For a healing touch

Interview with Dr. D. Nagaraja, Director, NIMHANS.

The Bangalore-based National Institute of Mental Health and Neurological Sciences (NIMHANS) is helping the tsunami-affected people in the country by offering them psychosocial counselling. Over 70 psychiatrists, doctors and social workers, including those from the Institute's Disaster Management Group, have been drafted for the task. About 21 members of them are in the Andaman and Nicobar Islands, Tamil Nadu, Kerala and Andhra Pradesh.

Just back from Cuddalore, one of the worse affected spots in Tamil Nadu, NIMHANS' Director Dr. D. Nagaraja spoke to Ravi Sharma on the Institute's initiatives and experiences. Excerpts from the interview:

Is intervention and counselling the key ingredient in treating people affected by disasters of this sort...

Yes. Once the affected people realise the gravity of the situation they go into depression and develop panic anxiety. You see a number of those affected complaining that nothing is being done for them. In reality it may not be completely accurate. But since their emotions are so heightened, even a minor lapse becomes a major issue. Even a small disturbance, makes them anxious, panicky and they get palpitations. It disturbs their routine and interferes with their ability to go back to their normal work. They can have problems in establishing a pattern of life, getting proper sleep, concentrating on anything and even develop a guilt complex that they survived while others died. If it is very severe, some can also become suicidal.

How do you tackle this?

It must be remembered that what we are tackling is not a mental illness. It is a natural emotional reaction to an abnormal situation. It is not psychiatric but a psychological problem. That is why medicines are not the major items with only a few persons requiring medication. What is required is a healing touch. We have to make the affected people cope with the abnormal situation. The major fear for entire communities is that the disaster [tsunami] will occur again and that they will be wiped out. So they are always in a state of tension. They have to be convinced that it won't occur all the time.

How do you convince them?

By talking to them. The moment they start accepting their emotions, half their tensions will abate. But though their emotions are heightened, they can't express this to anybody. Probably there is nobody at home and neighbours may not be prepared to listen since they also are in a similar predicament. So it is important to get them to talk about their experiences. Another important thing in the management of these patients is to normalise, as soon as it is possible, their day to day activities. Even if housed in a relief camp, children should be made to attend school, adults encouraged to do the work they normally do at home such as cooking and washing. The tendency should not be to house them in camps, feeding them morning to night. Activities should be started at the earliest. A normalisation of their activities at the earliest will help them recover quickly. If not, they will keep brooding.

Is there a difference in the way children and adults react to disasters?

Adults may have experienced bereavements, but in the case of children it will be for the first time that they are seeing so much of destruction and death, family members dying in front of them. All of a sudden they are on the streets, their homes and schools destroyed. They are in a worse state of anxiety. It is essential that they are not left in the same emotional state. They should be made to play, sent to school, so that normal emotions come into the picture.

How difficult is the situation on the ground?

Some people are severely disturbed, they stop talking, eating and working. They are not able to tolerate the situation and become depressed. But the number is small, say 10 or 15 people in a camp of a 1,000. They need immediate intervention. So our psychiatrists, doctors and social workers start handling them straight away. But since the tsunamis have affected people on a massive scale it cannot be tackled by one or two psychiatrists, or even just by psychiatrists. So we need a team and it has to work in tandem with the existing personnel. What NIMHANS has developed is a Disaster Management Group that trains volunteers/officials/social workers to provide this psychosocial help even as they are distributing other relief materials.

But volunteers cannot help people ventilate their feelings unless they themselves are trained. Everybody can't listen. Our training helps volunteers to learn how to get the affected people to ventilate their feelings and emotions. Normally when somebody relates something the other person also starts reacting to it, putting his own emotions into the conversation. What is required here is a patient listener, someone who can encourage the affected person to speak, ventilate without inhibition, while at the same time ensuring that none of the listener's negative feelings is introduced into the conversation. This has to be taught to the volunteers.

So the volunteers themselves need counselling.

Yes. Initially, most of the volunteers are in a heroic phase, being prepared to work without proper shelter and even food. But after a week or so, fatigue sets in. By then they would have seen so many dead bodies, got a first-hand experience of the disaster and seen things which most of them would never have seen in their lives. This will not only shatter their morale to work and provide relief, but worse, make them go into depression.

The training, which is chiefly imparted by the Institute's Psychiatric Social Work Department, seeks to augment resources on the ground...

Yes. The department has started conducting programmes for non-governmental organisations (NGOs), volunteers and employees of hospitals and the government. This sort of training is not required for too long but it is needed to prepare the volunteers and others to handle a situation that will last not a week but at least a year to get back to near normal. The three-tier training entails training master trainers who are professionals, doctors, psychologists, psychiatrists and social workers. They in turn train the trainers. Each trainer will then train about 25 people at a time. This way we hope to train around 26,000 people by the end of January.

Where are the programmes being conducted?

We plan to conduct one in Chennai. Thereafter the trained people will conduct programmes in every district that has been affected in Tamil Nadu (13), Kerala (two) and Andhra Pradesh (two). The six-day programmes are open to local psychiatrists, government officials and volunteer organisations.

It should also be remembered that we are not the only people who are providing psychosocial relief. Local organisations and government doctors are also counselling people.

Are there any programmes for the Andaman and Nicobar islands?

What we have experienced is that on the mainland there are some psychiatrists, voluntary agencies who have an inkling of the concept of psychosocial relief. But in the Andamans the concept is totally absent. There is only one psychiatrist for the whole island. So we had to develop the whole machinery. Six of our people are presently there working in tandem with 10 staff members from the All India Institute of Medical Sciences.

How different is the present disaster from other calamities such as the Latur earthquake (1993) or the Gujarat earthquake (2001)?

In the other two disasters there were a lot of injured people and a massive effort in medical attention was required. In this disaster, there are mostly only two categories of victims - those who are dead and those who have survived. There are not so many injured victims.

NIMHANS has also provided its expertise in dealing with disasters such as Latur, Gujarat and the Orissa cyclone. What lessons have been learnt?

The government, after any such calamity, plans to build shelters, provides food, create jobs, and so on. But that alone in not enough. You've got to talk to the people about their emotions, support them, draw out their negative emotions and strengthen the positive aspects. This will go a long way in their recovery and normalisation.

What are the long-term effects of such disasters?

We have clearly established from our experience in Gujarat and Latur and from other studies that these disasters result in a significant degree of psychosocial morbidity, which interferes with the recovery, production and quality of life. And unless it is tackled and normalisation restored recovery will take much longer. We are learning after all the concept of psychosocial rehabilitation is only around 15 years old. Earlier it was known as acute care but not seen as a medical concept.