Care During Rehabilitation
Psychosocial Care During Rehabilitation A Thematic Approach
Psychosocial Coordinator, CARE India
The practice of psychological in Indian context has been initiated two decades before and a systematic intervention of psychological support in the form of disaster mental health, trauma counseling, crisis intervention and psychosocial care is very new. After tsunami International Non Governmental Organisations (INGOs) provided few days' training package on psychosocial aspects for field staff of NGOs and they made the conditions of victim's emotionally worse due to lack of professionalism. Since the relief phase is over, many INGOs have withdrawn their focus on psychosocial care. But for long term rehabilitation there is a definite need of psychosocial care for the victims. The Environment, Livelihood, Infrastructure and Institution re-building - ELII Approach suggested in this article is a theoretical model that is more appropriate in planning the community rebuilding process.
Psychosocial Care During Rehabilitation A Thematic Approach
In what ways do the individual victims recover from their mental trauma and participate in community re-building process in the rehabilitation phase? The ELII Approach explained in this article is a theoretical model that focuses on the individuals to recover and to participate in the rehabilitation phase.
In India, the reactions following a disaster like distress and suffering, which is psychiatric in nature, is not given much importance, whereas relief and rehabilitation to build up the communities is given more importance. In Tamil Nadu scenario, development projects were ignored as INGOs perceived that it is a developed state prior to tsunami. In the aftermath of tsunami, INGOs came with funds for the relief and rehabilitation along with an allocated budget for psychosocial interventions. INGOs focused on capacity building for NGOs with tailor-made training modules for few days and in coordination with field level NGOs implemented psychosocial care interventions.
Quantitative indicators like number of trainings organized for the number of NGO staff trained, Integrated Child Development Scheme volunteers, Public Health Center staff and Panchayat (village institution) members trained were given priority. Qualitative indicators to assess the impact of psychosocial care were not given priority. Follow-up of victims to specialized institutions for advanced treatment was totally missing.
Field level observations in worst affected districts of Tamil Nadu revealed that a person who lost his family member/livelihoods had problem in interacting with INGO/NGO staff as they are not from their own village. Also the personals trained in psychosocial interventions for few days had lack of professionalism in handling the victims. There were incidences that the staff of NGOs adding magnitude to the grievances of the victims by asking questions and made them emotionally worst as a part of their immature training on ventilation of the victims.
The various components of the psychosocial interventions in the post disaster phase (Joseph O.Prewitt et. al 2004) based on the needs of the survivors are given below.
Immediately after the disaster, Disaster Mental Health interventions are initiated between I to IV weeks. The disaster mental health has been implemented towards restoring the psychological and social functioning of individuals and communities (Aats, P.G.H. 2000). Psychosocial care and first aid is the most important phase for mental health interventions that has been initiated from II to VI months.
As these two phases after the tsunami is over, there are many learnings from the field. It is critically reviewed that the trained staff of NGOs/Government have not extended proper psychosocial care and support. The community could able to recover on their own due to lack of professionalism and commitment from the NGO/Government personals.
ELII Approach A Theoretical Model
The approach on rehabilitation with focus on psychosocial care should have real meaning among the victims of disasters in re-building their lives. As the First and Second phases are handled without much professionalism, the Third phase of rehabilitation and rebuilding can have the following Four Fold Interventions called the ELII Approach, that focus on the individual in specific and the community in general, thereby making the rebuilding process more effective.
Loss of life within the family and community Institutions will definitely have setbacks in rebuilding the institutions. After tsunami many families availed compensations and capital accrual was the net result and in many families and in-equilibrium was observed. There are case studies that husbands who lost wives have availed compensations and leading a flamboyant life and also selecting life partners ten years younger for re-marriage. On the other hand, the women who have lost their husband and availed compensations made investments in long term returns for their childrens education and marriage. Hence there is a need for proper psycho social support for the victims, who have availed compensations to cope up with the family/societal institutions.
A woman who lost the bread winner within the family will be forced to take
up livelihood interventions for the first time; will definitely need a continuous
and a professional counseling to build up her mind to venture into livelihood
In India family planning was given more focus and many women in rural areas have undergone family planning operations. After tsunami, the women in their early ages, who have lost their children, are doing re-canalisation operations. They are undergoing lot of stress due to family circumstances and also from their family members. They need a series of counseling to cope up to normal situation in bearing a child.
Special care and counseling has to be given for people with difficulties and physically challenged to cope up with the situation. If chronic cases are identified advanced counseling services have to be planned and linkages to be made. After tsunami, many people had head injury and there is a probability of more epileptic cases in the area. Such cases have to be identified and to be followed up for special referral services.
Socialization process itself is the best recovery mechanism, but continuous motivation and counseling is required to bring the victims out from the state of shock and mind set. This twin prong intervention of individual counseling and making them participate in community institutions will definitely develop the individual and the community to cope up with the changing realities and in re-building the institutions thereby paving way for individual and community development.
Loss of Infrastructures like houses will definitely affect the state of mind of individuals and damages to community infrastructures will have sentimental attachments among the community and will have its own impact.
For a woman, a house built by her husband with minimum standards of 0.075 million cannot be replaced by a house built by an NGO for 0.2 million cost covering 250 sq.ft. A woman will have attachment always to a house built by her husband with their own hardships involved in the process. After tsunami, in many villages, people are not interested to occupy the permanent houses built by NGOs, due to lack of sentimental attachment and lack of participation by the family in the building process.
Rebuilding the individual infrastructures and community infrastructures by involving the individuals within the community in planning, designing and monitoring will revive their sentiments. Community participation in designing their individual and community infrastructures by considering their sentiments and values will definitely have acceptance of the infrastructures. Psychosocial intervention is the best medium to bring the community back into planning and implementing the infrastructure development within the family and at the community level.
Loss of Livelihood assets is definitely a strain within the family. Eventhough livelihood assets are provided by INGOs, there are un-identified gaps and the most vulnerable are excluded from livelihood support. A family who had lost their traditional livelihood assets will have barrier to take up alternate livelihoods due to lack of skills and fear to cope up with the new venture. Hence proper psychosocial care and support have to be extended to make the individual to take up alternate livelihoods.
The availability of consumer credit has grown in the tsunami affected areas by the focus of banks, financial institutions and Government Schemes for alternate livelihoods. All the credit mechanisms and institutions are focusing on women SHGs as a platform to provide credit to develop their business. After tsunami the discipline of SHGs has declined as same individuals are enrolled in 3 to 10 SHGs promoted by various NGOs in availing credit facilities. Rural credit for alternate livelihoods and in developing rural entrepreneurs is undoubtedly beneficial. But there is a need for financial education and budget counseling sessions for the borrowers by trained counselors to make the individual a successful entrepreneur and in maintaining credit discipline.
The practices and cultural beliefs related to Environment have been disturbed after tsunami. Since dead bodies were found in village ponds, the people requested the Panchayats to level the ponds as the village ponds became water grave for their children during tsunami. If village ponds are leveled then there will be drainage problems and also re-charge of ground water will be much disturbed. The sand dunes and shade trees once served as the places of socialization were lost due to tsunami. Hence people can be made aware of coastal ecology and environment on a case to case approach and can be discussed in community meetings as a part of counseling strategy.
Also huge amount of funds were spent in establishing temporary sanitation facilities. As the habit of fisherfolk was open defecation, there were problems in using toilets. Eventhough awareness education is emphasized; there is a need for regular case to case counseling in changing their habits.
ELII approach should focus on individuals to participate in all recovery and rehabilitation efforts while linking with interventions on Institution building, Infrastructure Development, Livelihoods and restoring Eco System and Environment. Rebuilding individual and community through ELII approach is the prime component in stabilizing lives and livelihoods. Psychosocial care interventions for rehabilitation need to be designed after needs assessment, which is carried out professionally based on a clear cultural understanding on the situation and the phase/nature of the disaster. ELII approach includes psychosocial care for individuals in specific and community in general to recover and participate in rehabilitation interventions for the holistic development.
Action Aid India (2002a). Emergency Strategy Paper (Draft Unpublished).
Aats, P.G.H. (2000). Guidelines for Programmes: Psychosocial and Mental Health Care assistance in (post) disaster and conflict areas. Utrecht, The Netherlands: International Centre Netherlands Institute of Care and Welfare.
Prewitt Diaz, J.O., Srinivasa Murthy, R., & Lakshminarayana, R. (2004) India: Disaster Mental Health In India. New Delhi: Indian Red Cross Society.
Lakshminarayana , R. (2003) India: Environmental and organizational assessment: Disaster mental health and psychosocial care, New Delhi: American Red Cross.
Massey University, New Zealand
November 7, 2007