independent in 1948 after over four centuries of colonial ... reported on the psychological after-effects of torture ... use or value within a refugee camp setting.
Inter national Review of Psychiatr y (1999) 11, 184- 190
Psychological intervention with displaced widows in Sri Lanka RACHEL TRIBE 1 & PADMAL DE SILVA 2 Department of Psychology, University of East London, London, UK & 2 Department of Psychology, Institute of Psychiatr y, De Crespigny Park, London, UK 1
Summ ary This paper describes a prog ramme for war widows residing in refugee camps in Sri Lanka. The country has been traumatized by civil con¯ ict for over 15 years and one in seventeen people have been displaced.The explicit aim of the programme is to promote mental health among the refugees, mainly by facilitating coping strategies. Self-help pr inciples are utilized. An additional aim of the programme is to help foster relationships between women from the different sides of the con¯ ict, thereby providing an opportunity for changing perceptions, attitudes and stereotyped beliefs. A blend of traditional models based on expert knowledge and a more radical model, which maximizes the resources of the women themselves, is used.The cultural and socio-political issues de® ning the inter vention at micro- and macro-levels are also discussed.
The con¯ ict in Sri Lanka
The adverse psychological consequences of war and civil con¯ ict are well known (e.g. Boman, 1986; Figley, 1978, 1986; Solomon, 1993). There is an extensive literature on the psycholog ical and psychiatric sequelae of war and con¯ ict, both in combat exposed soldiers, and civilians exposed to the war or con¯ ict including those trapped in war zones. The con¯ ict situation also leads, often, to large numbers of civilians being displaced from their homes. Many lose family members, and many others get victimized and tortured. All of these groups are highly vulnerable to psychiatric disorders, and the literature detailing those effects now spans several parts of the world (see de Silva, 1993, for a review). The introduction of the diagnostic category of post-traumatic stress disorder (PTSD) has helped to promote the study of these problems in a systematic way, and has consequently led to an enormous amount of publications. The literature covers not just the effects of war and conflict, but also other traum atic events such as natural disasters (e.g. Green & Lindy, 1994). While much work has been done and reported on the treatment of those affected by war and con¯ ict, there has also been an increasing recognition, among clinicians and researchers, of the vulnerability of those exposed to con¯ ict situations to psychological and psychiatric problems (e.g. Green, 1993).This has meant that preventive work is also needed in con¯ ict-torn areas, so that these vulnerable groups are rendered less likely to develop frank psychiatric problems. In this communication we describe a psychological intervention programme aimed at such prophylaxis. The work is being carried out in Sri Lanka.
Sri Lanka is a small island to the South of India, 25,000 square m iles in size. Sri Lanka became independent in 1948 after over four centuries of colonial domination, and became a republic in 1972. The population of Sri Lanka is close to 18 million. Sri Lanka has been involved in a civil con¯ ict for over 15 years. The two protagonists are the Sinhalese m ajority, w ho tend to be B udd hist and are approximately 74% of the population, and the Tamils who are largely Hindu and reside in the north and east of the country, forming approximately 18% of the population. There are also smaller populations of M uslims, Burghers (who are descendants of the European colonialists) and others (see Department of Census & Statistics, 1990). Sri Lanka is a nation state. A strong Tamil movement wants the north and east of the country to become a separate Tamil State, while the Sinhalese would like the country to remain as one state. That is crudely what the civil con¯ ict is about. Within the armed con¯ ict, the Tamil militants are m ainly represented by the Tamil Tigers (LT TE, standing for Liberation Tigers of Tamil Elaam) and the Sinhalese by the government army. The civilian populations on both sides of the ethnic divide hold a range of views about the problem and ways of dealing with it. The armed struggle is not supported by all Sri Lankans, regardless of ethnicity. T he Tam il and Sinhalese communities have their own languages. This, and some cultural and religious differences that ex ist despite an overlapping heritage, help to exacerbate differences. Overall, there have been at least 50,000 casualties as a result of the con¯ ict.
Correspondence to: Rachel Tribe, Departm ent of Psychology, University of East London, Romford Road, London E15 4LZ, UK. 0954± 0261/99/02/30184± 07 ½
1999 , Institute of Psychiatry
Psychological inter vention for war widows There are numerous accounts of this con¯ ict in the literature. Daya Somasundaram’s book (1998) is among the most recent, and its early chapters give a detailed description of the con¯ ict and its background. Dissanayaka (1995) also provides an account of the con¯ ict and its political aspects. Historical roots and antecedents of the ethnic con¯ ict are analysed in several chapters of Spencer’s book (1990). The psychological effects of the on-going war and con¯ ict in Sri Lanka has been commented on by several authors. De Silva (1993) referred to a study, carried out with N. Kodagoda, on combat-exposed soldiers in the country. A more extensive study has been published recently (Somasundaram, 1998; see also Somasundaram & Sivayokan, 1994; Somasundaram & R ajadurai, 1 995 ). D on ey (1 998 ) has reported on the psychological after-effects of torture in ex-detainees in Sri Lanka. Amnesty International, in a report on Sri Lanka in 1996, details gross human rights violations by both the warring factions, and expresses concerns about sub-groups acting with apparent immunity from the law. It also reports disappearances, kidnappings and torture. Several studies on various aspects of the psychological effects of the war and con¯ ict are in progress, including one of naval personnel by D r Raveen H anwella of the University of Colombo. Physical displacement caused by the war/civil con¯ ict The civil con¯ ict has led to many people being forced to ¯ ee from their homes, either into another part of Sri Lanka, often a refugee camp, or to ¯ ee the country and seek refugee status overseas. Internally displaced people, or internal refugees, may have ¯ ed because of fears about the army, out of fear of the Tamil militants, or simply because their homes are located within the potential theatre of war. The following personal account details one family’s experience of m akin g the decision to becom e displaced as a result of the ongoing con¯ ict: We were asleep, suddenly we heard a rustling sound, then I knew that someone was in our house. We thought we would all die. They took my husband awayÐ we have not seen him since that day. Other people from our village also disappeared that night. They told me to `behave and keep quiet’ , otherwise they would be back for me and my small one. We stayed for weeks waiting. It was very difficult, we had no money, and I was scared they may come back. I received some threats. I would not leave my house in case my husband returned. Someone told me to look out, that they were coming for me. W hat to do? I decided to run away and I walked for many hours and then I came to the refugee camp people. I am not living now, I am just existing. It is all hopeless. This war is bad for us all, we are suffering.The refugee camp is full of human misery.
We do not like to even wake up in the morning. W hat will the life be for my baby? Someone must stop this madness. On the 1 September 1997, the number of internally displaced people drawing dry rations within Sri Lankan refugee camps was 377,629 families. These consisted of 1,017,131 individuals. Forty per cent of internal refugees in Sri Lanka are children of school age, and many have no experience of a stable and secure home life. The Refugee Council (UK) 1996 ® gures show that there are 300,000± 400,000 Sri Lankan refugees outside Sri Lanka. T hey have sought refugee status in m any co u n t ries in c lu d in g the f ollo w in g Ð Australia, the US, Canada, the UK and other parts of Europe. T here is a dear th of literature on internally displaced people, the m ajority of the research concentrating on refugees who end up in refugeereceiving countries in the West. Only 17% of the world refu gee population live in ind ustr ialized countries (The Refugee C ouncil, 1996). So the majority of the psychological literature draws on a small and particular sample of this population. The majority of refugees merely cross national borders, or move into the relative safety of refugee camps or so-called safe havens, w ithin d evelopin g non-industrialized countries (M uecke, 1992). In a refugee camp, social mores and life skills may be entirely different from those previously held. Skills, beliefs and knowledge which served the individual well in their `normal’ life, before ¯ ight, have limited use or value within a refugee camp setting. Also, the individual has suffered enormous losses. The losses may include home, job, family, security, and friends as well as less tangible but equally distressing losses including their world view, a sense of the world as a safe place. In a situation of civil con¯ ict, people may go missingÐ sometimes to return, sometimes not. This means that families may not know for a long period of time what happened, leaving them unable to start mourning. They may feel unable to move forward in any way and are left in what can be described as a state of suspended animation. This process may be further compounded by issues of loyalty to a political cause and the socio-political context. T his has immense implications not only for them, but also for future generations. As Melzak (1991) writes: `These are strange losses to assimilate . . . and present a different task to the m ourning of loss by death. Psychological problems are often a consequence’ (p. 14). Relationships between becoming a refugee and mental health A number of correlations between becoming a refugee and mental health have been found. The initial studies
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were concerned with the period following World War II, when large-scale refugee movements occurred. These include those conducted by Eitinger (1959) working in N orway, Krupinksi & Stoller (1965) working in Australia, and Murphy (1955) in Britain. These studies appear to show a consistent link between major psychiatric disorder and refugee status. All three studies found signi® cantly higher rates of psychiatric disorder in the refugees, compared to the native populations of the host countries, for periods of up to 10 years after ¯ ight. More recent studies (e.g. Mollica et al., 1987; Kinzie & Sack, 1991; Fuller, 1993) have reported sim ilar ® ndings relating to psychological distress and symptomatology. Given the enormity of the experience of becoming a refugee, this would seem frighteningly inevitable. Jeyanthy et al. (19 93 ), working w ith displaced f am ilies in Northern Sri Lanka, found that since displacement psycholog ical disturbances were more com m on. Furthermore, depression, anxiety, sleep disturbances and somatoform disorders increased with the longer duration of displacement, and were found m ore prevalent in m others w ho faced increased responsibility. Children who were displaced were found to suffer from separation anxiety, cognitive im pair m en t, c ond uct disord ers and sleep disturbances. Women widowed by the war, in addition to coping with the grief of losing their husband and the major breadwinner of the family, are faced with many problems relating to socio-economic, health and legal issues. They may be left almost destitute with no skills to sell in the market place. Refugee camps are frequently frightening places, which are desperately overcrowded with few resources; and the rest of the population often treats their residents with little sympathy. They may experience problems obtaining school places for their children, and being accepted by the local community. Somasundaram & Sivayokan (1994) have observed that the refugee population from all communities have become the forgotten symbols of the war, uncared for and rejected by all. In many ways refugees are treated as outcasts by society.
Relationship between war experiences and mental health As noted in an earlier paragraph, a clear relationship between m enta l health problem s an d w ar experiences has been docum ented by a number of writers in a variety of countr iesÐ for exam ple, Thompson (1997) and Hunt (1997), among others, have written about the long-term psycholog ical effects of World Wars I and II, on both combatants and civilians. They were writing particularly, though not exclusively, in relation to post-traumatic stress disorder. Hunt (1997) raises concerns about the long-term
effects of war experiences, in relation to the mediating effect of ageing on these experiences. He states that the recollections of these experiences may continue to be psychologically damaging up to 50 years after the con¯ ict has ended. Waugh (1997) has written about the effects on women who stayed at home; it has been claimed that women respond more negatively to war experiences than do men, especially when essential services are affected. These and other similar ® ndings must give cause for concern in terms of the psychological effects of 15 years of civil con¯ ict on internally displaced Sri Lankan women.They are a group whose mental health status might be particularly vulnerable. The women’s construction of the world as a reasonably safe, dependable place may have been shattered, and their perception of themselves as in¯ uential or in charge of their lives, destroyed. For many refugees internal representations of the world (with respect to which their identity has been developed) are systematically challenged by the instability and changes in their external world.This may leave little stable ground for (re)constructing either a coherent self-image or a world view.
The work of the Family Rehabilitation Centre The work reported here has been carried out under the auspices of the Family Rehabilitation Centre (FRC). The FRC, which was established in 1991, is a non-governmental, humanitarian, non-pro® t making service organization, working with victims of the political violence regardless of ethnicity or political views. The main objectives of the FRC are: (1) to assist persons suffering from psychological distress, by providing combined medical attention, physiotherapy, counselling and other relevant activities; (2) to network w ith relevant governm ental and non-governmental organizations (NGOs), in order to achieve full utilization of resources for furthering the process of rehabilitation in respect of socioeconomic, health and mental health activities; and (3) to promote ethnic harmony. The target groups assisted by the FRC include torture survivors and their immediate families, families of the disappeared, women widowed by the war, orphans and children exposed to armed con¯ ict, detainees and ex-detainees, youth under rehabilitation, displaced persons, youth exposed to armed con¯ ict, and direct victims of the armed con¯ ict, including bomb blast survivors. Over the last 7 years, the FRC has developed a range of programmes and intervention strategies, which the senior author has been involved in planning, establishing and modifying, both as a regular visiting consultant and as a member of its International Advisory Board. The women’s empowerment programme is one of several activities run by the FRC.
Psychological inter vention for war widows Objectives of the women’s empowerment programme T he wo m en ’ s em powerm ent prog ram m e w as developed by the FRC as one which aims to function as a therapeutic intervention, and as a means of providing for the promotion of mental health in an identi® ed high-risk groupÐ the widows of the conflict. There are 60,000 widows living in refugee camps in Sri Lanka, many of whom are still in their twenties and thirties. The objectives of the empowerment programme were developed through conducting a needs analysis and through consultation with a wide ran ge of individ uals and ag encies. T he overall programme operates in the form of a series of locally run programmes. Each local programme is conducted close to a refugee cam p and a m aximum of 35 participants are invited to attend. They are selected by community leaders and the NGOs working in the geographical area.
Organizing principles underpinning the empowerment programme Promoting and improving psychological health is seen as a primary aim of the programme, but this is essentially embedded in a matrix of general wellbeing and functioning. This is based on the premise that human needs are multi-factorial and that the acquisition of contextually relevant knowledge and skills will be empowering, through giving the women more control over their lives and assisting them in developing coping strateg ies. In add ition, the programme attempts to maximize the considerable resources of the wom en in the g roup, through developing self-help principles and access to information. The programme uses cascade learning models to ensure that as many widows as possible can access the programme should they wish to, in a somewhat similar manner to that of Kristic et al. (1993), who assisted a large population of refugees with few staff with m ental health quali® cations in the form er Yugoslavia. Mitchell & Everly (1993) claim that, by helping traumatized people believe in their ability to overcome a crisis and by reinforcing their feelings of safety and the predictability of life, they are arming them with a set of skills to help them through. One component of this is to show that their reactions may be normal reactions to abnormal events. This enables them to increase their tolerance and acceptance of these reactions, and to enhance the feelings of affinity of those going through a disaster/trauma together. In the women’s empowerment programme, women from the four main ethnic groups (Sinhalese, Tamil, Muslim and Burgher) of Sri Lanka are invited to attend together. Promoting peace and ethnic harmony is one of the objectives of the project. The rationale is that, through helping develop relationships between
women from the different sides of the con¯ ict, an opportunity will be created to reframe perceptions, attitudes and stereotyped beliefs. This derived from Amir’s (1969) work. Amir (1969) developed what has come to be known as the `contact hypothesis’ . Brie¯ y, this suggests that contact between groups who are in con¯ ict will be enhanced by the opportunity for them to spend time together in a safe and contained environment, where they can discover that they may have common experiences, and appreciate some of the other group’s choices. A number of recommendations have been made about the ideal conditions for this hypothesis to work. Hewstone & Brown (1986) and Mi’ ari (1989) claim that short-term contact schemes may be of limited value if the only objective is the improvement of community relations. Issues of generalizability have plagued research in this area. W hat appears to be crucial is the wider structuring of relationships between the opposing groups. It is hoped that through working at the micro-level, small-scale changes may occur and that these may have implications at the macro-level. An extract from a longer narrative given by one of the wom en on com pletion of one of the local em pow erm e nt prog ram m es is g iven below, to highlight this aspect: I am most happy that all of usÐ Sinhalese, Muslims, Tamils and BurghersÐ got very friendly with each other after talking and discussing our problems. We know the other women are also suffering. I like the unity here, though we are different. W hen we see each other now we do not cross the road and think total hostility and hatred, but we talk. We are the innocent victims of the big people’s war, we all want it to stop. While a part of the programme does focus exclusively on psychological health, this is one aim among many. In addition, the team of counsellors and health workers running the programmes are available for individ ual an d g rou p con sultation. W ithin the programme, workshops are held about the possible psychological and physiological reactions to traumatic events, such as those the participants may have experienced. Many principles of group work and systems theory are utilized in this programme.The programme draws speci® cally on the work of Yalom (1975) on groups. It also draws upon psychological principles and theories bearing upon the following: the development of a sense of belonging; the acceptance of people’s anger; the overcoming of isolation; and the restoration of `broken’ group relationships by establishing warm new relationships among group m embers. Social suppor t has been show n to be an im por ta nt intervening variable in times of stress, and attempting to optim ize this option is one of the organizing principles. Hassan (1994) notes that, while social support is not therapy in its most rigid sense, it has
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proved most helpful when working with refugees. Attem pts are m ade to foster social suppor t, by providing an opportunity for establishing friendships and support networks.
® nancial affairs (conducted by relevant NGO/FRC staff).
Evaluation of the programme Intervention models used in the programme A blend of traditional m odels based on expert kn ow ledge with a m ore radical m odel which maximizes the considerable resources of the women in the group is used. It is considered to be important that the widows are given time and opportunity to consider their own needs and future, rather than `live through their children’ . This may cause undue pressure on the children and lead to longer term problems. The women’s empowerment programme is run as a residential programme over 3± 5 days, with the hope that the widows may then set up their own local selfhelp groups with the support of the organization’s area office. Each area where a local empowerment programme has been run is used as a base to set up an extension office to provide continuing support and advice to the widows. Ten women are selected from each training programme to undertake more intensive training in the capital city of Colombo, in order to prepare them to act as group facilitators and leaders based at the local extension office.
Components of the programme
The major components of the programme are a mixture of workshops, role-plays, games, lecturettes, exercises, small group discussions and other appropriate events. Local resource people are used whenever possible, partly because they may be strategic in assisting the widows, and partly to sensitize them to the issues facing the widows. The programme is run with simultaneous translation into the two national languages, Sinhalese and Tamil. Each local programme attempts to build on previous events so there is continuing development, in the overall programme. The content areas of the programme are described brie¯ y below: primary health care and ® rst aid (delivered by the local medical officer or matron responsible for the geographical area and frequently an Ayurvedic/ indigenous doctor); mental health (FRC staff and if available a local resource person); legal assistance (regarding rights and entitlements, conducted by an appropriate lawyer from the area); compensation issues (conducted by the Government Agent’s Office); self-employment opportunities (conducted by a relevant NGO); job ® nding skills (conducted by relevant NGO/FRC staff);
The empowerment programme is an ongoing project. By the end of 1998 local programm es had been conducted in most of the refugee camp areas. The total number is 40. Given the ongoing civil con¯ ict, the concomitant difficulties associated with this, and the lack of much culturally validated psychometric instrumentation, it has not been possible to obtain any quantitative data to evaluate the effectiveness of the programm e. Some qualitative data has been obtained through semi-structured interviews and open group discussion. In addition, a team of independent consultants undertook a form al evaluation, and concluded that the programme has made a positive impact. The in-built evaluation consists of the following. At the end of each day, the participants are asked to describe what they achieved, what they would have liked done differently and any changes they would like made for the future.The staff team also meets to review the day, and to consider changes for future local programmes. On the ® nal day of each programme, women who have attended programmes in the past are invited to report on what has happened to them since, and to re¯ ect on their experience of attending. Some of the women are then nominated to act as mentors or advisors to those freshly completing the scheme. Some extracts from women’s personal accounts after participating in the local programmes are given below: Due to the ethnic con¯ ict we have undergone many hardships. I have been able to share my problems with others. We were unable to face the future after we lost our husbands. The programme has strengthened me. We have learned so muchÐ the importance of playing with our children, about our legal rights, about obtaining ® nancial compensation for the loss of our husbands. I have learned many things and I will share my knowledge with others when I return to my camp. I have learned that self-con® dence is important to mental health. I have decided to form a co-operative society when I return to the camp. We will start with a small amount to be paid as membership. This will enable us to give loans to members for self-employment such as mat weaving, poultry keeping, etc. We do not have access to medical services. Now I can help those in my camp. Since we cannot go out of the camp from 4 pm to 8 am the next day, babies may need to be delivered in the camp.
Psychological inter vention for war widows Though I have delivered babies in the camp, I have had no training. I wish to receive more practical knowledge on delivering babies. We had problems trying to obtain death certificates for our husbands. I am happy to learn from the lawyer who spoke to us how to obtain the death certi® cates. Som e addition al d ata are obtain ed throug h conducting semi-structured tape-recorded interviews with the participants after the completion of each local empowerment programme. The data are then examined, in an attempt to learn from each local programm e how to improve the next. The data collected have been very positive. The success is also illustrated by the concrete outcom es that have happened as a result of this, including the establishment of a number of women’s groups and credit unions by some groups of women. Further, a number of small-scale commercial co-operative ventures have also been set up. A more formal evaluation is currently being conducted.
Conclusions In this paper, an account was given of an innovative psychological intervention aimed at helping displaced widows in Sri Lanka. The need for material and psychological resources for people affected by an ongoing war or con¯ ict is obvious. The planning and the delivery of the latter, however, requires careful consideration and imaginativeness. Tribe (1998), in a previous paper, has discussed in detail some of the issues related to the use of psychological theory, and to the services of professional psychologists, in offering help in con¯ icts overseas. There is a need to be ¯ exible, and to be innovative. The women’s empowerment programme described here has been planned and carried out in response to speci® c needs, in a well-de® ned group of victims.The approach is needsbased, and the principles and methods used were selected to su it those needs and the local circumstances. From the psychological and psychiatric perspective, the programme focuses more on the promotion of mental health, rather than on the treatment of afflicted individuals, although such help is also given where needed through related programmes. The widows, who are also displaced and are therefore internal refugees, are a highly vulnerable group in terms of psychological disturbance. The aim has been to act preventatively, by giving information, providing skills and training, helping the women to use and maximize their own potential, and attempting to create an atmosphere of harmony among different ethnic groups. This has required some expert-led presentations and advice, but much of the work has also relied on local resources and the wom en’ s own strengths. It was felt that such an approach was the best option for long-term bene® ts, as well as for
promoting self-con® dence in the women about their own ability to cope with problems and handle them effectively. The shor tage of highly trained professional personnel is often seen as a major problem in providing services in situations such as the con¯ ict in Sri Lanka; it is our view that the model used in the present programme offers an approach that enables the implementation of such services with limited expert staff. The literature on the prevention of psychiatric disorder in traumatized people has identi® ed some of the requirements for such preventive work. Kleber et al. (1992), for example, highlight, among others, practical help and information, support, and contact with support workers over a period of time. They also comment on the value of self-help groups. In the present programme, all these elements are used, along with others. The experience of running the programme has been positive and rewarding.The in-built mechanisms for evolving the programme on the basis of the experience of each local event has helped to make it dynamic and responsive to the reactions of the participants. Qualitative feedback from the participants through open g rou p d iscussion s and sem i-s tr u ctu red interviews is used for assessing the value and effectiveness of the interventions. This feedback has been most encouraging. Tangible outcomes, such as groups of wom en setting up sm all-scale busin ess and ventures, have reinforced this positive message. More rigorous and quantitative evaluations of the programme, and of its ingredients, will be most valuable. This is a matter for the future. References A M IR , Y. (1969). Contact hypothesis in ethnic relations. Psychological B ulletin, 71, 319± 342. A M N E ST Y I N TER N AT IO N AL (1996). Sri Lanka: wavering commitment to human rights. London: Amnesty International. B O M A N , B. (1986). Com bat stress, post-traumatic stress disorder, and associated psychiatric disorder. Psychosomatics, 27, 567± 573. D E S IL VA , P. (1993). Post-traumatic stress disorder: crosscultural aspects. International Review of Psychiatry, 5, 217± 229. D E P AR TM E N T O F C E N S U S A N D S TA T IS TIC S (1990). Statistical pocketbook of the Democratic Socialist Republic of Sri Lanka. Colombo: G overnment Press. D I SS A N AYA K A , T.D.S.A. (1995). War or peace in Sri Lanka. Colombo: Swastika Press. D O N E Y, A. (1998).The psychological after-effects of torture: a survey of Sri Lankan ex-detainees. In: D. S O M AS U N D A RA M (Ed.), Scarred minds: the psychological impact of war on Sri Lankan Tamils. Colombo: Vijitha Yapa. E ITIN G E R , L. (1959).The incidence of mental disease among refugees in Norway. Jour nal of M ental Science, 105, 326± 338. F I G L E Y, C .R. (1978). Stress disorders amongVietnam veterans: theory, research and treatment. New York: Brunner/M azel. F I G L E Y, C.R. (1986). Trauma and its wake (Vol. 2). New York: Brunner/M azel. F U L L E R , K.L. (1993). Refugee mental health in Aalborg, Denmark: traumatic stress and cross-cultural treatment issues. Nordic Journal of Psychiatry, 47, 251± 256.
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