Psychiatrists Responding to Tsunami Tragedy : Disaster Psychiatry Outreach hopes to train local leaders in Sri Lanka to work as counselors.

Members of Disaster Psychiatry Outreach who traveled to Sri Lanka after the late December tsunami say their initial efforts to assist survivors are just the beginning.

“What we did was the easy part,” Craig Katz, M.D., cofounder and president of the New York-based DPO, told CLINICAL PSYCHIATRY NEWS. “What we saw and what we're going to do [about it] are the harder parts.”

Dr. Katz, who in January was accompanied by Nalaini Sriskandarajah, M.D., a DPO board member and child psychiatrist, said their objective was to develop a needs and assessment plan, and to determine how they could help.

The psychiatrists, who were hosted by local clubs, worked with the Rotary Council of Sri Lanka.

The devastation left by the tsunami that struck countries bordering the Indian Ocean on the morning of Dec. 26, 2004, is almost incomprehensible. Conservative estimates put the loss of life at 265,000-310,000, but a definitive count may be impossible.

The tsunami caused death and destruction in more than 11 countries, including Sri Lanka–where more than 31,000 people were killed, 12,000 of whom were children.

Nearly 1 million people in Sri Lanka were left homeless. The World Health Organization estimates that 90% of those displaced by the tsunami had also been displaced in the past because of more than 20 years of fighting between government forces and Tamil Tiger rebels.

Other countries affected were Indonesia, India, Thailand, Somalia, and South Africa. Centered off the western coast of north Sumatra, the undersea earthquake triggered waves up to 100 feet and will go down in history as the second largest ever recorded, at 9.3 on the seismograph.

While based in the city of Colombo, Dr. Katz and Dr. Sriskandarajah traveled through the affected southern districts of the country for several days. Then they visited northeast Sri Lanka, a region occupied by Tamil Tiger rebels. The regions are distinctly different.

“The reasons those distinctions are important is because [northern residents] are just emerging from years of war,” said Dr. Katz of the department of psychiatry at Mount Sinai School of Medicine, New York.

“They've had a truce there for about 2 years, and they were just climbing out of that and finally rebuilding economically and socially–and then [the tsunami] hit.”

While in the welfare camps, Dr. Katz said he remembers seeing a house that had been destroyed. Part of a wall was still standing and in it were bullet holes–apparently because the house was shot at during the war.

“It was a complete symbol of one bad thing happening on top of another,” Dr. Katz said. “That was rather powerful, and it was just a piece of concrete.”

In this part of the country, a group of about 18 counselors has been active since 1996. Their work during the conflict better prepared them to deal with this event, he said. They're not health professionals, but they've acquired a lot of training and experience over the years.

“We're hoping to work with them and give them some more specialized training … in child work and a little bit of [cognitive-behavioral therapy] to help them,” Dr. Katz said.

Whenever they could, he and Dr. Sriskandarajah visited “child-centered spaces,” which are designed to give children a place to play together.

Those spaces proved to be particularly important given the range of problems –including sleeplessness, nightmares, and flashbacks–that officials observed among the children at the newly established base hospitals in each district.

“In the daytime, they were happy and playing, because they were given structured activities,” Dr. Sriskandarajah said in an interview with this newspaper. “But they were waking up in the middle of the night or having nightmares, or refusing to go to sleep.”

The children sometimes have weekly visits from a psychiatrist who supervises the camp coordinators, which are the Sri Lankan equivalent of what we would call house officers, Dr. Katz said.

But resources are limited, and an on-site mental health staff is nonexistent.

Many children have been unable to sleep because they fear that the tsunami might return, one counselor told Dr. Sriskandarajah.

The counselors responded by lighting a fire outside. They told the children that if the fire went out, it would mean that the tsunami was returning–and the children could run.

“It seems to have helped the children a little bit,” said Dr. Sriskandarajah, who was born in Sri Lanka, is in private practice in Poughkeepsie, N.Y., and serves as chairwoman of the DPO's child and adolescent committee.

“These were [the] kinds of things that people were doing.”

She described a case of what she called tsunami hysteria. “While we were there, a little girl started yelling 'tsunami is coming; tsunami is coming.'

“Sure enough, on that day, there was another minor tremor. There was no tidal wave, but people got scared. The moral of the story is that through the hysteria they were expressing, the children got the whole camp riled up,” said Dr. Sriskandarajah, speaking prior to the 8.7 earthquake that hit the area March 28.

Tsunami survivors are best helped by other survivors, said Vijay Chandra, M.D., a World Health Organization regional mental health adviser.

“The best method of dealing with [the devastation] would be to find people in neighboring villages or communities, people of similar cultural background, who understand the cultural norms to help them,” Dr. Chandra said in a statement.

Additionally, the WHO is improving mental health services in Sri Lanka and has provided a 1-day refresher workshop on psychosocial approaches for 150 school advisers, who will work with teachers in tsunami-affected areas.

The WHO has encouraged aid workers in affected countries to implement the organization's document “Mental Health in Emergencies,” which emphasizes a culturally sensitive approach to care through increased community outreach efforts and by customizing support to meet the special needs of children, women, and the elderly.

The Rotary Clubs have asked Disaster Psychiatry Outreach to train lay counselors to help in affected communities, but Dr. Katz acknowledged that the prospect is overwhelming.

“It's much easier for us to train a bunch of psychiatrists on how to do disaster psychiatry–or train a bunch of physicians on how to identify PTSD [posttraumatic stress disorder],” he said.

Another possibility is to send psychiatrists over there to do direct care, which is how the DPO was originally envisioned: “as a kind of Doctors Without Borders for psychiatry.

” I don't think we've ruled that out for Sri Lanka, but it would require a lot of resources and funding that I'm not sure we'd have in place,” he said.

The organization plans to reach out to Sri Lankan expatriates in the North American psychiatric community a bit further, and Dr. Sriskandarajah also has contacts in the United Kingdom and in Australia.

“We want to send some child psychiatrists,” she said. “But child psychiatrists are in short supply here.”

In late March, the DPO led a team of four physicians to the Kilinochichi and Mullaitivu district on a 2-week mission to work with counselors in the Annai Illam counseling program. They will be trained in general disaster psychiatry, post-disaster child interventions, and cognitive-behavioral therapy for trauma-affected people. These were the same counselors who helped area residents recover psychologically from years of civil war.

And the DPO undertook another trip to Sri Lanka in late April–this time to the southern and western areas.

According to Dr. Katz, the DPO is committed to developing a sustainable program for Sri Lanka and not having its efforts turn into “2 weeks of disaster tourism and then it's over.”

Ultimately, the organization hopes to work with community groups and to train local leaders to be counselors within their communities.

“We can't make them psychiatrists overnight. But we can build up basic knowledge of mental health in these communities so that they can be peer counselors and use what we know is a crucial part of recovery from trauma: good psychosocial support,” Dr. Katz said. We want them to “somehow use their instincts of supporting each other and add a pinch of psychiatric expertise.

“That is what we are hoping to be able to do.”

If you'd like to participate in preparations for and/or direct missions to Sri Lanka, contact the DPO for more information at 212-598-9995 or visitwww.disasterpsych.org

Members of Disaster Psychiatry Outreach who traveled to Sri Lanka after the late December tsunami say their initial efforts to assist survivors are just the beginning.

“What we did was the easy part,” Craig Katz, M.D., cofounder and president of the New York-based DPO, told CLINICAL PSYCHIATRY NEWS. “What we saw and what we're going to do [about it] are the harder parts.”

Dr. Katz, who in January was accompanied by Nalaini Sriskandarajah, M.D., a DPO board member and child psychiatrist, said their objective was to develop a needs and assessment plan, and to determine how they could help.

The psychiatrists, who were hosted by local clubs, worked with the Rotary Council of Sri Lanka.

The devastation left by the tsunami that struck countries bordering the Indian Ocean on the morning of Dec. 26, 2004, is almost incomprehensible. Conservative estimates put the loss of life at 265,000-310,000, but a definitive count may be impossible.

The tsunami caused death and destruction in more than 11 countries, including Sri Lanka–where more than 31,000 people were killed, 12,000 of whom were children.

Nearly 1 million people in Sri Lanka were left homeless. The World Health Organization estimates that 90% of those displaced by the tsunami had also been displaced in the past because of more than 20 years of fighting between government forces and Tamil Tiger rebels.

Other countries affected were Indonesia, India, Thailand, Somalia, and South Africa. Centered off the western coast of north Sumatra, the undersea earthquake triggered waves up to 100 feet and will go down in history as the second largest ever recorded, at 9.3 on the seismograph.

While based in the city of Colombo, Dr. Katz and Dr. Sriskandarajah traveled through the affected southern districts of the country for several days. Then they visited northeast Sri Lanka, a region occupied by Tamil Tiger rebels. The regions are distinctly different.

“The reasons those distinctions are important is because [northern residents] are just emerging from years of war,” said Dr. Katz of the department of psychiatry at Mount Sinai School of Medicine, New York.

“They've had a truce there for about 2 years, and they were just climbing out of that and finally rebuilding economically and socially–and then [the tsunami] hit.”

While in the welfare camps, Dr. Katz said he remembers seeing a house that had been destroyed. Part of a wall was still standing and in it were bullet holes–apparently because the house was shot at during the war.

“It was a complete symbol of one bad thing happening on top of another,” Dr. Katz said. “That was rather powerful, and it was just a piece of concrete.”

In this part of the country, a group of about 18 counselors has been active since 1996. Their work during the conflict better prepared them to deal with this event, he said. They're not health professionals, but they've acquired a lot of training and experience over the years.

“We're hoping to work with them and give them some more specialized training … in child work and a little bit of [cognitive-behavioral therapy] to help them,” Dr. Katz said.

Whenever they could, he and Dr. Sriskandarajah visited “child-centered spaces,” which are designed to give children a place to play together.

Those spaces proved to be particularly important given the range of problems –including sleeplessness, nightmares, and flashbacks–that officials observed among the children at the newly established base hospitals in each district.

“In the daytime, they were happy and playing, because they were given structured activities,” Dr. Sriskandarajah said in an interview with this newspaper. “But they were waking up in the middle of the night or having nightmares, or refusing to go to sleep.”

The children sometimes have weekly visits from a psychiatrist who supervises the camp coordinators, which are the Sri Lankan equivalent of what we would call house officers, Dr. Katz said.

But resources are limited, and an on-site mental health staff is nonexistent.

Many children have been unable to sleep because they fear that the tsunami might return, one counselor told Dr. Sriskandarajah.

The counselors responded by lighting a fire outside. They told the children that if the fire went out, it would mean that the tsunami was returning–and the children could run.

“It seems to have helped the children a little bit,” said Dr. Sriskandarajah, who was born in Sri Lanka, is in private practice in Poughkeepsie, N.Y., and serves as chairwoman of the DPO's child and adolescent committee.

“These were [the] kinds of things that people were doing.”

She described a case of what she called tsunami hysteria. “While we were there, a little girl started yelling 'tsunami is coming; tsunami is coming.'

“Sure enough, on that day, there was another minor tremor. There was no tidal wave, but people got scared. The moral of the story is that through the hysteria they were expressing, the children got the whole camp riled up,” said Dr. Sriskandarajah, speaking prior to the 8.7 earthquake that hit the area March 28.

Tsunami survivors are best helped by other survivors, said Vijay Chandra, M.D., a World Health Organization regional mental health adviser.

“The best method of dealing with [the devastation] would be to find people in neighboring villages or communities, people of similar cultural background, who understand the cultural norms to help them,” Dr. Chandra said in a statement.

Additionally, the WHO is improving mental health services in Sri Lanka and has provided a 1-day refresher workshop on psychosocial approaches for 150 school advisers, who will work with teachers in tsunami-affected areas.

The WHO has encouraged aid workers in affected countries to implement the organization's document “Mental Health in Emergencies,” which emphasizes a culturally sensitive approach to care through increased community outreach efforts and by customizing support to meet the special needs of children, women, and the elderly.

The Rotary Clubs have asked Disaster Psychiatry Outreach to train lay counselors to help in affected communities, but Dr. Katz acknowledged that the prospect is overwhelming.

“It's much easier for us to train a bunch of psychiatrists on how to do disaster psychiatry–or train a bunch of physicians on how to identify PTSD [posttraumatic stress disorder],” he said.

Another possibility is to send psychiatrists over there to do direct care, which is how the DPO was originally envisioned: “as a kind of Doctors Without Borders for psychiatry.

” I don't think we've ruled that out for Sri Lanka, but it would require a lot of resources and funding that I'm not sure we'd have in place,” he said.

The organization plans to reach out to Sri Lankan expatriates in the North American psychiatric community a bit further, and Dr. Sriskandarajah also has contacts in the United Kingdom and in Australia.

“We want to send some child psychiatrists,” she said. “But child psychiatrists are in short supply here.”

In late March, the DPO led a team of four physicians to the Kilinochichi and Mullaitivu district on a 2-week mission to work with counselors in the Annai Illam counseling program. They will be trained in general disaster psychiatry, post-disaster child interventions, and cognitive-behavioral therapy for trauma-affected people. These were the same counselors who helped area residents recover psychologically from years of civil war.

And the DPO undertook another trip to Sri Lanka in late April–this time to the southern and western areas.

According to Dr. Katz, the DPO is committed to developing a sustainable program for Sri Lanka and not having its efforts turn into “2 weeks of disaster tourism and then it's over.”

Ultimately, the organization hopes to work with community groups and to train local leaders to be counselors within their communities.

“We can't make them psychiatrists overnight. But we can build up basic knowledge of mental health in these communities so that they can be peer counselors and use what we know is a crucial part of recovery from trauma: good psychosocial support,” Dr. Katz said. We want them to “somehow use their instincts of supporting each other and add a pinch of psychiatric expertise.

“That is what we are hoping to be able to do.”

If you'd like to participate in preparations for and/or direct missions to Sri Lanka, contact the DPO for more information at 212-598-9995 or visitwww.disasterpsych.org

Members of Disaster Psychiatry Outreach who traveled to Sri Lanka after the late December tsunami say their initial efforts to assist survivors are just the beginning.

“What we did was the easy part,” Craig Katz, M.D., cofounder and president of the New York-based DPO, told CLINICAL PSYCHIATRY NEWS. “What we saw and what we're going to do [about it] are the harder parts.”

Dr. Katz, who in January was accompanied by Nalaini Sriskandarajah, M.D., a DPO board member and child psychiatrist, said their objective was to develop a needs and assessment plan, and to determine how they could help.

The psychiatrists, who were hosted by local clubs, worked with the Rotary Council of Sri Lanka.

The devastation left by the tsunami that struck countries bordering the Indian Ocean on the morning of Dec. 26, 2004, is almost incomprehensible. Conservative estimates put the loss of life at 265,000-310,000, but a definitive count may be impossible.

The tsunami caused death and destruction in more than 11 countries, including Sri Lanka–where more than 31,000 people were killed, 12,000 of whom were children.

Nearly 1 million people in Sri Lanka were left homeless. The World Health Organization estimates that 90% of those displaced by the tsunami had also been displaced in the past because of more than 20 years of fighting between government forces and Tamil Tiger rebels.

Other countries affected were Indonesia, India, Thailand, Somalia, and South Africa. Centered off the western coast of north Sumatra, the undersea earthquake triggered waves up to 100 feet and will go down in history as the second largest ever recorded, at 9.3 on the seismograph.

While based in the city of Colombo, Dr. Katz and Dr. Sriskandarajah traveled through the affected southern districts of the country for several days. Then they visited northeast Sri Lanka, a region occupied by Tamil Tiger rebels. The regions are distinctly different.

“The reasons those distinctions are important is because [northern residents] are just emerging from years of war,” said Dr. Katz of the department of psychiatry at Mount Sinai School of Medicine, New York.

“They've had a truce there for about 2 years, and they were just climbing out of that and finally rebuilding economically and socially–and then [the tsunami] hit.”

While in the welfare camps, Dr. Katz said he remembers seeing a house that had been destroyed. Part of a wall was still standing and in it were bullet holes–apparently because the house was shot at during the war.

“It was a complete symbol of one bad thing happening on top of another,” Dr. Katz said. “That was rather powerful, and it was just a piece of concrete.”

In this part of the country, a group of about 18 counselors has been active since 1996. Their work during the conflict better prepared them to deal with this event, he said. They're not health professionals, but they've acquired a lot of training and experience over the years.

“We're hoping to work with them and give them some more specialized training … in child work and a little bit of [cognitive-behavioral therapy] to help them,” Dr. Katz said.

Whenever they could, he and Dr. Sriskandarajah visited “child-centered spaces,” which are designed to give children a place to play together.

Those spaces proved to be particularly important given the range of problems –including sleeplessness, nightmares, and flashbacks–that officials observed among the children at the newly established base hospitals in each district.

“In the daytime, they were happy and playing, because they were given structured activities,” Dr. Sriskandarajah said in an interview with this newspaper. “But they were waking up in the middle of the night or having nightmares, or refusing to go to sleep.”

The children sometimes have weekly visits from a psychiatrist who supervises the camp coordinators, which are the Sri Lankan equivalent of what we would call house officers, Dr. Katz said.

But resources are limited, and an on-site mental health staff is nonexistent.

Many children have been unable to sleep because they fear that the tsunami might return, one counselor told Dr. Sriskandarajah.

The counselors responded by lighting a fire outside. They told the children that if the fire went out, it would mean that the tsunami was returning–and the children could run.

“It seems to have helped the children a little bit,” said Dr. Sriskandarajah, who was born in Sri Lanka, is in private practice in Poughkeepsie, N.Y., and serves as chairwoman of the DPO's child and adolescent committee.

“These were [the] kinds of things that people were doing.”

She described a case of what she called tsunami hysteria. “While we were there, a little girl started yelling 'tsunami is coming; tsunami is coming.'

“Sure enough, on that day, there was another minor tremor. There was no tidal wave, but people got scared. The moral of the story is that through the hysteria they were expressing, the children got the whole camp riled up,” said Dr. Sriskandarajah, speaking prior to the 8.7 earthquake that hit the area March 28.

Tsunami survivors are best helped by other survivors, said Vijay Chandra, M.D., a World Health Organization regional mental health adviser.

“The best method of dealing with [the devastation] would be to find people in neighboring villages or communities, people of similar cultural background, who understand the cultural norms to help them,” Dr. Chandra said in a statement.

Additionally, the WHO is improving mental health services in Sri Lanka and has provided a 1-day refresher workshop on psychosocial approaches for 150 school advisers, who will work with teachers in tsunami-affected areas.

The WHO has encouraged aid workers in affected countries to implement the organization's document “Mental Health in Emergencies,” which emphasizes a culturally sensitive approach to care through increased community outreach efforts and by customizing support to meet the special needs of children, women, and the elderly.

The Rotary Clubs have asked Disaster Psychiatry Outreach to train lay counselors to help in affected communities, but Dr. Katz acknowledged that the prospect is overwhelming.

“It's much easier for us to train a bunch of psychiatrists on how to do disaster psychiatry–or train a bunch of physicians on how to identify PTSD [posttraumatic stress disorder],” he said.

Another possibility is to send psychiatrists over there to do direct care, which is how the DPO was originally envisioned: “as a kind of Doctors Without Borders for psychiatry.

” I don't think we've ruled that out for Sri Lanka, but it would require a lot of resources and funding that I'm not sure we'd have in place,” he said.

The organization plans to reach out to Sri Lankan expatriates in the North American psychiatric community a bit further, and Dr. Sriskandarajah also has contacts in the United Kingdom and in Australia.

“We want to send some child psychiatrists,” she said. “But child psychiatrists are in short supply here.”

In late March, the DPO led a team of four physicians to the Kilinochichi and Mullaitivu district on a 2-week mission to work with counselors in the Annai Illam counseling program. They will be trained in general disaster psychiatry, post-disaster child interventions, and cognitive-behavioral therapy for trauma-affected people. These were the same counselors who helped area residents recover psychologically from years of civil war.

And the DPO undertook another trip to Sri Lanka in late April–this time to the southern and western areas.

According to Dr. Katz, the DPO is committed to developing a sustainable program for Sri Lanka and not having its efforts turn into “2 weeks of disaster tourism and then it's over.”

Ultimately, the organization hopes to work with community groups and to train local leaders to be counselors within their communities.

“We can't make them psychiatrists overnight. But we can build up basic knowledge of mental health in these communities so that they can be peer counselors and use what we know is a crucial part of recovery from trauma: good psychosocial support,” Dr. Katz said. We want them to “somehow use their instincts of supporting each other and add a pinch of psychiatric expertise.

“That is what we are hoping to be able to do.”

If you'd like to participate in preparations for and/or direct missions to Sri Lanka, contact the DPO for more information at 212-598-9995 or visitwww.disasterpsych.org