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INFORMATION MANUAL 2PSYCHOSOCIAL CAREbyCOMMUNITY LEVEL HELPERSfor1SURVIVORS

INFORMATION MANUAL 2RIOTSPSYCHOSOCIAL CAREbyCOMMUNITY LEVEL HELPERSforSURVIVORS3

INFORMATION MANUAL 2RIOTSPSYCHOSOCIAL CAREbyCOMMUNITY LEVEL HELPERSforSURVIVORSPrepared by:Dr K Sekar – M A, PhD*Senior ConsultantMs Antara Sen Dave – M S W, M.Ed*ConsultantMr Subhashis Bhadra – M S W, M Phil.,**Psycho Social Programme Co-ordinatorMr G P Rajashekar – M A**Social WorkerDr K V Kishore Kumar – DPM***Senior PsychiatristDr R Srinivasa Murthy – M D***Professor of Psychiatry*ACTIONAID INDIA, **OXFAM INDIA, ***NIMHANS5

INFORMATION MANUAL 2RIOTSPSYCHOSOCIAL CARE by COMMUNITY LEVELHELPERS for SURVIVORSPublished byBOOKS for CHANGE(A Unit of ActionAid Karnataka Projects)139, Richmond RoadBangalore – 560 025Ph: 080-5586682e-mail: bfc@actionaidindia.orgEdition: First, 2002Copyright © Aman Samudhaywww.actionaidindia.orgwww.oxfamindia.orgwww.indiadisaster.comThis document may be freely reviewed, abstracted, reproduced or translated, in part or in whole, purely on a non-profitbasis. We welcome receiving information of its adaptation or use. The opinions, analysis and recommendations expressed inthis document are solely the responsibility of the authors.6

CONTENTSPrefaceAcknowledgementsviiviiiEvents in Gujarat 1Impact on the People 4Psychosocial Support 8Understanding Psychosocial Needs 11Role of a Community Level Helper 24Psychosocial Interventions 27PrinciplesIndividualFamilyCommunitySpecial Groups 41Referral 48Self Care 52Riots and the Community 547

Dedicated tothe Survivors of the 2002Gujarat Riots8

PREFACERiots pose a monumental challenge to the total community. Everyone who is exposedto 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 familymembers 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-termstudies of psychological problems of disaster were studied in the Bhopal populationas well as the survivors of Marathwarda earthquake. Both of them demonstratedthat there is higher emotional illnesses even years after the disaster.For the first time, following the Orissa Super cyclone a programme of psychosocialcare with community level workers (Snehakarmis) was implemented. This interventiondemonstrated the nature of the needs of the vulnerable groups, the possibility ofcommunity 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 andwhat it means for the survivors and the approach to psychosocial care is the scope ofthe current manual. This manual differs from earlier efforts. It outlines the anger,anguish and betrayal felt by the survivors and normalisation of their emotions. Theapproaches outlined are totally based on extensive field work, the initial experiencesof the Aman Pathiks in providing care and the observations of the mental healthprofessionals to provide support and supervision.The rebuilding of people, reconstruction of not only of shelters and livelihood but ofthe 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 teamin Gujarat.R Srinivasa MurthyProfessor of PsychiatryNIMHANSBangalore 560 029Harsh ManderCountry DirectorActionAid IndiaNew Delhi 110 0499vii

ACKNOCKNOWLEDGEMENTWe would like to take this opportunity to thank all the people who helped to enrich this manual invaried ways. While it may not be possible to acknowledge them all here, we would like to start byextending our gratitude to the Aman Pathiks (their names have been listed in p. 56) without whomnone 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 beour learnings.We gratefully acknowledge the people and the organisations associated with the Citizens Initiativewithout whom the peace movement would not have been possible. Our special thanks to AmanSamudaya supporters, Fr Victor Moses r. j. of St Xavier’s Social Service Society, Mira Maleek ofCentre for Development, Mishra of Kamdhar Swasthya Seva Mandal, Rajendar of SAATH whobraved 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 JPucadyil 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 andDr P V Unnikrishnan of Oxfam India for all their commitment to actualise psychosocial carecomponent in the normalization process of the riot victims.There have been others who have given their time through discussions and review of our materialand we would like to thank them too: Fr. Jimmy Dabhi, Prasad and Persie Ginwille of BehaviouralScience Centre, Kiran Patel, Consultant/Trainer from Oakland, C. Balaji Singh of CARE, BinoyAcharya of Unnati, Swaroopaben of St. Xavier’s College, Dr Darshan Trivedi, Dr Chandraguptsananand Prof. Vankar of Department of Psychiatry, Civil Hospital, Ahmedabad. We also place on recordthe service support provided by Dr Ajay Chauhan, Medical Superintendent, Institute of MentalHealth 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 regionwho 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 Booksfor Change deserve special mention for the effort and time devoted to this work. We would like tothank Suresh for the excellent illustrations.July 2002.THE AUTHORSviii10

EVENTS INGUJARATE VENTS AND CHALLENGES AHEADThe state of Gujarat was torn apart by savage sectarian violence, possibly the mostbrutal since Independence. This carnage has convulsed the state of Gujarat in overfour months since 27 February 2002 and left a trail of profound human tragedy.The violence has resulted in the death of nearly1000 persons, many of them women andchildren. It targeted a large number of womenand girls with rape and sexual violence. Manyothers were injured and disabled. Houses andcommercial establishments were looteddestroyed and charred to the ground acrossthe state, resulting in mass destruction oflivelihoods and displacement of people.Thousands of people, mostly from theminority community, were rendered homeless. Places of worship of the minoritycommunity 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 peoplewere in similar such camps across the state in Gujarat. Having lost everything theyonce 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 threemonths of their world being devastated, survivors subsist in makeshift camps inschools, darghas or graveyards. ‘The monumental pain, loss, betrayal and injusticesuffered during the riots’, ‘the depth of anger and longing for revenge’ and ‘thewounds may not heal for generations’, document the intensity of the psychologicalscar in the minds of the survivors.Very little was done even to meet the basic survival needs of the people who wereeconomically and socially displaced. There is also little evidence of significant stateor 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 survivorsof the mass violence, including for those in the remaining camps. Communal hatredhas been actively fostered in Gujarati society in recent decades, with ghettoisation intowns and cities, and deep distrust infecting the countryside.111

The media reports: ‘Trauma haunts children’, ‘crying need for the healing touch’,‘practising meditation to come out of their mental depression’, ‘share theresponsibility to assuage, heal and rebuild’, ‘social organisations bound together toheal’. These statements very clearly indicate that the impact of the recent riots inGujarat on the affected people is not only a reality but also widely recognised.C HALLENGES AHEADIt is against this grim scenario that any strategy for relief, rehabilitation andreconciliation in Gujarat needs to be positively considered. Following are the mainchallenges that confront the government and indeed the entire nation:●Ensuring that people living in the relief camps have access to◆◆◆◆◆◆Regular food supplies, especially for infants and childrenAdditional sets of clothes and allowance for daily expensesSanitation, drainage, toilets and clean drinking water, all vital to protect publichealth, are especially endangered during the monsoonsPublic health interventions like immunisation, preventive health care in termsof monitoring expectant mothers and people suffering from tuberculosisHeat and rainproof sheltersChild 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 homesand livelihood back to the same levels as before the riot◆There are hurdles in the way of families accessing the special welfare schemesmeant for them in terms of relief grants, compensation, housing, livelihood,etc. By now the Gujarat Government has issued at least ten GovernmentOrders. However, information on these orders is not accessible to the survivorssince it is either not readily available, or complicated in explaining proceduresand not survivor friendly. Hence the urgency lies in the need for support toenable community groups to access compensation, relief and rehabilitationpackages meant for them so that they can rebuild their homes and livelihoodto a certain extent.Ensuring livelihood reintegration◆Majority of the riot victims living in the camps have no personal support base tofall back on. People have lost their jobs, their means of livelihood and their smallinvestments. There is need to rebuild livelihoods of people based on their earliervocations and their own choice. This would require the mobilisation of enormousresources of the government, financial institutions, aid agencies and private sector.212

●●●●Ensuring legal rights and social justice to the riot survivors, including filing ofFIRs, investigation and contesting cases in the court.◆Legal aid is essential for the riot victims because in many cases FIRs have notbeen registered. Also in several cases, entire families have been wiped out andno one or sometimes no responsible person is left to file the claims. All thesemake the riot victims feel very vulnerable and demoralised. They need a lot ofmoral support and confidence building. For them to even be able to think oftaking legal action against the perpetrators is a big step.Providing psychosocial counselling and support for dealing with loss, betrayaland anger.◆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/experiencesa riot is traumatised to various degrees. Also responses vary from one anotherand manifestations change with time. However, if any of these are unattended,it can lead to serious mental health problems. Thus preventive measures suchas psychosocial support is needed. Psychosocial support to individuals, childrenand women in particular and communities in general enable them to relievethe trauma. It also helps and guides them to locate the various support systemsavailable, along with rebuilding their hopes and self-esteem.Community based care/rehabilitation for widows, orphans and those who arephysically disabled by burnsThe specific population at risk subsequent to the riots is the women who wereraped, persons with burn injuries, widows, orphans, physically handicapped andthe uncared aged. Long-term community based care/rehabilitation activity needsto be initiated for these groups.Actively rebuilding a culture of communal harmony and trustThere is a need for active resistance to communal violence and divisive ideology.Campaigns for communal harmony which are culturally relevant need to be carriedout for the entire community with a long-term perspective to resist the prevailingsocial boycott of the minorities, such as not renting out houses to them, lawersrefusing to fight their cause, not employing in their establishments and overcoming`borders’ in the mindset, like ‘their’ area and ‘our’ area.133

IMPACTONTHE PEOPLEAny human-made disaster leaves people with a great sense of betrayal, ripping apartthe social fabric that is essential for any person’s sense of well-being. The deep hurtand anguish caused by the loss of human life, as well as the disruption of dailyliving 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 orthe people who are indirectly affected or living under threat. Along with relief,rehabilitation and care of physical health and injuries, emotional needs have to begiven priority. This in the long run ensures rebuilding of confidence and peace. Whilerebuilding 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 theaffected population.In order to take care of the emotional needs of the riot-affected people, five majorchallenges need to be considered:●●●●●Severe stress and trauma due tothe riots.Sudden forced displacement.Difficulties of living in the camps.Uncertainty about the future andcontinuation of threat.Process of rebuilding personal,family and community life.The socio-economic impact, like thelack of employment, homelessness,environmental destruction and disorganisation emerges as a consequencefollowing the devastation. Disaster-affected people show various kinds ofreactions. Emotional reactions immediately follow the event. The following pageillustrates some of the responses of affected persons.414

Physical impactStomach-aches, Diarrohea, Headaches, Body aches, Burns(heat, acid), Physical impairments (limbs, sight, voice, hearing),Injuries (bullet, sharp objects and others), Fever, Cough andCold, Miscarriage, Physical Assault.Emotional reactionsAnger, Betrayal, Irritability, Revenge-seeking, Fear, Anxiety, Depression,Withdrawal, Grief, Addiction to pan masala, cigarette, beedi, Drug abuse.Repeated thoughts about thedisaster and related eventsWorrySocio-economic impactLoss of trust between communities, Lack of privacy, Single parent families, Widows,Orphan state with loss of both parents, Discontinuity in educational plans.Loss of employmentHomelessnessLoss of handcartDisorganisationof life routinesMigration155

It is important to note that all these reactions are inter-linked to one another. Forexample, due to loss of livelihood opportunities an individual may get depressedand feel helpless, or a physical injury may prevent him/her from work, therebyresulting in the loss of his/her source of income. Hence, an impact on the socioeconomicfront causes emotional reactions in the first case, whereas in the secondcase, an impact on the physical aspect influences the socio-economic front. This clearlyindicates that all the three areas are inter-linked.For appropriate and effective interventions it is very important to have a clearunderstanding of the emotional reactions to disasters. It is now clear that these reactions:●●●●●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 andusually also undergo change over time. Therefore, post-disaster psychologicalinterventions should be flexible and based on an ongoing assessment of needs. Theemotional reactions should be understood based on the manifestation of variousstress reactions, level of individual effort invested by the people for their ownreconstruction, the pattern and degree of disability as a result of these psychologicalstress, etc. Some factors that could influence the reactions among people are:●●●●●●●●●●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 asense of loss that is unique to them, for example:● a lady widowed 6 months after marriage.● an elderly couple losing all their life’s savings.616

→● 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 onthe individual.➢ Emotional reactions need to be recognised.→depresssionanxiety→looking aheadreaching out/networkingEmotional reactions undergo change over time.177

PSYCHOSOCIALSUPPORTC OPING WITH EMOTIONSThe emotional reactions of anger, irritability, panic attacks, sleeplessness, withdrawalfrom others, anxiety attacks in adults and nightmares in children are universalresponses of people experiencing events beyond their coping capacity in disastrousevents like riots. The level of depression varies with the kind of torment they wereforced to experience. Women who witnessed brutal killings and sexual harassmenthave high level of trauma. The aged, women, children and disabled people experiencegreater degree of emotional reactions. These reactions reported by the people are anormal response to an abnormal experience. It is important to recognise this so thatpeople experiencing emotional reactions are not made to feel that they are weak orunable to cope in any way.C OPING WITH LOSSLoss due to the death of a near and dear one, separation from loved ones and materiallosses are an inseparable part of human existence. Under normal circumstances,everyone goes through this process without much difficulty because the family andrelatives come together to share the loss. Support from friends, relatives and neighboursoccur automatically. Rituals are initiated soon after the death. For example, soon aftera death in the family, arrangements are made for cremation, all the daily activities aretemporarily suspended, prayers are offered to the deceased, and rituals are completedon 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 toterms with the changed situation and continue with their lives.N EED FOR EXTERNAL SUPPORT SYSTEMSAs discussed above, after a traumatic incident, all acquaintances, friends, neighboursand relatives of the victims/survivors (both close and distant) have a definite role tohelp in recovery. However, in a disaster, the naturally available support systems andhealing mechanisms are disrupted as most of the people are either themselves affectedor incapable of providing such support. Hence, in a disaster situation, the existingsocial structure does not play the normal critical role in the healing process, becauseeach individual in the area has been affected by the disaster. The family as a unitmay no longer exist. For many this leads to a sense of isolation, helplessness anddespair. The normal process of mourning and other related rituals do not occurautomatically. In such cases, establishing a system of support by an external agencybecomes important in order to help people who have been affected.818

Usually people who come from outside the community are doctors, lawyers, NGOsvolunteers and such individuals, who in their own capacity contribute/donate food/other basic essentials/money, and offer time and their skills and expertise. Alongwith them a group of volunteers, Community Level Helpers (CLHs), mostly fromwithin the community come together and work towards rebuilding and rehabilitationin a comprehensive manner.Local Community Level Helpers (CLHs) have been seen to be more effective inproviding psychosocial care and support to the affected people. Aman Samudaya isan example where the community level support system has been effective. The AmanPathiks (CLHs) are part of a larger network of 30 NGOs, who have come togetherunder 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 talkabout their experiences. As time goes by and with no help forthcoming, the survivorsstart withdrawing into a defensive, non-cooperative attitude. Therefore, it is of utmostimportance that survivors are encouraged to seek help, share and talk about theiremotional problems as early as possible, to prevent problems and development offurther complications.In general, people do not readily/directly talk abouttheir emotional problems. Even during visits to thehealth centres, they generally report physicalproblems. Emotional problems may be indirectlymanifested as unidentifiable aches, pains, headaches,tiredness, etc. When given an opportunity, peopledo talk about themselves.It is important that the aid agencies be sensitiveto the emotional needs of the affected populationand provide them opportunities to talk and sharetheir feelings. Rebuilding and Rehabilitation cantake place with such sensitivity.I MPORTANCE OF PSYCHOSOCIAL CAREEmotional problems following disasters often tend to be neglected. This happensbecause they are relatively invisible when compared tothe damage caused to life, physical health and property.It is important to remember that emotional problemsoccur very commonly. Distress is intense and leads tohelplessness, isolation and apathy. Everyone whowitnesses/experiences a disaster is affected by it.Hence, early identification of this problem, followed byintervention help the survivor to recover.199

It is important to realise that rebuilding of an individual’s lifeand reconstruction of the entire community following thedisaster depend upon the survivor’s ability to accept the lossesas early as possible. It will help him/her understand andemotionally accept the current reality and thereby worktowards reconstruction of life both at the individual, familyand community levels.An example: Let us take an analogy of a person with an injury. An injury to any partof the body will heal over a period of time because the body has the ability to repairthe damage. The natural repair process takes some time.However, if the person gets immediate first aidfor his injury (e.g., cleaning the wound withuncontaminated water and covering it with a sterileor clean cloth), the healing will be hastened, therebygradually reducing the pain and discomfort. But onthe other hand, imagine if the wound is unattended.The wound is likely to get infected and healing willbe delayed, leaving a bad scar. This might even causesome limitation in the normal functioning of that partof 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 andproduces a limitation for a long time.Similarly, any emotional reaction like anger, betrayal and paindue to loss and death requires help to facilitate ventilation orreliving. This works like the sterile cloth preventing infection,and allowing the body to work and heal. Non-availability ofsuch help to release or share these emotions leaves a scar inthe mind. Therefore, it is very important for people to sharethe 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 facilitatingrecovery among people.➢ Psychosocial care is an important aspect of the rehabilitation process.➢ Early recognition and intervention lead to better outcomes.1020

natural buffers in the community, mental health interventions, such as outreach,support groups and community organisations which seek to re-establish linkagesbetween individuals and groups, become extremely essential.●●●●●Displaced living causes many problemsMany emotional reactions of survivors stemfrom problems of living caused by thedisaster. Disaster disrupts/displaces allaspects of daily life resulting in practicalproblems, like finding temporary housing,food, clothing, etc. Timely and appropriaterelief and support measures are very vital tohelp survivors handle the disruption.Disaster mental health services must be uniquely tailored to the communitiesthey serveMental health interventions should be based on the demography andcharacteristics of the population. It is also essential to consider the ethnic andcultural groups in the community so as to provide help in a manner which isculturally relevant, and in the language of the people. Hence, the emphasis is thatsuch programmes are more effective when workers indigenous to the communityand to its various ethnic and cultural groups are integrally involved.Survivors respond to active interest and concernSurvivors will usually be eager to talk abouttheir experiences when approached withwarmth and genuine interest. Workers shouldnot hold back from talking with survivors outof any apprehension of intruding or invadingtheir privacy.Interventions must be appropriate to the phase of disasterIt is of paramount importance to recognise different phases of the disaster, varyingemotional reactions of each phase and the need for appropriate interventionstrategies. In the initial phase, listening, supporting, ventilation, catharsis andgrief resolution help, while in the latter phase handling frustration, anger anddisillusionment becomes important.Support systems are crucial for recoveryThe most essential support for individuals is the family. Attempts should be madeto keep the family together and the members encouraged to be involved in each1222

other’s recovery. For those who are orphaned or widowed or lone survivors,support from other groups are extremely important.●Attitude of the caregiverThe caregiver (CLH) should avoid use of mental health labels like ‘neurotic’,‘counselling’, ‘psychotic’, ‘psychotherapy’, etc., and use an active outreachapproach to intervene successfully in the disaster. The caregivers need to besensitive, non-judgemental and a confidante in all interactions with the survivors.U NDERSTANDING THE EXPERIENCE OF STRESSSurvivor’s stress is the result of unpleasant experiences, inadequate livingconditions, a sense of insecurity and a constant feeling of being under threat.Stress causes unhappiness and prevents people from doing useful work and mayaffect all areas of a person’s life. An individual suffering from stress and anxietymay not be able to talk about the stress directly but the existence of stress can berecognised through different symptoms such as:●Behavioural SymptomsTraumatic experiences cause a lot of stress, which is often beyond the copingcapacity of an individual. The inability to cope effectively leads to symptoms in aperson, some of which are manifested in his/her behaviour, such as:◆Loss of interest in lifeWhy should I be living anymore? What is the use of my life withoutmy grandson and granddaughter? They should have killedme too.◆◆Reduced activity, no energyThere 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 bodyaches, I cannot concentrate/focus on anything (‘mera maan nahin lagta’).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 isstiff. I am not able to sit or stand for a single minute.2313

◆◆◆◆Difficulty in concentrationSitting in front of the kerosene stove reminds me of the fire. I am worried and preoccupiedall the time. I keep making mistakes while cooking. I forget to put salt or chilly or otheringredients in the food.Sleep disturbances and problemAn aged man talks about his inability to have a restful sleep:If I start thinking about something, the whole night I lie awake.Feel as though I cannot breatheThe moment I enter my burnt house, I feel choking in the throat. I am not able tobreathe at all inside my house.FlashbacksA young boy saw his family members being killed and burnt alive in front ofhis eyes. Only his father was saved. At night he wakes up disturbed and cryingand remembers the horrendous moment when he saw his mother trying toprotect 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 brotherto save him, before they cut her up in two.◆Taking intoxicants or drugsThere is no work or any activity in the camp. Let me atleast keep munching paanmasala. My child has also developed a liking for it.●Physical SymptomsOften 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 emotionalstress a person is undergoing. For instance, a headache can be due to both physicalas well as emotional reasons. It is important to recognise and understand the kindof bodily symptoms that an individual experiences while under stress.◆◆◆HeadacheMy head aches all the time.TirednessI feel like just lying down.Tense musclesMy daughter is young and she got so scared that her whole body became stiff.1424

◆◆◆Palpitation/irregular heartbeatEven now, if I hear some noise I get so alarmed as to what is happening. My heart startsracing (‘Mera dil tez dhadakta hai’).Poor appetite, pain in abdomen, vomiting sensationI do not feel like eating; sometimes I do, otherwise I do not (‘Bhook nahin lagti, kabhikha liya to khaya nahin to aise hi’).Unidentifiable pain in arms, leg, chest or all over the bodyA woman who used to sell items on a handcart talks abouther 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 thedoctor has given do not seem to really help.●Emotional SymptomsA person who experiences stress will exhibit a lot of behavioural symptoms inhis/her emotions. Emotional reactions are very apparent as they bring a distinctchange in the survivor’s behaviour. It is important for us to identify and understandthese manifestations as reactions to stress:◆◆AngerWe 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 asafe 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.IrritabilityA 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.2515

◆◆◆RevengeA 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 whenthey grow up? Isn’t it natural that they will become terrorists.Fear, vigilance and anxietyA young boy saw his entire family being killed by the rioters. Whenever hesees a group of people coming close to him, he believes they are coming tokill him:Let’s go from here, they are coming here.A woman used to earn her living by sewing. But now whenshe hears the whirr of the sewing machine, it reminds her ofthe rioters coming and closing in on her house. Loud voicesor 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 slightsound makes us tense.Helplessness, sadness and guiltAn 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 voicedoes not come out, I get so scared. Memories of whathappened haunt my mind.A 30-year-old woman who was running with threechildren lost the younger one in the melee. She is notsure whether the child is alive or dead. She repeatedlykeeps saying:I should have carried him on the back. This thought never occured to me. I am responsiblefor the loss. I am not able to get the scene out of my mind.1626

A middle-aged lady talks about how helpless she felt when she came tothe camp:Coming here I felt like a beggar, having to wait in line for tea, for food, etc. We often didnot feel like eating. We were all here like orphans (lawaris), wearing whatever clotheswe 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 haveno support, only the camp people are there.A woman who witnessed other women being molested, raped and harassedbut could not help, expresses her sadness and guilt:When the rioters (tola) came I was hiding with other women. They started cutting uppeople, burning homes and doing ugly things to women. We were watching but couldnot 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 beingraped, they called out to me for help but I just hid and sat there, I could not do anything.◆◆Repeated thoughts about the same thingA woman talks about what she witnessed during the riots:I saw the mob who tortured and harassed the women by stripping them naked, physicallyabusing them and then burning them alive. I do not know, I just feel very tired. I keepgetting the same thought in my head again and again. Even now I remember thoseevents (‘Abhi bhi yaad aata hai’).Moods that keep changing frequently: Poorconcentration, Forgetfulness and Suicidal thoughtsAll my family is gone; W hat do I have to live for?At times Ifeel I should go and hang myself.●Relational ChangesWhen a person experiences stress, certain emotionalreactions appear, as observed in the earlier examples. These reactions lower thequality of interpersonal relationships and interactions with others, and result in:◆Disagreement and argument, unpleasantnessMy husband was ill and I used to repeatedly ask people around in my room to stoptalking or lower their tone just for a few days while he needed rest. But they would notstop; they talked ceaselessly.I was in the toilet and a lady said, ‘Are you sleeping there?’ I had just gone in and whenI came out I retorted, ‘Is this some place one would like to sleep?’2717

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.◆◆Lack of emotionInitially when Ms X came she was in a very bad condition; like a dead body. She used tojust 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 oremotions associated with the event.I had two daughters, both were killed in these riots. They were raped and then burnt. I havenot been able to get the postmortem report till now. I have not got my compensation money.Too much dependence on others for decisions and supportA 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 themto initiate activities.U NDERSTANDING THE STAGES OF SYMPTOMS REACTIONSPsychological reactions tend to change over time, it is essential to understand thedifferent reactions in a phased manner. The reactions could be following a normalmode of occurrence or an abnormal mode:●Immediately after the event, i.e. within few hours to a few daysThese reactions are short lived and generally seen in all people:◆Panic, tension, anxietyThe event happens so suddenly that there is no time to think. The immediatereaction is to run for safety. Fear is predominant among everyone till they reacha safe place.We ran out without even wearing slippers (‘Aise bhage ki chappal bhi nahin pehne’).◆Shock or numbnessDifficulty in accepting the reality of the event. Survivorsbehave 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 throughthe motions of life while actually feeling little. At the sametime, physical symptoms such as confusion and loss ofappetite are common.1828

NORMAL REACTIONOUTCRY(Fear, sadness and rage)DENIAL(Refusing to face the memoryof the disaster)INTRUSION(Unbidden thoughts of the events)WORKING THROUGH(Facing the reality of whathas happened)ABNORMAL REACTIONOVERWHELMED(Swept away by the immediateemotional reactions)PANIC/EXHAUSTION(From the escalated emotions)EXTREME AVOIDANCE(Drugs etc., to deny the pain)FLOODED STATES(Disturbing images and thoughtsabout the event)PSYCHOSOMATIC RESPONSES(Bodily complaints)◆◆◆For a few days I did not even understand what happened. (‘Thode din to smaje meinbhi nahi aaya ki huya kya hai’).My daughter was so scared that she seemed a little lost for sometime (‘Yeh, ladki itnadar gai the ki iske hosh khoye hua se the’).Relief, elation, euphoria among the survivorsSome would feel a sense of joy to have escaped unharmed andhave their family members safe.AngerThis reaction usually occurs when an individual feels helpless and powerless.It may result from feeling abandoned. Feelings of resentment may occur due tothe injustice of this loss. Some survivors may ask questions, “What did wedo?” “Why us?” “How could they do it?” Then slowly anger towards the peoplewho have brought them to this state will emerge. It can be a mild feeling or araging irrational emotion. People will talk of revenge.A woman while relating her experiences became very angry andstarted shouting: Tell me what would your situation be if you were inmy position; what wrong did we do?Survivor guiltFew survivors experience feelings of guilt and regret. “I shouldhave done more”, “If only I had known”, are thoughts that haunt2919

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 bachaneke liye’).A woman talking about her daughter-in-law who had gone home for herdelivery 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.◆DepressionExperiencing a sense of great loss, mood fluctuations and feeling of wanting tobe alone, may follow. Sleep and appetite disturbances, lack of energy andconcentration, and crying spells are some of the typical symptoms. Feelings ofloneliness, emptiness, isolation, and self-pity can also surface during this phase.After shock and denial have passed and anger has been exhausted, sadnessand even hopelessness may set in. A person may have no energy even to dothe 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 joebanaya tha’).Restlessness, confusion, sleeplessness, repeated experiences of the events,nightmares, and arousal symptoms may come up.●●As the days pass by (within 1 to 6 months) new reactions appear, these areseen in about 40–50%of the population in the form of◆◆◆◆◆GriefApathyLack of response to othersInhibition of outward activityPhysical symptoms of anxietyDelayed reactions manifest after 6 months and may be seen as anintensification of the reactions seen earlier, in about 30% of the population.GriefGrief occurs in response to the loss of someone or something. Theloss may involve a loved one, a job, or some material possession.Grief is a normal and natural response to loss. There are a varietyof ways the individuals respond to loss. Some are healthy copingmechanisms and some may hinder the grieving process. It is2030

important to realise that acknowledging grief promotes the healing process. Spendingquality time and giving support facilitate the individual’s grieving process, providingan opportunity to appropriately mourn the loss.Bereavement is a painful process and at times seems unbearable. It is a combinationof many emotions that come and go, sometimes without warning. Grieving is theperiod during which the individual actively experiences these emotions. The durationand intensity of the grieving period vary from each individual. The length of timepeople grieve can be weeks, months, and even years but it gradually becomes lessand less painful.Because it is so painful, some people try to ‘get over’ a loss by denying pain. Whenpeople do not deal with emotions of grief, the pain does not go away. Understandingthe emotions of grief and its accompanying feelings and symptoms are importantsteps to heal and to help others who may be grieving. Some manifestations of this are:◆◆◆◆◆◆◆◆◆◆◆SadnessDistressDepressionYearning for what has been lostAngerGuiltSleeplessnessLoss of appetite.Severe irritabilitySuicidal tendenciesBeing 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 isto help him/her share the feelings of loneliness, anger, and sadness openly andhonestly. Next is to help them to understand that such feelings and reactions areabsolutely normal in anyone coping with a personal loss. Practising relaxation,deep breathing exercises, listening to music and getting involved in other lifeactivities will help in handling the symptoms of grief. Encouraging them to adopta 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 overwhelmingevent that is perceived as dangerous and beyond the normal coping capacity, theability to respond adequately gets hampered. The symptoms that might develop inPTSD are understandable:◆Reliving the trauma in intrusive memories or dreams which are painful, comeuninvited.3121

◆◆◆◆◆◆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 theslightest 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 example14-year-old S belongs to a low socio-economic status family. She was witness to hermother being killed during the riots (Dhanga). She vividly recalls how the mob wasrushing 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. Swas able to reunite with her father and brother at one of the camps. The father describesthat most of the nights S gets up from her sleep and shouts, ‘The mob is coming’ (tolaagaya) and subsequently her whole body shivers and she gasps for breath on someoccasions. S reports that she is repeatedly haunted by the gory incident. She is unable toremove the scenes or the images from her mind. She very often re-experiences thesememories. Returning from the camp to their house, she is scared of going near thetheatre where the event occurred. She practically avoids going that side and even lookingthat side reminds her of the gory day and the events. Even a small cycle tyre burst in theroad and she starts running away screaming, and is then found to be irritable for thenext 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 ofsymptoms like re-experiencing, avoidance, hypervigilance, numbness and irritabilityin a person.A person can recover from PTSD on his or her own over a period of time throughthe combined actions of education, support, anxiety-management and lifestylemodification which can hasten the process of recovery:◆◆Education, the first step, involves helping the person understand his/hercondition and reassuring that the reactions are a result of the stress due to thetraumatic event.Support from family, friends and anyone working with the person by lettingthe person know that he/she is not alone and is not responsible for the event,etc., helps in the recovery process.2232

◆◆Teaching anxiety management strategies like relaxation, breathing techniquesand diverting the individual’s mind through involvement in activities.Changes in their lifestyle is very important. This means following a healthydiet, avoiding stimulants or intoxicants, regular exercise and adequate sleep.In certain cases use of medication maybe recommended. All these help in therecovery process.●Other delayed reactions◆◆◆◆◆◆Loss of productivityFamily problemsSubstance abuseIncreased vulnerability to stressPoor physical healthSuicidal 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 thesymptoms.3323

ROLE OFA COMMUNITYLEVEL HELPERAs mentioned earlier, the CLHs play a critical role in the rebuilding efforts after anycommunity has experienced a disaster. In the Orissa cyclone disaster it was theSnehakarmis and in the Gujarat earthquake it was the Viklang Bandhus who providedpsychosocial care. During the Gujarat riots, it has been the Aman Pathiks who areproviding 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 thecommunity, and are likely to know the area well and have close ties with severalpeople in the locality. They will also be able to work in a more intense and sustainedmanner with the community.Emotional interventions can be provided to the family by daily visits. During suchvisits, time should be spent to talk about the survivor’s feelings and experiences,imparting health education, discussion of health problems, engaging in paralegalwork, motivating individuals to hold group meetings, organising educationalactivities and maintaining a routine despite loss.The most important step in the psychosocial care and recovery process is torecognise that such care is essential for the entire population exposed to thecatastrophic 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 addressedby the CLH (see box). The focus will be, identification of needs and attention tospecific problems. Referrals would be made as and when required and there wouldbe a commitment for long-term work. They would be working not only with thepeople who have been affected but also the larger society and others in the AmanSamudaya team.2434

Spectrum of care would cover issues related toRights and JusticeCompensationHealth CareParalegalHousing andLivelihoodINDIVIDUALPsychosocialSelf HelpRole of a CLHThe foremost task of a CLH would be to meet and interact with many families at thecamps. He/she should initiate interactions among the families using culturallyappropriate greetings and gestures like, ‘salaam valikum’, ‘namasthe’, ‘aadhab’. Insubsequent interactions, the CLH would help them with:●Understanding the changes that they experience in their body and mind.When people face any traumatic event, they experience both emotional andphysical reactions. Helping them to understand that it is absolutely normalto feel this way is very important. It will make them feel more comfortable todeal with what they are experiencing. Knowing what they are experiencingcurrently is just a temporary phase and thatover time they will be able to get back to theirnormal life, will benefit them.●Decreasing the physical and emotional effectsby listening, relaxation, externalisation ofinterests and activities.Here the CLH would use the basic principles to extend emotional support andestablish a relationship with individuals . This helps the survivors to relate whatthey have experienced, and share their feelings. By ventilating, the pressure ofthe strong emotions within them gets lighter and lighter over a period of time.3525

●Support and rebuild their shattered lives in the areas of housing, work, healthand community.After establishing rapport, facilitating reliving and grief resolution, the CLH wouldgo on to observe or enquire about any specific help aperson may need. This could be in the form of◆◆◆◆◆◆Guidance to get compensation, assistance in paralegalwork, house damage assessment.Practical help like getting forms/accompanyingsurvivors to the offices or helping the individual opena bank account, etc.Medical help if need be, specially going to the hospitals.Mobilising help from neighbours/relatives to support anorphan or an elderly survivor.Getting livelihood reorganised.Networking and coordinating with other agencies are alsoimportant for sourcing various other kinds of support.The wholistic approach is more substantial not only in termsof meeting varied needs of an individual but also gives theCLH more entry points for intervention.Once the CLH has been able to establish rapport and built relationships withpeople, he/she would need to identify groups that need special attention andwork closely with them. These groups are:◆◆◆◆◆◆◆WidowsOrphaned 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, theyare an important link.➢ CLHs have critical roles to play.➢ CLHs need to identify and give special attention to people who arevulnerable.2636

PSYCHOSOCIALINTERVENTIONSUnder normal circumstances, most people can take care of their problems. Theriots being an abnormal situation, the people’s equilibrium is temporarily upsetbecause of the emotional reactions they experience. Till the time they can developsuccessful coping strategies and handle their lives independently, they requireemotional support.It is like extending help to a person who has fallen on the ground. Extend your handto help the person sit, then slowly make him/her stand. Then walk a few paces withhim/her and gradually he/she will walk independently. The following diagramwould help understand at a glance the three areas of focus for psychosocialinterventions:DISASTERCan lead toDISTRESSANDDISABILITYROLE OF COMMUNITY LEVEL HELPERSHelp peopleunderstand thechanges that theyexperience in theirbody and mind by●●●VentilationActive listeningEmpathyDecrease thephysical andemotional effects by●●●●●●RelaxationExternalisation ofinterestsLifestyle choicesSocial supportHealth careSpiritualityAll the above three lead toSupport and rebuildtheir shattered livesthrough●●●●●Help with housingAssistance forcompensationParalegal aidEducational helpEmployment➡ADJUSTMENT AND MASTERY OVEREMOTIONAL DISTRESS3727

P RINCIPLESThere are 7 principles that can be applied to give psychosocial support to any personin a post-disaster situation.VentilationA person (i.e., in this case survivors of the riot) whohas experienced trauma will have strong emotionswhich will very often be suppressed. The dangeris that if there is no space or appropriate stimulusfor release of these emotions, then the pressure willkeep on building until one day the person can breakdown. Hence it is extremely important for the CLHto meet the people, interact with them and helpthem talk about (ventilate) what they haveexperienced and share their feelings and emotions.For exampleFor instance, in a pressure cooker the safety valve is very important. It systematicallyand 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 orother emotions that they have supressed within them. This is an extremely importantpart of the role of a CLH.This process involves release of emotions and feelings. It is a very importantintervention and should be used as soon as possible. People under stress find itdifficult to relax and may have other symptoms. Even in crowded camps, peoplecan be very lonely.For exampleMr A whose daughters were raped and killed in front of him says, “I had two daughtersboth were killed in these riots. They were raped and then burnt. I have not been able toget the postmortem report till now. I have not got my compensation money.”When you talk with him, his conversation revolves around more practical issueslike compensation, etc. He is not in touch with his feelings that relate to the loss ofhis children and the trauma he has experienced. He has managed to suppress thosefeelings; but they are simmering inside. If not given timely help, one day the pressureof those emotions can cause a break down in him.2838

EmpathyOften when we look at others we do not see their distress and everything appearsvery 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 willgive us a clearer picture of what that person is going through. This same goes for theCLH. The idea of being able to feel and experience the pain as your own by tryingto 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, listeningattentively 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 andexperience the pain of the survivors while working with them. This will give them agreat sense of relief of having been truly understood. As one Aman Pathik saidListening to her story and the way she was crying, even I had tears in my eyes.Active listeningIn 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 toprovide emotional support and all the more in the camp situation. Practising someof the guidelines given below can help you work better:◆◆◆◆◆Look into the eyes of the person while he/she is talking: This indicates beinginterested in what is being said.Respond occasionally while listening: The person speaking feels convincedthat you understand and take him/her seriously Sometimes it helps toparaphrase what has been said, often giving the speaker another viewpoint.Avoid interruptions: Let the other person finish his/her thoughts. Do notinterrupt unless there is confusion and the details are jumbled.Be accepting: Do not prejudge, moralise, condemn, or interpret how the otherperson 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 personis going through certain feelings or emotional experiences.Social supportEveryone feels very comfortable with a certain level of emotional support thatcomes from others around. Social support networks are extremely importantfor feeling comfortable and secure. In a disaster situation these support systemsget disrupted.3929

For exampleIf 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, andwant 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 bondingin terms of almost being like a family member. The losses during such riots are notonly personal in terms of family members, belongings, etc., but also the loss of largersupport systems like friends, neighbours, community, and so on, who/whichotherwise could have been of help. The involvement of external agencies and CLHsspecifically can play a great role in extending emotional support.Externalisation of interestsThe women at camps are engaging in community kitchens. They have somethingmeaningful to do during some part of the day. Similarly, older children are seentransporting firewood from the truck to the storage area. All these, though smallactivities, give people a sense of being productive and help in enhancing their recoveryprocess. The people are engaged in activities and their minds are meaningfullyoccupied. Also, any physical activity energises people and makes them feel better.For exampleOne woman mentioned to the Aman Pathik that she would like to work with the childrenin the Bal Muskaan programme being run in the camp. It is important for this womannot only to be given an opportunity to work because she feels she has the skills, but alsobecause it will help her personally to divert her thoughts from the traumatic experienceshe has experienced, to something which makes her regain her self-esteem and self-respect.In some camps, lists of women interested in sewingwere drawn up and machines were provided tothem. It is essential to identify vocational intereststhe person may exhibit and help him/her getinvolved in these activities.This was seen in the camps with the Bal Muskaanprogramme that was started for children. Herechildren spend time in non-formal activities, singingsongs and playing games. Some books were alsoprovided. Initially the children at camps used to while away their time. They didnot have anything to look forward to and often sat with elders, listening repeatedly3040

to horrific stories and negative messages. With the introduction of the Bal Muskaanprogramme, having their day filled with activities became a reality. The children nowhave something to divert their mind from the painful memories and emotions. Thishas 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 anAman Pathik has been healing for many. One lady said, My mind has become ‘fresh’ afterI started working here (Aman Samudaya). Now I work with everyone and today the situationis such that I feel this camp is my home. This is a clear indication that if survivors are ableto divert their mind and get interested in other activities, they feel better.The value of relaxation and recreationGetting back to a routine is a great way to divert one’s mind and deal with the stressof emotional reactions. The more the people engage in activities or recreationalpursuits, the faster and greater will be the normalisation of their life. Some examplesof how relaxation was occuring at the camps in Gujarat was seen among men in thecamps who listened to the radio. In some camps, a loudspeaker played music and atthe other camps movies were also shown. These helped in changing the atmosphereof the place.At one point of time, each camp had a street play performed by a cultural team fromoutside, which everyone watched and appreciated. The whole process of having astreet play generated a lot of interest and energised the group. In some camps, peoplediscussed their personal experiences, and identified themselves with the charactersin the play. There were some people in the audience who started crying, leading to aform of mass ventilation and feeling of relief.During the mass wedding event, the whole camp resembled one big joint familypreparing 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 beserved and other arrangements to be made. There was music. During the Haldiceremony everyone came out and there was some fun and laughter. Most women andyoung girls had put Mehndi on their hands. The act of encouraging people to undertakerelaxation 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. Dothis 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. Takea deep breathe and exhale slowly. This should be done for 5 minutesseveral times a day. Concentrate on fresh air that is coming in andthe warm stale air that is going out of your body.4131

SpiritualityIn our country, religious beliefs or belief in a higher power greater than humanbeings is an integral part of our being and gives us great relief and support duringtesting times.We may question this power at times to ask whywe are suffering and why we have to gothrough the pain, but at the same time we willagain lean on the same power to get throughany crisis we are facing. So it is important toreinforce this spirituality in anyone we areworking 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 threelevels, i.e., The individual, the family and the community. The example whichfollows illustrates all these principles.ExampleS, 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 motherwas not someone who went out of the house but unfortunately this time on hearingsomething is happening in the next lane she became curious and went out to see. Whilerunning back she was killed in the police firing. Subsequently the family members werereacting to the incident of loss as all others did. The daughter who was very attached tothe mother was very angry and disturbed. Anyone who went to provide her with helphad to face a volley of questions like, “Can you bring back my mother? Or get the fourpolicemen who killed her?”In their culture, when someone passes away, the members from the extendedfamily invite the bereaved family members to stay with them. In S’s case, theextended family did not invite them over. So S and her brothers had to manageon their own. In addition, S’s family as such did not have very good relationswith their immediate neighbours.In this case, the normal social support systems (family and friends) that usuallyhelp people recover from traumatic events were missing. Also, the loss tookplace in an unnatural manner and not as a natural death; so the level of painand anger is very high.The Amanpathik of that area visited the home. What follows is the process ofhelping S to cope with her loss.The Amanpathik came to know about this family in the camp and on enquiryhe found that the family had moved to their house in the neighbourhood. Afteridentifying the family he visited them for the first time.3242

First visitThe Amanpathik, P who went to meet the family was greeted with hostility bythe entire family. He was told that they had not done anything to the Hinduneighbours in the area. Although the other family members were angry, theytalked to P but then S told him to leave saying, “You get back my mother or getthe policemen who killed her and I will take care of them.” She refused to talkand left the room. She pulled the other family members into the house andclosed the door.What is happening?As can be seen, the level of anger and resentment is immense. S has not even come toterms with her actual loss. She is at the stage of outrage right now. The family as aninstitution had been fostering her faulty coping methods rather than helping hernormalise her reactions.What needs to be done?It was decided that a four-pronged approach would be taken to normalise the familiesreaction to the loss. Firstly, the local Clergy would approach the father. Secondly, afoster mother would be brought in to help S ventilate or share her feelings about themother. 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. Itwas 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 wouldtake charge of S since she may be identifying P with the policemen and her anger couldbe enhanced with his presence. Also, a female Amanpathik would be able to establishbetter rapport with S.Second visitG, the female Amanpathik who was put in touch with this family went over tothe neighbourhood and was able to identify the opposite house lady who waswilling to help the girl after long persuasion. This lady was requested to findout 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 youresemble – your mother or your father?’ These were questions which wouldhelp 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 Smade no attempts even to acknowledge this, the neighbour was motivated to continueto go over regularly and try and talk to S. This interaction is very critical because theneighbour 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, theseregular visits of the neighbour helped to establish trust and somewhere S was able tosense that the neighbour lady was genuinely concerned about her.4333

Third visitThe male Amanpathik met one of his elderly Muslim friends in the area andrequested him to help to talk to the father of S. With some reluctance the oldman agreed but the father did not heed his request.His friends, at the request of the Amanpathik, approached the elder brother ofthe girl. After severe argument about his sister’s welfare, the brother relentedto 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 multifacetedapproach and at times you will meet with failures but one of the interventions willhave the desired effect. Also in any situation the entire family needs to be workedwith and not just one person.Fourth visitThe coordinator of the children’s support team monitored the developments.She visited the house along with the brother and gained entry after sorting outthe 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 pentup feelings. During this visit he shared his concerns with his sister saying hewould like her to start carrying on with her life. He talked to her saying he toomissed their mother. While sharing some memories, S started to cry silently.The neighbour who had been reinforcing the same messages put her arm aroundS, comforting her as she cried. S expressed that she felt totally lost without hermother and now had no one to talk to. She felt totally frustrated that nothinghad happened to punish those responsible for her mother’s death and she wasvery 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, herfears and worries.What is happening?This joint meeting was really beneficial in helping S feel comfortable to talk about herfeelings and fears for the first time. It is the start of a process but demonstrates anacceptance as well as the importance of external support networks to come forwardand help a family cope with its loss.The neighbour is continuing her work with S and ensures that she maintainsher rapport and offers space for S to share her feelings and emotions. TheAmanpathik, through regular visits, supports her. As of now, S is muchbetter and is excited about her cousin’s marriage and is getting ready forthe occasion mentally.3444

Learning Points◆◆◆◆◆◆Initial entry was difficult – work to be done by a group than by individualAmanpathiks.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 channelsfor recovery to take place.Taking part in ceremonies/rituals is one example of how externalisation ofinterest helps in normalisation of the life for the survivor.W ORK WITH INDIVIDUALS●For people who are willing to talk immediately:◆◆◆◆◆◆◆◆Listen attentively.Do not interrupt.Acknowledge that you understand the pain anddistress by leaning forward.Look into their eyes.Console them by patting on the shoulders or touching or holding their hand asthey cry. Caution: be sensitive to community norms about touching members of theopposite 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 yourdistress 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.◆◆◆◆◆Do not get anxious or feel rejected that they are not communicating. Remaincalm; 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, distressof being alone, helplessness, isolation, etc. This will help them to feel their painand get it out of their system.Acknowledge that you understand their distress; the frustration, emptinessand also subsequent anger because of the vacuum created by the loss.Share their grief and console them that losing someone dear is terrible andunfortunate.4535

◆◆◆Make them understand they are not to blame for the tragedy and need notfeel guiltyTell them you will return the next day or in a couple of daysTell them you are not upset or angry because he/she did not talk. Meanwhileask him/her to think about whatever has been told. “Memories of good daysyou spent with each one must be alive in your memory and coming to yourmind again and again. You must be tense inside! Try and let the steam out, thatwill make you feel better.”Take the example of a father who was unwilling to talk after he lost his son. TheCLH working with him was able to reach out to him and help him ventilate hispain and deal with his loss.For exampleIn Orissa, during the cyclone, a father lost his children. For quite some time he wasunable to accept the death of his youngest child and went into silence. If you talkedabout this child he would get very angry. The youngest child, a boy, had been very goodlooking with big round eyes and a mole on his face.Often at night, when everyone was asleep, the father would walk down to the placewhere the dead bodies had been burnt. This was noticed by the CLH (Sneh Karmi). Oneday the CLH followed him to the place.Standing behind the father, the CLH said, “Look there is the skull of your youngestchild.” The father shouted very angrily and told him to go away, but the CLH continuedtelling him, “Look closely, the eyes are round just like your son’s; the face would havehad a mole there.” The father stood for some time in silence and then suddenly brokedown sobbing and crying. All the feelings he had been suppressing, suddenly came outin the form of tears.In this situation the CLH was able to use a ‘skull’ to help the father ventilate andbring out the feelings and emotions he had been suppressing within him. It helpedthe father accept his loss in entirety. This release was very healthy for the fatherand a very critical part of the recovery process.Once the person talks about the loss and personal grief, he/she feels better. It becomeseasier to take stock of his/her life and understand the feeling of a vacuum, anemptiness created by the loss. This facilitates in rebuilding his/her life. Hence, themore he/she releases the pent up feelings, the lighter they will feel.●Once the person starts talking, maintain a conversation using the followingqueries:◆How are you and how are your other family members?3646

◆◆◆◆◆◆◆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, reliefworkers, 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 problemslike 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.●What can individuals do to recover?◆◆◆◆◆◆◆◆◆◆Listen to authentic information about the situation; do not believe in rumoursStay 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 orfriends. 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 alwaysbe functioning at your usual level of efficiency for a few weeks/months.W ORK WITH FAMILIESIn addition to individual specific interventions, the family as a whole can also behelped simultaneously. This depends on the number of individuals surviving inthe family. If some family members are present, encourage them to adopt thefollowing activities:◆◆◆◆◆Share their experience of loss as a family.Contact relatives to mobilise support andfacilitate recovery.Participate in rituals like prayers, keeping thedead persons photographs and preserving his/her belongings of the deadperson.Make time for recreation using what is available like the radio, television, visitingreligious places, playing with children and engaging in activities like sewing.Resume normal activities of the pre-disaster days with the family.4737

◆◆◆◆◆Try and do things together as a unit andsupport one another.Be together as family members. Do not sendwomen, children and the aged to far offplaces for the sake of safety; separation inthis case can cause a lot of anxiety to themand to you.Restart activities that are special to yourfamily, 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 butalso make the other person feel the same.Keep in constant touch in case of a member of the family having to be shifted toa far off hospital or residence. Update him/her about yourself as well as findout about him/herself. This gives a feeling of being cared for.W ORK WITH THE COMMUNITYThe following activities help in rebuilding community life and setting up the socialsupport systems, which are essential in the long-term rehabilitation process.Group mourningGrief resolution should occur at the personal, family and the community levels.Group mourning is a process of mass grieving. It expresses solidarity of thegrief-stricken community and facilitates unity and collective action. Such activitiesshould be initially organised on a weekly basis, gradually on a monthly basis, andlater, annually. In Maharashtra there is a process wherein traditional coloured pastes(Haldi Kumkum) are applied to a widow beforebreaking her bangles. This process helps her toaccept her loss and relate to her feelings.In Gujarat there is a traditional process ‘Iddath’ amongthe community, wherein the widow stays away from therest of the people for some time before getting back toregular societal routines.Similarly in other communities, mass prayers with lighting of candles are done. Allof these are traditional methods for people to come to terms with their loss and starttheir grieving process, which in turn helps them move ahead in their life.3848

Group meetingsGroup meetings are important activities where the community as a whole participates.This stimulates the people to think, and brainstorm about various measures/initiativesfor rebuilding the community. It not only helps the community to come to termswith the reality of loss and emptiness but also helps them to initiate collective actionand rebuild their lives.An ‘Aman Bhojan’ (community meal) was organisedwhere people from both the communities along withfew prominent leaders came and ate together. Thishelped in establishing some faith and a feeling ofnormalcy among the people. It also showed peoplethat others were with them. Coming together onoccasions has taken place, like in the preparations for mass marriages.Supporting group initiativesThe local community, on its own starts responding appropriately and effectively tothe disaster by using healthy coping strategies. Hence, one important task of theAmanpatiks is to encourage, initiate, sustain and guide such local community action.The Amanpathiks can take the initiative to organise community-based actions specificto 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 anothercommunity. At another place, a local person had taken charge of running a certain camp.Cultural aspectsThere 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 thecommunity. It was observed that putting Mehndi was an essential part of the pre-disasterlife among this community and has returned even without a wedding taking place. Many areengaging in decorating their hands with mehndi. Such activities lead to faster recoveryand normalisation of lives of the affected population.RallyOrganise a rally to sensitise the administration regarding delays in implementationof action for restoration, rebuilding, relocation, compensation, etc. Rallies are also apowerful expression of solidarity. ‘All for one, one for all’, demonstrate strengthand determination to fight for a just cause. Such rallies can also be used to sensitisegroups, for instance to create awareness among students about issues around themand bring about a feeling of confidence and normalisation among them.4939

A rally was taken out involving key members of thegovernment and this was done in an area where therewas great insecurity earlier. The rally helped in rebuildingthe faith of the people in the government agency. It alsohelped sensitise the government officials about the realityof the situation.Group participation for rebuilding effortsClearing rubble from broken homes and burntresidences, putting up temporary shelters andproviding food for those who are the survivors orthose who are disabled or dependent – all theseactions help people to recognise that there areothers around to help them and that they are notalone. A lot of people were engaged in communitycooking, bringing in the raw material and storingit in the camps. Encourage people/survivors to share their success stories (recoveringfrom the loss) with others during group meeting. This will make them feel good andalso 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 comeforward to rebuild certain number of homes, etc.Sensitisation processInvolve religious leaders and opinion leaders, in all community activities. Talk aboutre-education of the larger community, especially on ways to handle rumours. Alsogroup discussions would help in expressing their feelings and extending support toeach other and together being able to think about a future course of action. The culturalwing of the Aman Samudaya is holding street plays both within and outside the camps, andthese are very popular among the survivors.P OINTS TO REMEMBER➢ There are seven basic aspects that a CLH can use as psychosocialinterventions to work with people who have been affected.➢ Rebuilding of life occurs at the level of individuals, the family and thecommunity.4050

SPECIALGROUPS‘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 chapteron Impact of People, pp. 4-7), there are groups of people who are more vulnerableand need greater attention. We need to identify and work with such groups.For exampleThere may be a child who has become an orphan. This child has not only been throughthe traumatic event but also lost the primary support unit and hence would requireadditional 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 HAVEWITNESSED RAPEWomen and girls are often discouraged by theirculture and religion from reliving or talking abouttheir experience of rape. This problem then remainshidden and creates psychological pain and sufferingfor the victim. It is essential to identify the rape victimsby intensive interaction with the community, familyand the individuals. Identifying emotional reactionsor signs of physical violence is absolutely vital.Women/girls who have been raped often◆ 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.5141

When working with a person who has been raped:◆ Respect the woman and maintain a high level of confidentiality with her, evenregarding her name, etc.◆ Do not be judgemental. Give her the confidence that she is not to blame forwhat has happened.◆ Help her to overcome the feelings of being unclean and make her understandthat she is not responsible for what happened.◆ Help the woman ventilate painful experiences and feelings related to it. Throughall 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 hasconfidence in you, she will share her feelings and thoughts.◆ Convince her that her disturbing thoughts and the pain she undergoes arenatural and a result of this kind of a horrific incident.◆ Let her express her anger towards the people who tortured her, as it helps inreleasing pent up tensions.◆ Encourage her to recognise the trauma as a small scar compared to severalpositive 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 thestigma.◆ Identify ways to end her social isolation and if there are support groups workingon this issue make sure that she participates in them.◆ Look at other support that she might require like livelihood, or medical carefor 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 VIOLENCEWhenever people experience pain and suffering, the body and mind tend to showemotional reactions, such as:◆◆◆◆◆◆Constant compulsive reliving of the painfulexperiences from the past.Suffering from sleeplessness and nightmareswhen falling asleep.Developing unidentifiable physical painsand problems.Losing interest in routine life activities, feeling tired, low and depressed allthe time.Having lack of concentration, poor memory.Loss of appetite.4252

◆◆◆◆◆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:◆ Anyone who suffers painful and hurtful experiences reacts physically andemotionally 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 realisethat the incident is not unique to them but there are others also who have beenvictimised. These sessions enable them to share their pain and feelings andslowly help to reduce the negative effects of those memories.◆ Help them recognise that during the ugly incident there is nothing they didwhich is unique and isolated, since anybody in a similar situation would reactthe same way. This helps them get over the shame and guilt.It is essential for the CLH to:◆◆◆◆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 exercisesregularly.A GED PEOPLEVery old people are often not totally in control of the situation. They may take alonger time to recover from the disaster. The kind of disaster they witness and alsothe death of many young people before their eyes might make them:◆◆◆◆Withdraw and weep.Suffer from sleeplessness and refuse to eat.Be agitated, feel lonely and hopeless and havesuicidal tendencies.Susceptible to falling ill as a result of beingdisturbed emotionally.5343

You can help by:◆◆◆◆◆◆◆◆◆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 isnot too difficult.Getting them involved in relief work by requesting for their suggestions andadvice, etc.Keeping them informed of positive news.Attending to their medical ailments by helping out with Doctor’s visits andconsultations, etc.Organising small group prayer meetings.D ISABLED PEOPLEPeople with disabilities may face some hindrance in the recovery process.Their recovery may get prolonged or they might regress to a lower level offunctioning.You can help by:◆◆◆◆◆◆◆Removing them to places of safety.Always keeping them informed of what is happening so that they do not feelisolated and ignored.Getting them involved in activities which can be performed by them takinginto consideration their limitations.Integrate the disabled people in group discussions.Attending to their specific needs like supplying the various aids, such aswheelchairs, hearing aid, aids for walking, etc. which may have got lost.Helping them overcome their feeling of insecurity in case of having lost theirlivelihood. The skills they were using prior to the disaster should be looked into.Taking cognisance of the fact that the mentally challenged people, especiallythe women and children are vulnerable to sexual abuse, they have to be givenspecial attention and care.W OMENWomen tend to feel more vulnerable. There may be many affected groups like youngwidows, single people, orphans, the disabled people, those who have lost children,single parents, aged, etc. Their emotional reactions will be far more visible and theirresponse is different from men:◆They might weep and later become depressed.4454

◆◆Experience vague body aches and pains and feel weak.Show more resilience in taking care of younger children, the elderly and disabledpeople.You can help by:◆◆◆◆◆◆◆◆Enabling them to overcome their feeling of vulnerability by making them stayin a place close to their families rather than moving away.Keeping them informed about the safety of other family members, especially ifthey are away.Getting them involved actively in routine activities, like taking care of theyoung, caring for the sick or old family members.Involving them in community level activities like working in/supervisingcommunity kitchens and caring for other sick people.Involving them in relief and rehabilitation activities, like maintenance ofcleanliness, etc.Initiating self-help group formation to enable sharing losses and suffering.Encouraging them to spend time in activities that are more fun, like mehndiceremoniesat the camps, participating in wedding preparations, etc.Making them spend time working with groups like young widows, or peoplewho have lost their children and supporting them.C HILDRENChildren are always disturbed by change. They are often treated as young and hencenot to be informed of what exactly is happening. Thus,they cannot comprehend what has happened aroundthem and to them. They seek the comfort of adults asthey feel the need to discuss and sort out their fearswith an adult. They are not very sure of the options toget out of problem situations. They are dependent onadults physically and emotionally. Events like loudnoises, shouting, running and panic and anxiety,separation from loved ones, loss of the comfortableenvironment, deprivation of food and drink, impact achild much more than an adult.Very young children would react by:◆◆◆Weeping.Clinging to adults, especially those familiar to them, for fear of once againlosing whatever security they have.Becoming listless and apathetic, if they do not get the warmth and security ofsurviving adults.5545

◆◆◆◆Experiencing disturbed sleep.Wetting their bed at night.Developing health problems.Regressive behaviour, for instance, he/she may want to becarried around now even though he/she have been walkingearlier, or may start talking like a baby.Schoolgoing children react by:◆ Experiencing nightmares about the eventsrepeatedly, and inability to gain control overwhat has happened.◆ Regressive behaviour (wetting their bed,sucking their thumb, wanting to be carriedaround, etc.).◆ Refusing to separate from their familymembers even for a short while.◆ Returning to school and doing badly in their studies.◆ Expressing physical complaints like headaches, stomach aches, difficulties inmoving some parts of their bodies.◆ Feeling depressed and taking responsibilty for the death and loss of theirloved 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. Adultsaround need to understand that these changes are normal and takemeasures to help the child get over the stress by:◆◆◆◆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 andthereby giving them a sense of security.Providing the child with a sense of control – allowing him/herto talk about the event and listen to them without givingany advice.4656

◆ 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 expresstheir emotions. This is very healing.◆ Organise story telling sessions, singing songs and games involving physicalmovement.◆ Paying attention to and praising a child’s coping behaviour, like when he/shefollows a routine, makes an attempt to reduce his/her anger, agitation, etc.◆ Working with other caregivers in theenvironment to help the child recover,like getting him/her to work with the BalMuskaan facilitator.◆ Providing referral to Mental Health Centreif required.◆ Paying more attention and spending time ontheir studies once they return to school.P OINTS TO REMEMBER➢ Although everyone needs care and support, there are groups among theaffected people who need special attention, as they are more vulnerabledue to their age or other factors.➢ We need to work with these groups.5747

REFERRALThe referral process should be done using the spectrum of care framework discussedin the chapter on Role of the Community Level Helper (p. 25). We are looking at awholistic model of care rather than one focusing purely on the emotional aspect of therehabilitation work. There are seven basic areas to consider for each family that we areworking with. It is important to be able to identify the needs in any of these categoriesand know whom to contact for further assistance. Also CLHs need to tap sources fromwithin the larger social network that go beyond the Aman Samudaya network.R EFERRAL MAY BE DONE FOR ANY OF THE ISSUES LISTED BELOW◆◆◆◆◆◆◆Livelihood issues, like assessment of needs, procurement of the material andgrants.Issues relating to children, like educational needs, adoption or fostering andfinancial assistance.Paralegal issues, like compensation, reassessment of homes and FIRs.Medical issues, like regular health problems, special needs of crutches orpregnancy-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 behaviourpatterns you can use as a guideline to identify individuals or families with whomyou can work and probably help. Some of the people may be in a state of mindwhere they may require professional assistance or the help of a specialist. Thiswould mean you have to become a link and know how to enable the person toaccess the guidance of a specialist.Referring a person to a specialist will requiretact and sensitivity because of factors like socialstigma, etc. Help may be essential but theindividual may not readily accept referral fora variety of reasons. However, the first task isto be able to recognise when it may not bewithin your own capabilities and skill to helpa person and thus you have to refer him/herfor professional attention.4858

Examples◆◆◆A man had a business of cars like Maruthi, Ford, etc. He had a house plus newlymarried sons. Within a week of the riots he lost everything. When hiscompensation packet came with only Rs1250 at that time, he had a paralyticattack and went into a state of shock. For him, having lost so much, he could notbelieve that he would not get his full reimbursement. Now he does not talkproperly 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 isvisible 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. Shetalks and suddenly gets angry and looks as if she is going to do something. Tocalm her down, water is given and to distract her, she is made to involve insome activity. She cannot concentrate for too long.The first referral centre would be the PrimaryHealth Care Centre (PHC) or the doctor attendingyour camp. The doctor at this centre would beable to provide appropriate care. Contact thevisiting Psychiatrist and then follow up at thehospital if required.There are four areas which you can consider while deciding whether you canhelp or if you need to refer the person:Alertness and AwarenessHandle the situation if the person●●Is aware of who he/she is, wherehe/she is, and what has happened.Is only slightly confused or dazed,or shows slight difficulty in thinkingclearly or concentrating on a subject.Consider referral if the person:●●Is unable to give his/her own nameor of people with whom he/she isliving.Cannot recollect the date or statewhere he/she is from or even tellwhat he/she does.● Cannot recall events of the past 24hours.Complains of memory gaps.5949

BehaviourHandle the situation if the person:●●●●Wrings his/her hands or appearsstill and rigid or clenches the fists.Is restless, mildly agitated, andexcited.Has sleep difficulty.Has rapid or halting speech.Consider referral if the person:●●●●●●Is depressed and shows agitation,restlessness, and paces up anddown.Is apathetic, immobile, and unableto 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, andchange into fresh clothes.Repeats ritualistic acts.SpeechHandle the situation if the person:● Has an appropriate feelingof depression, despair, anddiscouragement.●●●●Has a doubt of his/her ability torecoverIs overly concerned with minorthings and neglects more pressingproblems.Denies problems or states he/shecan take care of everything himself.Blames his/her problems on others,is vague in planning and bitter withanger that he/she is a victim.Consider referral if the person:● Hears voices, sees visions, or hasunverified bodily sensations, likehallucinations.●●●●●●States the body feels unreal and fearshe/she is losing his/her mind.Is excessively preoccupied with oneidea or thought.Has the delusion that someone orsomething is out to get him/her andthe family.Is afraid he/she will kill him/herselfor another.Is unable to make simple decisionsor carry out everyday functions.Shows extreme pressure of speech,like his/her talk overflowing.5060

EmotionsHandle the situation if the person:●●●●Is crying, weeping, with continuousretelling of disaster.Has blunted emotions, hardly reactsto what is going on around him/herright now.Shows high spirits, laughs excessively.Is easily irritated and angered overtrifles.Consider referral if the person:●●●Is very quiet, show no emotions.Unable to be aroused and completelywithdrawn.Is excessively emotional and showsinappropriate emotional reactions.In the Aman Samudaya programme, both intra- as well as inter-referral processes need tobe continued. For instance, when the Aman Pathik identifies a woman who has been rapedand 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 paralegalissues could be directed to the respective support teams. Links need to be made with thelocal government agencies like the Welfare, Hospitals and Police, who provide specialistcare to the community.P OINTS TO REMEMBER➢ There may be some people who need guidance for specific issues and youneed to refer them to the right person.➢ For emotional support and care at times specialist help may be required andit is important to identify those needs and refer the person.6151

SELF CAREIt is important for the CLH to understand that he/she is involved in work that isgoing to make demands on his/her physical as well as emotional life. The dailystress can cause internal tension within the CLH group. It is important for each CLHto understand this aspect and take some preventive actions to enable themselves tocope with this stress.An analogy of a tree is useful to understand this. Unless the tree has strong roots tosupport 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 andnourishment in each CLH’s life to enable him/her to be strong and positive. Onlythen will they have the energy to support others.●S OME THINGS TO DO FOR YOURSELFWith other colleagues◆◆◆◆◆◆◆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 supportothers if they are down.Develop a buddy system with a co-worker. Agree to keep an eye on each other’sfunctioning. Check for fatigue and stress symptoms. Take a break when required.●Personally for yourself◆◆◆◆◆◆◆◆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.5262

S EEK HELP IF◆◆◆◆◆◆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 threenegative and three positive qualities thatyou have. These are the qualities withwhich you reach out to people. In the boxesrepresenting the roots of the tree, put thenames of people whom you can turn tofor care and support when you needcomfort. In the clouds above the tree listout things that give you a sense of peaceand happiness.This is tree is symbolic of you. If the rootsare strong and supportive and the tree hasclouds for water, the tree remains healthyand happy and is able to give more shadeand fruits to people for a longer time.Similarly have things and people aroundto care and support you. Since you areworking in a field that draws on a lot ofyour emotional and physical strength,these people and things can providenourishment 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 personalwell-being.6353

RIOTS AND THECOMMUNITYDisasters present a challenge to the totalcommunity. It is well known that exposure toany disaster situation itself is a stress for allpersons involved. The degree of effect isdirectly proportional to the degree of stressexperienced by individuals due to thedisruption caused by the disaster. From thisperspective, the people who experienced thedirect effect of the riots are the most vulnerable. The Manual describes what isexpected to happen to this population and the measures that can be initiated by theAman Pathiks to meet the psychosocial needs. This chapter refers to the generalpopulation 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 riotsdisrupted the lives of all of the people in one way or the other. They were exposed toexperiences that are far from normal, like the scenes of destruction, violence, seriousdisruption of routines and a sense of uncertainty and fear. For riot situation, thesocial fabric is torn apart, socio-economic bonds that have bound people acrosscommunities in complex measures weaken and are destroyed. Prejudices are fostered,poisons of hatred are unleasehd and rumours are rife. Emotions are high and peoplefeel spurred by motives of hatred unlike normal times. There is frequent feeling ofbetrayal, anger and loneliness. The economy also tends to be disrupted and dailywage earners, small self-employed people and the destitutes are the worst hit. Tothis extent, their mental health is compromised as a consequence of the riots in thestate. Some people will experience serious symptoms, while the majority willexperience 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● Recognise and acknowledge that the community as a whole is passing through adisaster situation and no one is immune to the effects of riots.● Sharing of individual feelings and perceptions, and initiating activities to rebuildthe community are important.● Adapting positive lifestyles described in the Manual is helpful for recovery. Findtime to think about the events and what it means to your values and the sense ofwhat the community should be.5464

●●●●Volunteer your time to be part of the larger efforts to bring normalcy to the societyat the individual, family and community levels.Seek professional help if you are experiencing difficulties of coming to terms withany 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 mentionedproblems to seek professional help to hasten recovery.Mastery of the riot situation is a slow and positive process and will occur overtime and not overnight.At the family level● Make time to bring together family members to openly discuss their ideas, feelingsand reactions which will help in better understanding and mutual support.● If you in a group situation, periodically open up the subject to facilitate sharingand supporting each other.● You can do many things to protect and promote your mental health and that ofyour family and the larger community.At the community level● Irrespective of the meaning given to the riots (Why? Who? What? How?), it is tobe recognised as a source of stress that will demand adjustment to the alteredsituation in the relationships of the communities.● It is important to be involved in the developments of the local area (readnewspapers, listen to the radio, watch television, attend group meetings) andparticipate in the relief, rehabilitation and reconstruction activities.● The community can resume its normal functioning only with the returning ofnormalcy to all the affected population.● Reaching out to assist the severely affected population by sharing time with them,listening to them, giving assistance in whatever manner possible and communicatingthe fellow feelings to the distressed population are mutually helpful.● Rumours must be actively resisted. Prejudices must be acknowledged and dealt with.● Sense of normalcy and safety can come only from everyone feeling safe and notwith one group feeling superior or more powerful than the other.● The free supply of food in riot areas under curfew deals with some of the worstinsecurities● Early establishement of relief camps by governments with leaders of all communityhelps rebuilding trust.● Community efforts like peace committees, meetings and peace marches can bevery healing.● 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.6555

Ahmed Hussain Mansuri,Ajmeri Jubedha Bhen, Alaudin SyedHussain, Ansari Abdul Hakim, Ansari AnwarHussain, Ansari Jameela, Ansari Makbul Ahmed, Ansari MdSultan T, Ansari Mohammed Faraz, Ansari Mustaq Ahmed, AnsariNoorjahan 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 BhavanBhai, Bilkish T, Chauhan Kishor, Chowdary Satish, Christian Rupal J, DamthediRamand Bhai, Dave Hardik Kanaiyalal, Desai Natwar T, Desai Sikander M, Desai TejaBai, Devika Bhen, Dinesh Goswami, Dipak Vegada, Diwan Noorjahan H, Dubhi GoutamKumar, 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, ImtiazBhai Kureshi, Irshad Banu Shriyad, Jaswant K Rathod, Johara Bibi, Kailash J Damthadi, KalpanaK Parmar, Kasim Khan, Kazi Mo Mobeen, Khabetha Nasim Ansari, Khan Mamnoon, KhaniaLaxmanbhai, 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 BhenHasan Bai, Mansuri Shaukat Md. Bhai, Mansuri Zakir Hussain Usmaan, Maqsood Bhai, MazharKhan 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, NeelamP Parmar, Nirmala K Dhuri, Noorani Mohammed Abbas, Noorjahan Aziz Khan, PadhiyarHimanshu, Panchal Malthi Bhen, Paramarak Dinesh, Parmar Rakesh, Parmar Vijay L, ParvathiMohanlal, Patadiya Mukesh, Pateriya Jignesh B, Pathan Abdul Latif, Pathan Abdul Wafa A, PathanImran Khan A, Pathan Mahar Angag, Pathan Nazima, Pathan Shah Nawaz H, Pazi Seemab,Praful Jacob Khambalia, Pravin R Sharma, Premsagar Mahender J, Priyakant Pandey, QaziSubahut, Rajesh Bhai D Rathod, Rajesh Kumar, Rajesh Kumar Mishra, Ramesh N Bagade,Rashida Pathan, Rekha, Sailesh Kumar N, Saiyad Mohsin Y, Saiyed Gulzal Fatma, SaiyedNikhat Parveen, Saiyez Zulfikar, Sajid Bai Mallick, Sajid Bai Qureshi, Saleem Bhai KMansuri, Salim Bai Mansoori, Salmania Bardat, Sanda Sameer S, Sarif Bhai BabuBhai, Saroj Jaunbhai, Satish Bai Chowdry, Savabhai, Savitha Bhen, Savitri BDubey, 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. RafiMehaboob, Shaikh Md. Saleem, Shaikh Mohammed Rafi,Shaikh Naseem Bano, Shaikh Siraj K, Sharda Bhen,Sharifa Banu, Shariff Bhai, Sheik AbdulKasim, Sheik FerozAhmed, Sheik Idris Ranjanbhai, Sheik Nasim Banu, SheikSarfaraz Ahmed, Sheikh Afsar Hussain, Sheikh Anish, SheikhAnjuman Ara, Sheikh Anjuman Banu, Sheikh Ashia, Sheikh Azim Bhai,Sheikh Jahunisa, Sheikh Mehrunissa, Sheikh Nilofar, Sheikh Shabnam, SheikhShafikudhin, Sheikh Shamim Akthar, Sheikh Zuber, Shilpa M Chirstian, ShrimaliBanubhai, Shubash Sukhdev Vasanik, Siraj Ud Din, Solanki Chethan C, Solanki Dinesh,Solanki Girish, Solanki Shilpa Bhen, Sufiya Bano, Suhana J Mansuri, Surekha B Guptha, SyedNasir Ali, Trupthi Bhai Solanki, Ujay Pathan Noorjahan, Ujjaini Hozefa M, Umar Farook Md S, VagelaChimanlal, Vagela Shantha Bhen, Varsha Bai Qureshi, Varsha Bhen, Vipur Patel Chand,Yousuf Bai Mansoori, Zakir S Kazi56AmanPathiks66

WHAT WE KNOW...◆◆◆◆◆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 subsidingwithin 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 sometimesconflictual. The vast majority of reactions are in the normal range and the intensitywill diminish for most people over time without the need for professional help. Supportfrom family and friends is critical. For some, however, the degree of exposure maylead to more serious and prolonged reactions.The range of feelings experienced may be quite broad. People may describe intensefeelings of sadness followed by anger. Others may experience fearfulness andhypervigilance to the environment among numerous other reactions.There may be temporary disruptions in normal coping mechanisms for many peopleand some may go on to develop problems with sleep, nightmares, concentration,intrusive thoughts and a preoccupation with reliving the events. These reactions aregenerally short lived but if they persist, professional consultation should be sought.WHAT CAN BE DONE?◆◆◆◆◆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 orcommunity centers.Provide accurate and practical information especially concerning the larger recoveryefforts. Special attention to the needs of relief applicants is necessary as relating to therules and regulations of the relief organizations during the crisis can be overwhelming.Give particular consideration to the needs of special groups such as children, thosewho have been most intensely exposed or had a history of previous events (exposureto trauma), rescue workers, and people with pre existing mental health conditions.Children and adolescents will need the support of their caregivers. This support shouldreflect accurate concerns, and diminish any words or actions that would increase thechild or adolescent’s anxiety. Caregivers should offer reassurance as to their presenceand availability during this time. Exposure to television, movies or print matter thatoffers 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 tothe events may go on to develop more serious mental health concerns and should bereferred for services if they develop persistent issues.Overwhelming feelings are to be expected and can stress individuals, communities andnations. There are many actions that can be taken at the level of governments, internationalNGOs and local groups to appropriately and effectively support victims of such acatastrophe.WHO, October 200167

INFORMATION MANUAL 2RIOTSPSYCHOSOCIAL CAREbyCOMMUNITY LEVEL HELPERSforSURVIVORSDisasters pose a monumental challenge to the total community.There has been a gradual acceptance of the need for psychosocialcare. The recent Gujarat Riots has left behind a trail of anger,anguish, betrayal and emotional scars that poses an enormouschallenge of normalising the people’s feelings, rebuilding thepeople, reconstruction not only of shelters and livelihood but ofthe 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 andgatekeepers interviews.It is a collaborative effort of professionals, voluntary agenciesand survivors.139, Richmond Road, Bangalore – 560 025Ph: 080-5586682 e-mail: bfc@actionaidindia.org68