Post-tsunami mental heath care in Aceh, Indonesia

MSF has mental health projects staffed by Indonesian and expatriate psychologists giving consultations in Banda Aceh, Sigli, Meulaboh and Lamno; all areas devastated by the tsunami. © MSF Member of the MSF psychological support team working with children in Meulaboh, on the west coast of Banda Aceh. If anything, the tsunami has strengthened peoples' faith. Most of them pray three times a day with the community and twice individually. Not only is this a psychological support but it is also a ritual that brings some order back into their lives. Having rituals is extremely important. Rituals give them the control over their lives that they lost during the tsunami.
How would you describe the state of mind of the survivors of the tsunami in Aceh? People are in a state of acute stress following the tsunami. This is natural given what they have gone through. In fact, it would actually be more frightening if this wasn't the case. Most of the people are experiencing a very heavy, but normal, grief process for the moment. During the consultations we are doing in Banda Aceh - as well as elsewhere - we see that people are reacting in different ways; some are crying and some are even laughing as though nothing had happened. People have asked me if it is a cultural trait - if the Acehnese have some sort of special way of dealing with events such as this. For those that we see laughing, my interpretation is that they are not yet ready to cry. In psychological terms this is called disassociation - a kind of the freezing of the grieving process. The tsunami left thousands of dead, literally razing peoples' lives to the ground. Grieving drains your physical and mental energy, often to the detriment of anything else. Those living in Banda Aceh have nothing left, no houses, no belongings, nothing at all. So people that are still alive have carried on through a kind of survival mechanism. They have to find a place to live and something to eat. Once their lives have regained at least some stability then the grieving process can begin. But for the moment, Aceh is a mental health emergency and people are in great need of support. How do people recover from such an event? In the case of the Acehnese, religion has been a great help. If anything, the tsunami has strengthened peoples' faith. Most of them pray three times a day with the community and twice individually. Not only is this a psychological support but it is also a ritual that brings some order back into their lives. Having rituals is extremely important. Rituals give them the control over their lives that they lost during the tsunami. During the consultations we look at what gives people strength and keeps them alive, and for many here, that strength comes from God. People say that it is Allah who has given life and it is Him that can take it away. In a way they feel that those killed in the tsunami have been returned to Allah. That is why prayer helps them so much at the moment. It also helps people to re-centre themselves, it has a very calming effect. There is also a lot of solidarity within the community here. In the displacement camps, when there is somebody who has lost everything and everybody, the others spend time to talk with this person and try to comfort them. They sit together and discuss what has happened. Even for those that have been displaced, the Indonesian way is for a kind of social structure to come into being in the camps. So there is always a camp leader, a head of the previous village, an imam and a teacher for example. This happens within days. How do people react to you when you tell them you are a psychologist? Firstly, we don't come out and say we are psychologists, as that can frighten people off. We say that we are here to listen and that we are doctors for feelings rather than for physical ailments. People are generally very open and want to talk. I worked for a year in Ambon before, there it was very different. There people came to us with psychosomatic complaints like headaches and breathing difficulties. So we had to work in tandem with a doctor in order to have access to these people. Here, they realise that something abnormal has happened to them and they have the urge to speak. They also realise when somebody is traumatised here, and that means that they come to us for help. They are not afraid of psychologists. People have a lot of confused thoughts in their heads and sometimes it comes out about the conflict. Since in everyday life people have difficulty speaking about it or sharing it, often they are in a state of real anxiety. They come saying that they don't know what is going on.
How are the MSF teams working practically? For example, in Banda Aceh we arrive in a place where there are displaced people, we lay down a blanket, set out tea and coffee, some information about us and what we are doing, and we invite people to join us. The people who we are specifically targeting at the moment are those going back to see where their houses were, are clearing their houses, and are digging up bodies. Then we give information about the tsunami - which already lowers their anxiety levels - and we answer the questions that they ask us. It doesn't take them very long to start to talk about their experiences. And if they want, we offer them a more confidential place to talk. The individual consultations usually last for between 40 minutes and an hour. The next objective for us is to identify a house near to the camps which will give us more possibility to carry out more individual consultations. It is important for us to have a place where people know us and where they can come to visit. Do you come across other types of trauma in Aceh? There is an enormous amount of anxiety when people talk about the conflict in Aceh. People come to us saying that they have a pain here or there but these are actually psychosomatic complaints. When we ask for how long this has gone on, often they will say something like, 'a year or so, you know, life is hard here.' Then they start to explain. People have a lot of confused thoughts in their heads and sometimes it comes out about the conflict. Since in everyday life people have difficulty speaking about it or sharing it, often they are in a state of real anxiety. They come saying that they don't know what is going on. With the conflict, they really don't know who is who, they are caught in the middle. You can see the trauma, as they even seem to struggle for breath when talking about it. With the tsunami on top of that as well, it might be just too much. There could come a point when they break down. What support does MSF give people? We listen. This is the most important. Even though there is solidarity in the community, there is a difference between people exchanging their experiences and their pain, and another thing to have a person really listen with empathy to what you have to say. This is what we can do. As they haven't spoken, they have enormous amounts of emotion and everything is confused in their head. When they manage to speak about what has happened, they make links between the different events in their head, they can cry and they can release the tension. We explain that such strong feelings are totally normal under the circumstances. I find it difficult when I talk with people who feel guilty about what has happened, like a 15 years old girl who couldn't hold on to her mother in the force of the waves because her mother was bigger than her. Or mothers that have had babies torn out of their arms by the water. But again, the feeling of guilt is a normal reaction and we do our best to show that they did all that they were humanly able to do. Again, this comes as a relief. Also, we don't judge, but we are able to give technical information about the tsunami. People justify the events in many ways. For instance, some say that Allah has singled out Aceh for the tsunami because they were not pious enough. When we tell them that Aceh was not the only place that the tsunami struck, and that it is a known phenomenon which has happened before in other parts of the world, you can immediately see the relief. There are huge amounts of interpretations, and the practical information we give is a real help. Above all, what is most striking about the Acehnese for me is their resilience following such an event. Its through this that you realise just how resourceful they are.