Tsunami at six months - the trauma continues
Suriati is 30 years old. She is the mother of five children, the youngest of whom is a baby of just three months who she bounces proudly on her lap.
Unfortunately the baby's father, brother and two sisters are no longer here to share her joy. They have never known their new family member as they were killed in the tsunami. Since that day Suriati has been finding it difficult to deal with day to day life and now describes herself as "a little strange".
"Ever since the tsunami, I find it hard to think properly," she explained. "When people talk to me, it's as though I'm disconnected from my brain. I can't understand what they're asking me. I also forget things. Sometimes I can't remember where I am or what I'm doing. At times I even forget the tsunami happened. At other times I feel so very very angry. So angry I don't know what to do. The worst is just sitting in these barracks doing nothing all day."
Suriati's story is told again and again by victims of the tsunami. Many suffer from general confusion and forgetfulness like she does. Others cannot sleep or find themselves gripped by irrational fear. Still others suffer from physical pains like headaches and stomach cramps that seem to have no physical cause. The one point all these people have in common is an inability to cope with their new situation.
In a region where there is no concept of mental health care and the idea of individual counselling is quite alien, getting people to seek help can be a challenge. This is especially true now that the emergency phase is over and people no longer talk so freely about what happened. But although many people have successfully turned their back on the pain and moved on, there are others for whom the trauma continues. The importance of reaching out to these individuals couldn't be greater.
"In the beginning, people were suffering from shock," said Mental Health Coordinator Fabienne de Leval. They would come in for medical consultations with mental health problems and we could refer them on to our psychologists for counselling. We were seeing hundreds and hundreds of patients like this. But now the context is changing and a more sophisticated approach is required."
To respond to these changing needs, MSF is adapting its programmes. Whereas before it focused on patients coming to them through the referral system, now it is finding new ways of proactively reaching out to patients in their own environment. This is done through a combination of psychosocial education to schools, community leaders and religious heads; group activities and discussions and individual counselling. Across the board the approach has been community based and context specific.
Fabienne explains, "Everywhere we go we rely heavily on our national psychologists to help us put together appropriate programmes for the context. Although there are certain symptoms and approaches to mental health that are cross-cultural, there is no point adopting a rigid, uniform approach as it may not be suitable.
"You also need to be acutely aware of the natural coping mechanisms of a community. Perhaps they're very religious or have very strong extended families. Or maybe there are individuals within the community people traditionally turn to during periods of stress. We try to work very closely with the people themselves to establish what they want and will work."
In Lamno, an isolated conflict area where suspicion is high, MSF has focused on community activities, such as boat building, to gain the trust of the people and encourage them to talk in a relaxed and non-confrontational way. Such activities can also be a form of therapy in their own right, getting people out of the barracks and in control of their lives again.
In Banda Aceh and Sigli, drop-in counselling houses have been opened specifically for individual counselling and training. Outreach programmes to villages and camps, and training programmes for health staff, other NGOs and community leaders seek to raise awareness about these facilities and encourage individuals to make use of them.
Across all projects MSF is also offering training and support to the national network of health clinics and has set up a referral system.
It was through one of these health clinics that Nur, a 52 year old mother of 11, came to be sitting with MSF Indonesian psychologist Ferdy Fabian. She was so tired of being incapacitated by incessant bouts of crying that she had sought medical help at her local health clinic. They had in turn referred her on to MSF.
"She was so tired of crying she just didn't know what to do," remembered Ferdy. "She had lost one of her daughters in the tsunami and simply wasn't able to get over it. In that first session with me, she just cried and cried."
After five months of ceaseless crying, Nur was exhausted and desperate to move on. Ferdy's first step was to establish what helped calm her in moments of stress, and what still made her happy. The woman was deeply religious and found prayer comforting. She also loved her other ten children and her husband too.
During the one hour session, Ferdy helped Nur talk through her pain and gradually focus on what was positive. However it was not until the next session that he was able to see if any progress had been made.
"Nur came back saying she had stopped crying, and had finally accepted her daughter's death. She felt she was now ready to move on and was already feeling much better," said Ferdy. "I think simply coming here was the first step. She'd made up her mind she wanted to get over this. She just needed some help getting there."
Nevertheless Ferdy recommended Nur return for another session.
Of course it would be foolish to presume that Nur will be happy from here on, or that all problems can be cured with a one hour session of counselling. Most cases are far more complex than this. But it is a reflection of the kind of relief MSF's mental health programmes can provide. MSF is not going to solve everyone's problems overnight.
The mental health problems in Aceh are too deep and the numbers affected too great. But they can give people a few tools to help them cope with their frustrations and fears.
For some, it doesn't take much.