Psychosocial Care for Women Survivors of the Tsunami Disaster in India

Abstract

Objectives. I investigated the effectiveness of Psychosocial Care, a community-based mental health initiative for survivors of the 2004 tsunami disaster in India.

Methods. Mental health teams from the National Institute of Mental Health and Neurosciences (NIMHANS) in India implemented a train-the-trainer model of psychosocial care in one of the worst tsunami-affected areas of south India. Three months of psychosocial care was provided for an intervention group of women, but not for a control group recruited from an exposed neighboring village. Impact of Event Scale (IES) scores—both total scores and scores for subscales on hypervigilance, avoidance, and intrusion—were compiled for both the intervention and control groups and used as outcome measures.

Results. For the intervention group, posttest total IES and subscale scores were significantly lower than pretest scores (P < .001), indicating improvement in symptoms. Posttest total IES and subscale scores were significantly lower for the intervention group than for the control group (P < .001).

Conclusions. Psychosocial care is an effective mental health strategy for women survivors of disasters and should be an integral component of disaster response in resource-poor countries.

Mental health aspects of relief and rehabilitation are increasingly recognized as an integral part of disaster response,¹ but studies of mental health interventions have been lacking because of logistical and ethical constraints in conducting research in disaster situations.² Recent studies of the 2004 tsunami disaster have focused on the prevalence of postdisaster psychiatric symptomatology,^3,4 without giving attention to evidence-based mental health interventions that promote the recovery of affected populations.

PSYCHOSOCIAL CARE

During the last 2 decades, a model of psychosocial care has been developed in India to meet the mental health needs of large populations of survivors of manmade and natural disasters. In India, disaster mental health response has evolved from identifying and treating psychiatric cases with individual treatments to preventing psychiatric morbidity by strengthening the coping abilities of survivors in community-based self-help groups, with community-level workers as providers of psychological care and facilitators of recovery for affected communities.⁵ The National Institute of Mental Health and Neurosciences (NIMHANS), located in Bangalore, India, has been instrumental in implementing this model of psychosocial care for survivors of the tsunami. Psychosocial care is a generic intervention, with previous applications to men, women, and children in a range of disaster situations.^6–9

Psychosocial care views emotional reactions to disasters as normal reactions to an abnormal event, thereby normalizing and removing clinical labels from reactive emotional distress.^5,8,10 Community-level workers involved in relief, rehabilitation, and reconstruction receive training in the essentials of psychosocial care, including ventilation of emotions, empathy, active listening, problem solving, and facilitation of group support. Local community workers, trained by mental health professionals, ensure that the psychosocial care program is appropriate and sensitive to the culture and language of the disaster survivors.

Following the identification and engagement of survivors through outreach efforts, support groups are organized and facilitated by trained community workers. These groups participate in activities (e.g., constructing shelters, distributing food, caring for children) that give them a sense of purpose and accomplishment and counteract feelings of helplessness. These activities allow widows and individuals without existing social networks to build cohesive relationships with others, thus reinforcing the belief that they are not alone. To facilitate a sense of normality and predictability and to counteract anxiety and the development of phobic avoidance, survivors are encouraged to maintain routines of daily living.

To decrease the physical and emotional effects of the disaster, relaxation and breathing exercises are taught and practiced regularly in group settings.⁶ The survivors are encouraged to practice their spiritual beliefs and rituals, their songs and hymns, and to discuss cultural proverbs and metaphors applicable to the disaster, thus allowing them to build and reinforce a social support system while making sense of the disaster. In sum, therapeutic components of psychosocial care include ventilation of emotions, normalization of emotional responses, and cognitive processing of the event within a supportive group environment. Over time, support groups engage in problem solving, which lays the foundation for longer-range, community-level initiatives that rebuild self-help.

TRAIN-THE-TRAINER PROGRAM

Psychosocial care is designed and implemented as a train-the-trainer program. In resource-poor countries with few mental health professionals, the training of community-level workers builds capacity to deliver psychosocial care to large populations of survivors. Training sessions, which are moderated by psychiatrists and social workers, include presentations, role playing, and experiential exercises. Mental health professionals are involved in planning and implementing the training format; preparing short lectures, manuals for trainees, and educational materials for survivors; and providing support for cases that require referral for specialized care. Trainees develop the competency to train other community workers, thereby increasing capacity to provide mental health services to persons in areas in which there are few professionals.

The training format, along with structured therapeutic activities and instructive manuals, was developed by NIMHANS teams in response to the Orissa supercyclone of 1999,^11,12 the Gujarat earthquake disaster of 2001,⁶ and the Gujarat riots of 2002⁷; it was then adapted for the aftermath of the 2004 tsunami.^10,13 Topics include understanding physical, behavioral, and psychological reactions to disaster, rapid assessment of survivors, confidentiality, basic crisis intervention skills, the role of a caregiver, techniques of psychosocial care, self-care for workers, and referrals. Basic knowledge and skills are taught through the use of presentations, role plays, experiential activities, thematic story cards, and group discussions. Psychosocial care is a community-based, preventive approach, but local mental health and primary care referral services are identified for a small number of persons who require professional assistance or emergency mental health care.

For my study, I investigated the effectiveness of a mental health intervention of psychosocial care in a group of women survivors of the 2004 tsunami in India. The women survivors of the tsunami experienced multiple losses and special problems. Some who were widowed became heads of single-parent families without a means of earning income in a society with discriminatory attitudes toward unmarried women. Husbands blamed wives for the loss of children; depression and grief were rampant, with many somatic complaints among the women, possibly the physical expression of their emotional distress.¹⁰ In a study of tsunami survivors in India's Tamil Nadu state, the odds of posttraumatic stress was almost 3 times higher among women than among men (odds ratio [OR] = 2.83); the authors recommended that mental health initiatives for women be a priority.³ A higher prevalence of depression, anxiety disorders, and posttraumatic stress disorder among women than among men has been reported in epidemiological studies in developed and developing countries, with exposure to stressful life events demonstrated to be a significant risk factor and the single most important predictor of mental disorders among women.¹⁴ Women were therefore selected as the intervention group in my study.

METHODS

To investigate the effectiveness of the psychosocial care intervention, a team of 3 psychiatric social workers and 1 psychiatrist from NIMHANS traveled to Cuddalore, one of the worst tsunami-affected areas of Tamil Nadu. In March 2006, these mental health professionals provided a 3-day experiential train-the-trainer program, “Essentials of Psychosocial Care,” to a group of 10 nongovernmental organization (NGO) and community health workers. After receiving the training, each of these 10 community trainees provided 3 months of psychosocial care to a group of 10 women survivors of the tsunami.

The sample receiving the psychosocial care intervention consisted of the first 100 women from an affected village near Cuddalore who volunteered for the study and were available to participate during the study period. (After 6 of the women were excluded because of cultural restrictions or the lack of approval from husbands or extended family, enrollment reopened until the final number was back to 100.) The control group, which was recruited from a nearby affected village, comprised the first 100 women who volunteered to provide information; this group did not receive psychosocial care, neither at the time of the study nor beforehand. A sample size of 100 for both groups was chosen on the basis of the availability of trainers, resources of the research officer, and previous surveys done by NIMHANS during riots and the Gujarat earthquake disaster.^7,9

A local nongovernmental organization, Swayam Shosak Prayog, which had worked with village women's self-help groups and was known to the people of both villages before the 2004 tsunami, recruited participants for the intervention and control groups, both through written advertisement and verbally (for those unable to read). A research officer from NIMHANS administered the Self-Reporting Questionnaire and the Impact of Event Scale (IES) to the women. The psychosocial care intervention took place in the affected village over a 3-month period (April–June 2006).

The Self-Reporting Questionnaire, a mental health screening instrument developed by the World Health Organization and validated in India,¹⁵ was used to assess the level of mental disability among the women participants. The IES¹⁶ was used to measure emotional distress in the intervention and control groups. The IES is a psychometrically sound self-report instrument that measures current subjective distress related to a specific event.¹⁷ It is recognized as a valid self-report tool for assessing traumatic stress,¹⁸ and a significant relationship between IES scores and number of symptoms of posttraumatic stress disorder listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV TR)¹⁹ has been demonstrated.²⁰ The IES consists of a total score and 3 subscales: (1) avoidance, (2) hypervigilance, and (3) intrusiveness; these are consistent with DSM-IV TR diagnostic criteria for posttraumatic stress disorder, which include symptoms of avoidance, hyperexcitability, and flashbacks. Higher scores indicate greater severity of symptoms. The IES has been used in Indian research studies and validated with Indian populations.^4,11,21

For the psychosocial care intervention group, 10 trained community-level workers provided group sessions consisting of 10 participants, conducted in the affected community 3 times a week for 2 hours per session from April through June 2006. Women survivors were encouraged to speak about their experiences, and they received emotional support and learned relaxation exercises in a group setting. Cultural rituals and spirituality were incorporated into the sessions. At the same time, practical issues were discussed with sensitivity, and trained workers related to survivors in their language, preserving cultural traditions while maintaining continuity of care. There were a few individual sessions for personal and family support when needed. Toward the end of the intervention period, there was discussion of means of improving families' economic status; these included microfinance loans for sustainable livelihoods, because much of the farmland of the survivors had been inundated and ruined by seawater. In this way, the women were offered a comprehensive spectrum of services.

IES pretest measurements in the intervention group were recorded in April 2006, before psychosocial care was begun. Posttest measurements for intervention and control groups were taken in July 2006, at the close of the intervention period. Measurements on all 3 subscales and the total IES scores were included. I used the t test to compare pre- and posttest data for the intervention group and of posttest data for the intervention and control groups. The χ² test was utilized to test for demographic differences between intervention and control groups.

RESULTS

Intervention and control groups were similar in age, marital status, income, and exposure to the disaster. Although the 2 groups differed regarding years of education (χ² = 18.34; P < .001), most participants in both the intervention and control groups (74% and 65%, respectively) had less than 5 years of education.

In both the intervention and control groups, most women were aged 26 to 45 years and the vast majority (94% and 92%, respectively) was married. Income and family type were similar in the 2 groups. Demographic characteristics of the intervention and control groups are described in Table 1.

TABLE 1.

Marital Status, Age, Education, Family Type, and Income of Psychosocial Care Intervention and Control Groups: Tamil Nadu, India, 2006

	Intervention, %	Control, %
Marital status
Unmarried	1	2
Married	94	92
Widowed	5	6
Age, y
< 26	16	18
26–35	33	45
36–45	34	25
46–55	15	11
≥ 56	2	1
Education, y
None	54	61
1–4	20	4
5–7	15	30
8–10	11	5
Family type
Nuclear	82	84
Joint	17	16
Live alone	1	0
Income, rupees/mo	1
< 1000	81	85
1001–3000	16	14
3001–5000	2	1
> 5000	1	0

Note. Total sample size for both groups was N = 100.

In the intervention group, 71% had experienced 2 or more of the following (called here “multiple losses”): the death of a loved one, loss of livelihood, loss of property, personal injury, and having witnessed a neighbor's loss of loved one, property, or livelihood. In the control group, 69% had experienced multiple losses. All participants in both the intervention and control groups had experienced some form of loss. The Self-Reporting Questionnaire was used to assess the level of mental distress among the women participants. At baseline, 32% reported severe symptoms and 22% reported moderate symptoms in the intervention group, compared with 34% and 24%, respectively, in the control group. For both intervention and control groups, the highest Self-Reporting Questionnaire scores, indicating mental distress, were among those in the 46-to-55-year age group.

As shown in Table 2, following the intervention there was a significant decrease in total IES scores (P < .001) and subscale IES scores of avoidance (P < .001), intrusion (P < .001), and hypervigilance (P < .001), indicating an improvement in symptoms for the psychosocial intervention group.

TABLE 2.

Pre- and Posttest Impact of Event Scores for Psychosocial Care Intervention Group (n = 100): Tamil Nadu, India, 2006

	Pretest Scores, Mean (SD)	Posttest Scores, Mean (SD)
Total	25.16 (12.18)	17.16 (7.07)
Avoidance	8.18 (4.03)	5.00 (2.41)
Intrusion	8.41 (5.84)	6.00 (2.01)
Hypervigilance	8.57 (4.82)	6.16 (2.58)

Note. For all comparisons, P < .001. Higher Impact of Event scores indicate more severe symptoms.

As shown in Table 3, posttest IES scores, both total and subscale, were lower for the intervention group than for the control group for all scores (P < .001). For ethical reasons, we could not collect pretest data on the control group while planning to withhold from them the intervention.

TABLE 3.

Posttest Comparison of Impact of Event Scores for Psychosocial Care Intervention and Control Groups: Tamil Nadu, India, 2006

	Intervention, Mean Score (SD)	Control, Mean Score (SD)
Total	17.16 (7.07)	23.01 (9.13)
Avoidance	5.00 (2.41)	6.36 (2.76)
Intrusion	6.00 (2.91)	8.60 (4.12)
Hypervigilance	6.16 (2.58)	8.05 (3.02)

Note. For the intervention group, N = 99; for the comparison, N = 100. One woman in the intervention group could not be located for the postintervention test. For all comparisons, P < .001. Higher Impact of Event scores indicate more severe symptoms.

DISCUSSION

Because disasters by nature are intermittent, arrive unexpectedly, and require massive recovery efforts, they do not logistically lend themselves to the research process. Researchers who study disaster victims, who can be perceived as not “pitching in to help,” can meet resistance from both the individuals who are the target of inquiry and the organizations involved in the interventions to be evaluated. The literature on disaster research in general reflects the paucity of research in this area, with few quantitative evidence-based studies.²

Indian mental health professionals have made significant contributions to understanding and responding to the mental health needs of disaster-affected populations and developing and implementing a model of care for the recovery of survivors. Disaster-related mental health initiatives have progressed from simple emotional support in the Bangalore circus disaster of 1981²² to the mental health training of health care providers following the Bhopal gas disaster of 1984.²³ In the Marathwada earthquake of 1993, the training of professionals, as well as of lay counselors for individuals and groups, was developed by the Maharashtra Institute of Mental Health, which reported that the 5-year psychological morbidity of the affected population was twice that of a control group not affected by the disaster.²⁴ Data from the Orissa supercyclone of 1999 demonstrated that, 1 year after the disaster, one third of the survivors had disabling psychiatric symptoms that affected their recovery²⁵; consequently, NIMHANS implemented interventions for vulnerable groups of women, children, and the disabled. Structured training programs with standardized manuals for interventions in psychosocial care were written and refined for recovery initiatives in the Gujarat earthquake of 2001^6,9 and Gujarat riots of 2002.⁷ In 2003, the International Federation of the Red Cross established a policy that encourages integration of psychological support into existing disaster infrastructures,²⁶ with training programs for lay counselors to address the overwhelming mental health needs of affected populations in resource-poor settings. These programs have been implemented in actual disaster situations and further revised over time.^21–27 In 2005 and 2006, more than 1000 community-level workers were trained by the NIMHANS teams and their trainees to provide psychosocial care for tsunami survivors.

Psychosocial care in disasters involves (1) community self-help groups for emotional support and reestablishment of social connections; (2) relaxation exercises for controlling and mastering physiological and psychological stress reactions, including hypervigilance and avoidance; and (3) cultural metaphors and spiritual beliefs to facilitate cognitive processing and coming to terms with an overwhelming experience. These mental health interventions were implemented in the psychosocial care program described in this study.

Limitations

Because it was not possible to collect pretest data on the control group, a quasi-experimental design was used and only posttest comparisons were made between intervention and control groups. Ethical constraints complicate disaster research and affected the ability of the research and intervention team to collect pretest control group data, which could have strengthened my findings.

One of the problems with the train-the-trainer component of psychosocial care is that some of the trainees are themselves survivors of the disaster, which results in empathy with the survivors but some loss of objectivity in providing services. Trainees went on to train many groups of community-level workers to offer basic psychosocial care to disaster survivors, with NIMHANS teams available for support and consultation. The essentials of psychosocial care can be learned in a 3-day training period, but there are no data at this time to attest to the quality of care trainees provided to survivors or their retention of skills from the training program. These issues need to be addressed in future studies.

Conclusions

My study contributes evidence in support of a mental health intervention that reduces emotional distress for women survivors of disasters. After the psychosocial care intervention, women tsunami survivors had lower total IES scores and decreases in the intrusion, avoidance, and hypervigilance subscales, indicating improvement in symptoms. The limitations in the design of this study and the delayed implementation of the intervention reflect the fact that disaster response does not logistically or ethically lend itself to the research process.

Psychosocial care, developed and implemented in India and based on long-term experience with disaster survivors, has become an integral part of national disaster policy in India.²⁷ The World Health Organization recommends training and strengthening of infrastructure for psychosocial capacity building as a fundamental part of public health relief and reconstruction programs for survivors of human-made or natural disasters in developed and developing countries.^28,29 Recent disasters in Iran, Pakistan, China, and the United States underscore the urgent need for mental health services as a crucial component of disaster policy and disaster response.