose appetite and are disinterested in life. Lose faith, become negative and there is a fear of change. Feel helpless.
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When working with a person who has been raped:
x

x

x

x

x

x

x

x

x

x

x

x

Respect the woman and maintain a high level of confidentiality with her, even regarding her name, etc. Do not be judgemental. Give her the confidence that she is not to blame for what has happened. Help her to overcome the feelings of being unclean and make her understand that she is not responsible for what happened. Help the woman ventilate painful experiences and feelings related to it. Through all this be attentive, sensitive and give all support to her. If initially she appears withdrawn do not force her to talk to you. Once she has confidence in you, she will share her feelings and thoughts. Convince her that her disturbing thoughts and the pain she undergoes are natural and a result of this kind of a horrific incident. Let her express her anger towards the people who tortured her, as it helps in releasing pent up tensions. Encourage her to recognise the trauma as a small scar compared to several positive qualities and experiences she has. Help her regain the support of the family and community if she has lost it. Work with the family and help them give support to the her and reduce the stigma. Identify ways to end her social isolation and if there are support groups working on this issue make sure that she participates in them. Look at other support that she might require like livelihood, or medical care for physical problems, etc. to enable her get back on to the recovery process If necessary referral may be required, arrange for that meeting.

P EOPLE WHO FACED VIOLENCE
Whenever people experience pain and suffering, the body and mind tend to show emotional reactions, such as:
x

x

x

x

x x

Constant compulsive reliving of the painful experiences from the past. Suffering from sleeplessness and nightmares when falling asleep. Developing unidentifiable physical pains and problems. Losing interest in routine life activities, feeling tired, low and depressed all the time. Having lack of concentration, poor memory. Loss of appetite.

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x x x x x

Irritable over small things and frequent mood changes. Feel afraid or nervous. Feel guilty for not having done enough for others. Feel humiliated and weak. A growing feeling of revenge.

It is important for people who have suffered violence to understand that:
x

x x

x

Anyone who suffers painful and hurtful experiences reacts physically and emotionally in a similar manner. They are not sick, weak or guilty and in time they will feel better . They are safe and will be cared for. Conduct group sessions where they realise that the incident is not unique to them but there are others also who have been victimised. These sessions enable them to share their pain and feelings and slowly help to reduce the negative effects of those memories. Help them recognise that during the ugly incident there is nothing they did which is unique and isolated, since anybody in a similar situation would react the same way. This helps them get over the shame and guilt.

It is essential for the CLH to:
x x x

x

Get the person to talk and listen to his/her experience. Respect the person and treat him/her with sensitivity and understanding. Involve the family to take care and support the person where medical attention, etc. are needed. Motivate the individual to indulge in breathing and relaxation exercises regularly.

A GED PEOPLE
Very old people are often not totally in control of the situation. They may take a longer time to recover from the disaster. The kind of disaster they witness and also the death of many young people before their eyes might make them:
x x x

x

Withdraw and weep. Suffer from sleeplessness and refuse to eat. Be agitated, feel lonely and hopeless and have suicidal tendencies. Susceptible to falling ill as a result of being disturbed emotionally.

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You can help by:
x x x x x x x x x

Keeping them with their near and dear ones. Visiting them regularly and spending time with them. Touching them and allowing them to cry. Re-establishing their daily routines. Making them feel responsible by giving them some work to carry out which is not too difficult. Getting them involved in relief work by requesting for their suggestions and advice, etc. Keeping them informed of positive news. Attending to their medical ailments by helping out with Doctor’s visits and consultations, etc. Organising small group prayer meetings.

D ISABLED PEOPLE
People with disabilities may face some hindrance in the recovery process. Their recovery may get prolonged or they might regress to a lower level of functioning. You can help by:
x x x x x x x

Removing them to places of safety. Always keeping them informed of what is happening so that they do not feel isolated and ignored. Getting them involved in activities which can be performed by them taking into consideration their limitations. Integrate the disabled people in group discussions. Attending to their specific needs like supplying the various aids, such as wheelchairs, hearing aid, aids for walking, etc. which may have got lost. Helping them overcome their feeling of insecurity in case of having lost their livelihood. The skills they were using prior to the disaster should be looked into. Taking cognisance of the fact that the mentally challenged people, especially the women and children are vulnerable to sexual abuse, they have to be given special attention and care.

W OMEN
Women tend to feel more vulnerable. There may be many affected groups like young widows, single people, orphans, the disabled people, those who have lost children, single parents, aged, etc. Their emotional reactions will be far more visible and their response is different from men:
x

They might weep and later become depressed.
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x x

Experience vague body aches and pains and feel weak. Show more resilience in taking care of younger children, the elderly and disabled people.

You can help by:
x x x x x x x x

Enabling them to overcome their feeling of vulnerability by making them stay in a place close to their families rather than moving away. Keeping them informed about the safety of other family members, especially if they are away. Getting them involved actively in routine activities, like taking care of the young, caring for the sick or old family members. Involving them in community level activities like working in/supervising community kitchens and caring for other sick people. Involving them in relief and rehabilitation activities, like maintenance of cleanliness, etc. Initiating self-help group formation to enable sharing losses and suffering. Encouraging them to spend time in activities that are more fun, like mehndiceremonies at the camps, participating in wedding preparations, etc. Making them spend time working with groups like young widows, or people who have lost their children and supporting them.

C HILDREN
Children are always disturbed by change. They are often treated as young and hence not to be informed of what exactly is happening. Thus, they cannot comprehend what has happened around them and to them. They seek the comfort of adults as they feel the need to discuss and sort out their fears with an adult. They are not very sure of the options to get out of problem situations. They are dependent on adults physically and emotionally. Events like loud noises, shouting, running and panic and anxiety, separation from loved ones, loss of the comfortable environment, deprivation of food and drink, impact a child much more than an adult. Very young children would react by:
x x x

Weeping. Clinging to adults, especially those familiar to them, for fear of once again losing whatever security they have. Becoming listless and apathetic, if they do not get the warmth and security of surviving adults.
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x x x x

Experiencing disturbed sleep. Wetting their bed at night. Developing health problems. Regressive behaviour, for instance, he/she may want to be carried around now even though he/she have been walking earlier, or may start talking like a baby.

Schoolgoing children react by:
x

x

x

x x

x

x x x

Experiencing nightmares about the events repeatedly, and inability to gain control over what has happened. Regressive behaviour (wetting their bed, sucking their thumb, wanting to be carried around, etc.). Refusing to separate from their family members even for a short while. Returning to school and doing badly in their studies. Expressing physical complaints like headaches, stomach aches, difficulties in moving some parts of their bodies. Feeling depressed and taking responsibilty for the death and loss of their loved ones. Withdrawing from everybody and everything around. Falling ill because of loss of appetite and reduced sleep. Angry at what has happened and expressing this by being restless, irritable, quarrelsome, disobedient and telling lies, etc.

You can help by: A child cannot talk about why he/she is behaving that way. Adults around need to understand that these changes are normal and take measures to help the child get over the stress by:
x x

x

x

Letting him/her be close to adults who are loved and familiar. Re-establishing some sort of a routine for them like eating, sleeping, going for programmes like ‘Bal Muskaan’. Actions like touching, hugging, reassuring them verbally and thereby giving them a sense of security. Providing the child with a sense of control – allowing him/her to talk about the event and listen to them without giving any advice.

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x

x

x

x

x

x

x

Encouraging them to play – invariably they will play/act out what happened. Allow them do it, then discuss what happened and how the people were feeling. Giving them opportunities for painting and drawing where they can express their emotions. This is very healing. Organise story telling sessions, singing songs and games involving physical movement. Paying attention to and praising a child’s coping behaviour, like when he/she follows a routine, makes an attempt to reduce his/her anger, agitation, etc. Working with other caregivers in the environment to help the child recover, like getting him/her to work with the Bal Muskaan facilitator. Providing referral to Mental Health Centre if required. Paying more attention and spending time on their studies once they return to school.

P OINTS TO REMEMBER
➢ Although everyone needs care and support, there are groups among the affected people who need special attention, as they are more vulnerable due to their age or other factors. ➢ We need to work with these groups.

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REFERRAL
The referral process should be done using the spectrum of care framework discussed in the chapter on Role of the Community Level Helper (p. 25). We are looking at a wholistic model of care rather than one focusing purely on the emotional aspect of the rehabilitation work. There are seven basic areas to consider for each family that we are working with. It is important to be able to identify the needs in any of these categories and know whom to contact for further assistance. Also CLHs need to tap sources from within the larger social network that go beyond the Aman Samudaya network.

R EFERRAL MAY BE DONE FOR ANY OF THE ISSUES LISTED BELOW
x x

x x

x x

x

Livelihood issues, like assessment of needs, procurement of the material and grants. Issues relating to children, like educational needs, adoption or fostering and financial assistance. Paralegal issues, like compensation, reassessment of homes and FIRs. Medical issues, like regular health problems, special needs of crutches or pregnancy-related issues. Housing plans, like assessment and getting construction material. Women support group, like special needs of a single parent who faced violence, rape victims. Emotional issues.

For emotional issues it is important to understand that there are certain behaviour patterns you can use as a guideline to identify individuals or families with whom you can work and probably help. Some of the people may be in a state of mind where they may require professional assistance or the help of a specialist. This would mean you have to become a link and know how to enable the person to access the guidance of a specialist. Referring a person to a specialist will require tact and sensitivity because of factors like social stigma, etc. Help may be essential but the individual may not readily accept referral for a variety of reasons. However, the first task is to be able to recognise when it may not be within your own capabilities and skill to help a person and thus you have to refer him/her for professional attention. 48

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Examples
x

A man had a business of cars like Maruthi, Ford, etc. He had a house plus newly married sons. Within a week of the riots he lost everything. When his compensation packet came with only Rs1250 at that time, he had a paralytic attack and went into a state of shock. For him, having lost so much, he could not believe that he would not get his full reimbursement. Now he does not talk properly and does not respond. If you ask him questions, all he does is smile, lies down on his side and slowly tears well up in his eyes. No expression is visible on his face. A 20-year-old girl behaves in an abnormal way. She hits boys from the front, irritates them, tears clothes when she sees boys. A 35-year-old woman just keeps running and does not listen to anyone. She talks and suddenly gets angry and looks as if she is going to do something. To calm her down, water is given and to distract her, she is made to involve in some activity. She cannot concentrate for too long.

x

x

The first referral centre would be the Primary Health Care Centre (PHC) or the doctor attending your camp. The doctor at this centre would be able to provide appropriate care. Contact the visiting Psychiatrist and then follow up at the hospital if required.

There are four areas which you can consider while deciding whether you can help or if you need to refer the person: Alertness and Awareness Handle the situation if the person
q

Consider referral if the person:
q

Is aware of who he/she is, where he/she is, and what has happened. Is only slightly confused or dazed, or shows slight difficulty in thinking clearly or concentrating on a subject.

q

Is unable to give his/her own name or of people with whom he/she is living. Cannot recollect the date or state where he/she is from or even tell what he/she does. Cannot recall events of the past 24 hours.Complains of memory gaps.

q

q

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Behaviour Handle the situation if the person:
q

Consider referral if the person:
q

Wrings his/her hands or appears still and rigid or clenches the fists. Is restless, mildly agitated, and excited. Has sleep difficulty. Has rapid or halting speech.

q

Is depressed and shows agitation, restlessness, and paces up and down. Is apathetic, immobile, and unable to move around. Is discontent and mutilates him/ herself. Uses alcohol or drugs excessively. Is unable to care for him/herself, e.g., does not eat, drink, bathe, and change into fresh clothes. Repeats ritualistic acts.

q

q q

q

q q

q

Speech Handle the situation if the person:
q

Consider referral if the person:
q

Has an appropriate feeling of depression, despair, and discouragement. Has a doubt of his/her ability to recover Is overly concerned with minor things and neglects more pressing problems. Denies problems or states he/she can take care of everything himself. Blames his/her problems on others, is vague in planning and bitter with anger that he/she is a victim.

Hears voices, sees visions, or has unverified bodily sensations, like hallucinations. States the body feels unreal and fears he/she is losing his/her mind. Is excessively preoccupied with one idea or thought. Has the delusion that someone or something is out to get him/her and the family. Is afraid he/she will kill him/herself or another. Is unable to make simple decisions or carry out everyday functions. Shows extreme pressure of speech, like his/her talk overflowing.

q

q

q

q

q

q

q

q

q

q

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Emotions Handle the situation if the person:
q

Consider referral if the person:
q q

Is crying, weeping, with continuous retelling of disaster. Has blunted emotions, hardly reacts to what is going on around him/her right now. Shows high spirits, laughs excessively. Is easily irritated and angered over trifles.

Is very quiet, show no emotions. Unable to be aroused and completely withdrawn. Is excessively emotional and shows inappropriate emotional reactions.

q

q

q q

In the Aman Samudaya programme, both intra- as well as inter-referral processes need to be continued. For instance, when the Aman Pathik identifies a woman who has been raped and finds it difficult to work, he/she could always refer the case to the women support team, who would then make specific interventions. Similarly, problems with children and paralegal issues could be directed to the respective support teams. Links need to be made with the local government agencies like the Welfare, Hospitals and Police, who provide specialist care to the community.

P OINTS TO REMEMBER
➢ There may be some people who need guidance for specific issues and you need to refer them to the right person. ➢ For emotional support and care at times specialist help may be required and it is important to identify those needs and refer the person.

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SELF CARE
It is important for the CLH to understand that he/she is involved in work that is going to make demands on his/her physical as well as emotional life. The daily stress can cause internal tension within the CLH group. It is important for each CLH to understand this aspect and take some preventive actions to enable themselves to cope with this stress. An analogy of a tree is useful to understand this. Unless the tree has strong roots to support it the tree will not be able to withstand strong winds or give shade to others. This is applicable to the CLH too. There must also be some source of sustenance and nourishment in each CLH’s life to enable him/her to be strong and positive. Only then will they have the energy to support others.

S
q x x x x x x

OME THINGS TO DO FOR YOURSELF
Listen to each other’s feelings. Do not take anger too personally. Avoid criticism unless necessary. Give each other comfort and care. Encourage and support co-workers. Reach out to others when you are feeling low as well as look around and support others if they are down. Develop a buddy system with a co-worker. Agree to keep an eye on each other’s functioning. Check for fatigue and stress symptoms. Take a break when required.

With other colleagues

x

q

Personally for yourself
x x x x x x x x

Get some physical exercise daily. Regularize your life leaving enough spare time for rest. Listen to music, read books, watch television everyday. Try and eat frequently and get enough sleep. Practice relaxation techniques frequently. Stay in touch with your family and share your thoughts and feelings with them. Keep a diary of your activities and experiences. Identify one day in the week for your personal work and relaxation.

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S EEK HELP IF
x x x x x x

You find it difficult to leave your work even for a short period. Your sleep, appetite is disturbed. You are unable to enjoy things. You want to avoid going to work. You are easily irritable. You cry easily. Make a ‘Tree of Sustenance’ for yourself.

In the leaves of the tree put down three negative and three positive qualities that you have. These are the qualities with which you reach out to people. In the boxes representing the roots of the tree, put the names of people whom you can turn to for care and support when you need comfort. In the clouds above the tree list out things that give you a sense of peace and happiness. This is tree is symbolic of you. If the roots are strong and supportive and the tree has clouds for water, the tree remains healthy and happy and is able to give more shade and fruits to people for a longer time. Similarly have things and people around to care and support you. Since you are working in a field that draws on a lot of your emotional and physical strength, these people and things can provide nourishment and rejuvenation.

P OINTS TO REMEMBER
➢ The work is going to be taxing on the mind and the body. ➢ It is important to build support systems to take care of one’s personal well-being.
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RIOTS AND THE COMMUNITY
Disasters present a challenge to the total community. It is well known that exposure to any disaster situation itself is a stress for all persons involved. The degree of effect is directly proportional to the degree of stress experienced by individuals due to the disruption caused by the disaster. From this perspective, the people who experienced the direct effect of the riots are the most vulnerable. The Manual describes what is expected to happen to this population and the measures that can be initiated by the Aman Pathiks to meet the psychosocial needs. This chapter refers to the general population exposed indirectly to the riots and how they should care for themselves. The entire population is a disaster-affected population in the larger sense as the riots disrupted the lives of all of the people in one way or the other. They were exposed to experiences that are far from normal, like the scenes of destruction, violence, serious disruption of routines and a sense of uncertainty and fear. For riot situation, the social fabric is torn apart, socio-economic bonds that have bound people across communities in complex measures weaken and are destroyed. Prejudices are fostered, poisons of hatred are unleasehd and rumours are rife. Emotions are high and people feel spurred by motives of hatred unlike normal times. There is frequent feeling of betrayal, anger and loneliness. The economy also tends to be disrupted and daily wage earners, small self-employed people and the destitutes are the worst hit. To this extent, their mental health is compromised as a consequence of the riots in the state. Some people will experience serious symptoms, while the majority will experience some of the symptoms for varying periods of time. The measures that can be adapted by the general population are the following: At the individual level q Recognise and acknowledge that the community as a whole is passing through a disaster situation and no one is immune to the effects of riots. q Sharing of individual feelings and perceptions, and initiating activities to rebuild the community are important. q Adapting positive lifestyles described in the Manual is helpful for recovery. Find time to think about the events and what it means to your values and the sense of what the community should be. 54
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q

q

q

q

Volunteer your time to be part of the larger efforts to bring normalcy to the society at the individual, family and community levels. Seek professional help if you are experiencing difficulties of coming to terms with any aspect of the riots. These could be changes in your body function (sleep, appetite), or emotional function (irritability, anger, fear) At home, at work, or in the neighbourhood help people with the above mentioned problems to seek professional help to hasten recovery. Mastery of the riot situation is a slow and positive process and will occur over time and not overnight.

At the family level q Make time to bring together family members to openly discuss their ideas, feelings and reactions which will help in better understanding and mutual support. q If you in a group situation, periodically open up the subject to facilitate sharing and supporting each other. q You can do many things to protect and promote your mental health and that of your family and the larger community. At the community level q Irrespective of the meaning given to the riots (Why? Who? What? How?), it is to be recognised as a source of stress that will demand adjustment to the altered situation in the relationships of the communities. q It is important to be involved in the developments of the local area (read newspapers, listen to the radio, watch television, attend group meetings) and participate in the relief, rehabilitation and reconstruction activities. q The community can resume its normal functioning only with the returning of normalcy to all the affected population. q Reaching out to assist the severely affected population by sharing time with them, listening to them, giving assistance in whatever manner possible and communicating the fellow feelings to the distressed population are mutually helpful. q Rumours must be actively resisted. Prejudices must be acknowledged and dealt with. q Sense of normalcy and safety can come only from everyone feeling safe and not with one group feeling superior or more powerful than the other. q The free supply of food in riot areas under curfew deals with some of the worst insecurities q Early establishement of relief camps by governments with leaders of all community helps rebuilding trust. q Community efforts like peace committees, meetings and peace marches can be very healing. q Involving inter-faith groups of youth,women etc., for relief is a valuable step ahead.
DISASTER AFFECTS EVERYONE. YOU CAN MAKE A DIFFERENCE TO REBUILD THE COMMUNITY.

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Aman

Pathiks

Ahmed Hussain Mansuri, Ajmeri Jubedha Bhen, Alaudin Syed Hussain, Ansari Abdul Hakim, Ansari Anwar Hussain, Ansari Jameela, Ansari Makbul Ahmed, Ansari Md Sultan T, Ansari Mohammed Faraz, Ansari Mustaq Ahmed, Ansari Noorjahan A, Ansari Rashida, Ansari Saleem M, Ansari Shamsu Dhuha, Ansari Shehanaaz Banu, Anwar Ali Sheikh, Anwar Khan, Arifkhan Pathan, Asif Bai Sheikh, Ayub Bhai S Bhai, Babu Bhai Rathod, Baluram, Bharvad Bhavan Bhai, Bilkish T, Chauhan Kishor, Chowdary Satish, Christian Rupal J, Damthedi Ramand Bhai, Dave Hardik Kanaiyalal, Desai Natwar T, Desai Sikander M, Desai Teja Bai, Devika Bhen, Dinesh Goswami, Dipak Vegada, Diwan Noorjahan H, Dubhi Goutam Kumar, Feroz Khan N, Ganchi Irfan M, Gayathri S Pandey, Gevam Bhai, Goswami Durga, Goswami Harshad V, Gulshan Banu, I R Pathan, Imran Iqbal Khan, Imran Khan Pattan, Imtiaz Bhai Kureshi, Irshad Banu Shriyad, Jaswant K Rathod, Johara Bibi, Kailash J Damthadi, Kalpana K Parmar, Kasim Khan, Kazi Mo Mobeen, Khabetha Nasim Ansari, Khan Mamnoon, Khania Laxmanbhai, Macwone Palvin M, Madhupurawala I A, Mahesh R Vaghela, Makwana Jayesh, Malek Akthar, Mamesha G Vegalha, Manish Bai Solanki, Mansuri Md Zakir Y, Mansuri Nasim Bhen Hasan Bai, Mansuri Shaukat Md. Bhai, Mansuri Zakir Hussain Usmaan, Maqsood Bhai, Mazhar Khan A Khan Warsi, Md. Razak J Bhai Mansuri, Meena Bhen, Mehrunissa Sheikh, Memon Dilavar, Mohammed Javed, Mustaq Hussain, Nasir Bhai Phattan, Nayak Ashok Bhai, Nazma Banu, Neelam P Parmar, Nirmala K Dhuri, Noorani Mohammed Abbas, Noorjahan Aziz Khan, Padhiyar Himanshu, Panchal Malthi Bhen, Paramarak Dinesh, Parmar Rakesh, Parmar Vijay L, Parvathi Mohanlal, Patadiya Mukesh, Pateriya Jignesh B, Pathan Abdul Latif, Pathan Abdul Wafa A, Pathan Imran Khan A, Pathan Mahar Angag, Pathan Nazima, Pathan Shah Nawaz H, Pazi Seemab, Praful Jacob Khambalia, Pravin R Sharma, Premsagar Mahender J, Priyakant Pandey, Qazi Subahut, Rajesh Bhai D Rathod, Rajesh Kumar, Rajesh Kumar Mishra, Ramesh N Bagade, Rashida Pathan, Rekha, Sailesh Kumar N, Saiyad Mohsin Y, Saiyed Gulzal Fatma, Saiyed Nikhat Parveen, Saiyez Zulfikar, Sajid Bai Mallick, Sajid Bai Qureshi, Saleem Bhai K Mansuri, Salim Bai Mansoori, Salmania Bardat, Sanda Sameer S, Sarif Bhai Babu Bhai, Saroj Jaunbhai, Satish Bai Chowdry, Savabhai, Savitha Bhen, Savitri B Dubey, Shah Gulam Hussain, Shaik Mohammed Rashid, Shaikh Amin, Shaikh Amjed Ali, Shaikh Arshad, Shaikh Ezaz, Shaikh Imran H, Shaikh Mayudhin, Shaikh Md Saleem Md H, Shaikh Md. Rafi Mehaboob, Shaikh Md. Saleem, Shaikh Mohammed Rafi, Shaikh Naseem Bano, Shaikh Siraj K, Sharda Bhen, Sharifa Banu, Shariff Bhai, Sheik Abdul Kasim, Sheik Feroz
Ahmed, Sheik Idris Ranjanbhai, Sheik Nasim Banu, Sheik Sarfaraz Ahmed, Sheikh Afsar Hussain, Sheikh Anish, Sheikh Anjuman Ara, Sheikh Anjuman Banu, Sheikh Ashia, Sheikh Azim Bhai, Sheikh Jahunisa, Sheikh Mehrunissa, Sheikh Nilofar, Sheikh Shabnam, Sheikh Shafikudhin, Sheikh Shamim Akthar, Sheikh Zuber, Shilpa M Chirstian, Shrimali Banubhai, Shubash Sukhdev Vasanik, Siraj Ud Din, Solanki Chethan C, Solanki Dinesh, Solanki Girish, Solanki Shilpa Bhen, Sufiya Bano, Suhana J Mansuri, Surekha B Guptha, Syed Nasir Ali, Trupthi Bhai Solanki, Ujay Pathan Noorjahan, Ujjaini Hozefa M, Umar Farook Md S, Vagela Chimanlal, Vagela Shantha Bhen, Varsha Bai Qureshi, Varsha Bhen, Vipur Patel Chand, Yousuf Bai Mansoori, Zakir S Kazi

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WHAT WE KNOW...
x x

x

x

x

Intense emotional reactions in the face of these events are expected and normal. There is a trajectory of responses over time most often starting early and subsiding within weeks and months. But for some people, the onset of responses may be delayed. In others, the reactions may become long-term leading to considerable disability. Responses will be highly individual in nature, often quite intense and sometimes conflictual. The vast majority of reactions are in the normal range and the intensity will diminish for most people over time without the need for professional help. Support from family and friends is critical. For some, however, the degree of exposure may lead to more serious and prolonged reactions. The range of feelings experienced may be quite broad. People may describe intense feelings of sadness followed by anger. Others may experience fearfulness and hypervigilance to the environment among numerous other reactions. There may be temporary disruptions in normal coping mechanisms for many people and some may go on to develop problems with sleep, nightmares, concentration, intrusive thoughts and a preoccupation with reliving the events. These reactions are generally short lived but if they persist, professional consultation should be sought.

WHAT CAN BE DONE?
x

x

x

x

x

Create opportunities for people to talk and share experiences in supportive groups. This is often done best in familiar surroundings such as religious places, schools or community centers. Provide accurate and practical information especially concerning the larger recovery efforts. Special attention to the needs of relief applicants is necessary as relating to the rules and regulations of the relief organizations during the crisis can be overwhelming. Give particular consideration to the needs of special groups such as children, those who have been most intensely exposed or had a history of previous events (exposure to trauma), rescue workers, and people with pre existing mental health conditions. Children and adolescents will need the support of their caregivers. This support should reflect accurate concerns, and diminish any words or actions that would increase the child or adolescent’s anxiety. Caregivers should offer reassurance as to their presence and availability during this time. Exposure to television, movies or print matter that offers too graphic depictions of the destruction or victims should be limited. A percentage of people, as high as 30%, who experience the most direct exposure to the events may go on to develop more serious mental health concerns and should be referred for services if they develop persistent issues.

Overwhelming feelings are to be expected and can stress individuals, communities and nations. There are many actions that can be taken at the level of governments, international NGOs and local groups to appropriately and effectively support victims of such a catastrophe. WHO, October 2001

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INFORMATION MANUAL 2

RIOTS
PSYCHOSOCIAL CARE by COMMUNITY LEVEL HELPERS for SURVIVORS
Disasters pose a monumental challenge to the total community. There has been a gradual acceptance of the need for psychosocial care. The recent Gujarat Riots has left behind a trail of anger, anguish, betrayal and emotional scars that poses an enormous challenge of normalising the people’s feelings, rebuilding the people, reconstruction not only of shelters and livelihood but of the human spirit and communal harmony. The information booklet is unique because: 1. It addresses normalisation of emotional reaction. 2. It carries a large amount of relevant field experiences. 3. It is based on the actual training of 200 Amanpathiks. 4. It is user friendly, based on the field level pre-testing and gatekeepers interviews. It is a collaborative effort of professionals, voluntary agencies and survivors.

139, Richmond Road, Bangalore – 560 025 Ph: 080-5586682 e-mail: bfc@actionaidindia.org
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