Effect of daily stressors and collective efficacy on post-traumatic stress symptoms among internally displaced persons in post-war northern Sri Lanka.

BACKGROUND: Daily stressors have been shown to mediate the relationship of war trauma and trauma-related distress among refugees and internally displaced persons exposed to war and conflict. AIMS: To examine the extent to which the relationship between war-related trauma and mental distress was mediated by daily stressors and collective efficacy among internally displaced communities a decade after exposure to war. METHOD: In a cross-sectional study, we recruited a random sample of residents in villages severely affected by conflict in five districts in the Northern Province of Sri Lanka. Measures of war trauma, daily stressors, collective efficacy and post-traumatic stress symptoms (PTSS) were examined. Statistical analyses of the mediating and moderating effects of daily stressors were conducted using regression based methods. RESULTS: Daily stressors mediated the association of war trauma and PTSS, as both paths of the indirect effect, war trauma to daily stressors and daily stressors to PTSS, were significant. The predictive effect of war trauma on PTSS was positive and significant at moderate and high levels of daily stressors but not at low levels. Higher levels of neighbourhood informal social control, a component of collective efficacy, function as a protective factor to reduce effects of war trauma and daily stressors on mental distress in this population. CONCLUSIONS: Daily stressors are an important mediator in the well-established relationship between war exposure and traumatic stress among internally displaced persons, even a decade after the conflict. Mental health and psychosocial support programmes that aim to address mental distress among war-affected communities could reduce daily stressors and enhance collective efficacy in this context.

Possession states in Northern Sri Lanka.

BACKGROUND: Possession states are still commonly seen in developing societies as acceptable cultural phenomena in normal persons as well as in those with psychiatric illness. 'Possession' is defined here as the experience of being taken over, controlled or occupied by another spirit or force. SAMPLING AND METHODS: This is a descriptive cross-sectional study of possession states among psychiatric patients, general population and popular adepts in Northern Sri Lanka, using semi-structured questionnaires and clinical observations. RESULTS: Thirty psychiatric patients were identified as having possession states. They were compared with 30 controls each from the general population admitted to a general hospital outpatient department and selected popular adepts in the community. The latter are individuals who are well known as having possession states. An analysis of social factors and other variables showed that education, marital status, age, employment, strength of belief, alterations in personality, past or family psychiatric history, previous exposure to similar phenomena, help-seeking behavior and treatment outcome differed between the three groups. Religion of the subjects or recent changes in values showed no correlation with possession while monetary gain from possession states showed only a partial correlation. Western medical treatment was of value only when possession states were seen as part of psychotic illness. DISCUSSION: Possession is a spectrum of experiential and behavioral phenomena seen in culturally acceptable form in normal people, popular adepts, as well as manifestations of psychotic illness. Possession states which fit normal cultural stereotypes could, if necessary, be better managed by traditional methods. However, clinicians need to be familiar with culturally abnormal forms of possession which are manifestations of psychotic illness that benefit from western psychiatric treatment.

A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD.

The World Health Organization's proposals for posttraumatic stress disorder (PTSD) in the 11th edition of the International Classification of Diseases, scheduled for release in 2018, involve a very brief set of symptoms and a distinction between two sibling disorders, PTSD and Complex PTSD. This review of studies conducted to test the validity and implications of the diagnostic proposals generally supports the proposed 3-factor structure of PTSD symptoms, the 6-factor structure of Complex PTSD symptoms, and the distinction between PTSD and Complex PTSD. Estimates derived from DSM-based items suggest the likely prevalence of ICD-11 PTSD in adults is lower than ICD-10 PTSD and lower than DSM-IV or DSM-5 PTSD, but this may change with the development of items that directly measure the ICD-11 re-experiencing requirement. Preliminary evidence suggests the prevalence of ICD-11 PTSD in community samples of children and adolescents is similar to DSM-IV and DSM-5. ICD-11 PTSD detects some individuals with significant impairment who would not receive a diagnosis under DSM-IV or DSM-5. ICD-11 CPTSD identifies a distinct group who have more often experienced multiple and sustained traumas and have greater functional impairment than those with PTSD.

Management of trauma in special populations after a disaster.

Special populations are particularly vulnerable to mental health problems in the aftermath of a disaster. Efficient delivery of mental health services, the integrated use of psychosocial services and mental health facilities, and the active intervention of trained community health care workers can offer effective management of the psychosocial problems of special populations. Women, children, adolescents, the poor, the elderly, and individuals with preexisting health problems have been identified as special populations who often suffer psychological morbidity as a result of a catastrophic disaster. Understanding the cultural, ethnic, and socioeconomic factors in a postdisaster situation is crucial to helping special populations overcome debilitating mental illness and declining quality of life. Planning the delivery of mental health services is critical and includes hazard mapping to identify vulnerable geographic and social areas, screening instruments to identify at-risk populations, and education of community leaders and health care workers. An integrated approach using psychosocial and institutionalized interventions can provide better outcomes than either approach alone. A community-based approach with trained grassroots health care workers can provide effective psychosocial support and rehabilitation services.

Vicarious resilience and vicarious traumatisation: Experiences of working with refugees and asylum seekers in South Australia.

The negative psychological impacts of working with traumatised people are well documented and include vicarious traumatisation (VT): the cumulative effect of identifying with clients' trauma stories that negatively impacts on service providers' memory, emotions, thoughts, and worldviews. More recently, the concept of vicarious resilience (VR) has been also identified: the strength, growth, and empowerment experienced by trauma workers as a consequence of their work. VR includes service providers' awareness and appreciation of their clients' capacity to grow, maintaining hope for change, as well as learning from and reassessing personal problems in the light of clients' stories of perseverance, strength, and growth. This study aimed at exploring the experiences of mental health, physical healthcare, and settlement workers caring for refugees and asylum seekers in South Australia. Using a qualitative method (data-based thematic analysis) to collect and analyse 26 semi-structured face-to-face interviews, we identified four prominent and recurring themes emanating from the data: VT, VR, work satisfaction, and cultural flexibility. These findings-among the first to describe both VT and VR in Australians working with refugee people-have important implications for policy, service quality, service providers' wellbeing, and refugee clients' lives.

The psychosocial effects of landmines in Jaffna.

The victims of landmines in Jaffna were studied from a psychosocial perspective in order to identity major problem areas and give priorities for rehabilitation. Sixty-seven victims of landmines from April 1996 to March 1998 in the Valikamam area of Jaffna were studied. There were three times as many males as females. About 48 per cent were aged 20-39 years. About one-fifth of the victims were children. Of the females, 60 per cent were unmarried. The majority belonged to the lower socioeconomic strata. Half lost their earning capacity after the injury. Post-traumatic stress disorder (72 per cent), acute stress reaction (73 per cent), anxiety disorder (80 per cent) and depression (73 per cent) were found to be very significantly higher in this group than in the general population. There were also remarkable changes in the areas of functional ability, religious practice, use of alcohol and social relationships. The 'phantom limb' phenomenon was a striking feature among amputees. The psychosocial impact of landmine injuries has to be considered seriously in rehabilitation work.

Recent disasters in Sri Lanka: lessons learned.

Sri Lanka has faced several disasters in the recent past, both manmade and natural. The mental health and psychosocial consequences have been felt at the individual, family, and collective levels. Individuals developed normal distress, posttraumatic stress disorder, depression, or alcohol abuse. There were changes in family and social processes causing a tearing of the social fabric, lack of social cohesion, disconnection, mistrust, hopelessness, dependency, lack of motivation, powerlessness, and despondency. Because of the widespread nature of mental health needs, a community approach would reach the most number of people.

Rebuilding community resilience in a post-war context: developing insight and recommendations - a qualitative study in Northern Sri Lanka.

BACKGROUND: Individuals, families and communities in Northern Sri Lanka have undergone three decades of war trauma, multiple displacements, and loss of family, kin, friends, homes, employment and other valued resources. The objective of the study was understanding common psychosocial problems faced by families and communities, and the associated risk and protective factors, so that practical and effective community based interventions can be recommended to rebuild strengths, adaptation, coping strategies and resilience. METHODS: This qualitative, ecological study is a psychosocial ethnography in post-war Northern Sri Lanka obtained through participant observation; case studies; key- informant interviews; and focus groups discussions with mental health and psychosocial community workers as well as literature survey of media and organizational reports. Qualitative analysis of the data used ethnography, case studies, phenomenology, grounded theory, hermeneutics and symbolic interactionism techniques. Quantitative data on suicide was collected for Jaffna and Killinochchi districts. RESULTS: Complex mental health and psychosocial problems at the individual, family and community levels in a post-war context were found to impair recovery. These included unresolved grief; individual and collective trauma; insecurity, self-harm and suicides; poverty and unemployment; teenage and unwanted pregnancies; alcoholism; child abuse and neglect; gender based violence and vulnerability including domestic violence, widows and female headed-household, family conflict and separation; physical injuries and handicap; problems specific for children and elderly; abuse and/or neglect of elderly and disabled; anti-social and socially irresponsible behaviour; distrust, hopelessness, and powerlessness. Protective factors included families; female leadership and engagement; cultural and traditional beliefs, practices and rituals; and creative potential in narratives, drama and other arts. Risk factors that were impeding community rehabilitation and recovery included continuing military governance, depletion of social capital particularly lack of trust, hope and socio-economic opportunity structures for development that would engender a sense of collective efficacy. CONCLUSIONS: In view of the widespread trauma at the individual, family and collective levels, community based programmes to increase local awareness, knowledge and skills to deal with common mental health and psychosocial issues; and training of community level workers and others in basic mental health and psychosocial problem solving are recommended to rebuild family and community agency and resilience. The use of cultural practices and school based programmes would rekindle community processes.

Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11.

The diagnostic concepts of post-traumatic stress disorder (PTSD) and other disorders specifically associated with stress have been intensively discussed among neuro- and social scientists, clinicians, epidemiologists, public health planners and humanitarian aid workers around the world. PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. This paper describes proposals that aim to maximize clinical utility for the classification and grouping of disorders specifically associated with stress in the forthcoming 11th revision of the International Classification of Diseases (ICD-11). Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non-specific symptoms; a new complex PTSD category that comprises three clusters of intra- and interpersonal symptoms in addition to core PTSD symptoms; a new diagnosis of prolonged grief disorder, used to describe patients that undergo an intensely painful, disabling, and abnormally persistent response to bereavement; a major revision of "adjustment disorder" involving increased specification of symptoms; and a conceptualization of "acute stress reaction" as a normal phenomenon that still may require clinical intervention. These proposals were developed with specific considerations given to clinical utility and global applicability in both low- and high-income countries.

Collective trauma in the Vanni- a qualitative inquiry into the mental health of the internally displaced due to the civil war in Sri Lanka.

BACKGROUND: From January to May, 2009, a population of 300,000 in the Vanni, northern Sri Lanka underwent multiple displacements, deaths, injuries, deprivation of water, food, medical care and other basic needs caught between the shelling and bombings of the state forces and the LTTE which forcefully recruited men, women and children to fight on the frontlines and held the rest hostage. This study explores the long term psychosocial and mental health consequences of exposure to massive, existential trauma. METHODS: This paper is a qualitative inquiry into the psychosocial situation of the Vanni displaced and their ethnography using narratives and observations obtained through participant observation; in depth interviews; key informant, family and extended family interviews; and focus groups using a prescribed, semi structured open ended questionnaire. RESULTS: The narratives, drawings, letters and poems as well as data from observations, key informant interviews, extended family and focus group discussions show considerable impact at the family and community. The family and community relationships, networks, processes and structures are destroyed. There develops collective symptoms of despair, passivity, silence, loss of values and ethical mores, amotivation, dependency on external assistance, but also resilience and post-traumatic growth. CONCLUSIONS: Considering the severity of family and community level adverse effects and implication for resettlement, rehabilitation, and development programmes; interventions for healing of memories, psychosocial regeneration of the family and community structures and processes are essential.

Psychosocial responses to disaster: An Asian perspective.

The psychological and psychiatric impact of great natural disasters are beginning to be understood leading to new methods of prevention, intervention and mitigation. There is limited data from the Asian continent, however, which has been the location of some of the greatest disasters of recent times. In this paper, we outline the psychosocial intervention efforts from nine Asian nations when confronted with large-scale natural catastrophic events. These include reports from situations where local services have some capacity to respond as well as those where services are destroyed or overwhelmed. From this it is possible to draw some general principles of psychosocial disaster intervention: (1) Assessment of disaster, extant service systems and incoming resources. (2) Assessment of help-seeking pathways and cultural models of illness. (3) Facilitation and support for family reunion, identification of the dead and cultural and religious practices to address death and grief. (4) Foster and bolster community group activities where possible. (5) Psychosocial training of community, aid and health workers using a train the trainer model to promote case identification, psychoeducation and intervention, with specific emphasis on vulnerable groups, especially children. (6) Promote general community psychoeducation. (7) Train medical and health staff in basic psychiatric and psychological assessment and intervention for post-traumatic stress, mood and anxiety disorders. (8) Minimise risk factors for psychiatric morbidity such as displacement and loss of gainful activity. (9) Reshape mental health systems recognising the long-term psychiatric sequelae of disaster. The collective learnt experience from Asian natural disasters may be constructively used to plan strategies to respond appropriately to the psychosocial consequences of disaster both within Asia and in the rest of the world.

Collective trauma in northern Sri Lanka: a qualitative psychosocial-ecological study.

BACKGROUND: Complex situations that follow war and natural disasters have a psychosocial impact on not only the individual but also on the family, community and society. Just as the mental health effects on the individual psyche can result in non pathological distress as well as a variety of psychiatric disorders; massive and widespread trauma and loss can impact on family and social processes causing changes at the family, community and societal levels. METHOD: This qualitative, ecological study is a naturalistic, psychosocial ethnography in Northern Sri Lanka, while actively involved in psychosocial and community mental health programmes among the Tamil community. Participatory observation, key informant interviews and focus group discussion with community level relief and rehabilitation workers and government and non-governmental officials were used to gather data. The effects on the community of the chronic, man-made disaster, war, in Northern Sri Lanka were compared with the contexts found before the war and after the tsunami. RESULTS: Fundamental changes in the functioning of the family and the community were observed. While the changes after the tsunami were not so prominent, the chronic war situation caused more fundamental social transformations. At the family level, the dynamics of single parent families, lack of trust among members, and changes in significant relationships, and child rearing practices were seen. Communities tended to be more dependent, passive, silent, without leadership, mistrustful, and suspicious. Additional adverse effects included the breakdown in traditional structures, institutions and familiar ways of life, and deterioration in social norms and ethics. A variety of community level interventions were tried. CONCLUSION: Exposure to conflict, war and disaster situations impact on fundamental family and community dynamics resulting in changes at a collective level. Relief, rehabilitation and development programmes to be effective will need to address the problem of collective trauma, particularly using integrated multi-level approaches.

Collective trauma in northern Sri Lanka: A Qualitative psychological-ecological study

Background: Complex situations that follow war and natural disasters have a psychosocial impact on not only the individual but also on the family, community and society. Just as the mental health effects on the individual psyche can result in non pathological distress as well as variety of psychiatric disorders; massive and widespread trauma and loss can impact on family and social processes causing changes at the family, community and societal levels. Method: This qualitative, ecological study ia a naturalistic, psychosocial ethnography in Northern Sri Lanka, while actively involved in psychosocial and community mental health programmes among the Tamil community. Participatory observation, key informant interviews and focus group discussiion with community level relief and rehabilitation workers and government and non-governmental officials were userd to gather data. The effects on the community of the chronic, manmade disaster, war, in Northern Sri Lanka were compared with the contexts found before the war after the tsunami. Results: Fundamental changes in the functioning of the family and the community were observed. While the changes after the tsunam were not so prominent, the chronic war situation caused more fundamental social transformations. At the family level, the dynamics of single parent families, lack of trust among members, and changes in significant relationships, and child rearing practices were seen. Communities tended to be more dependent, passive, silent, without leadership, mistrustful, and suspicious. Additional adverse effects included the breakdown in traditional structures, institutions and familiar ways of life, and deterioration in social norms and ethics. A variety of community level interventions were tried. Conclusion: Exposure to conflict, war adn disaster situations impact on fundamental family and community dynamics resulting in changes at a collective level. Relief, rehabilitation and development programmes to be effective... (AU)