Bruised but not beaten

In parts of Asia worst hit by last December's tsunami, the mentally ill were habitually tied to trees because villagers couldn't cope with them.

But as communities pull together, psychiatric professionals are rebuilding the land's ravaged psyche. Raj Persaud reports

While I normally love visiting Asia - my great great grandparents came over from India to the West Indies, where I was brought up - I'm not looking forward to this trip.

I've been invited to visit tsunami-hit areas by the Disaster Emergency Committee and I'm sure I am going to encounter a lot of tragedy and suffering. After all, more than 128,000 people are thought to have died in the disaster, while at least 37,000 others remain missing.

Accompanying me on the visit is Niall Sookoo of the charity ActionAid. In a strange form of role reversal (for me), he spends most of the journey out to India reassuring me that things are not going to be as bad as I anticipate. In a hectic couple of days we visit the worst hit regions of southern India, such as Nagapattinam and Cuddalore in Tamil Nadu and parts of Pondicherry.

ActionAid and other charities have been pioneering probably the most extensive psychosocial rehabilitation programme ever developed. The idea is to train local people to return to their neighbourhood and provide pragmatic psychological assistance to those traumatised by the disaster.

Historically, when faced with catastrophes on the scale of the tsunami, the priority has been to rescue people and provide shelter and basic medicines and sustenance - basically, to save life and limb. Yet it is increasingly understood that although a broken mind may not be as visible as a broken arm, it needs just as much patching.

The consequences of untreated psychological trauma can be as profound as physical injuries left to fester. Suicide rates, violence, secondary alcoholism, disabling depression and phobic responses, such as post-traumatic stress disorder, characterise whole populations who have lived through a catastrophe on the scale of a tsunami. A traumatised population tend to want to flee their environment in the immediate aftermath. It's an understandable phobic response - would you want to continue living by the sea once it had washed away your home, your livelihood and your family?

Coastal communities were tempted to relocate further inland, something encouraged by local politicians who coveted the beaches for hotels and tourism. But fishermen need to live by the sea and, in the long run, this would have been disastrous. Through psychological projects sponsored by ActionAid, the communities adjusted to living by the sea and have largely stayed and even returned to fishing. Techniques used in the projects included graded exposure to fears, such as playing games in the sea, rather than sitting around and emoting about your childhood.

This is a vital consideration, as there is research evidence that introducing de-briefing or counselling post-disaster to survivors without taking account of their practical needs can worsen their long-term psychological outcome.

But this is not what I see - instead I find communities which appear remarkably resilient thanks to local cultural and emotional resources as well as the aid offered from outside.

First I meet a psychiatrist working in a general hospital who has responsibility for roughly 300,000 people - almost 10 times the size of the catchment area I look after for the good old NHS in Croydon. Back home, psychiatrists, social workers and nurses constantly complain about how their areas are too big and beyond Royal College of Psychiatry guidelines.

We are put to shame by the incessant good spirits of mental health workers here and their willingness to put their shoulders to the wheel no matter what the demands upon them.

The psychiatrist mentions an incident of a hospital porter who, in the first few days after the tsunami, helped to bring hundreds of bodies into the hospital mortuary for identification. He believed his own son was safe but, among the bodies he was moving about the mortuary, found that of his son who had, in fact, died in the wave.

Almost a year on that man has returned to work and is soldiering on - one can only imagine how after a shock like that.

After the tsunami, community psychiatric nurses visited the worst hit villages and found patients tied to trees because they were so psychotic and raving the villagers couldn't cope with them. For the personal safety of both patient and community their only solution was to chain them up out of harm's way.

I have seen this "tied to a tree" treatment elsewhere in the developing world and it's probably the most widespread and ancient approach to serious psychiatric disorder. One of the untold stories of disasters such as hurricanes, floods and tsunamis is that the long-term mentally ill who are tied to trees perish because they are unable to flee like the rest of the population.

Yet nurses had freed these severely mentally ill patients and taken them to the local hospital for treatment. Some of them are now sleeping in their parents' homes and appear much better - though one or two still harbour delusions about being Hindu Gods.

While I have no doubt that the work of ActionAid and other charities like it has been instrumental in salvaging the minds of many survivors, it seems to me I am also witnessing something remarkable in the therapeutic atmosphere created by sheer bonding of the community following this disaster.

I return to Britain humbled and inspired by these stories. But I also develop a vague sense of dej... vu; that somewhere else I've seen something similar in the face of overwhelming catastrophe. Then it hits me on the plane back, as I'm leafing through a glossy magazine with some pictures of London. It was that "Blitz spirit" during the Second World War, when Londoners and the rest of the country came together. It makes me wonder if they now have in those tsunami-hit areas something rare and wonderful which we in the West have been missing for rather a long time.

Raj Persuad is Gresham Professor for Public Understanding of Psychiatry.

You can hear a documentary made about his visit to tsunami-hit areas on the BBC World Service at 10.05am, 3.05pm and 8.05pm on Boxing Day

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