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Introduction

Sri Lanka gained independence in 1948; thereafter the Prime Minister S.W.R.D Bandaranaike made Singhalese the country's official language and Buddhism the state religion. This action alienated all other ethnic groups, including the Tamil Hindus and caused the first inter-communal riots in Colombo. Continuous episodes of violence were reported between Singhalese and Tamil extremists throughout the 1970s. The first major Tamil rebellion happened in 1979, in northern and eastern Sri Lanka. This resulted in violent civil wars and killings between Tamils and Singhalese, and forced thousands of Tamils to flee to safer surrounding countries. The Liberation Tigers of Tamil Eelam (LTTE) was the strongest militant group countering the Singhalese in a 17 year civil war that killed over 60,000 people.

Humanitarian conditions in these regions were degenerating and repeated violence forced a huge number of the population to relocation camps. The number of displaced persons was estimated at 800,000 (UNHCR). 297,200 of these IDPs are still currently staying in the Vavuniya region but the consequences of the civil war has resulted in an increased prevalence of psychological disorders, traumatic stress etc.

Case Study

These relocation camps are known as Welfare Centres (WFCs) for internally displaced people (IDPs). WFCs were established in Vavuniya to offer safe, temporary settlement until the region is safe enough for the IDPs to resettle back. However, due to ongoing insecurity in the area, many WFC inhabitants have permanently settled in the Centres. The following report reveals findings from a mental health survey conducted at twenty-one WFCs in Vavuniya, Sri Lanka.

A survey undertaken in these WFC's revealed that WFC residents have few hopes to resettle back to their areas, and very little capacity to have a stable source of income. 94% of residents are dependent on WFC facilities and a small government allowance for survival. Only 6% have full-time work. A majority them witnessed actions of war like attacks on villages, aerial bombing, mortar fire and human mortality. 60% witnessed wounding; 51% torture; 38% death by house fire. 18% of residents have experienced arrests/kidnappings, 17% hostage/detention, and 18% maltreatment. Consequently, these people have psychological burdens of past traumatic experiences. 87% claim they feel unsafe in their surroundings. 37% record that they would like to permanently resettle back while a minority (12%) wanted to continue staying in the WFCs, the rest were undecided.

Traumatic stress and psychological problems are frequently recorded in these camps while Suicide rates among WFC residents are among the highest in the world. A quarter of the respondents claim to have friends or family members who have attempted suicide.

The Impact of Event Scale (IES) evaluated the level of traumatic stress among WFC residents by assessing reactions of intrusion and avoidance. No significant difference was found between the two modalities. The total scores of the IES show that 82% of them show signs of serious mental disturbance. These findings are consistent with the outcomes of the appraisal of the traumatic experiences. Both indicate high levels of traumatic stress.

Recommendations from the conducted mental health survey indicate that WFC residents in Vavuniya could benefit from psycho-social support programmes to improve the psychological well-being of IDPs in Vavuniya. An appropriate psycho-social programme should address the past experiences (e.g. war-related traumas) and present circumstances (e.g. feelings of insecurity, poor living conditions, and restricted movement) that contribute to the mental health of WFC residents.

Stressors and consequences

The mental health of WFC residents is influenced both their past traumatic experiences and ongoing traumatic events. Ongoing sources of trauma include occasional harassment by authorities due to the recently introduced pass system and restrictions on mobility during times of intensified violence. In addition to this most families share an area of 10 square feet. They record issues with hygiene and sanitation, due to lack of water and proper sanitation.

Living in an environment of conflict and difficult living conditions have contributed to an increase in psycho-social problems among WFCs residents. According to the health survey in WFC's, young people report symptoms of back pains while older residents complain of headaches, sleeping problems, anxiety, depression, alcoholism and bad moods . There are increasing rates of alcoholism, domestic violence, community disharmony and suicide.

A risk analysis of WFC residents' coping mechanisms shows that residents have difficulty balancing a normal living situation (protective factor) and their past traumatic experiences (risk factors), since they live an unstable environment. WFCs residents are worried that the community support systems are dwindling. It is apparent that social support from friends and family often unattainable, since they are in dispersed and inaccessible areas. External support offered through NGOs is said to be insufficient and professional aid in psychology seldom reaches Vavuniya.

Due the lack of formal and informal psycho-social support in the WFCs, it is logical to expect increased psycho-social problems (alcoholism, domestic violence etc.), increased prevalence of traumatic stress and psychiatric disorders (e.g. anxiety, depression and post-traumatic stress disorder) and increased rate of suicide.

Post-Traumatic Stress Disorder (PTSD) causes serious and prolonged disturbances (McFarlane, Atkison, Rafalowicz & Papay, 1994). Diagnostic criteria for PTSD include; an extreme stressor, intrusive and re-experiencing symptoms, avoidance and numbing symptoms, Symptoms of hyper arousal, Symptoms of criteria 2, 3, and 4 should be present at least one month. Traumatic occurrences result in a variety of mental disorders. Not all disorders emanating after traumatic events comprise PTSD. Others like Co-morbidity has been found to be more prominent in trauma patients than was originally assumed (Kleber, 1997). The Western conceptual frameworks for psychological stress and mental disorders are not entirely valid in the case of WFC's residents. Understanding mental disturbance them requires a new psycho-social theoretical framework and practical approach (Kleber, Figley & Gersons, 1995).

Research shows that nearly all war victims experience recurrent and intrusive recollections, dreams, and sudden feelings of re-living the event (e.g. Bramsen, 1996). These recollections are combined with increased avoidance of stimuli, associated with the trauma, and numbing. Cognitive processing models show that people deal with traumatic experiences by oscillating between reactions of intrusion and avoidance (Creamer: 1995). Physical symptoms such as stomach pains, headaches and back pains also manifest a lot.

One of the theoretical spectrums is the Western 'unitary' approach, it interprets mental disorders as having universal biological and behavioural symptoms; the other is the school of trans-cultural psychiatry, this interprets mental disorders as having distinct, culture-specific behavioural symptoms. A Western cognitive theoretical framework is therefore best applied for this study since No trans-cultural psychiatric model specific to Sri Lanka exists; therefore, the Western model was as good as any.

The psycho-social and traumatic stress caused by the situation in Vavuniya is partly acute and partly chronic. One can expect a combination of acute traumatic stress, various psycho-social problems, PTSD and psychiatric co-morbidity (e.g. depression, anxiety disorders, etc.). Therefore there is need to focus primarily on chronic traumatic stress. Diagnostic and measurement techniques for psycho-social disorders caused by chronic conflict need to be developed using three key indicators:

Risk & protective factors: It is important to understand the extent to which someone is traumatized and the type of trauma they have experienced (Kleber, Brom; 1992). The intensity, with which an individual suffers from trauma, depends on their 'protective' environment. Individuals who live within a 'protective' environment generally develop coping mechanisms to deal with their trauma and, consequently, are able to restore psycho-social health. Individuals who have no source of psycho-social support, on the other hand, often struggle to re-adapt. The psychological impact of stress between individuals who actually experience horrific events (e.g. direct confrontation through torture, rape, etc.) and those that have been exposed to it (e.g. live in an insecure environment) can be the same. Both are equally at risk of developing psycho-social problems or psychiatric disorders, such as PTSD, depression, anxiety disorder (Kleber, Brom: 1992).

Impact of the events: The Impact of Events Scale (IES) is used to measure levels of intrusion and avoidance; however the only concern that it may not be entirely appropriate for use in WFC's context is that cut-off scores developed from experiences in Western Europe (i.e. no problem: 0-10, at risk: 11-25, Serious metal Disturbances: 26-75) were used to compensate for this problem. The correlation between IES and PTSD scores is indirect.

Appraisal of physical complaints: People suffering from traumatic stress and PTSD often express somatic symptoms, such as stomach problems, general body pain, dizziness or palpitations and headaches. The occurrence of unspecified health complaints indicates a possible high level of traumatic stress or PTSD.

The presence of all three indicators of traumatic stress among WFC residents - namely, i) previous traumatic experience (e.g. direct confrontation, witnessing, personal loss and/or exposure), ii) IES measurements of intrusion and avoidance and iii) somatisation of mental problems) provide strong circumstantial evidence for the prevalence of traumatic stress.

Conclusions

All indicators show that WCF respondents suffer high levels of traumatic stress; causes being the inability to maintain a health and sustainable livelihood and the pass system.

The solution lies in a clear system for psycho-social intervention that addresses both the emotional and social needs of WFC residents. The system should address past traumatic experiences and address residents' current concerns about lack of security, poor living conditions and the inability to move freely. A serious dialogue between programme implementers and health authorities should be initiated to help facilitate the process.

There is also need for a balance between clinical services and social rehabilitation. Psycho-education would be useful to assist people with the concept of stress and help them identify and treat it. The community should also be equipped to counteract 'imposed helplessness'. Local organisations and WFC residents should collaborate to organise community activities.

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