Module-2

National Disaster Management Training Module

Psychosocial Care in Disasters

Work Marriage Law

Health Others

Finance Education
Family &
Social
Courtship & Bereavement
Cohabitation

March 2023

Jointly Developed by

National Disaster Management Authority National Institute of Mental Health and Neuro Sciences
(NDMA) (NIMHANS)
National Disaster Management Training
Module-2

Psychosocial Care in
Disasters

Authors
Dr. K. Sekar
Dr. Jayakumar C
Dr. Patrick Jude

NDMA, New Delhi

NIMHANS, Bengaluru
 National Disaster Management Training Module-2
Psychosocial Care in Disasters

Supported by
National Disaster Management Authority,
Government of India,
NDMA Bhawan,
A-1, Safdarjung Enclave,
New Delhi – 110029.

Published by
NIMHANS, Bengaluru
NDMA, New Delhi.

Layout & Printed by::

Futura Digital Colour Press
# 4/4, 3rd Main, Tata Silk Farm
Near Yediyur Lake
Bengaluru - 560 082, INDIA.
E-mail: futuradigital1@[Link]

Edition First, March 2023

Copyright @ NIMHANS, NDMA

When citing this manual, the following citation should be used:

National Disaster Management Training Module-2, Psychosocial Care in Disasters.

2023 © National Disaster Management Authority (NDMA) and National Institute of

Mental Health and Neuro Sciences All rights reserved. No part of this work may be
reproduced in any form, by mimeograph or any other means, without permission in writing
from the National Institute of Mental Health and Neuro Sciences and the National Disaster
Management Authority.

[Link]
[Link]

II
 CONTENT

Chapter Title Page No

Section1- Psychosocial Support in Disasters

1 Introduction to disaster and psychosocial first aid 1-4

2 Psychosocial triage 5-9
3 Psychosocial support in disasters 10 - 13
4 Psychosocial needs assessment 14 - 16
5 Stress during disasters 17 - 23
6 Mental health issues among disaster survivors 24 - 29
7 Life events, family life cycle and disaster 30 - 32
8 Psychosocial support techniques 33 - 38
9 Referrals and follow-up 39 - 40
Section 2- Working with Vulnerable Groups

1 Vulnerable groups in disasters 41 - 44

2 Impact of disasters on vulnerable groups 45 - 50

3 Strategies for working with vulnerable groups 51 - 59

Section 3 - Caring for Carers

1 Roles of psychosocial caregivers 61 - 64

2 Disaster related work & mental health complications 65 - 67
3 Mental health preservation strategies 68 - 72

Facilitator’s guide 75 - 92

Workbook 93 - 132

References 133

III
 FOREWORD

Disaster will have a long-lasting impact on different areas of life of the affected
community. Psychological reactions of the disaster survivors determined by social
factors like homelessness, loss of employment, destruction of the surrounding, loss of
dear ones etc. Unlike physical health issues, mental health problems remain unnoticed
most often. Early identification of psychosocial concerns of the disaster survivors and
providing timely Psychosocial Support Services (PSS) plays a significant role in
speedy recovery.

In our country there is a huge gap between the number of people who are in need for
PSS services and available number of trained human resources. India being one of the
disaster-prone countries, it is important to bridge this gap by increasing the number of
trained human resources. This module aimed to bridge this gap by providing the
information on PSS in disasters that can be used by the community level workers,
across the country. Through this information and training material people with
minimum education can be trained to be psychosocial caregivers.

IV
 PREFACE

Disasters harm both people and the environment in numerous ways, Disaster-related
psychological and social problems frequently overwhelm the ability of the afflicted population
to cope. The effects are physiological, psychological and socio economic. These risks are a
combination of both hazard and vulnerability. The mental health sequelae of disaster have been
observed to include Post-traumatic stress Disorder(PTSD), anxiety, depression, sleep
disturbances and emotional distress and these may persist even in the aftermath of the disaster.
Studies have proven that distressing emotional reactions are followed by every disaster. It is thus
necessary to offer and arrange appropriate psychosocial interventions, both in order to prevent
normal responses developing into abnormal reactions. In the context of disasters, psychosocial
support (PSS) refers to comprehensive interventions designed to address a variety of
psychosocial issues that arise in the wake of a disaster. NIMHANS has a long history of
providing psychosocial care to the disaster-affected communities by helping them deal and cope
effectively. NIMHANS has observed in the past that during disasters, the distribution of material
aid and attention to physical reconstruction (of the individual and surroundings) take
precedence, whereas psychosocial care tends to be ignored. Communities affected by disasters
are more resilient when PSS is integrated with other relief efforts. Early detection and treatment
of mental health issues are made possible with the aid of prompt and organised psychosocial
support services. NIMHANS, the nodal center for Psychosocial Care has worked, in association
with NDMA through the project, ‘Preparation of Psychosocial Care and Preparedness Modules
and IEC Materials’.

The manual takes into account the need for psychosocial support and care in disasters along with
strategies and techniques for the same. It has been curated with illustrations, case studies and
includes evidence-based practice. There are 4 sections and each section describes working in
disasters, with vulnerable groups and caring for carers. My hearty congratulations to the team. I
wish them the best for implementation of the same

Dr. Pratima Murthy

Director,
NIMHANS,
Bengaluru.
V
 AUTHORS NOTE

This ‘Psychosocial Support in Disasters’ module is the second module developed as a part of
larger project titled ‘Development of Psychosocial Care and Preparedness Module and IEC
Materials’ funded by National Disaster Management Authority (NDMA), New Delhi. Aim of
this module is to enable the people from community in providing PSS services in disaster.

This module is divided into three parts. Part-1 is the information module, part-2 is the facilitators
guide and part-3 have the workbook. Part-1 has 3 sections. ‘PSS in Disaster’ is elaborated under
9 chapters in section-1. This section begins with the brief overview to disaster and psychosocial
first aid (PSFA), ways to establish psychosocial triage, significance PSS in disaster, assessment
of psychosocial needs, stress and mental health issues among disaster survivors, impact of life
events caused by disaster on family life cycle, PSS techniques and steps in facilitation of
referrals/follow-up. Section-2 has 3 chapters focusing on working with vulnerable groups in
disasters and section-3 discusses on caring for the care givers under 3 chapters.

In the facilitators guide (part-2), sessions have been designed in accordance to the information
module. This module has 25:30 hours (section-1 14:30 hours; section-2: 6 hours; and section-3:
5 hours) of training programme. Each session consists of an activity (can be adopted both at
onsite/offsite session) to facilitate the better participation of the participants. In the last part
(part-3) ‘workbook’ is given along with the assessment materials. Participants can use it as take-
home exercise.

This module is an essence of the field experience of the authors. Culture specific illustrations
have been given throughout the information module considering different types of disasters. It is
recommended to use the information module along with the facilitators guide while training the
psychosocial caregivers.

Across the districts and states, wide range of target population such as, community level
workers/community level health workers (CLW/CLH), NGO functionaries, GO grass root
personnel, panchayat raj members, spiritual institutions, schools of social work, NSS
volunteers, and community volunteers etc., can be trained to provide PSS services during
disasters using this module.

We are extremely pleased to acknowledge the immense support obtained from everyone in
successfully developing and bringing out this module.

We sincerely acknowledge, the National Disaster Management Authority (NDMA), New Delhi
for the funding support and percipient periodical review in originating this module. Special
gratitude to Shri Sanjeeva Kumar, IAS, Member Secretary, Shri Krishna S. Vatsa, Member, Shri
Kamal Kishore, Member, Shri Rajendra Singh, PTM, TM, Former Director General, Indian
Coast Guard, ShriRavinesh Kumar, Financial Advisor, and Ms Maithreyee Mukherjee, Senior
Consultant, Psychosocial Care and Social Vulnerability Reduction for their immense support.

We are thankful to the honourable Director of National Institute of Health and Neuro Sciences
(NIMHANS), Bengaluru Dr. Prathima Murthy and Former Directors Dr G Gururaj and Dr B N
Gangadhar for their administrative support. We would also like to extend heartfelt thanks to

VI
[Link] Bengal, Prof. and Head, Department of Psychosocial Support in Disaster Management
(DPSSDM) for his continuous support and guidance. Special thanks to Dr. D. Dinakaran,
Assistant Professor, DPSSDM for his valuable inputs in shaping this manual.

The consultation meeting held with SDMAs, DDMAs, first responders, and other volunteers
substantially facilitated in plotting the content for this module. We greatly appreciate each and
every member took part in the insightful discussion.

Mr. Rinse Thomas has done a wonderful job in grounding the language for the great cognizance
of the target population. Exceptional illustrations have been developed by Mr. Govindaraju and
Ms Christella Sowmya.

We would like to acknowledge all the direct and indirect support received from all the team
members of DPSSDM, NIMHANS, [Link] thank Ms Christella Sowmya for
representing different illustration in this module. We would like to appreciate the support
rendered by Dr. Balashanthi Nikketha, Dr. Rajamanikandan Savarimalai, Ms. Sandhya P.D, Mr.
Allen Daniel Christopher, Ms. Jane Maria, Mr. Kannan .M, Mr. Sathish and Ms. Sharmila.

VII
 LIST OF ABBREVIATIONS

Abbreviation Explanation
DM Disaster Management

DDMA District Disaster Management Authority

DMHP District Mental Health Programmes

MoHA Ministry of Home Affairs

NDMA National Disaster Management Authority

NGO Non-Government Organizations

NMHP National Mental Health Programmes

NPDM National Policy on Disaster Management

NDMTM National Disaster Management Training Module

PFA Psychological First Aid

PSFA Psychosocial First Aid

PSS Psychosocial Support

PSSMHS Psycho-Social Support and Mental Health Services

SDMA State Disaster Management Authority

WHO World Health Organization

VIII
 LIST OF TABLES

Table No Title Page No

Section1- Psychosocial Support in Disasters

2.1 Psychosocial triage matrix 5

Section 2- Working with Vulnerable Groups

1.1 Vulnerable groups, during different types of disasters 41

2.1 Impact of disaster on children 45

2.2 Impact of disaster on women 47

2.3 Impact of disaster on older adult 48

2.4 Impact of disaster on persons with disability 49

3.1 Mediums that suit children based on their age 54

3.2 Measures to help women in disasters 55

Section 3 - Caring for Carers

2.1 Reactions post-disasters and necessary actions 65

2.2 Common reactions experienced by caregivers 66

2.3 Common reactions among caregivers experiencing burnout 67

IX
 LIST OF FIGURES

Figure No Title Page No

Section1- Psychosocial Support in Disasters

1.1 Nature of disaster 1

1.2 Pyramid of disaster survivors needs 2

2.1 Psychosocial Triage 7

2.2 Nature of psychosocial services provided based on the risk level 8

Implementation of psychosocial services in the past four
3.1 11
decades in India
3.1.1 Psychosocial factors impacting the mental health of disaster
12
affected communities
3.1.2 PSS activities – CAREFUL 12

3.2 Levels of psychosocial support 13

Psychosocial Needs Assessment Techniques, ICRC &
4.1 15
IFRC, 2008
4.2 Pyramid of Psychosocial needs 16

5.1 Reactions during Disasters 17

5.2 Stressful Reactions during Disasters 21

7.1 Family life cycle 31

7.2 Influence of Life Events on Family Life Cycle Post-disaster 32

9.1 Steps in the Facilitation of Referral 40

Section 2- Working with Vulnerable Groups

1.1 Indicators of vulnerability 42

3.1 Framework for using the psychosocial mediums 52

X
 Section - 1
PSYCHOSOCIAL SUPPORT IN DISASTERS
 INTRODUCTION TO DISASTER
CHAPTER 1 AND PSYCHOSOCIAL FIRST AID
Introduction to disaster

Disaster is a natural or human-made event. It causes severe damage to both human

beings and the environment. The psychological and social issues caused by disasters
generally go beyond the coping capacity of the affected community.

The intensity of the impact, damage created, and assistance required are the indicators
that suggest whether any impact (natural or human-made) is a disaster. For example,
an earthquake with large magnitude that happens in a desert cannot be termed as a
disaster. If it occurs in a place where people live, it is said to be a disaster.

Figure 1.1: Nature of disaster

Disaster experiences vary from individual to individual. The severity is influenced by

the type of loss and exposure, emotional or physical closeness of the individual with
the disaster, pre-existing vulnerabilities, his/her coping strategies and community
resources. The interaction between the individual and environmental factors over the
timespan shape experiences of the survivors who are directly affected or the care
providers who involve in the rescue/relief operations.

1
Impact of disaster

The impact caused by any disaster can be broadly classified into following
domains;

Physical: Damage caused to body/physical structures or

worsening of pre-existing physical condition. E.g., injuries, rashes,
fracture, maternity complications etc.

Psychological: The psychological, emotional or behavioural responses to

a disaster. E.g., shock, denial, fear, anger, sadness, flashbacks, increased
use of substance etc.

Social: Hardship created in the family or society due to the disaster. E.g.,
emergence of single parent families, migration, displacement, increase in
crime rate etc.

Economic: Financial, property and livelihood losses incurred. E.g., financial loss,
loss of property, debt traps etc.

These impacts are interconnected. Therefore, caregivers need to understand the

connection between these impacts and to normalise it through psychosocial support.

Needs of the disaster survivors

Figure 1.2: Pyramid of disaster survivors needs

2
PSYCHOSOCIAL FIRST AID (PSFA)
PSFA is a humane, supportive and practical assistance provided to a person
immediately after a disaster. It involves providing support, assessing needs and
concerns, helping people to meet basic needs, listening, comforting people and
helping them to feel calm, helping people connect to information, services and social
support and protecting people from further harm.

Who needs PSFA? When is it provided? Where is it provided?

People who are in During or immediately
distress and need after a crisis event. In any safe
support following It may last for days or place/settings where
a crisis event. weeks depending upon privacy/confidentiality
the severity. can be ensured.

World Health Organization (WHO) has given following four first aid strategies to
guide the caregivers to deliver their service effectively.

PREPARE
l Understand people and situation specific to a disaster
l Understand the biopsychosocial factors that make people
vulnerable to a disaster
l Locate the survivors in the disaster area
l Identify resources within the community
l Immediate emotional reactions
l Physical health issues
l Psychosocial needs and concerns
l Availability of support within the family
l Availability of local/community resources
l Strengths of the survivors, their family and the community

l Listen to their needs and concerns

l Acknowledge their strengths
l Normalize the feelings and thoughts
l Give reassurance
l Ensure their safety
l Provide basic needs

l Connect survivors to their primary caregivers or loved ones

l Connect them to a safe place for shelter and fulfil their basic needs
l Connect them to a care facility based on their bio-psycho-social
concerns (persons with mental illness to respective district
mental health programs; unaccompanied child with the child
protection agency; and hearing aid for persons with hearing
impairment).

3
Remember
l Disaster generally goes beyond the coping ability of the survivors
l Disasters can be broadly classified into natural and human-made
l Impact of disaster is inter-connected
l Primary needs of the survivors have to be addressed before focusing on the
higher needs
l PSFA is a humane, supportive and practical assistance provided to a person
immediately after a disaster
l Prepare, look, listen and link are the four strategies of PSFA

4
CHAPTER 2 PSYCHOSOCIAL TRIAGE

Triaging is a systematic assessment and classification of survivors to optimise and

prioritise care based on their condition. It facilitates early identification and prompt
mental health treatment for disaster-affected communities. Planning and arrangement
of appropriate psychosocial support and mental health services can be done through
psychosocial triage. This would not only reduce the consequences generated by
disaster impact, but also ensure quality of psychosocial and mental health services.
Psychological trauma is caused or worsened by the persons' closeness (physical or
psychological) to the disaster, personal and environmental vulnerabilities, immediate
and post disaster reactions and coping strategies/resources. Knowledge about these
factors help frontline workers/community level workers/helpers to systematically
code individuals affected by disasters as persons with low/medium/high risks and
help them to decide upon what services to be given.

The psychosocial triage helps the caregiver to identify who requires immediate
mental health attention, who has to be assigned for psychosocial care or PSFA and
who has to be monitored by local health surveillance bodies. Psychosocial triage
matrix (table 2.1) and figure (2.2) give the clearer picture of the same.

Table 2.1: Psychosocial triage matrix

Indicators Low Risk Moderate Risk High Risk

Greater distance Closer to the
Physical from the epicentre epicentre but not in
Present in the
closeness (disaster affected site). epicentre.
the epicentre.

Closely related or
Expressive Does not know Knows/friend to
best friend of
closeness the survivor/s the survivor /s
the survivor/s

1. No history of 1. Not certain about 1. History of chronic

chronic physical or pre-existing physical or mental
mental illness. physical/mental illness.
2. Able to regulate illness. 2. Poor emotional
emotions. 2. Certain problems self-regulation.
Individual 3. Connected with with emotional 3. Active social
social ties. regulation. withdrawal.
vulnerabilities 3. Partial social
4. No significant life 4. Presence of
events in the past. withdrawal. significant life
5. Not a person in the 4. Past life events events in the past.
vulnerable group present but not very 5. Absolutely fitting
(children, women, significant. into a vulnerable
PwD, migrant, farmer, 5. Partially fitting in group.
third gender, etc.). to a vulnerable group. 6. Extreme
6. Optimistic. 6. Partial Pessimism. Pessimism.

5
Environmental 1. Living with all 1. Living with some 1. Not living with
vulnerabilities family members. family members. family members.
2. Adequate parent- 2. Tenuous parent- 2. Strained parent-
child relationship. child relationship. child relationship.
3. Adequate family 3. Inconsistent family 3. Poor family
functioning. functioning. functioning.
4. Absence of 4. Presence of 4. Presence of
significant traumatic minimal traumatic significant traumatic
stress among parents. stress among parents. parental stress.
5. No history of 5. Not sure about 5. History of mental
mental illness in the mental illness in the illness in the family.
family. family. 6. Inadequate family
6. Adequate family 6. Erratic family / or community
or community community resources.
resources. resources. 7. Dire victim of
7. Not a victim of 7. Partial victim of stigma or
stigma or stigma or discrimination.
discrimination. discrimination.

Instant reactions Appeared relaxed Expressed mild to Expressed acute

during the disaster during the impact. moderate distress. distress.

Ongoing reactions Expressed few Expressed many Florid manifestation

common crisis common crisis indicating mental
reactions. reactions. health treatment
(self-harm or causing
harm to others, hyper
vigilance, depression,
acute dissociation,
psychotic features,
elated mood, etc.).

Coping Active or adaptive Uncertain coping Avoidant or

coping (Able to deal (Unaware of how to Maladaptive coping
with the impact deal with the impact). (Harming self/others,
effectively). use of substances).
Source: Richter & Flowers 2008

6
 Figure 2.1 Psychosocial Triage

Assess risk level using psychosocial Does the person require mental
triage matrix (see table 2.1) and health follow-up based on the
current medical condition
assign to specific services. (injuries, fractures,
malnourishment, loss of limbs etc)?

Earlier diagnosis
of Mental Illness.

Referral to Mental
Health Service
High risk PSFA/PSS within 24 hours.
MHSH

Medium PSFA/PSC within a

risk week or month.

PSFA + Continue long-term

Low risk (month to year)
mental health surveillance.

Adapted from Brannen et al., 2013

To identify the persons who need psychosocial support, they need to be assessed based
on their post-disaster reactions (excessive worry, fear, prolonged sadness, increased
anger, sleep disturbance, disturbance in appetite etc.) and functioning (inability to
perform everyday routine, lack of concentration in work, decreased quality of work,
lack of interest in taking care of self, inability to socialise, interpersonal relationship
issues, etc.).

Based on the intensity of risk, the psychosocial support services need to be planned.
For instance, persons who are at high risk, have to be referred to appropriate Mental
Health Services within 24 hours. PSFA and PSS have to be provided within a week or
month for the people who are at medium risk. For the low-risk people PSFA alone is
sufficient. However, they have to be kept under mental health surveillance for a long-
term (month to year).

7
 Figure 2.2: Nature of psychosocial services provided based on the risk level

Case Illustrations in varied disasters

(1) “It was raining heavily for weeks. Houses, livelihoods and lives got swept away.
The flood situation made me feel the lowest that I have ever felt in my life. I was
afraid that I might lose my son”. A 42 years old mother affected by flood.

(2) “My family was traveling to our hometown for a wedding. I was busy with my
work and could not join them. They left home by midnight. I woke up to hear the
news of a bus crashing against a container. The news channels flashed saying 40
persons died including '4 members of a family'. I was praying hard that it was not
mine. My life shattered in a flash”. A 35 years old husband.

(3) One day B, a nine years old girl woke up early in the morning hearing a
crash and was told that a terrorist attack had taken place in the market. She took
her teddy and rushed to check if Farina, her cook's daughter who loved her teddy
was fine. She saw a tiny human drenched in blood. She kept the teddy next to her
dead body. It has been two weeks already and she has not got out of her room even
once. Whenever she hears a noise, she cries, shouting Farina.

(4) “There was a heavy pouring and forecast of landslide vulnerability, most people
were evacuated from the danger. The next day, the landslide hit the small-town
causing loss of property and causalities. I could not reach my people as the
telecommunication services in that area was affected.”. A 44 years old woman.
8
(5) C, a 22 years old visually challenged boy lost his entire family in the cyclone.
He started questioning his existence asking himself whether he was a curse. He
experienced feelings of grief, guilt and sadness. He wanted to kill himself, as he
felt left out without any support. The only comfort was the dog that he adopted
after the disaster.

(6) D, 34 years old police men worked in the frontline evacuation process during
the Mangalore Air crash. He was staying away from his family and friends. After
the first response with passengers, he felt traumatized seeing many lifeless
passengers who lost their lives. He started losing interest in his daily activities,
experienced disturbances in sleep and appeared to be moody and irritable. He
complained of stress because of heightened societal pressure to aid the needy.

Remember
l The psychosocial triage helps the caregiver to identify persons at risk and
provide them necessary psychosocial interventions.
l Persons with pre-existing mental health conditions warrant quick mental
health evaluation.
l Higher the psychosocial vulnerability – higher the psychosocial impact.
l Persons with adaptive coping strategies are more resilient.

9
CHAPTER 3 PSYCHOSOCIAL SUPPORT
IN DISASTERS
Disaster-affected communities experience various psychological reactions which are
often determined by social factors, such as; homelessness, loss of employment,
destruction of the surrounding environment, loss of dear ones etc. These
psychological problems remain unnoticed unlike physical symptoms. PSFA is the
entry point for psychosocial care interventions. Providing opportunities for people to
express their concerns and connecting people with spectrum of psychosocial services
enable speedy recovery. Psychosocial Support (PSS), in the context of disasters refers
to comprehensive interventions aimed at addressing a wide range of psychosocial
problems arising in the aftermath of a disaster. In the past, we see that distributing
material relief and focus on physical reconstruction (body and environment) take
priority during disasters. Integration of PSS along with other relief services enhance
resilience among disaster-affected communities. Prompt and systematic psychosocial
support services help in early identification and treatment of mental health problems.

PSYCHOSOCIAL SUPPORT PRISM

10
Evolution of Psychosocial Support in India

Psychosocial support is an integral part of Indian culture and religion. It gives

dominance to rendering care for the weaker sections of the society, customs and
practices that facilitate ventilation after loss and values that build community
resilience. Many stakeholders have involved in the administration of psychosocial
care services in the past. Large volume of work done in the area remain
undocumented. The first documentation of psychosocial support appeared in 1981
after the Venus Circus Tragedy in Bengaluru. The initial phases were more individual
centric and rendered by mental health professionals. There is shortage of work force in
the field of mental health service delivery in India. Considering the Indian population
and the magnitude of the psychosocial needs of disaster affected communities,
training of non-professionals especially the local community in psychosocial care
service delivery has become a time-tested effective model. The constitution of
National Disaster Management Authority (NDMA), State Disaster Management
Authority (SDMA) and District Disaster Management Authority (DDMA)
constituted to plan, execute and monitor disaster management policies and its
implementation. This helps in instrumentation of psychosocial support and mental
health services in the country. Major psychosocial services are carried out during the
relief and restoration phase. The preparedness and mitigation efforts in PSSMHS is in
progress and need to be further expanded.

Figure 3.1: Implementation of psychosocial services in the past four decades

in India

11
Figure 3.1.1: Psychosocial factors impacting the mental health of disaster
affected communities

Figure3.1.2: PSS activities – CAREFUL

Creating capacity (professional and non-professional bodies including the

community) on Psychosocial Care activities in the affected communities.

Awareness generation on psychosocial and mental health issues

and services available.

Recreation and group activities- facilitating group mourning by ensuring

religious or culture specific services to cope with the loss of the loved ones,
initiating community kitchens, encouraging recreation and group sharing.

Empowering communities through multi-sectoral collaboration involving

governmental, non-governmental and voluntary bodies.

Facilitating individual centric care for disaster survivors (listening to

the individual, providing reassurances, being available and assessing
their needs and resources).

Updating and supporting the careivers with information, resources and

self-care strategies.

Linking community to services to enhance livelihood options,

reconstruction of homes, getting compensation, etc.

(Adapted from Seto et al., 2019)

12
 Psychosocial support ‘IS’ Psychosocial support ‘IS NOT’
l Supportive services that ensure practical l Individual specific
needs focusing on enhancing the well- l A relief service that focuses only on the
being of disaster survivors/communities immediate needs
l Holistic service that helps survivors / l A programme that goes for a shorter
families overcome physical, duration
psychological social and economic l One-time activity
impact of disaster l A stigmatising or labelling activity
l Care and reconstruction services that run l A service that focuses on obtaining
for a longer duration solution for a single problem
l A coordinated and systematic resilience
building activity that aims at early
identification of mental health problems
in individual/community and facilitates
prompt treatment back to the community

Figure 3.2: Levels of psychosocial support

Mental Health Specific mental health interventions for persons /

Support family/community with acute and complex

Targeted
Focus on vulnerable groups and people in the
Psychosocial community with prolonged abnormal emotional reactions
Support

Universal
Informational and practical, physical and emotional
Psychosocial support for the entire community
Support

Remember
l Psychosocial support involves a spectrum of psychosocial services
(providing psychosocial support and linking to services)
l Psychosocial support services ensure early identification and prompt mental
health treatment
l The goal of psychosocial care is achieving optimal individual/ family/
community resilience
l First documented work on PSSMHS in India is Bengaluru Venus Circus
Tragedy Incident
l The present focus is on promoting the community resilience in all the phases
of disaster

13
CHAPTER 4 PSYCHOSOCIAL NEEDS
ASSESSMENT
Psychosocial needs are the psychological and social requirements that communities,
families or individuals have just after the disasters. Knowledge on the psychosocial
needs of the individuals, families or communities help in planning better intervention
strategies. Any psychosocial assessment should provide information regarding the
following:

Individual Assessment Family Assessment Community Assessment

l Demographic l Family Composition. l Hazard, risks and

information. l Family Dynamics: vulnerability in the
l Biopsychosocial Roles and community.
aspects and responsibilities, l The nature and intensity
vulnerabilities. leadership, adaptive of the disaster (physical,
l Socio-vocational patterns, problem psychological, economic
aspects and its solving abilities, and social consequences).
limitations. decision making l Nature and types of
l Coping (Adaptive and capabilities, rituals. services required (needs
maladaptive). l Family rules. of vulnerable groups).
l Daily functioning. l Changes in family l Available manpower and
l Prior/present trauma structure. infrastructure
experiences and l Resources available in (opportunities,
perception. the family. community adaptations).
l Trauma in the family. l Gap between needs and
resources (challenges in
accessing healthcare).

Rapid need assessment in first two weeks after the disaster would reduce recall bias
(not remembering the accurate information). The need assessment should also
maintain conformity with the socio-cultural context of the community (traditions,
beliefs, values, practices, norms and local perceptions and cultural/religious coping).

14
 Figure 4.1: Psychosocial Needs Assessment Techniques, ICRC & IFRC, 2008
SWOD analysis: Assessment of the Strengths, Weaknesses, Opportunities and Difficulties

Availability Rumours
Coordination Poor awareness
between systems

Proper preparedness Lack of resources

Strengths Weaknesses
Good interpersonal Poorfinance
relationship

Emergency
Underdeveloped
response
systems
Research Opportunities Difficulties
Well-informed Higher impact
community
Social groups, Poor community
events participation

Community Assessment Tools

l Routine change mapping: It shows how the community members used to spend
their whole day and how it has changed after the disaster.
l Disaster timeline: A chronological account of disaster events that has happened
in the past and how people reacted to it.
l Resource claim: It is a method used to quantify or know the number of people
receiving a particular service or belonging to a particular group.
l Calendar of seasons: This is used especially in rural environments to know
about the local seasons, climate, patterns of rainfall, livestock management,
agriculture/livestock production, sales, workforce involved and common
problems experienced (drought, famine, over production, etc.). It can also talk
about the seasonal outbreaks, health condition, and hazards.
l Ranking of issues: This method helps in understanding the local preferences
and order of ranking by the community.
l Stakeholder exploration: Identifying individuals, groups, local authorities
affected by the disaster, their interests, power relations, roles, existing strengths
and resources.
l Root cause identification: It is a debate that is organised in the community to
unveil the core causes for a specific problem and explains cause/effect
relationship.
l Understanding community organisations: It helps in understanding the nature
and type of support provided or available in an organisation.

15
 Figure 4.2: Pyramid of Psychosocial needs

MHS

Psychococial
support

Physical support

Essential safety services

The need assessment should bridge between the needs and the services. Almost all the
people affected by disaster would require basic facilities and services that ensure
safety and security. If there are 100 people in the community, 95 persons will have
different reactions to the event; around 50 to 70 people would suffer from mild,
moderate to severe psychological distress. The distress created after any disasters can
be minimised by strategies aiming at promotion of family or community support. Of
the 100 affected people, 15 to 30 people might develop mild to moderate mental
disorder. It is essential to focus on those people using appropriate psychosocial
support services to prevent further worsening. Only 3 to 4 might suffer severe mental
disorder and such individuals need to be identified earlier and have to be referred for
mental health treatment. Along with the details discussed above, the needs assessment
should also help in providing answers to the following questions: NGOs working in
the community, availability of trained manpower for PSSMHS, assessment of
additional manpower required for future work, who would require PSFA, PSS and
MHS and vulnerable groups in the community.
Assessment of needs should involve all the stakeholders in the community like local
leaders, community groups, government (health, education, WCD, youth
development, SJD, revenue) and nongovernment organisations, faith-based
institutions, etc. Methods like observation, field surveys, individual interviews, group
discussions would help in assessing the psychosocial needs of the disaster-affected
communities. Diverse populations including all the genders, age groups, cultural,
linguistic, religious groups need to be included. Care should be taken that assessment
fatigue (same community being assessed repeatedly by different stakeholders) does
not happen. Structured and scientific need assessment helps in developing accurate
intervention measures and enhances the quality of the intervention.

Remember
l Need assessment after two weeks would invite recall bias.
l Care needs to be taken to avoid assessment fatigue.
l Proper need assessment results in better planning and outcomes.

16
CHAPTER 5 STRESS DURING DISASTERS

One of the salient features of psychosocial care is enabling disaster survivors to

understand stress and its reactions. The unpredictable environment, unexpected living
conditions and unpleasant experiences cause excessive distress. Traumatic
experiences yield anxiety and stress when it exceeds the coping capacity and
resources of the individual, family and community. If people understand the reactions
caused by the disaster, it is easy for them to deal with the changes caused by it.
Numerous reactions are generated by stress and its manifestations. This varies from
person to person during different phases of disaster. Prior knowledge about the
stressful reactions and its consequences helps both the disaster survivor and the
caregiver to identify the body's response to stress. This also facilitates early
identification and quick treatment during the response, relief and rehabilitation
phases.
Figure 5.1: Reactions during disasters

Physical Reactions
Physical reactions are easily noticeable. One of the most common physical
symptoms, experienced by disaster survivors is body pain/aches. For relief from pain,
people visit doctors or take self-prescribed medicines. Mostly, psychological
reactions experienced by disaster survivors are portrayed as physiological reactions
such as tension, fatigue, restlessness, disturbances in sleep and appetite, body
pain/ache, muscle cramps, variations in blood sugar/pressure levels and rapid startle
reactions. Some examples of physical reactions are given below:
17
 Stomach ache and change in appetite
“Nowadays I feel severe stomach ache. I don’t even feel like eating anything”. (22
years old female)

Headache
“Its been 6 months, I have a terrible headache. I am not able to sleep or focus on my
work. Medicines are also not helping me”. (43 years old male)

Behavioural Reactions
Stress caused due to traumatic experiences, when goes beyond the coping capacity of a person lead
to adaptive and maladaptive behaviours. Some of the common maladaptive behaviours are: lack of
interest in life, reduced energy/activity level, excessive consumption of substances (alcohol,
tobacco etc), isolating self from persons, places or environment.

Change in behaviour
“My wife and I generally don’t fight. After the disaster, we argue even for petty things. I
lost peace of mind”. (32-year-old male)

School refusal
“My close friend died in the disaster. We used to play together but now I am all alone.I
don’t feel like going to school”. (10-year-old child)

Psychological/Emotional Reactions

Psychological or emotional reactions are subjective experiences. There may be change in the
person’s behaviour, emotional expressions, and thinking patterns. For instance; trouble in
concentrating, confusion, issues with memory, difficulty in making decisions and problem solving,
anger, irritability, fear, anxiety, repetitive thoughts, suicidal thoughts/attempts, forgetfulness, grief,
guilt, lack of interest, hopelessness, worthlessness and helplessness etc. Like physical or
behavioural reactions, psychological reactions might not be visible. All the other reactions would
eventually lead to a psychological reaction and vice versa.

Despair about losses

“My children are busy in their own life. I have nobody to listen to me. My husband went
early leaving me alone”. (52-year-old female)

Helplessness, sadness and guilt

“My engagement was fixed. My father had started preparing for the ceremony, but now
I am left alone. We lost all the gold and money that my grandparents had saved by
selling the land. It is all my fate. I am a bad sign for the family”. (21-year-old female)

Nightmares
“I have had sleepless nights thinking about not being around my family and wonder if I
would ever see them for one last time”.(23-year-old male)

18
Relational Reactions

Stress can have significant impact on the relationships. It makes the person avoid or
increase interactions with others. This would affect the person’s social support and
help-seeking behaviour. Change in roles and responsibilities post disaster would
impact the family or community interaction patterns. Interpersonal reactions include
trust issues, increased conflicts, feeling of rejection or abandonment, not
accepting/judging others and exercising control over others.

Change in interaction “Because of lockdown, I am attending online

classes. My parents don’t understand my difficulties and are blaming me
for holding laptop. I feel like running away from home”. (17-year-old
female child)

Being aloof
“I do not want to meet or talk to anyone. I want to be left alone”. (24 -year -
old male)

Multiple reactions experienced by different age groups in the post-disaster phase

(Adapted from NSW Health, 2000)

Reactions among Children

l Physical: Poor bowel or bladder control, difficulties in speech (stuttering, baby

talk), poor or increased appetite, physical complaints (headache, stomach pain).
l Behavioural: Inactiveness, thumb sucking, throwing temper tantrum,
aggression, school refusal/avoidance.
l Psychological: Fear (new circumstances, being separated, dark, animals,
weather, safety), irritability, nightmares, poor attention, poor concentration, lack
of interest, preoccupation and thinking about the events related to the disaster.
l Relational: Not leaving parents, seeking parental attention, not mingling with
peers.

Reactions among Adolescents

l Physical: Problems with sleep and food intake, pain/ache in the body.
l Behavioural: Rebelliousness, issues at school (quarrelling, picking up fights,
poor interest in studies), increased or decreased activity/energy, engaging in
unlawful/criminal behaviour, using drugs/alcohol.
l Psychological: Non-responsiveness, mood swings.
l Relational: Seeking attention, poor prosocial behaviour, displaying avoidant
behaviour, change in peer groups.

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Reactions among adults

l Physical: Sleep disturbances, poor/increased appetite, feeling tired or

exhausted, somatic problems (gastrointestinal, multiple body pain, worsening of
existing medical/psychiatric conditions).
l Behavioural: Avoiding (person/place), increased/decreased activity, anger
outbursts, using substances.
l Psychological: Sadness, continuous crying, feeling sad, anxious, guilty, being
irritable, fearful, having depressive thoughts (hopelessness, worthlessness,
helplessness), having mood swings, self-blame/doubt.
l Relational: Frequent family conflicts, self- isolation from others.

Reactions among older adult

l Physical: Worsening of chronic medical/psychiatric conditions, change in sleep

and eating patterns, decline in physical health.
l Behavioural: Agitation/irritability.
l Psychological: Feeling depressed, disoriented, having confusion, memory
problems, poor interest, being suspicious, feeling of despair, being anxious about
unfamiliar environment, feeling of embarrassment.
l Relational: Withdrawn behaviour, adjustment issues.

All of these reactions are normal reactions to a disaster. Survivors experience different
emotional reactions during different phases of disaster. Understanding the variations
in the psychological reactions over different time intervals and differentiating
between normal and abnormal reactions help in developing appropriate psychosocial
or mental health interventions. The figure below helps in understanding the
distinction between normal and abnormal reactions during the disaster cycle.

20
 Figure 5.2: Stressful Reactions during Disasters

Denial: Refusal reaction

to accept the disaster
(one to two weeks)

Dealing with the Psychological Reactions among Different Age Groups

Children (1 to 5 years)
l Provide simple and direct messages.
l Provide verbal reassurance and appropriate physical touch.
l Help in restarting and following the daily routine.
l Make the child to name the emotions she/he is experiencing.
l Facilitate living with family or with familiar and safe individuals/environment.
l Reduce or eliminate images/news/sounds/persons that remind the disaster.
l Encourage the child to talk about the feelings (especially the losses).
l Create opportunities for active play or group activities.
l Make sure that the child knows that you can be approached for help in times of distress.

Children (6 to 11 years)
l Reduce home/school expectations from the child.
l Enable structured but flexible activities at home/relief camp.
l Encourage the child to talk about his/her traumatic feelings.
l Actively listen to the child with warmth and care.
l Provide authentic information and correct misconceptions.
l Create peer activities using expressive arts.
l Have an eye on the needs of special children.
l Educate on safe/unsafe touch.
l Make the child know that there is help always.
l Monitor the child’s screen time.

21
Adolescents
l Set the realistic home/school expectations.
l Facilitate sharing traumatic experiences.
l Ensure confidentiality.
l Do not force to talk.
l Create routine involving physical activities, self-care activities,
group meeting and other social activities.
l Do not confront behaviour/feelings.
l Connect the adolescents’ impulsivity or reckless behaviour to
the disaster event.
l Educate on staying away from psychoactive substances.
(alcohol, tobacco or other drugs), risky sexual behaviour, abuse
and other social evils.
l Regulate the adolescent’s screen time.
l Provide information of healthy coping, whom to approach in
times of distress/crisis.
l Take care of adolescents with special needs (persons with
disability, history of child sexual abuse, abandoned, orphaned,
etc.).

Adults
l Enable access to essential resources.
l Create channels for the adult to talk about the disaster experiences.
l Provide authentic information on services, systems and aid.
l Correct false information.
l Help them to improve their problem-solving abilities.
l Encourage direct and frequent communication between family members.
l Provide information on strategies to follow while being with their
spouses, children or older adults in the family.
l Empower the adults on the adaptive coping strategies and discourage
maladaptive patterns.
l The community is the first responder in any disaster so empower the
adult to take care of themselves and the community.
l Assess for abnormal reactions and facilitate appropriate mental health
services.

Elderly
l Provide verbal and physical reassurance.
l Ensure access to essentials.
l Help in sustaining or rebuilding the support systems.
l Enable easy access to medical and financial resources.
l Create avenues to express their traumatic experiences.
l Educate on elderly abuse.
l Provide legal options available in case of elderly abuse.

22
Remember
l Stress is the body's response to external stimuli.
l Stress reactions can be physical, emotional, behavioral and relational.
l It is normal for survivors to experience negative psychological reactions
after disaster.
l Awareness on stress reactions aid in early recovery.
l Appropriate and immediate psychosocial services curtail manifestation
of mental disorders.

23
 MENTAL HEALTH ISSUES AMONG
CHAPTER 6 DISASTER SURVIVORS
Mental health problems can affect anyone. Disaster might cause the mental health
problems among certain individuals. All the disaster survivors need not necessarily
develop mental health problems. Persons who have suffered significant loss (poor
social support), victims of abuse and persons with inadequate coping resources or
maladaptive coping strategies and vulnerable groups are more susceptible to mental
health problems. Persons with underlying mental health conditions, persons who have
stopped psychiatric medications due to non-availability or difficulty in accessing
medicines during disaster phases are also more prone to develop mental health
problems.

Knowing about the mental health complications post-disaster would help in early
identification and prompt treatment. Ongoing assessments, periodic visits by the
caregiver, sensitising the community on mental illness, help in early identification of
persons with mental health problems, and facilitation of appropriate mental health
services.

After any disaster, the mental health issues among disaster survivors can be viewed as
one of these four ways.

Blossomy flower: Survivors who experience psychosocial distress but

are able to cope with it and do not develop any mental health problems.

Withering floret: Persons who display elaborate mental

health problems (chronic symptoms) during mental health
assessments that happen at multiple time intervals.

Slow bloomer: The survivor initially manifests the

symptoms but gets better even without any intervention as time advances.

Bud blast: The survivor does not display mental health

problems for a long time and has delayed manifestation of symptoms
(more than 6 months to one year).

24
The most common mental health problems post-disasters are shown below;

Adjustment Problems: Disasters warrant significant adjustment and adaptation

among survivors. Failure to adjust or adapt yields to adjustment disorders. They
generally commence from three months to not more than six months of the disaster. It
includes a group of emotional or behavioural symptoms that cause significant
impairment in the survivors work or home functioning. The survivor experiences
constant sadness, depressive thoughts (hopelessness, helplessness and
worthlessness), reduced interest in work or other activities.

For instance, Mrs. S, 32-year-old female, lost her house in Tsunami. She was feeling
low and did not talk to anyone, not even to her close friends. She felt helpless and
hopeless. Even after 6 months of disaster, she had slowness in doing all her daily
activities. She was not able to adjust and get along with the family members. The
family members got back to their usual routine, but she was not able to resume normal
life.

Along with referral to nearby mental health care facility, the caregiver can allow the
individual to express freely on his/her difficulties. The focus of the intervention
should be on creating adaptive coping strategies, problem-solving abilities, looking at
the opportunities and solutions in spite of the threats, creating or rebuilding social
support and building interpersonal skills.

Post-Traumatic Stress Disorder (PTSD): PTSD is characterised by repetitive

disturbing thoughts or images of the disaster (intrusion), avoiding
persons/place/things related to the impact (avoidance), being hypervigilant and
having low emotional alertness. The onset of the symptoms range between one month
to three months. In rare circumstances, the survivor can also experience the symptoms
more than three months and at times six months after the impact. The symptoms affect
the daily functioning of the individual. The survivor may also experience nightmares
or flashbacks, refrain from coming in contact with people/place/things related to the
impact, being aloof and significant sleep disturbance. The survivor may also have
anger outbursts, worry, fear, guilt and despair.

Mr. R, a 17-year-old male, after the air crash incident in Calicut lost his parents and
sibling. After the loss, his paternal uncle took him into custody. Since then, he was
getting repetitive disturbing thoughts and images of crash. He had nightmares often
and was not able to sleep most of the times. Whenever he heard the sound of a flight, he
would get disturbed. At times, he would shout and yell at the uncle without reason. The
symptoms lasted for more than 4 months.

After referral to nearby mental health care facility, the caregiver can educate the
person that the reactions s/he is experiencing is a product of the stress triggered by
disaster, should strengthen support from family/friends/other social units, teach
25
anxiety management techniques (relaxation techniques, yoga, breathing exercises,
diversion techniques) and restart healthy routine (sleep, food, exercise) and curb
unhealthy lifestyle.

Anxiety related problems: The symptoms include increased worry and fear that last
for six months or more. The survivors experience restlessness, difficulty in breathing,
irritability, sleep problems, increased heartbeat, profuse sweating, and feeling dizzy.
The individual experiences fear of forthcoming danger may be because of
vulnerability or uncertainty.

Mr. K, 38-year-old adult was evacuated with his family during the Chennai flood.
After reaching his home, he was sweating profusely. He experienced increased
heartbeat, restlessness and was irritable in doing activities. At times, he had
disturbances in sleep and breathing difficulties. He is afraid that rains may come
again and had constant worry and preoccupation about the same.
The caregiver has to refer the person with the above-mentioned difficulties to the
nearby mental health care centre. The care provider can do the following to help in the
person's recovery: Help the person to create a healthy routine and follow it, teach
relaxation techniques (yoga, breathing exercises), provide reassurances and instil
hope and support.
Depression: The survivor who is depressed shows persistent sadness, low energy
levels, depressive cognitions, negative thinking, lack of interest in pleasurable
activities, alteration in sleep and eating patterns and suicidal ideation or suicide
attempt. They also might have low self-esteem. These individuals avoid social
activities and have significant impairment in activities of daily functioning.

Ms. S, a 32-year-old female lost her husband who was working abroad, due to
COVID. She got this news only two days after his death. It was very difficult for her to
get the body. She was not even able to believe that her husband was dead. She does not
have children and had no other support. She attempted suicide twice. She had feelings
of hopelessness, helplessness and felt unworthy to live. She lost her appetite and could
not sleep. She was not able to do any of her activities. She was weeping continuously
and was thinking that life is miserable.
After facilitating mental health referral, the caregiver can make the person feel that
s/he is available for the person to talk about his/her feelings, teach on adaptive coping
strategies, establish routine, monitor for suicidal thoughts/ideation. The care provider
also can encourage the participant to engage in constructive hobbies like listening to
music, weaving, etc.
Panic Disorder: This disorder is characterised by recurring panic attacks that spans
between few minutes (rarely hours). The person experiences extreme anxiety and
unreasonable fear. Some of the symptoms during the panic attacks are racing
heartbeat, pain in the chest region, shortness of breath, shivering, giddiness, profuse
sweating, vomiting sensation and abdominal pain.

26
Mr. R, a 35-year-old male, escaped miraculously from the Avalanche in Kashmir.
Since then, he was feeling restless, anxious and had unreasonable fear. This attack
used to last for few minutes. He would experience increased heartbeat, ache in chest
region, breathing difficulty and pain in abdomen.
Along with referral to mental health care facility, the care provider can ensure safety
and security, teach anxiety reduction strategies and provide reassurances.

Dissociative reactions: After disaster, few people may have jerky movements in the
body that might appear like fits (seizures). These episodes might occur when they
meet specific persons or during specific situations. Here the person might not hurt
himself/herself, does not lose consciousness and would express the views in an
unusual voice. These indicate that the person is experiencing excessive distress and
has certain unfinished desired goals. To achieve these secondary gains, the person
might display such abnormal behaviour. It should not be considered that the person is
acting.

During Latur earthquake, Mrs. L, a 50-year-old female, escaped from the collapsing
building along with the family members. After the calamity, she had unusual jerky
movements in the body. This happens whenever she meets her son or daughter. During
such episodes, she falls and appears unconscious. She would speak in an unusual
voice. During those times, family members give more attention to her.
Psychosocial Interventions would include interventions targeted towards the
individual as well as the family members. The person needs to be oriented on the
body-mind relationship saying how the repressed unconscious needs are manifested
through bodily symptoms. Helping the person to talk about the feelings would help
the person feel better. The family members need to be told to minimise giving
attention to the person's symptoms without compromising the quality time.
Other Mental health Implications
Loss of productivity
People, after losing everything feel empty and lack interest to work. When people lose
their families in disaster, they feel meaningless in living and do not take efforts to
make their lives better.

“I don't feel like doing anything”. (32-year-old woman)

Increase in substance use
Alcohol consumption is increasing day by day and many cultures encourage alcohol
use. Disaster survivors, after the huge loss tend to increase the intake of alcohol,
tobacco and other substances to cope with the loss. It acts as a temporary relief with lot
of negative physical, psychological and social impact. The caregiver needs to
sensitise the population on the ill-effects of harmful substance use.

27
“When I drink, I feel less for the loss of my loved ones”. (45-year-old man)
Suicidal thoughts, attempts and suicides
After losing the dear ones and all the property, some might have suicidal thoughts,
tend to harm themselves or even attempt suicide. Repetitive thoughts to end life are
most common in the rebuilding phase. The care provider needs to orient community in
general on help available when individuals think of committing suicide, should give
information about suicide help-lines and other suicide prevention strategies. As
suicide is a cry for help, the caregiver should also develop crisis intervention plans for
persons who wish to end their lives and hasten appropriate physical and mental health
interventions in case of an attempt.

“I don't feel like living. God has taken all my dear ones. I feel lonely and I want to end
my life soon”. (39-year-old female)

Marital discord and family problems

Emotional reactions that are subjective mostly shown as behavioural or relational
reactions. Subjective distress is usually vented over the family. It leads to strained
interpersonal relationship resulting in significant marital issues or issues with
children or parents. The balance of the family system gets disturbed after the calamity.

“My mother and father are always fighting. I do not want to go home at all. I used to
play with my sister. The waves took my sister. I am all alone now. My parents don't talk
to me properly”. (9-year-old boy)
Somatisation
Subsequent to disaster, physical symptoms are common. At times even after a year of
the disaster, few may experience continuous bodily symptoms such as headache,
stomach pain, vomiting sensation due to ongoing stressors.

“My entire body aches. I feel weak and numb. I feel dizzy. I have consulted many
doctors but the symptoms are not improving”. (37-year-old female)
Difficulties in restarting and managing livelihood
Disasters shatter the livelihood of the disaster-affected communities. Enormous work
needs to be done to rebuild the lives of disaster affected communities. Survivors have
trouble in restarting their jobs or business from the base, collecting monetary benefits
or compensation, etc. If the survivor is not multi-skilled and has only one work profile,
it limits him/her from getting a job. Limited vocational opportunities around the
disaster neighbourhood or losses incurred discourage restarting of livelihood.

“I lost my certificates and other important documents during the flood. It is very
difficult to start a new life here. It would take months to get duplicate ones. I don't
know what to do. I am now doing petty jobs which do not even match my education”.

28
(24 years old male).
Reactions to post-disaster can be delayed and manifested even after six months or one
year. Researches provide evidence that almost 30% of the population affected during
disaster are prone to one or more mental health condition. The caregiver needs to be
watchful of the abnormal reactions and should educate the community to look for the
reactions among the neighbours. As there is still stigma with respect to mental health
treatment, it is essential to sensitise the community on the importance of mental health
treatment and minimise or remove stigma with respect to seeking mental health
intervention. The care provider needs to undertake ongoing assessments. This would
help the care provider to know whether the person needs primary, secondary or
tertiary mental health interventions.

Remember
l Mental health reactions can be immediate or delayed.
l Common mental health problems are Acute Stress Disorders, Post Traumatic Stress
Disorder, Anxiety, Depression, etc.

29
 LIFE EVENTS, FAMILY LIFE
CHAPTER 7 CYCLE AND DISASTER
Stressful life events
Life events are significant events in a persons' life. They can be normative and non-
normative in nature. Normative life events are foreseeable or predictable and take
place in every individual's life, e.g., joining or leaving school, entering career or
family life etc. Non-normative events are mostly unexpected (disasters, accidents,
operation).
Life events can be;
l Desirable (Getting compensation promptly, moving to another place due to job)
or undesirable (Loss of life or house or being shifted to a temporary shelter)
l Expected (Getting relief materials or welfare measures) or unexpected (Losing
job, being a victim of accident, death)
l Entry (Birth, getting a new job, marriage) or exit (Death, getting terminated,
facing destruction)
l Personal (Loss of family members, loss of personal property) or impersonal
(Destruction to environment, damage to public property)
Stressful life events can impact the physical and mental health of individuals.
Negative life events that happen before or after a disaster can be an indicator for
predicting mental health problems. Understanding the life events help in establishing
mental health monitory systems wherein persons with significant life events can be
followed up closely. This would ease early identification and prompt treatment.
Bereavement followed by loss of loved ones due to disaster is one of the most
significant contributors to distress out of all the life events.
All individuals have significant events in their lives and the individual's coping
abilities and resources help in reducing the effect of the life event. Disaster situations
being unprecedented, increases the severity of life events in the individual. People
loss their loved ones and property. Disaster situations create changes in the persons'
roles and responsibilities. Moreover, the individuals suffer serious loss of support
systems and resources. The support systems and resources that acted as buffering
units prior to disaster from developing adverse mental health outcomes are now
absent or diminished. This disturbs the individual's coping and eventually, his/her
well-being gets affected. Hence, it is essential to look after the psychosocial and
mental health needs of such individuals who have significant life events with the walk
of disaster. Disaster makes people vulnerable and multiplies vulnerability among
people who are already vulnerable. Lack of support and resources, subsequent to
disaster impacts the coping of survivors resulting in higher distress. The life events
also influence the life cycle, roles, responsibilities and rituals of the family. Disaster
situations disrupt the family life cycle that induces distress among disaster survivors.
The change in the family environment subjected by disaster affects the functioning of
the individual, family and the community.

30
Family life cycle

Family is a recognized social group that nourishes emotional connection within the
members and serves as one of the fundamental units of society. As individuals in the
family grow, at every stage (a period in the life of a family) of development there is a
set of roles and responsibilities (developmental tasks) expected from every member in
the family. Each stage of family life involves natural changes, challenges and
demands. Typical family life cycle of an individual is shown in the figure below;

Figure 7.1: Family life cycle

Impact of Disaster in the Family Cycle

As already mentioned, every stage in the family life cycle has its own expectations and
concerns. When expectations and concerns in one stage is not fulfilled, it gets carried
over to the further stages. Failure to deal with the stressors and demands of one stage
would add stressors to the following stages. Disaster situation adds stress to the family
life cycle and impacts the family balance.

31
Disaster brings major impact to family life in terms of the person losing his/her
spouse, children, parents or at times the entire family. Loss of livelihood, loss of
employment opportunities and loss of habitat bring immense distress to the survivor.
Loss of family members drives incomparable distress. Family systems get disturbed
and the role expectation gets increased. When nominal or functional leaders of the
family die in disasters, change in leadership takes place. Calamity results in poor
adaptive patterns in the family especially poor problem solving and coping strategies.

Disaster uproots the family from the familiar neighborhood and the primary social
support gets affected. Role change, multiplicity of roles, role reversals take place in
the structure of the family when there is a death in the family. For instance, if the father
and mother of the family are dead in a disaster, the grandparents need to take up the
parent's role, if the father is dead, mother has to become the functional leader in
dispensing both the instrumental (money, food, other essentials) and expressive (love,
care, affection) roles leading to excessive burden due to multiplicity of roles. All these
difficulties, change the routine of the family life and members in the family become
vulnerable to multiple psychosocial issues.
Mental health complications are high when the family is left without any resources,
adaptive coping capacities and inadequate support. It is essential for caregivers to
look in to the needs of disaster survivors who lost balance in their family life cycle.
Appropriate individual, family and community based psychosocial interventions
would help in minimizing mental health problems among survivors whose family life
cycle flow is disrupted.

Figure 7.2: Influence of Life Events on Family Life Cycle Post-disaster

Remember
l Disaster disrupts the equilibrium and flow of the family life cycle.
l Life events are common for all individuals.
l Negative life events that happen before or after a disaster can be an indicator for predicting
mental health problems.
l Disaster situations disturb the family life cycle and cause distress among disaster survivors.

32
 PSYCHOSOCIAL SUPPORT
CHAPTER 8 TECHNIQUES

Disaster creates imbalance among individuals, families and communities. People will
be in a state of confusion and look for support. Therefore, it is essential to render
appropriate help for disaster survivors. This chapter talks about ten psychosocial
techniques that are essential in the helping process. These techniques can be practiced
by anyone who wants to assist the people hit by disasters and facilitates recovery.
While applying these psychosocial support techniques, the caregivers should bear
flowing points in minds;

l Disaster affects every individual in the community

l Reactions following a disaster are normal response
l Disaster contributes to both individual and collective trauma
l Even the survivors with good coping ability will have difficulties in sustaining
the earlier level of functioning for the initial days after disaster
l Problems with daily living results in psychosocial issues among disaster
survivors
l Cultural, religious and linguistic sensitivity is essential while developing
community based psychosocial programmes
l Survivors need to be motivated to express about their disaster experiences
l Phase specific interventions need to be developed
l Rebuilding and maintenance of support systems is essential
l The caregivers should be open minded while engaging themselves in the caring
process

PSYCHOSOCIAL SUPPORT TECHNIQUES

33
Ventilation

Disaster minimises individuals' coping abilities and resources.

Individuals generally suppress their strong negative emotions.
These pent-up emotions and feelings get bottled up and affect the
well-being of the individual. Channels need to be created for
individuals to ventilate their emotional distress that would help
in preventing emotional explosion. Creating space for the disaster survivor to talk
about his/her negative emotions is like a whistle in a pressure cooker. The whistle
regulates the pressure and if a whistle is absent, the pressure cooker might explode.
The ventilation process facilitated by the caregiver would act as a safety valve for the
survivor to release his/her negative emotions.

Timely expression of traumatic experiences, through talking, facilitate faster

recovery and prevent development of mental health complications. Sharing of
disaster specific experiences can happen individually or in groups. Individuals should
not be forced to talk but s/he should know that there are people or facilities available
for individuals to talk about their trauma. During the catharsis (venting of negative
emotions) through crying or talking or other acceptable ways of expressing crisis, the
caregiver should not interrupt or ask the person to stop crying or talking. Strict
confidentiality has to be ensured and the information shared by the survivor should
not be shared with others unless threat to self/others is observed. The caregivers
should not interrupt the survivor while s/he is talking until and unless it is vital. The
caregivers should not interrogate and should accept him/her as s/he is.

Active listening

People affected by disasters want to be heard and opportunities

need to be created for disaster survivors to vocalise their feelings
and emotions. Some of the barriers to active communication are
lack of privacy, noisy environment, preoccupation of the care
provider, poor help seeking behaviour among the survivor,
negative attitude of the care provider and lack of training in the
helping process.

The SLOWER technique helps in motivating the survivor to talk about the negative
experiences.

S – Sitting squarely
L – Leaning forward
O – Openness
W – Withhold your judgement
E – Eye-to-eye contact
R – Relaxed posture
34
To make the individual know that s/he is being listened, the caregiver can paraphrase
periodically, can ask whether s/he has understood the individuals' expression as the
individual felt and use adequate non-verbal communication (nods, mirroring of
emotions, etc.). When disaster survivors feel that they are listened to, they feel
comforted and safe. Active listening helps in providing warmth and positive regard
for the survivor.

Empathy
Empathy is one of the basic and crucial psychosocial care techniques
that help in building rapport and trust with the disaster survivors.
Here, the caregiver understands the subjective experience of the
survivor and communicates it to the survivor. E.g., 'I understand it
must be very difficult for you to witness the pain and suffering', 'I
can't imagine being in that situation', 'I know you have tried your best
to support your family', etc.

Expression of empathy can be practiced by these four basic elements;

l Viewing from the other person's perspective.
l Understanding their feelings and emotions.
l Non-judgmental acceptance.
l Communicating that the care provider has understood the other person's
situation.

Empathy also means experiencing the circumstances, feelings and emotions of the
other person despite not having the real traumatic experience. It is difficult to
experience from the other person's point of view and it is an art which develops out of
patient practice. Being empathetic towards the other person during the helping
process will help in understanding the pain of the survivor and in initiating responsive
psychosocial care activities for the survivor. Appropriate gender specific touch or
gestures, adequate reassurances, mirroring of the other person's facial
expressions/feelings and disclosure stories (when needed) aid in expressing empathy
towards the disaster survivors.

Maintaining Routine
Disaster breaks one's routine. Restarting one's daily activities is
essential to bring functionality among disaster survivors. Daily
routine might involve healthy eating habits, proper sleep,
engagement in household chores, resuming occupation, taking usual
medicines, physical activity, following family rituals and other social activities.
Restarting routine would be difficult initially because of factors like loss, confusion
and personal vulnerabilities. The caregiver has to motivate the survivors to start doing
their activities of daily living and can help those who have significant difficulty in
resuming earlier life. The caregiver should also monitor closely such individuals and
provide opportunities to ventilate and express their difficulties.

35
Avoiding maladaptive patterns

The techniques 1 to 9 foster positive coping strategies. During

disaster situations, availability of resources will be limited or become
scarce, exceeding the individual's coping abilities. The negative
consequences of disaster make people adapt negative coping
strategies. Along with encouraging disaster survivors to practice adaptive coping
strategies (active problem solving, talking or writing about the feelings, giving and
taking help), the caregivers should also discourage maladaptive coping strategies.
Some of the commonly used maladaptive patterns are; using drugs or psychoactive
substances, over or under eating, fighting/beating/quarrelling, avoiding or escaping
from thoughts/people/place, gambling etc.

All the above psychosocial techniques help in speedy recovery of the survivors.
Though all the techniques are important, the individuals can choose a particular or
combination of techniques based on their need. Care to be taken to align these
psychosocial techniques to the cultural and religious sentiments of the community.

Social Support

Social support makes people feel safe and assured. Social Support
can be classified into three orders:

(1) Primary Social Support: Family,

(2) Secondary Social Support: Friends, Neighbours, Colleagues, and
(3) Tertiary Social Support: Government, Legal bodies, Non - Governmental
Organisations, Religious Institutions.

All these three sources of support are important as they safeguard when individuals
face distress. Social support also enhances a person's well-being and coping. Disaster
situations disturb, uproot or wipe out social support units, especially the primary and
secondary support. For example, an individual can lose his/her family members or
friends in the disaster. It is essential for caregivers to develop strategies to recreate
social support units, create opportunities for survivors to gather in groups and
encourage individuals in family rituals and community engagement activities.

Yoga and relaxation

The unexpected confusion and uncertainty following any disaster,

result in anxiety and fear. It would be difficult for individuals to relax
because of the tremendous loss, continuous apprehension and fear of
future. It is essential to train the survivors with anxiety or panic
management strategies. Yoga and relaxation techniques can serve as such self-
management strategies. Some of the yoga/relaxation techniques that can be practiced
on a daily basis even in a restricted environment are given below:
36
 Victorious Breathing (Ujjayi): This technique helps in
calming the mind and body. The participants are asked to fill the
lungs with air and breathe through nose making a
snoring/hissing sound.

Bellows Breathing (Bhastrika): It involves

rapid inhalation and exhalation creating a yogic fire within
oneself. The participants have to sit in a cross-legged position.
Then they need to make a fist and place the folded arms near the
shoulders. While the participant inhales, s/he has to raise the
hands up and open the fists. Then exhale forcibly bringing the arms down and
closing the fist. The process can be repeated for 20 rounds.

Chanting: The participants are asked to create slow and progressive resonating
vibration using the sounds aaa… uuu…. mmm….

Purifying Breathing (SudharshanaKriya): This is a cyclical breathing

exercise in slow, medium and fast rates combining the victorious breathing,
bellows breathing and chanting.

Mindfulness: Imagining a peaceful and serene environment or natural

ambience and focusing on breathing or looking at serene objects like illuminated
candle, images of God, nature or meditating on religious texts with undivided
attention.

Jacobson’s Progressive Muscular Relaxation (JPMR): It’s progressively

tightening and loosening muscles in the multiple parts of the body starting from
head to toe. It is proved that stress gets accumulated in multiple parts of the body
and manifested as pain. Systematic tightening and loosening of body muscles
helps in releasing supressed emotions. The individual has to breathe in while
tightening and gently release the tightening muscles while breathing out slowly.

Recreation

Recreation helps in shifting one's focus from the negative emotions

triggered by the disaster. People can be encouraged to participate in
recreational activities like singing songs, dancing, playing and other
culture specific activities. These recreational activities help in fast
improvement of the normalization process. Recreation options can be made available
in the community through folk lore, puppet shows and other cultural media. This also
can be made use to provide disaster specific information and awareness. Humour can
also be a part of recreation. Providing channels for people to laugh and cherish would
drive faster recovery.
37
Spirituality

Spirituality refers to the positive inner experiences that provide

optimistic outlook towards life. It aims at establishing the connection
between inner self of an individual and outer world. Spirituality also
involves caring for self, others and the environment. It believes that
there are things that are outside one's control and testing times offer platform for
bettering oneself. It is a movement towards self-fulfilment. India, being a country of
multiple faiths and religions, belief in God/nature/ offers support and peacefulness
during difficult times. Questioning the supreme power is a part of the grieving
process. This might get extended during the acceptance phase. The caregiver should
not force anyone to perform specific spiritual rituals, but encourage survivors to
practice their spiritual practices.

Externalisation of interests

Individual's roles get disturbed during disaster. Hence, positive

rearrangement of roles based on the demands of the current situation
is important. This ensures adjustment among the survivors. Shifting
the focus to other constructive activities keeps the person engaged. It
enhances the person's functionality as well. The caregiver should look for the interests
and skills among the individuals or groups and encourage practicing the same on a
daily basis. Activities constructed to remember the interests and skills of the
individuals would make the survivors feel that their skills match with the need of the
emerging situation. This would make them feel that they are not a burden for others,
but a useful resource in community restoration.

Remember
l Psychosocial techniques help in enabling faster recovery of the disaster survivors.
l Disaster survivors have to be encouraged to practice the psychosocial techniques.
l Cultural sensitivity needs to be maintained while practicing psychosocial techniques.

38
CHAPTER 9 REFERRALS AND FOLLOW-UP

Individuals, families and communities affected by disasters have different needs.

Understanding the needs of disaster survivors and linking them to appropriate
services is essential to promote resilience among individuals who have experienced
the disaster. Referral is a linking process in which the caregiver initiates care
management for a specific identified problem. While initiating a referral, the
caregiver does not transfer care for the disaster survivor completely, but links the
person to an advanced/appropriate facility or person and follows it up to see whether
timely service is achieved. Though psychosocial support focuses on providing
psychological and social support for the disaster survivors, the holistic care is
achieved only through coordination of multiple service providers based on the needs
of the disaster survivors.

Referral is required while survivors experience following psychosocial issues;

Ethical practices to be followed while facilitating referrals:

l Do not force the survivor to talk about the issues.
l Do not break confidentiality.
l Do not flood the survivor with information.
l Verify the authenticity of the agency to which the survivor is being referred.
l Do not just stop with referral but periodically review progress.
l Be a bridge between the agency and the survivor.
l Not all the needs of the survivor can be fulfilled and it has to be communicated
clearly.

Follow-up
Follow-up is a process in which the caregiver understands whether the agenda for
referral has been achieved or not. Though the process might be time consuming,
rigorous and exhaustive, adequate follow-up ensures continuity of care and instils
hope among disaster survivors. The follow-up should be done in a mild way without
down scaling the relationship between the survivor and the service provider. During
follow-up, the caregiver has to assess the quality of work done by the referral agency,
satisfaction of the survivor, further assistance required, future plan of action,
difficulties in reaching the goal, changes that the referral has facilitated in the
survivor/family or society.

39
 Figure 9.1: Steps in the Facilitation of Referral
Establishing Rapport
Using psychosocial care techniques (Active listening & empathy).

Assessment of Needs
Biological, Psychological and Social.

Deciding the need for referral

Why? What? Whom? When? How?(Psychosocial care, Strengthening Social Support,
Paralegal Aid, Means of livelihood, Medical and Psychiatric Care, Compensation Claims).

Preparing the objectives for referral

l To link the needs of the disaster survivors to the resources.
l To reduce distress among survivors.
l To facilitate the normalisation process.

Exploring referral options

l Assessing whether the needs of the survivors’ match with the services of the
service providers.
l Having a list of service providers and their services will facilitate this process.

Communicating to the survivor and the agency

l Talking to the agency about the survivor’s needs.
l Selection of appropriate agency for referral.
l Discussing referral plan with the survivor and finalising the referral plan.
l Communicating the referral agenda to the survivor.

Actual referral
l The survivor meets the agency and the actual referral.

Receiving feedback
l The caregiver talks to the service provider and the survivor to know how the
referral is progressing.

Review and termination

l When the needs are met or the sessions are progressing as expected, the caregiver calls for
termination (termination does not mean that the care provider stops providing PSS for the
survivor).
l If the outcome of the referral is not happening as expected, the caregiver revisits the referral
plan, reorients both the agency and the survivor and identifies other stakeholders for
appropriate referral.

Remember
l Structured needs assessment precedes referrals.
l The care provider should have a directory of agencies to which survivors can be referred
and should update it periodically.
l The care provider should act as a bridge between the survivor and the service providers.

40
 Section - 2
WORKING WITH VULNERABLE GROUPS
 VULNERABLE GROUPS IN
CHAPTER 1 DISASTERS
When there is a threat of disaster, the vulnerable sections such as pregnant women,
orphan children, persons with disability and uncared older adult population need
special attention. There is a wide range of biological (sex, health conditions,
disability), social (poverty, gender, age, education), and environmental (place of stay)
factors that make a person vulnerable specific to different types of disaster. Following
questions would help in providing better clarity on understanding vulnerability:
1. What are the threats or hazards that make people vulnerable?
2. What are the factors that influence them to be vulnerable to a specific threat or
hazard?
Often vulnerable population is overlooked. Hence, understanding their needs help in
providing psychosocial support services effectively.

Table 1.1: Vulnerable groups, during different types of disasters

Factors Vulnerable Groups
Children and adolescents (unaccompanied children, orphans,
child labourers and children in conflict with law)
Age
Older adult (older adults not cared for in families,older adults in
older adult homes and older adult living alone)

Women (pregnant women, single women, widow and divorced women)

Gender
LGBTQIA+ (lesbian, gay, bisexual, transgender, questioning, queer,
intersex, pansexual, two-spirit (2S), androgynous and asexual)
Farmers, fisherman, daily wagers, bonded labour, first responders,
Occupation mine workers, commercial sex workers
Single parents, families with younger children, families with
Family large dependents
Ethnicity Indigenous groups, cultural, linguistic and religious minorities, nomads

Status Socio-economically disadvantaged, homeless, slumdwellers, unemployed

Long-term medical condition, addiction, immune compromised state,
Health persons with limited life span, persons in palliative care
Intimate partner violence, previous experiences of trauma, violence in
Trauma the family/community, victims of sexual/physical violence and abuse,
bereavement
Immigrants, migrants, environmentally displaced, internally displaced,
Displacement refugees
Low vision, locomotor disability, dwarfism, intellectual disability,
mental illness, cerebral palsy, specific learning disability, autism
spectrum disorders, speech and language impairment, hearing
Disability impairment, muscular dystrophy, multiple disability
Others (thalassemia, haemophilia, sickle cell disease,
chronic neurological disorders)

Others Tourists, prisoners, homeless people, unorganised workers, retired people

41
Vulnerability changes based on the pre-existing conditions, environment, political
scenario, etc. For example, a drought or heavy rainfall in the field areas make farmers
vulnerable; whereas, cyclone makes fishermen and people living in the coastal areas
vulnerable. It is essential that all the vulnerable groups need to be identified and
equipped with skills and resources to anticipate, cope better, resist and recover from
the impact of disasters. Though different factors contribute to vulnerability among
individuals, the major vulnerable groups are: Children, Women, Older adult and
Persons with Disabilities. It does not mean that other groups do not require attention.
Vulnerable groups change based on the nature and intensity of the hazard, pre-existing
risks and prevailing socio-political conditions. It is, hence essential to identify
persons based on their vulnerability and plan measures to reach them promptly using
assistive and easily accessible services. Type of vulnerable groups and the factors
leading to it keep changing. Therefore, care need to be taken to constantly update
information on 'persons at risk' and plan programmes that enhance the psychosocial
competencies of vulnerable groups.

Figure 1.1: Indicators of vulnerability

Environmental - Geographical nature, infrastructure, density of population

Health- Chronic health conditions, disability

Communications- Media, public health education, warning arrangements

Economy- Insurance,employment, production

Psychology- Stress, personality, behaviour, acceptance

Emergency management- Plans, capacity building, resources

Organisational- Political systems, agencies, legislations

Cultural/societal- Language, culture, norms

Principles of working with vulnerable groups

Vulnerable groups being physically, psychologically or socially disadvantaged, need
more attention, while providing PSS. As vulnerability refers to the compromised
capacity of an individual to foresee, handle, resist to and recover from the impact of
disaster, principles of working with vulnerable groups should focus on building
resilience in them.

42
1. Principle of human rights promotion (promotion of equality, respect, dignity and
autonomy)
2. Principle of non-discrimination (providing services without any discrimination)
3. Principle of accessibility (easy accessibility to information, resources and
services)
4. Principle of protection from violence and exploitation (promoting awareness on
legal framework that protects vulnerable populations from any form of violence or
exploitation and exercising the same)
5. Principle of priority of services (offering rescue, relief and reconstruction services
first to persons belonging to vulnerable population and then to the universal
community)
6. Principle of preserving family unity (not separating vulnerable groups from their
family or neighbourhood)
7. Principle of confidentiality (ensuring confidentiality to personal information of
vulnerable groups and enabling anonymity while discussing their issues and
concerns)
8. Principle of inclusion (including in decision-making, planning, execution and
evaluation)
9. Principle of acceptance (accepting individuals with his/her strengths and
limitations)
[Link] of resourcefulness (acknowledging the inherent strengths, knowledge
and abilities of persons belonging to vulnerable groups)

Steps in identifying and empowering vulnerable groups before/during/after

disasters
STEP 1: Identify vulnerable groups: The first step to identify vulnerable population
is to define vulnerable groups and their vulnerabilities. Understanding the socio-
demographic characteristics (age, gender, economic status, occupation etc.) of the
community helps in identification of people at risk in the community. The process
should aim at listing out the criteria for vulnerable groups and categorise individuals
based on the vulnerabilities.
STEP 2: Mapping of vulnerable groups: After identifying the vulnerable groups,
they should be traced by mapping. The mapping should include details on the name of
the person, type of vulnerability, contact details (personal as well as
family/caregiver), nearest resource centre and so on. This can be done through local
organisations, health centres and other stakeholders.

43
STEP 3: Identifying existing resources: Persons with vulnerability have internal
and external strengths/resources. Internal resources include adaptive coping abilities,
education, employment, family support, skills and awareness about disaster related
preparedness. External resources include availability of organisations working for the
respective vulnerable groups, existing plans, policies, legislations, services and
programmes.
STEP 4: Connecting persons with services: If individuals in the vulnerable group
are already receiving services, it is essential to evaluate whether the available services
improving their psychosocial competencies, preparedness and disaster risk reduction.
If individuals have not yet received the services, they need to be encouraged to register
and avail services.
STEP 5: Disaster risk reduction strategies for vulnerable groups: Existing
services on preparedness and psychosocial support has to be enhanced, ensure its
reachability to the vulnerable groups. Participation of the vulnerable groups in the
planning and implementation of services also has to be encouraged.

Remember
l Vulnerable groups are those groups whose biopsychosocial conditions
affect their capacity to anticipate, cope, resist and recover subsequent to
disasters.
l Children, Women, Elderly and Persons with Disability are commonly
known vulnerable groups.

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 IMPACT OF DISASTERS ON
CHAPTER 2 VULNERABLE GROUPS
As already discussed in Chapter 1, impact created by disaster can be grouped into
physical, psychological, social and economic domains. Though disaster affects all
groups of people, the impact caused by disasters on vulnerable groups are more. This
chapter talks about the impact caused by disasters on vulnerable groups.

Impact of disasters on Children

Unpleasant experiences such as; loss of family, friends, home, pets, belongings (toys,
clothes, other belongings), place of study (day care/preschool/school), teachers and
place of recreation (parks, sports centres, library) etc., subsequent to disaster will have
a severe impact on children. This affects the different areas of their life- physical,
psychological and social, as shown in the table below;

Table 2.1: Impact of disaster on children

Age group Physical impact Psychological impact Social impact

l Delay in l Temper tantrums l Increase in the

developmental l Excessive crying and number of
milestones clinging behaviour orphans
l Regressive patterns l Child
l Headache (thumb sucking, bed trafficking
l Vomiting wetting) l Child abuse
l Multiple body ache l Delay in bowel or (physical,
0 to 5 years bladder control psychological
l Change in appetite
l Sleep disturbances l Fear (darkness, being & sexual)
alone, strangers)
l Night mares
l High sensitivity
(noise, light)

l Headache l Aggression l School dropout

l Stomach pain l Regressive l Easy exposure to
l Giddiness behaviours negative
l Poor/increased l Nightmares elements of the
appetite l Low mood society
l Decreased sleep l Lack of interest (substance
6 to 12 years l Change in sleep l Not obeying abuse)
and appetite l Being disruptive l Runaway
l Increased anxiety tendency
and fear l Increased risk-
l Poor attention and taking behaviour
concentration
l Withdrawal

13 to 18 years l Change insleep and l Withdrawn behaviour l Increased risk -

appetite taking behavior

45
 l Easily getting l Feeling guilty l Increased
tired l Excessive irritability antisocial
l Multiple body and aggression behaviour
Negative cognitions (engaging in
pain l
criminal
Changes in (helplessness,
l
activities)
worthlessness,
menstrual cycle l Change in family
helplessness) structure, class
(for girls)
l Disobedience and roles
l Poor concentration l Avoiding social
and interest interaction
l Suicidal thoughts l Avoiding
l Poor problem solving places/people/thin
and decision-making gs associated with
skills disaster event

“My grandmother would buy me a lot of toys. She died six months ago. Those toys
used to make me feel her presence. I lost my toy box when our house got collapsed. I
want those toys back and don't want to play with new toys”. (7-year-old girl)

“The landslide killed my father and sister. My mother and I are left alone. We have no
one to help. I wish we also were dead”. (12-year-old boy)

How the forest caught fire, I don't know. It was in the night; we were all asleep… I feel
scared to close my eyes. Even if I sleep, I get dreams of the fire, scream of the people,
and dead bodies” (16-year-old girl)

“When I grow up, I want to kill them all and take revenge. They killed my father in
front me. I don't want to go to the same house again.... I am not able to remove that
incident from my mind” (8-year-old boy)

“We had two cows. They were my friends. I used to play with them every day. I saw
them getting washed away but couldn't save them. I miss them very much and want
them back”. (6-year-old child)

Impact of disasters on Women

Disaster situations change the status of women from married to being widowed or
from men headed families to women headed families. Even when there is no loss of
life, when individuals are asked to shift to relief camps, women lack privacy. Disaster
also makes women vulnerable to exploitation. The common impact of disasters on
women are:

46
 Table 2.2: Impact of disaster on women

Physical impact Psychological impact Economic impact Social impact

l Multiple body pain l Fear l Financial l Domestic

l Palpitation l Anger difficulties violence
l Chest pain l Anxiety l Unemployment l Sexual violence
l Diabetes & l Hatred l Loss of l Abuse
hypertension l Guilt economic l Women
l Infections l Sadness independence trafficking
l Respiratory l Rage l Livelihood l Change in family
diseases l Disgust challenges roles, structures
l Changes in sleep l Symptoms of l Increase in
and appetite PTSD crimes against
l Vomiting (Avoidance, women
l Skin diseases hypervigilance, l Increased
l Allergy intrusion) substance abuse
l Urinary tract l Chronic stress
infection l Preferring to stay
l Excessive alone
tiredness l Self-neglect
l Giddiness l Negative thoughts
l Complications in
pregnancy
l Miscarriage

“I lost my husband in the train accident. Now I need to take care of my children alone.
I am afraid. I don't know how I can survive without my husband. I don't want to take
anyone's help. They might exploit me”.(43-year-old female)

“During Tsunami, I lost both my children. The caregiver was talking to my husband
and me about recanalization process. I am still apprehensive about the process. I am
still not out of my children's loss”. (29-year-old female)

“Before seeing the world, my child left me. I dreamt so much of my baby. Why God has
punished us like this. I want my child back”. (23-year-old female)

The people who attacked us were people we knew. They were not even considerate
towards women, they pulled us and hit. We used to go to their weddings and we even
celebrated festivals together. I don't think that will happen again. I lost trust on
people.” (34-year-old woman)

“Earlier I used to be very patient with my children. But now I lose my temper very
soon. At times, even the sound of children playing irritates me. What is wrong with me,
I don't understand?” (26-year-old woman)

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Impact of disaster on Older adult

Deteriorating sensory abilities, pre-existing physical health conditions and decreased

ability to concentrate, judge what is right and wrong, decision making etc., affect the
physical and mental well-being of older adults and make them more vulnerable than
the general population. The difficulties faced by older adult subsequent to disasters
are listed below:

Table 2.3: Impact of disaster on Older adult

Physical impact Psychological impact Economic impact Social impact

l Increase in l Adjustment l Increased cost l Threat to life

physical health difficulties of living and property
problems l Emotional l Livelihood l Poor
l Decline in coldness challenges accessibility to
performing daily l Anxiety services
routine l Fear l Increase in
l Injury l Inability to take crimes
l Disturbances in decision l Loss of support
sleep and l Poor l Older adult
appetite concentration abuse
l Increased chance l Excessive l Neglect/abando
of infection cribbing nment
l Higher risk of l Forgetfulness
life threat
l Excessive
tiredness

“My grandson died in the school building collapse. I used to take him every day to
school. On the day of collapse also, I dropped him. Now, whenever I pass by the site, I
remember him. Why did such a thing happen? He was the treasure of our family”. (68-
year-old male)
“I lost my son and daughter-in-law due to flood. They had long way to go in their life. I
wish instead of them God would have taken me. I don't find any point in living”. (74-
year-old female)
“Here at this relief camp, I don't have my people. My family members have been put in
a different place. Even if I want some help, I don't feel like asking anyone. I am not able
sleep at all. I am waiting to go back home”. (81-year-old male)
“I have BP, diabetes, and asthma. Looking at the news I feel scared of what if I get
corona. I have been telling everyone to be careful. Nobody is listening to me. They
don't even take a bath soon after coming. I am fed up of telling. If I happen to get
corona, I am sure I am going to die like an orphan”. (86-year-old female)

48
Impact of disaster on Persons with Disability (PwD)
Persons with disability require more attention from the family, community and
government. The already existing difficulties such as poor mobility, dependence on
others, societal stigma or discrimination, lack of services or poor accessibility to
services, etc., make them suffer more post-disasters. Common issues faced by PwDs
are listed below:

Table 2.4: Impact of disaster on persons with disability

Physical impact Psychological impact Economic impact Social impact

l Worsening of l Negative l Loss of l Social exclusion

the existing thoughts about livelihood l Lack of access
condition self and others l Deprivation to resources
l Being bed- l Death wishes from basic l Communication
ridden l Negative facilities barriers
l Easy exposure emotions (fear, l No or l Loss of existing
to infection guilt, sadness, underpaid job support
and diseases hatred) l Delay in social l Poor support
l Reproductive l Mental health welfare l Violence against
issues problems benefits PwDs

“My father died in the recent earthquake. He was the only bread winner of our family.
I, being a person with visual impairment, need to be supported by my parents. My
mother and I are now left alone. I don't know what to do”. (22-year-old male with
visual impairment)

“When everybody was running to save their lives from the flood, I was helpless. With
the help of rescuers somehow my life was saved, but I got severely injured. Thinking of
my condition, I feel helpless. If I had been a normal person, my situation would not
have been like this”. (26-year-old male with locomotor disability)

l The groups mentioned above are the major vulnerable groups that are severely
impacted subsequent to disasters.

l Along with these, the caregiver should also look for groups that would have disaster
specific impact. For example, during droughts or heavy rainfall, farmers need to be
focused and during cyclones fisher folk living near the coastal areas might get
affected the most.

l Irrespective of disasters, people belonging to lower socioeconomic condition and

socially disadvantaged groups (scheduled castes, scheduled tribes, other backward
classes and minorities) get highly affected by disasters due to increased
vulnerability in the form of poverty, lack of resources and poor support.

49
l Other groups that might warrant increased attention are people living in houses
with poor quality construction and older construction sites.

l Homeless people and people with lower income also constitute groups that require
increased attention.

l Institutionalised persons like prisoners, children, women, older adults in shelter

homes, hospitalised persons, personnel working in hospitals also suffer greater loss
as well as decreased attention during emergencies. These groups might face
increased physical injuries and adverse physical effects. They experience
significant loss of life and property that disrupts their existing support and
resources leading to decreased social support and increased financial difficulties.
These make these individuals more vulnerable to stress related disorders and other
mental health problems (depression, anxiety, PTSD, etc.).

Remember
l Children, women, elderly and persons with disability suffer physical, psychological,
economic and social damages post disaster.
l Along with the above-mentioned persons in need of increased assistance, disasters
create new vulnerable groups.
l Lower socioeconomic condition and disadvantages faced by people in the society
make people more vulnerable.

50
 STRATEGIES FOR WORKING
CHAPTER 3 WITH VULNERABLE GROUPS
Vulnerable groups have diverse needs. The caregivers need to make sure that services
reach these groups. Adopting certain unique strategies while working with vulnerable
groups help in enhancing their coping. This chapter elaborates strategies which
caregivers need to incorporate while working with vulnerable population.

CHILDREN

Response of the children vary depending upon their age. Therefore, age of the
children has to be considered while working with them in disasters. Age-appropriate
activities need to be planned while providing PSS for the children. Along with
focusing on the child, the caregiver needs to focus on their family as well. Parents are
role models for the children. Therefore, parental coping influences the child. Parents
need to be informed in advance about adaptive coping strategies, so that they can be
the model for their children.

Some of the key measures to be adopted while working with children are:

l Help the child to be connected with significant people (parents, friends, teachers,
relatives, neighbours).
l Engage the child in intervention (PSS) process using psychosocial mediums.
l Instil a helping spirit in the child.
l Monitor the child's routine.
l Limit exposure to disaster related media.
l Teach child to name the emotions and express them.
l Help child to learn self-care and adaptive coping strategies.
l Foster goal setting skills (short and long term).
l Encourage the child to be hopeful about the future.
l Enable child to understand better about self.
l Facilitate acceptance to change.

Mediums for working with children

Strategies that work with adults do not work with children. Children require
expressive mediums that enable them to unconsciously express their feelings and
inner experiences. Psychosocial caregiver need to assess the psychosocial impact of
disaster and plan tailor-made intervention strategies. Mostly these mediums are done
in groups and the group experience facilitate the healing process. The psychosocial
mediums tap the emotional disturbances that children experience and facilitate
positive thinking and behaviour.

51
 Figure 3.1: Framework for using the psychosocial mediums
Assessment Intervention
Initiation Phase
Phase Phase
Assessing the l Enabling the
l Talking to the l

psychosocial child to talk

child's family about the
l Making the impact using
feelings and
child feel appropriate
emotions
comfortable psychosocial l Managing
l Buiding mediums resistance
rapport with l Using child l Empowering the
the child friendly child to think
strategies and behave
differently

Common psychosocial mediums that can be used while working with children

1. Facial expression cards: Facial expressions help in

naming the emotions. It is essential for children to
understand the emotions that they are undergoing.
Facial expressions help them to identify the emotions
they are experiencing and talk it out freely. Through the
facial expression card child's present feelings,
disturbing events in the past and its impact on the child
and his/her family and future plans will be explored.

2. Thematic story cards: The thematic story cards help in tapping the child's feelings,
thoughts and emotions in the present, after the impact
and helps in developing positive future goals. The
children are made to relate themselves with the
illustrations given in the thematic cards and asked to
make meaningful stories of their past, present and
future. It also reveals the child's current needs, coping
abilities and available support.

3. Family portrait: Family portrait is another

psychosocial medium through which the caregiver can
understand the environment of child's family. This
technique helps to minimize the resistance among
children to talk about their families and enables
communication, understanding and emotional
relatedness. It can also be used as an assessment tool
where the psychosocial caregiver can understand about
the family's structure, roles of different individuals in the family and their closeness to
the child. It also aid in understanding the communication patterns, roles, leadership
patterns, and conflicts in the family. The caregiver needs to look into the colour,
elements added in the portrait, distance between the members and emotions depicted
to understand the child in the family.

52
4. Drawing: Drawing helps to express the repressed
emotions, unspoken thoughts and improve the thinking
abilities of the child. The child's drawing represents the
child, his/her inner feelings, confined emotions, needs
and concerns. It also acts as an assessment tool, where
the caregiver can understand the child's emotional state
and create strategies to foster adaptation and effective
coping skills in the child. Drawing reduces anxiety among children. It also enhances
relationship with the caregiver.

5. Writing: Writing can be used as an expressive

medium for children who have difficulty in
communicating their subjective feelings and emotions.
Writing about distressing events also help children to
decrease anxiety levels. While other creative activities
help children cope with trauma, writing medium is
more helpful to communicate his/her thoughts and
feelings with words. It fosters self-understanding,
acceptance and decreases tension. It is a healing way of releasing negative emotions,
helps to imagine future positively and enhances reconciliation and reframing.

6. Family dolls: Story telling using dolls is fun and

enjoyable. Children like playing with dolls. Dolls act as
an encouraging medium for children while talking
about their life stories. The doll characters make
expression of the child's inner self easy. The inhibitions
children have in communicating can be broken by using
puppets and dolls for sharing personal experiences.
This medium helps the child talk about the life
experiences freely. Since the medium uses family dolls, it would help the caregivers to
understand environment of the child's family. The child's expectations from the other
family members, unity in the family and issues that are affecting the family
functioning can be easily taped. The activity also helps in loosening the association
the child has with the issues as the issues can be displaced to the doll while talking
about them.

7. Clay modelling: Clay modelling can be used to

reduce negative mood and anxiety, awaken creativity,
foster socialization and aid healing from trauma. Clay is
primarily a physical medium that has a soothing effect
on both adults and children. It enables safe outlet for
feelings while the child involves in reshaping of the
clay. During the activity, the end product is not
important but the process is more important. The child
need not focus on making creative things but the child's expression associated to the
things should be emphasised. Clay is a powerful tool for expression of
emotions/thoughts, reshape, and mould the nonliving object into whatever thing s/he
wishes.

53
Advantages of using psychosocial mediums

l Empowers children to understand their emotions and name them

l Helps in expressing negative beliefs and emotions
l Builds psychosocial competencies
l Enables identification with peers
l Creates cohesion and team spirit
l Models' positive self-concept and boosts esteem
l Improves communication and understanding
l Mediums help in fostering communication among children who are resistant,
less vocal and defensive
l Helps the caregiver to understand the inner feelings, thoughts and emotions of
the child

WOMEN

Women in many Indian societies are restricted to do the household chores. Mostly
they are economically dependent on men, poorly educated and culturally deprived of
rights. These pre-existing social vulnerabilities along with physical and mental
susceptibilities make women vulnerable during emergencies. The multiple losses
especially loss of husbands or male households make women more vulnerable and
make their livelihood and safety harder. There is increased chance of being abused
(physically, sexually and emotionally) during or after emergencies. Women also face
significant reproductive health and privacy issues during or after disasters. These
vulnerabilities make them deprived of support services or resources in relation to
disasters.

54
The caregiver needs to remember the following while working with women in
disasters:

l Opportunities need to be created for women to express the impact of disaster and
their needs.
l Services should focus on empowerment of women in making decision for their
lives.
l Safety of women need to be ensured at all times.
l Engage women in planning, implementation and evaluation of services related to
disaster risk reduction, relief and rehabilitation.
l Services need to be provided to assess domestic violence and sexual abuse of
women.
l Privacy of women get largely affected especially when they are made to stay at
relief camps. Hence, measures need to be taken to preserve the privacy of
women.
l The reproductive health of women needs to be given due attention.
l Recanalization option needs to be suggested for those women who have lost their
children in disasters.
l Special attention needs to be given to pregnant women, young women and
women who have lost their husbands/children/other households.

Table 3.2: Measures to help women in disasters

Pre-disasters Post-disasters

l Educate local leaders on the l Care needs to be taken to include

importance of including women in women headed households while
disaster risk reduction planning and providing the relief and
preparedness activities. reconstructive services.
l Enable gender perspectives in l Relief packages should be gender
vulnerability, risk and resource specific and aim at meeting the needs
mapping. of women.
l Include gender roles, inequalities and l Services aiming at addressing the
disaster specific impact on women as specific needs of women (dealing
a part of psychosocial assessment. with domestic violence, substance
l Incorporate gender dimensions in abuse, abuse of children/women,
DRR planning and community high risk pregnancy etc) need to be
resilience building activities. created and informed in advance.
l Establish coordination with agencies l Vulnerable groups among women
that work towards the empowerment (single woman, widows, pregnant
of women. etc) need to be closely monitored and
l Build psychosocial competencies supported adequately.
(coping with distress, identifying l Security and safety needs of need to
strengths/resources, seeking help, be given priority.
involving in decision making etc) of
women.

55
PERSONS WITH DISABILITY

Disasters can worsen the condition of persons with disability or can create new
persons with disability. Persons with disability have physical, communication and
attitudinal barriers due to their condition. Our society still remains unaware about the
needs of persons with disability. The vulnerabilities can worsen the condition of a
person during disaster who is already disabled. PSS should focus on minimising the
limitations of persons with disabilities and create accessibility for disaster related
services.

The following are the barriers to include the PWDs in Disaster Management Cycle:

l Poor awareness on available schemes, programmes and policies.

l Poor access to disaster related information.
l Difficulty in accessing escape routes.
l Extreme reliance on caregivers.
l Poor visibility in the society.
l Stigma and discrimination.
l Non availability of data pertaining to PWDs.
l Lack of funding for programme planning and implementation.

It is hence essential to eliminate the barriers and enhance inclusion of persons with
disability in planning and implementation strategies aiming at disaster risk reduction
and relief or rehabilitation services. The following framework helps in enhancing
coping, adaptation and resilience among persons with disability:

l Include in decision making: Persons with disability are resourceful. They know
their issues better than any other persons. It is vital to create positions in decision
making bodies for persons with disability such that they would be able to express
their issues and make decisions to deal with them adequately.
l Eliminate barriers: Persons with disability have physical, information, social and
economical barriers that act as a hurdle in receiving services. The barriers to
social, professional and personal lives need to be identified and eliminated.
l Enhance sensitivity: Community and other stakeholders are unaware of the
needs and concerns of persons with disability. It is hence essential to sensitise
these stakeholders on the same.
l Identify the persons with disabilty: It is essential to identify persons with
disability in advance so that preparedness, rescue, relief and rehabilitation efforts
focused on PWDs can be faster.
l Set up preparedness strategies: Preparing PWDs and their caregivers in advance
on disaster risk reduction and psychosocial competencies to minimise the impact
of disaster.

56
Some of the strategies to be followed while helping persons with disability are:

l Make the person with disability know that help is available in a way s/he
understands.
l Provide easy access to necessities (food, clothing, shelter, health, assistive
devices).
l Ensure personal safety.
l Communicate with the person in a modality in which s/he is able to access
information (e.g., sign language, brail).
l Respect the person and accept him/her with the limitations.
l Work from a rights perspective.
l Create easy accessibility to disaster related services.
l Assess the needs of persons with disability (physical, psychological, social and
economic) and plan services accordingly.
l Understand the strengths and skills of persons with disability.
l Assess support available and the individuals' support needs (activities of daily
living, livelihood, etc.).
l Along with the person with disability, the caregiver who predominantly takes
care of him/her needs to be given attention. Many a time these caregivers will be
more responsible than the individual himself/herself.

While designing any strategy for PwDs, their right to be included in planning,
implementation and monitoring of DRR activities and PSS services need to be
respected. Understanding their strengths along with their limitations make them feel
respected and accepted.

PERSONS WITH MENTAL ILLNESS

Though persons with mental illness come under persons with disability, strategies can
slightly differ while working with persons having mental illness. These persons might
have difficulty in expressing their needs due to the symptoms. Poor awareness and
stigma/discrimination towards mental illness, make people in the community difficult
to reach out this population to provide support. Because of their mental illness, these
individuals might have deficits in self-care and daily activities. Their
family/social/occupational functioning may also get affected because of their
condition. Emergencies can increase the symptoms due to the non-accessibility to
medication/hospital services, loss of support systems, distress precipitated by disaster
and non-availability of rehabilitative measures. Hence, while working with persons
having mental illness, the caregiver needs to remember the following:

l Ensure safety and dignity.

l Be patient while providing services.
l Understand that they are not harmful.
l Try to elicit treatment details from available record or caregivers.
57
 l Make a prompt link to the local DMHP team.
l Restart medication and facilitate regular treatment with help from local DMHP
team.
l Provide basic facilities.
l Give precise instructions and do not overload them with information.
l If the person is withdrawn, initiate a conversation but do not force the person to
talk.
l Do not try to argue with the person or debate on the symptoms.
l Give importance to the rights of person with mental illness.
l Include their primary caregivers or significant family members in planning and
providing services.

OLDER ADULT

Pre-existing health complications, easy vulnerability to infections, poor

responsiveness in the sense organs (hearing, vision, touch, smell etc), problem in
thoughts (difficulty in understanding, hopelessness, helplessness, worthlessness,
death wishes etc), poor accessibility to resources and support increase the
vulnerability of older adults during disasters. These factors decrease the ability of
older adults to recognise disaster related early warning signs, respond promptly
during emergencies and access post-disaster specific information. While working
with older adult the caregivers need to remember the following:

l Providing reassurance help them feel safe and comfortable.

l The rights of older adults need to be prioritised and respected.
l The caregiver needs to make a detailedassessment of the needs of older adults
such as physical (medicines, assistive devices), psychological (problems in
thoughts, mental health issues etc), social (family, religion, community, groups)
and economic needs.
l Older adults without primary support must be assisted by some volunteers from
the community.
l Some individuals might be reluctant to seek support. They should not be forced
to take support. Caregiver should understand the reason for reluctance and
formulate strategies to deal with it.
l While planning materials/services aiming at DRR, relief or rehabilitation,
limitations (physical and sensory) of older adults should be considered.
l Older adult people are also resourceful. They might have past experiences of
losses and have traditional knowledge related to disaster management.
Therefore, while planning for disaster management related services, such
knowledge and experiences need to be considered.
l Along with participation in planning, the skills and strengths of older adults can
be utilised in taking care of themselves and other people who are in need.
l There is increased risk for abuse/exploitation of older adult. They need to be
informed on the legal options available during such instances.
58
All the above strategies help in identifying the risks among vulnerable groups, help
them to communicate with the caregivers and, strengthen PSS strategies for
enhancing resilience among these groups.

Remember
l Vulnerable groups need to be given first preference in disaster related
services.
l The rights of persons in need of extra support during disasters need to be
respected.
l Assessing the needs of vulnerable population and tailoring appropriate
strategies enhance resilience among them.
l Psychosocial mediums help in tapping the unexpressed thoughts and
feelings of the child.
l Children feel at ease to talk about the issues while using psychosocial
mediums.
l Disasters create new persons with disability and can worsen the condition
of persons who are already disabled.
l Though persons with disability have pre-existing vulnerabilities,
identifying their personal strengths help in restructuring disaster
management activities.

59
 Section - 3
CARING FOR CARERS
 ROLES OF PSYCHOSOCIAL
CHAPTER 1 CAREGIVERS
Psychosocial support (PSS) in disasters mandates involvement of different
stakeholders. In India, there is a huge disparity between the distribution of mental
health professionals and the population density. This disparity makes mental health
services hard to reach to all people. Therefore, it is essential to increase the number of
trained human resources to reach out the persons in need for PSS. Any individuals
with adequate capacity building and handholding, can deliver psychosocial services.
Those individuals who are trained on implementing PSS services are called
psychosocial caregivers. Their role is vital as they are volunteers from the same
community and know the culture, sentiments, beliefs, attitudes and practices of the
community members. The figure below enlists the different individuals who can be
trained as psychosocial caregivers:

Importance of Psychosocial Caregivers

They act as a bridge between the survivors and the services.
They help in early identification, facilitation of referrals and follow-up.
They foster community participation, planning, implementation and continuity of
services
They enhance spectrum of care services (rights and justice, compensation, health
care, housing, psychosocial concerns, livelihood, self-help, legal and educational
services).
Psychosocial caregivers, most often, belong to the local community. Hence,
sustainability of the psychosocial services can be attained.
61
Role of Psychosocial Caregivers
The role of psychosocial caregivers is not restricted to providing emotional support.
They also act as enablers in providing complete support. The roles of the psychosocial
caregivers can be categorized as those prior to disasters and subsequent to disasters.

Some of the major roles and responsibilities are highlighted below:

PRE-DISASTER

l Creating psychosocial response team: Community members are the first

responders in any disasters. For the prompt response to limit the negative
consequences of disasters the psychosocial caregiver cannot function alone. It is
essential to form teams who will be responsible for different activities and to
work in collaboration. The psychosocial caregiver needs to be an enabler in
creation of psychosocial response teams. Along with being a facilitator, it is
necessary to be a catalyst in identifying short-term and long-term goals related
to provision of preparedness and PSS services in the community. Working as a
mediator between the existing services and people in need for support also
forms the role of caregivers. Along with playing the role of an organizer of
preparedness, mitigation and DRR activities, caregivers also need to evaluate
such activities periodically.

l Doing Hazard, Risk and Vulnerability (HRV) analysis and resource

mapping: Disasters cannot be prevented but the negative impact of the disasters
can be reduced through effective preparedness measures. A well planned HRV
analysis and resource mapping help in installing proper preparedness measures.
The psychosocial caregiver needs to enable community participation in planning
and implementation of HRV analysis and resource mapping.

l Formulating psychosocial response plan: The understanding gained through

analysis of community hazards, risks, vulnerabilities and resources help in
formulating preparedness and psychosocial response plans. Psychosocial
response plans act as blueprints to preparedness and PSS services.

l Conducting psychosocial mock drills: The plans that evolved through

community participation need to be communicated to the community through
mock drills. Psychosocial mock drills help in sensitising the community on the
psychosocial services, understanding community responses, knowledge and
skill building. It helps in identifying the gaps in knowledge, attitudes, beliefs and
practices. It also strengthens the community-based culturally sensitive
preparedness and PSS services.

62
 l Promoting the psychosocial competencies of disaster-prone communities:
Psychosocial competencies help in dealing with the daily stressors that people
experience in life. These skills help in enhancing the community's coping
abilities, adaptation and resilience. The psychosocial caregivers can conduct
group meetings that aim at nurturing psychosocial competencies among
community members especially vulnerable groups.

l Mobilising resources for better preparedness: Skills related to mapping of

resources, preservation of resources, creation of new resources and utilisation of
existing resources during emergencies important to promote resilient
communities. Each community and its members are resourceful. This
resourcefulness can be internal as well as external. Internal resources can be
traditional knowledge in anticipating emergencies, adaptive coping skills, etc.
External resources can be availability of support from family, neighbourhood,
non-governmental and governmental agencies.

l Networking with local agencies: Disaster impact is large and stress inducing.
The needs of survivors are diverse. To meet the needs of disaster-prone
communities, better preparedness initiatives need to be positioned through the
involvement of multiple stakeholders. Local agencies who are already working
with the community will have close ties with the community. If the community
has trust on the local agencies, reaching out to them will be easier. The
psychosocial caregiver needs to liaison with local agencies and instill spirit
among them to work on creating disaster resilient communities.

POST-DISASTER

l Assessing the post-disaster psychosocial needs of the community: Disaster

shatters individuals, families and communities. The psychosocial needs of
communities, subsequent to disasters, can be grouped into physical,
psychological, economic and social needs. The caregiver might be able to
provide active PSS services during the search and rescue operations. During this
time, the caregiver can engage in assessing the psychosocial needs of the
community while helping in the search/rescue operation.

l Psychosocial triaging: Large number of people might require only

psychosocial first aid. Certain individuals may require PSS and some people
may require mental health referral and treatment. The psychosocial triaging
would enable caregivers to categorise people based on their needs. Certain
individuals might not develop mental health complications initially, but they
need to be monitored closely. This facilitates prompt identification and early
treatment. Triaging also helps in regulating the utilization of resources.

63
l Providing multidimensional care: PSS does not mean providing only
emotional support. PSS services should also include a collection of services
ranging from linking survivors with resources related to provision of rights and
justice, compensation, health care, housing, livelihood, self-help and legal aid. It
should not stop with referral. Its focus needs to be also on whether the survivor
was able to access the resource, what change the link brought in the lives of the
survivors and how the spectrum of care services helped in the road to recovery.
The individuals need to be followed up periodically. Dependency issues need to
be tackled. Self-sufficiency and ownership need to be promoted.

l Focusing on people at risk: Though all individuals in disasters need to be

focused, special attention need to be given to vulnerable populations (children,
women, older adult, persons with disability, etc). Sensitivity has to be ensured
that priority is given to these groups while providing services.

l Dealing with the barriers in accessing psychosocial care services: There

might be individual (survivor's attitudes, vulnerabilities, inadequate support),
organisational (lack of professionals, services, professional attitudes) and
environmental (culture, societal stigma) barriers that prevent the accessibility of
PSC services. Psychosocial caregivers need to constantly assess the barriers and
improvise with strategies that ascertain accessibility.

l Facilitating coordination and communication: The psychosocial caregiver

should foster better communication and coordinate with stakeholders. Direct
and meaningful communication between the survivors and services is necessary
and it would enhance the quality of service.

l Promoting psychosocial resilience: The aim of psychosocial services is

promoting prompt recovery. The psychosocial caregiver visits survivors
periodically, provides emotional support, links with services and talks to them on
adaptation skills, better coping abilities and creates opportunities to widen
community support and resources. These individual and group psychosocial
services act as roadmap for psychosocial resilience among individuals, families
and communities.

Remember
l Psychosocial caregivers aid in preparing the community to anticipate, cope,
resist and recover during disasters and in provision of holistic care
subsequent to disaster.
l Psychosocial caregivers play a vital role in promoting resilience in the
community.

64
 DISASTER RELATED WORK &
CHAPTER 2 MENTAL HEALTH COMPLICATIONS
Working in harsh disaster situations, exposure to negative life experiences, death,
trauma of victims, staying away from families and dealing with extremities might
trigger significant distress among caregivers. Prolonged distress while working in
disasters might lead to burnout and secondary traumatic stress among caregivers. This
would affect their well-being and curtail the efficiency of service. The caregivers need
to distinguish between normal and abnormal reactions subsequent to disaster.

Table 2.1: Reactions post-disasters and necessary actions

Most first responders may experience mild

distress, disturbances in sleep, fear, anxiety, Normal reactions during disaster
sadness, increased use of substances

Some first respondents may have

Need to be monitored to avoid
prolonged sleep deprivation, moderate
worsening of symptoms
anxiety, changes in workplace behaviour

Few responders develop mental health

problems like post-traumatic stress Need prompt professional mental
disorder (PTSD), major depression, etc. health treatment

Source: Benedek, Fullerton, & Ursano, 2007

Working in emergencies propels multiple stressors for the caregivers. Stress that
experienced by the carers can be attributed by the work or the trauma caused by
disaster. Timely identification and management of stress experienced by carers
prevent them from having mental health adversities.

Pre-disaster stressors

Local response: Any individual will have strong bonding with the community in
which s/he lives. When caregivers work in their local areas, they might have personal
grievances about the family, friends and the neighbourhood.

Unprecedented call: Disasters can strike at any moment and caregivers may not be
always prepared to respond promptly. When they are summoned for relief and rescue
operations, they need to change their prior commitments and report.

Unfamiliar expedition: The caregivers need to travel long distances and work in
unfamiliar communities during disasters. Traveling long distance and working in
unacquainted environment would trigger stress among individuals.

65
Anticipating unknowns: Until and unless caregivers start disaster related
operations, they might be completely unaware of the impact. The caregivers will have
many questions for which s/he might not have immediate answers.

Stress during Disasters

Most of the caregivers working in disaster experience short-lived stress reactions and
few among them develop severe mental health complications. It is a known fact that
disaster carers experience shock, exhaustion, anger, despair, poor sleep, and change in
routine. They have complaints about the work environment as well.

Table 2.2: Common reactions experienced by caregivers

Shock, fear, despair, guilt, shame, depressive cognitions, lack of

interest, being emotionally cold, confusion, excessive worry, poor
Psychological attention and memory, problems in decision making and problem
solving, hatred.

Fatigue, multiple body pain, palpitation, perspiration, vomiting

Physical sensation, change in sleep and appetite, tension.

Preferring to be alone, disturbed relationship with family / friends /

Interpersonal colleagues, distrust, higher conflict.

Contributors to distress among caregivers

Work related Trauma related

l Extreme working conditions l Hearing the grievances of
l Uncomfortable resting disaster affected people
environment l Witnessing fatalities
l Poor Interpersonal relationship l Experiencing danger to self
with colleagues, subordinates l Having a disaster related
or higher ups physical impact (injury,
l Working in unfamiliar illness, exposure to harmful
environment radioactive substances)
l Inability to reach family or
connect to social ties
l Difficulty in completing the
assigned task
l Problems with planning and
prioritisation

66
Burnout
The unattended work-related prolonged distress causes burnout. Physical and
psychological exhaustion along with decreased interest in work are the key
characteristics of burnout.
Table 2.3: Common reactions among caregivers experiencing burnout
Work productivity (quality/quantity) decreases,
Work work disengagement, shifting of work priorities, escapism.
Poor sensitivity to the needs of others, being aloof,
Relational undue complaining and blaming, scapegoating.

Pessimism, irritability, mood fluctuations, persistent sadness,

feeling trapped, memory and concentration problems,
Psychological emotional exhaustion, poor decision making/problem solving
and ruminating about negative events.
Changes in sleep and appetite, fatigue, multiple body pain,
Physical easily getting sick or being prone to accidents.
Behavioural Increased use of psychotropic drugs, resorting to risky
behaviours.

Secondary Traumatic Stress

Repeated exposure to disaster related negative events/trauma might make caregivers

to mirror negative emotions (fear, anxiety, pain) experienced by survivors. Following
are the indicators of secondary traumatic stress;

l Extreme anxiety about uncertainties

l Occurrences in the present or future
l Being hyper vigilant
l Physical reactions to stress (pounding heart, palpitation, perspiration, etc.)
l Repetitive thoughts/imagery about disturbing events in the past
l Perceiving other's trauma as one's own
l Experiencing compassion fatigue (decreased sympathy towards the disaster
victims due to prolonged work in disaster settings)

Other mental health complications caregivers might develop are Depression, PTSD,
Substance Use Disorder and Anxiety Disorders.

Thought for the mind

l Working in disaster settings affect the mental health of caregivers.
l Caregivers experience stress due to disaster related work and trauma
witnessed/experienced in disasters.

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 MENTAL HEALTH PRESERVATION
CHAPTER 3 STRATEGIES
Initially, caregivers involve in disaster related work with a heroic spirit. As days pass
by, the spirit weans away and caregivers become susceptible to mental health
complications. Being in a disaster situation, seeing the turmoil of the disaster
victims/survivors, vigilant and risky work environment, erratic and intense work
schedules, staying away from family and involving in live saving decisions make
caregivers vulnerable to stress. Certain strategies need to be adopted by the caregivers
during different stages of disaster management to preserve their mental health and
avoid psychological problems.

1. SELF-CARE STRATEGIES FOR CAREGIVERS

Before During
l Following a healthy lifestyle. l Planning ahead and prioritising one’s
l Being informed about one’s personal work.
stressors and coping strategies. l Working in teams.
l Taking part in different training l Having a ‘dear comrade’ and talking to
programmes to acquire knowledge and him/her frequently.
skills related to rendering care during l Following healthy lifestyle (food, sleep,
emergencies. exercise, etc.).
l Being clear about one’s roles and l Taking adequate breaks.
responsibilities during the impact. l Following one’s routine.
l Being aware of the stressors that can be l Adhering to safety precautions.
precipitated during disasters and having l Having debriefing sessions periodically.
a rough plan to deal with the stressors. l Maintaining a well-being journal.
l Being prepared with a kit that contains l Talking to family and friends.
the essential amenities for survival l Practicing yoga or relaxation techniques.
during disaster situations. An ever- l Being assertive and setting limits.
ready survival kit can help in l Avoiding the use of substances.
eliminating last minute hassles. l Not over-identifying oneself with the
trauma survivors or victims.
l Carers with pre-existing physical or
mental health complications should
After
resume their treatment regimen and be
l Continuing healthy lifestyle. vigilant to avoid fresh surge of
l Evaluating one’s physical and mental symptoms.
health. l Appreciate self and others
l Focusing attention on reknitting with
social and spiritual connections.
l Spending time for self.
l Seeking professional help when things
are beyond one’s coping abilities.

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2. DEAR BUDDY

'Dear BUDDY' is a peer support system where the first responders are grouped
together in pairs of two. The pairs need to monitor one another's work, stress and well-
being. The system aims at promoting personal safety and resilience amidst disasters.

Steps to initiate buddyship

l Building rapport: Make the pairs understand one another. Facilitate a talk on
their origin, family, interests, experiences, achievements and plans. This should
capacitate the peers to develop awareness on either person's strengths or
weaknesses.
l Observe one another during the work.
l Have daily or frequent debriefing sessions. The debriefing sessions facilitate
ventilation and catharsis. The peers listen carefully to the feelings and emotions
of one another and provide reassurances and support.
l Share basic needs during disaster situations
l Monitor work load, check the stress levels and direct appropriate management
strategies

Do’s Don’ts
l Understand the needs of the co-
l Do not label or diagnose the co-
buddy before s/he vocalises it
comrade
l Be an empathetic and active
l Do not try to counsel or give
listener
advice
l Communicate frequently
l Do not be judgemental
l Provide reassurances adequately
l Do not demand the co-buddy to
l Provide appropriate help or
discuss about his/her problems
support when the co-buddy is in
l Do not force the co-buddy to
distress
follow the given directions/
l Motivate the co-buddy to seek
solutions/ alternatives
professional treatment when
needed

3. ENHANCING RESILIENCE AMONG CAREGIVERS

Distress experienced by most caregivers is temporary. The bouncing back ability
fosters posttraumatic growth. Knowledge of risk factors that trigger distress and
protective factors that favour resilience would enhance resiliency among caregivers.

69
 Risk Factors Protective Factors
Pre-Disaster l Pre-existing medical or l Longer experience working in
psychological conditions disaster situations
l Lack of experience or training l Proper induction through
l Poor leadership and decision- capacity building activities
making abilities l Enhanced professional skills
l Unhealthy lifestyle l Team cooperation and support
l Significant negative life events l Personal resilience and
in the past satisfaction with life/work

During Disaster l Closeness to the disaster l Adequate Social support

epicenter l Good interpersonal
l Hazardous use of substances relationship with superiors
l Longer working hours in and co-workers
unfamiliar and unprecedented
environment
l Working in spite of severe
injuries
l Long exposure to dead bodies
l Identifying oneself with
survivors/victims or becoming
emotionally involved
l Having poor information
l Poor coordination and support

Post-Disaster l Post disaster life events l Debriefing sessions

l Increased use of l Psychological counseling
technological devices services
l Media Reporting of the l Support from co-workers
disaster
l Use of avoidance coping
l Poor reinforcement

4. WELLS OF COPING

70
 PHYSICAL PSYCHOLOGICAL SOCIAL
l Cycling l Imagining the past l Meeting friends
l Walking positive events and relatives
l Trekking
l Journaling l Making new
l Jogging
l Dancing l Planning friends
l Aerobics l Singing l Talking to friends
l Playing sports l Drawing over phone

CREATIVE RECREATIONAL SPIRITUAL

l Doing something l Cooking l Praying
different l Embroidery l Reading religious
l Breaking the l Designing texts
monotony l Watching humour l Chanting
l Going for a l Pilgrimage
picnic/movie l Singing religious
l Taking a break hymns
l Participation in
religious ceremonies

Using the same adaptive coping strategies repeatedly might result in boredom. The
caregivers need to try different portals of adaptive patterns like physical,
psychological, social, creative, recreational and spiritual strategies to achieve holistic
well-being. Care needs to be taken that the carers are able to differentiate between
adaptive and maladaptive coping behaviours and practice the adaptive ones.

5. MAKING A TREE OF SUSTENANCE

71
Mitigation strategies for caregivers

l Positive and clear communication with colleagues

l Following routine
l Be connected with close ones
l Plan in advance
l Understand personal coping & follow adaptive coping strategies
l Be updated
l Monitor self-stress levels
l Seek professional help when distress escalates
l Update the tree of sustenance

Remember
l Adaptive coping strategies and coping resources are essential to preserve
the mental health of caregivers.
l Buddy system (dear comrade) will help in forming social ties in times of
distress.
l Risk factors deter the process of resilience and protective factors favor
resiliency.

72
Level-2: Certificate Course on Psychosocial Care in Disasters

The psychosocial care in disasters module can be provided as a certificate course. This would aim at
provision of psychosocial care in disasters for survivors of disaster and vulnerable groups. CLWs
can be proportionate trained persons from level-1, representatives from NGOs and CSO with
Bachelor’s Degree. The virtual training will be for three months and the participants will be provided
with psychosocial care in disasters manual cum facilitation guide and workbook. The participants
will be capacitated on psychosocial care in disasters services, PSS for vulnerable groups and caring
for self. On completion of the course curriculum of 12 online sessions of two hours each and 20
resource material provided and completion of assignments, case studies and other requirements they
will be provided a Certificate from NIMHANS and endorsed by NDMA/ SDMA.

73
National Disaster Management Training Module - 2
Facilitators Guide

Psychosocial Care in Disasters

Work Marriage Law

Health Others

Finance Education
Family &
Social
Courtship & Bereavement
Cohabitation

March 2023

Jointly Developed by

National Disaster Management Authority National Institute of Mental Health and Neuro Sciences
(NDMA) (NIMHANS)
 CONTENT

Chapter Title Page No

Section-1
1. Introduction to disaster and psychosocial first aid 77-78
2. Psychosocial Triage 79
3. Psychosocial support (PSS) in disasters 80
4. Psychosocial needs assessment 81
5. Stress during disasters 82
6. Mental health issues among disaster survivors 83
7. Life events, family life cycle and disaster 84
8. Psychosocial support (PSS) techniques 85
9. Referrals and follow ups 86

Section -2
1. Vulnerable groups in disasters 87
2. Impact of disasters on vulnerable groups 88
3. Strategies for working with vulnerable groups 89

Section-3
1. Roles of psychosocial caregivers 90
2. Disaster related work & mental health complications 91
3. Mental health preservation strategies 92

75
 PROGRAMME SCHEDULE

No Name of Session Methodology Duration

1 Introduction to disaster and psychosocial first aid Recap, Role plays 90 min
and Individual work

2 Psychosocial Triage Case discussion and 90 min

presentation

3 Psychosocial support (PSS) in disasters Presentation & 90 min

Discussion

4 Psychosocial needs assessment Free listing and 90 min

discussion

5 Stress during disasters Role play and 90 min

discussion

6 Mental health issues among disaster survivors Case discussion 90 min

Sharing of
7 Life events, family life cycle and disaster 90 min
experience

8 Psychosocial support (PSS) techniques Group activity 180 min

9 Referrals and follow ups Groups discussion 90 min

10 Vulnerable groups in disasters Brain storming and 90 min

Discussion

11 Impact of disasters on vulnerable groups Role play 90 min

12 Strategies for working with vulnerable groups Group activity and 90 min
discussion

13 Roles of psychosocial caregivers Brain storming and 90 min

discussion

14 Disaster related work & mental health complications Group activity and 90 min
Discussion
Group activity and
15 Mental health preservation strategies 90 min
discussion

76
 Section - 1

FACILITATORS GUIDE
Session 1: Introduction to disaster and psychosocial first aid.

Aim: To give an overview of disaster and Psychosocial First Aid (PSFA).

Methodology: Recap, Role plays and Individual work.

Duration: 90 min.

Process: Facilitator will give an introduction to disasters, various types of disaster and its impact.
Activity 1 given below will be conducted focusing on needs of disaster survivors. Followed by the
activity the facilitator discusses about the PSFA and its strategies. The session will be concluded
with activity 2..

Outcome of the session: Participants will understand the concept of disaster and PSFA.

Activity 1
Description of the activity: Needs Pyramid (Brainstorming).
Aim: To sensitize the participants on the needs of disaster survivors.
Duration: 30 min.
Materials Required: A4 sheets and pens.
The facilitator describes that the disaster survivors would have varied physical
and psychosocial needs and asks the participants to list out the various needs the
survivors experience after a disaster. The facilitator then helps the participants
collate the needs in the needs pyramid.

77
 Activity 2
Description of the activity: Psychosocial First Aid (Roleplay).
Aim: To help participants understand about Psychosocial First Aid.
Duration: 60 min
Materials Required: Role play cards.

Eight individuals will be asked to volunteer and will be paired into groups of two. In each
group, one individual has to act like a caregiver and the other as survivor of a recent disaster as
listed below.
Group 1: An 8 years old child who is alone (looking afraid and crying).
Group 2: A wounded transgender (not a very severe wound).
Group 3: A person who is wheelchair bound placed in a relief camp.
Group 4: A 30-year-old male looking for his family members who are missing.
After each roleplay, the facilitator asks how comforted the survivor felt, what are the various
PSFA techniques that were used by the caregiver and summarizes the components of PSFA
that can be integrated while dealing with the disaster affected individuals/communities.

78
 FACILITATORS GUIDE
Session 2: Psychosocial Triage.
Aim: To help participants understand psychosocial training.
Methodology: Case discussion and presentation.
Duration: 90 min.
Process: Facilitators will give an introduction to psychosocial triage. An activity given below will
be conducted and the session will be concluded.
Outcome of the session: Participants will understand the concept of psychosocial training.

Activity 3
Description of the activity: Psychosocial Triage.
Aim: To help participants understand psychosocial training matrix and facilitate psychosocial
training using the psychosocial triage flowchart.
Duration: 90 min.
Materials required: Case vignettes (Given in Module 2 - chapter 2)
The facilitator initially orients the participants on the indicators listed in the psychosocial
matrix and explains the participants about the psychosocial triage process using the
psychosocial triage flowchart. Then the participants will be divided into 6 teams and each
team will be given a case vignette. The teams need to read the case vignettes carefully and look
for vulnerabilities. Based on the presence or absence of the indicators, the teams need to
specify whether the person mentioned in the case belongs to high/moderate/low risk category.
After assessing, the groups need to use the flowchart and specify the appropriate service for
the person based on his/her level of psychosocial risk. In case of online instead of group
activity the case vignettes will be displayed on the slide and participants will be encouraged
take part in the discussion.

79
 FACILITATORS GUIDE
Session 3: Psychosocial support (PSS) in disasters.
Aim: To help participants understand PSS, its evolution and levels of PSS.
Methodology: Presentation & Discussion
Duration: 90 min.
Process: Facilitator will give an introduction to PSS in disaster and its evolution in India. An activity
given below will be conducted, then the facilitator will discuss about PSS activities, what is PSS and
what is not PSS. The session will be concluded after discussing about the levels of PSS.
Outcome of the session: Participants will understand the concept of PSS.

Activity 4
Description of the activity: What is PSS? (Brainstorming).
Aim: To enhance the understanding of the participants on PSS.
Duration: 90 minutes.
Materials Required: Nil.
The facilitator asks the participants on what do they think of PSS. Once the participants
respond on their thoughts about PSS, the facilitator discusses if the response given by the
participant is part of PSS or not.

80
 FACILITATORS GUIDE
Session 4: Psychosocial needs assessment.
Aim: To facilitate understanding of the participants on psychosocial needs assessment.
Methodology: Free listing and discussion.
Duration: 90 min.
Process: The session begins with the activity 5. Followed by the activity facilitator discusses about
the psychosocial needs assessment at individual, family and community level and SWOT analysis.
Brief overview of the community assessment tools will be given. The session will be concluded with
the discussion on pyramid of psychosocial needs.
Outcome of the session: Participants will be able to do the psychosocial needs assessment.

Activity 5
Description of the activity: Individual, family and community needs.
Aim: To help participants to understand psychosocial needs assessment at different levels.
Duration: 90 min.
Materials Required: Three chart papers and markers.
The facilitator divides the participants into three groups and will be ask them to discuss on
assessing the needs of individuals, families and communities. The discussion should cover
pre-existing conditions, impact, requirements, resources and gap between the needs and
resources pertaining to individuals/families and communities. Once all the groups finish their
discussion, the nominated person from each group will be asked to present the points to the
entire group. The facilitator summarizes the points after each presentation.

81
 FACILITATORS GUIDE
Session 5: Stress during disasters.
Aim: To help participants understand the stress during disasters.
Methodology: Role play and discussion.
Duration: 90 min.
Process: Facilitators will give an introduction to stress during disasters and various stress full
reactions. An activity given below will be conducted and then the facilitator will explain the ways to
deal the psychological reactions among different age groups and the session will be concluded.
Outcome of the session: Participants will understand the stress during disasters.

Activity 6
Description of the activity: Role Play.
Aim: To understand the different stress reactions during disaster.
Duration: 90 min.
Materials Required: Nil.
The participants are divided into 4 groups and each group is asked to perform a roleplay that
would express stressful reactions during disaster namely (1) physical, (2) psychological, (3)
behavioral and (4) relational reactions. Ten minutes is given for the groups to plan for the
roleplay. Facilitator goes around and clears the doubts of the participants. After planning, each
group is asked to perform the roleplay for 5 minutes. After each roleplay, the facilitator
brainstorms on the reactions expressed by each group and adds reactions pertaining to the
topic. Once all the groups finish their act, the facilitator summarises the key points and talks
about the importance of knowing the different reactions of stress reactions during disasters.

82
 FACILITATORS GUIDE
Session 6: Mental health issues among disaster survivors.

Aim: To facilitate understanding about the mental health issues among disaster survivors.

Methodology: Case discussion.

Duration: 90 min.

Process: Facilitator discusses about the common mental health conditions that occur in the
survivors’ post disasters. Once the participants get oriented about the mental health conditions the
session will be concluded followed by conducting activity 7.

Outcome of the session: Participants will be able to understand the common mental health
conditions among the disaster survivors.

Activity 7
Description of the activity: Case based discussion.
Aim: To orient the participants on mental health conditions that might arise post disasters.
Duration: 90 min.
Materials Required: Case vignettes.
The participants will be divided into six groups. Each group will be given a case vignette (refer
chapter 6) that explains about a mental health problem. The participants need to identify the
symptoms and the condition. Each of the group will be given time to share their observations
and other participants will be asked if they agree upon the same.

83
 FACILITATORS GUIDE
Session 7: Life events, family life cycle and disaster.
Aim: To orient participants about the life evens and its impact on family life cycle post disaster.
Methodology: Sharing of experience .
Duration: 90 min.
Process: The session will begin with activity 8. Followed by the activity the facilitator orients the
participants on stressful life events, family life cycle stages and impact of stressful events family life
cycle.
Outcome of the session: Participants will understand various stressful life events caused by disaster
and its impact on family life cycle.

Activity 8
Description of the activity: Paper pencil test.
Aim: To make the participants to understand the stressful life events in disaster.
Duration: 90 min.
Materials Required: Presumptive Stressful Life Events Scale (PSLES).
The facilitator distributes the PSLES Questionnaire (given in the annexure) to the participants
and gives the instructions to fill it. Once the participants have filled, the facilitator encourages
volunteers to share their personal experiences of stressful life events. The facilitator needs
ensure confidentiality and provide reassurances as and when required.

84
 FACILITATORS GUIDE
Session 8: Psychosocial support (PSS) techniques.
Aim: To introduce PSS techniques to the participants while working with disaster survivors.
Methodology: Group activity.
Duration: 180 mins.
Process: Facilitators will give an introduction to different PSS techniques and discusses 10 different
PSS techniques one after the other. After 1st technique (Empathy), the activity 9 will be conducted.
After participants’ share their observations, the facilitator introduces the importance of ventilation
and steps to be taken to facilitate ventilation of emotions and feelings among disaster survivors.
Outcome of the session: Participants will understand the PSS techniques.

Activity 9
Description of the activity: Breaking the balloon.
Aim: To teach the participants on the importance of ventilation and steps to follow to motivate
disaster survivors to talk.
Duration: 180 mins.
Materials Required: Balloons.
The facilitator calls 10 to 12 volunteers. All the volunteers will be given one balloon. Of the 10
or 12 volunteers, 5 to 6 are informed in advance (secretly) that they should act like blowing the
balloon and should not burst it. The facilitator calls all the volunteers and asks them to burst the
balloons saying, “let us see who breaks the balloon first”. Once all the volunteers (who did not
receive secret communication in advance) have broken their balloons, the facilitator asks the
overall group to talk about their observations.

85
 FACILITATORS GUIDE
Session 9: Referrals and follow ups.
Aim: To make participants understand the significance of referrals and follow ups while providing
PSS.
Methodology: Groups discussion.
Duration: 90 mins.
Process: Facilitator introduces the session and discusses about who needs referral in the process of
providing PSS, steps in facilitation of referrals, ethics to be followed while referring and follow up.
The session will be concluded with the following activity.
Outcome of the session: Participants will understand the ways of initiating referrals and doing
follow ups.

Activity 10
Description of the activity: Connecting people with services.
Aim: To help the participants understand the spectrum of care, how to initiate referrals and do
follow-ups.
Duration: 90 mins.
Materials Required: Case studies.
The facilitator divides the participants into three groups and gives one case vignette to each
group. The groups have to discuss on the needs of the survivor presented in each case and the
suitable referrals based on their needs. Once discussion is done, each group will be invited to
present their points. Facilitator will generate the discussion and add on the points.
Case study 1: A 46-year-old woman who was a housewife with a 23 years old daughter lost
her husband in the air crash. She was completely in a denial. The husband was the only bread
winner of the family. Her daughter’s marriage also got cancelled because of this. Both the
mother and daughter were completely shattered and did not know what to do as they had no
one to support.
Case study 2: A 16 years old female child lost both her parents in a bomb blast. She was
staying in her maternal uncle’s house since then. She was been crying for many months even
after the incident. There were vivid scars on her face. When asked to speak about it, she was
continuously crying and did not open up about it. Her uncle doesn’t let her talk to others. She
also seemed malnourished and poorly kempt and was not going to school.
Case study 3: A 60 years old man was found lying on the road. He was highly intoxicated. The
neighbors told that he lost everyone in his family during the earthquake. The neighbors told
that he is from an affluent family and had addiction issues even before the earthquake. The
drinking has increased after the earthquake. He lost his house during the earthquake. His
relatives cheated him recently and took most of his money. Because of it he mostly stays by the
road and begs to manage in necessities.

86
 Section - 2
FACILITATORS GUIDE
Session 1: Vulnerable groups in disasters.
Aim: To help participants understand the different vulnerable groups in disasters and factors leading
to vulnerability.
Methodology: Brain storming and Discussion.
Duration: 90 mins.
Process: Facilitators will give an introduction to vulnerable groups in disaster and the activity given
below will be conducted. In continuation to the activity, the discussion will be carried out on
different factors leading to vulnerability, indicators of vulnerability, principles to be followed while
working with vulnerable groups, and steps in identifying and working with vulnerable groups.
Outcome of the session: Participants will be able to identify different vulnerable groups, factors
leading to vulnerability and steps to be followed while working with this group.

Activity 1
Description of the activity: Identifying vulnerable groups.
Materials Required: Table 1.1 (Module 2b).
Aim: To orient participants on different vulnerable groups in disasters.
Duration: 90 mins.
The participants will be shown table 1.1 (Module 2b) and will be asked to identify people who
are vulnerable to disasters based on the vulnerability factors displayed in the table.

87
 FACILITATORS GUIDE
Session 2: Impact of disasters on vulnerable groups.
Aim: To enhance participants understanding on the impact of disasters on vulnerable groups.
Methodology: Role play.
Duration: 90 mins.
Process: Facilitator discusses about the impact of disaster on vulnerable groups with special focus
on children, women, older adult and persons with disability (PwD). The session will be concluded
with the activity given below.
Outcome of the session: Participants will understand the impact of disaster on vulnerable groups.

Activity 2
Description of the activity: Impact of disasters on vulnerable groups.
Aim: To help participants understand the impact of disasters on vulnerable populations.
Duration: 90 mins.
Materials Required: Role play cards.
8 volunteers will be called and they will paired into four groups. Following topics will be given
(one each) and the volunteers will be instructed to think of a case scenario depicting the
impact. One member will be asked to play the role of a survivor and other as caregiver. Others
will have to observe the role play and give their feedback.
Group 1: Impact of disaster on children
Group 2: Impact of disaster on women
Group 3: Impact of disaster on elderly
Group 4: Impact of disaster on persons with disability

88
 FACILITATORS GUIDE
Session 3: Strategies for working with vulnerable groups.
Aim: To help participants understand the impact of disasters on vulnerable groups.
Methodology: Group activity and discussion.
Duration: 90 mins.
Process: Facilitators will give an introduction about strategies to work with women, children, older
adult and person with disability. An activity will be conducted as given below and the session will be
concluded.
Outcome of the session: Participants will understand various strategies to work with vulnerable
groups.

Activity 3
Description of the activity: Planning strategies.
Aim: To orient the participants on the strategies for working with vulnerable groups.
Duration: 90 mins.
Materials Required: Four chart papers and markers.
The facilitator divides the participants into four groups and asks them to discuss on strategies
for working with vulnerable groups (children, women, persons with disability and elderly).
Then the facilitator adds on strategies to the discussion points.

89
 Section - 3
FACILITATORS GUIDE
Session 1: Roles of psychosocial caregivers.

Aim: To make the participants understand about the roles of psychosocial caregivers.

Methodology: Brain storming and discussion.

Duration: 90 mins.

Process: The session begins with the activity given below. After the activity the facilitator will
discuss about the roles of psychosocial caregivers in pre-disasters and post- disasters phases and also
the importance of psychosocial givers in providing PSS.

Outcome of the session: Participants will understand the roles of psychosocial caregivers in
disaster.

Activity 1
Description of the activity: Car and driver.

Aim: To orient participants about the roles of psychosocial care providers.

Duration: 90 mins.

Materials Required: Nil.

The participants will be asked to pair with each other. One of the persons (car) in the pair has to
stand in front of the other (the posterior side facing the person). The person in the back (driver)
has to lay both the hands on the other person’s shoulder. The person in the front has to close
his/her eyes and the person at the back has to direct movement without speaking and only with
touch. All the pairs walk and after sometime, the pairs exchange their roles. After the exercise,
the facilitator asks the group to share the experiences as a car and a driver. The facilitator
explains that the experiences shared by the driver are those of the caregiver and that shared by
the car are those experienced by the survivors.

90
 FACILITATORS GUIDE
Session 2: Disaster related work & mental health complications.
Aim: To help participants understand stressors and mental health complications of psychosocial
caregivers.
Methodology: Group activity and Discussion.
Duration: 90 mins.
Process: Facilitator introduces the topic and conducts the following activity. Once the activity is
done the facilitator discusses about the common reactions experienced by caregivers, factors
contributing to their distress, burnout and secondary traumatic stress in caregivers.
Outcome of the session: Participants will understand the common stressors and mental health
complications among psychosocial caregivers.

Activity 2
Description of the activity: “I am getting burdened”.
Aim: To sensitize participants on the mental health adversities experienced by caregivers due
to disaster related work.
Duration: 90 mins.
Materials Required: Nil.
One volunteer will be asked to come and sit in the center on a chair. Other participants will be
instructed to pile up things (books, files, other stationary in the training hall) one by one.
Initially the volunteer will be able to hold the objects but when they get exhausted, s/he will not
be able to hold it and they should stop taking the more of it. The facilitator then asks the
volunteer to share his/her experiences.

91
 FACILITATORS GUIDE
Session 3: Mental health preservation strategies.
Aim: To teach mental health preservation strategies to the participants.
Methodology: Group activity and discussion.
Duration: 90 mins.
Process: The session begins with activity 3. Followed by the activity the facilitator discusses
different strategies that can be used by the psychosocial caregivers before, during and post-disasters.
Outcome of the session: Participants will understand various mental health preservation strategies.

Activity 3
Description of the activity: Group discussion.
Aim: To generate discussion among the participants about the strategies that can be adapted
before, during and after disaster.
Duration: 90 mins.
Materials required: 3 papers and pens.
The participants will be divided into three groups and each group will be given the following
topics: (1) Strategies to be adopted before disaster, (2) Strategies to be adopted during disaster
and (3) Strategies to be adopted after disaster. Each of the group will be invited to present their
points to all the participants.

92
National Disaster Management Training Module - 2
Workbook

Psychosocial Care in Disasters

Work Marriage Law

Health Others

Finance Education
Family &
Social
Courtship & Bereavement
Cohabitation

March 2023

Jointly Developed by

National Disaster Management Authority National Institute of Mental Health and Neuro Sciences
(NDMA) (NIMHANS)
 CONTENTS

Chapter Title Page No

Socio-demographic profile 96

Knowledge on psychosocial support (PSS) in

disaster management 97

Section-1

1. Introduction to disaster and psychosocial first aid 98-100

2. Psychosocial Triage 101-103

3. Psychosocial support (PSS) in disasters 104-105

4. Psychosocial needs assessment 106

5. Stress during disasters 107-108

6. Mental health issues among disaster survivors 109-110

7. Life events, family life cycle and disaster 111

8. Psychosocial support (PSS) techniques 112

9. Referrals and follow ups 113-114

Section -2

1. Vulnerable groups in disasters 116-117

2. Impact of disasters on vulnerable groups 118-119

3. Strategies for working with vulnerable groups 120-123

Section-3

1. Roles of psychosocial caregivers 125-126

2. Disaster related work & mental health complications 127-129

3. Mental health preservation strategies 130-132

94
 Section - 1
PSYCHOSOCIAL SUPPORT
IN DISASTERS
SOCIO-DEMOGRAPHIC PROFILE

1. Name(Initials):

2. Contact Details: Email:

Phone Number (Optional):

3. Age:

4. Sex: Male Female Others

5. Marital Status: Married

Unmarried
Divorced / separated / widow / widower

6. Education: Schooling1-10th std Graduate

Post Graduate Others (specify)

7. Place of residence: Urban Rural Semiurban

8. Current Address:

9. Occupation:

10. Monthly Income:

11. Years of Experience:

12. What are your expectations from the training?

96
KNOWLEDGE ON PSYCHOSOCIAL SUPPORT (PSS) IN DISASTERMANAGEMENT

I don’t know anything about

PSS in disaster management.
1

I heard about PSS in

2 disaster management
but don’t know about it.

I have seen
others providing PSS in
disaster management but
3
I don’t know about it.

I know very little about

4 PSS
in disaster management.
I know the need for
PSS in disaster
management but know 5
very little about
how to provide it
I know the importance of
PSS in Disaster Management
6 and how to provide to
the general community.
I know the importance of
PSS in Disaster
Management and how to 7
provide it to the vulnerable groups.
I know the importance of
PSS in Disaster Management
8 and provide hand holding
services to the
affected community.
I know the importance of PSS
in Disaster Management and
confident in providing PSS to 9
the disaster hit communities
and vulnerable people.
I am aware of PSS in
Disaster Management and
10 can provide PSS and confident
in training others on the PSS.

97
Chapter-1: Introduction to Disaster and Psychosocial First Aid

Impact of Disaster

98
Needs of the Disaster Survivors

99
100
CHAPTER 2 PSYCHOSOCIAL TRIAGE

Psychosocial triage matrix

Indicators Low Risk Moderate Risk High Risk

Physical
closeness

Expressive
closeness

Individual
vulnerabilities

Environmental
vulnerabilities

Instant reactions
during the disaster

Ongoing reactions

Coping

101
Psychosocial Triage

102
Nature of psychosocial services provided based on the risk level

103
 PSYCHOSOCIAL SUPPORT
CHAPTER 3 IN DISASTERS

Psychosocial support (PSS) activities

104
Psychosocial support ‘IS’ Psychosocial support ‘IS NOT’

Levels of psychosocial support

105
 PSYCHOSOCIAL NEEDS
CHAPTER 4 ASSESSMENT
Different levels of psychosocial needs assessment

Individual Assessment Family Assessment Community Assessment

Psychosocial Needs Assessment Techniques, ICRC & IFRC, 2008

Strengths Weaknesses

Opportunities Difficulties

106
CHAPTER 5 STRESS DURING DISASTERS

Stressful reactions during disasters

Multiple reactions experienced by different age groups in the post-disaster phase

Reactions among Children

Reactions among Adolescents

Reactions among adults

Reactions among older adult

107
Normal and abnormal reactions during disasters

NORMAL REACTIONS ABNORMAL MENTAL HEALTH

REACTIONS PROBLEMS

Normal and abnormal reactions post-disasters

108
 MENTAL HEALTH ISSUES AMONG
CHAPTER 6 DISASTER SURVIVORS

109
THE MOST COMMON MENTAL HEALTH PROBLEMS POST-DISASTERS

Adjustment Problems:

Post-Traumatic Stress Disorder (PTSD):

Anxiety related problems:

Depression:

Panic Disorder:

Dissociative reactions:

Other mental health problems:

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 LIFE EVENTS, FAMILY LIFE
CHAPTER 7 CYCLE AND DISASTER

Family life cycle

Influence of life events on family life cycle post-disaster

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 PSYCHOSOCIAL SUPPORT
CHAPTER 8 TECHNIQUES
Psychosocial support techniques

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CHAPTER 9 REFERRALS AND FOLLOW-UP

Steps in the facilitation of referral

Establishing Rapport

Assessment of Needs

Deciding the need for referral

Preparing the objectives for referral

Exploring referral options

Communicating to the survivor and the agency

Actual referral

Receiving feedback

Review and termination

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Ethical practices to be followed while facilitating referrals

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 Section - 2
WORKING WITH VULNERABLE GROUPS
 VULNERABLE GROUPS IN
CHAPTER 1 DISASTERS

Table 1.1: Vulnerable groups, during different types of disasters

Factors Vulnerable Groups

Age

Gender

Occupation

Family

Ethnicity

Status

Health

Trauma

Displacement

Disability

Others

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Indicators of vulnerability

Environmental:

Health:

Communications:

Economy:

Psychology:

Emergency management:

Organisational:

Cultural/societal:

Steps in identifying and empowering vulnerable groups before/during/after disasters

Steps 1:____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Steps 2:____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Steps 3:____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Steps 4:____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Steps 5:____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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 IMPACT OF DISASTERS ON
CHAPTER 2 VULNERABLE GROUPS

Impact of disaster on children

Age group Physical impact Psychological impact Social impact

0 to 5 years

6 to 12 years

13 to 18 years

Impact of disaster on women

Physical Psychological
Economic impact Social impact
impact impact

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Impact of disaster on older adult

Physical Psychological
Economic impact Social impact
impact impact

Impact of disaster on persons with disability (PWD)

Physical Psychological
Economic impact Social impact
impact impact

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 STRATEGIES FOR WORKING
CHAPTER 3 WITH VULNERABLE GROUPS

Some of the key measures to be adopted while working with children

120
Common psychosocial mediums that can be used while working with children

121
 The caregiver needs to remember the following while working with women in disasters:

Measures to help women in disasters

Pre-disasters Post-disasters

The barriers to include the PWDs in Disaster Management Cycle

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While working with persons having mental illness, the caregiver needs to remember
the following:

While working with elderly the caregivers need to remember the following:

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 Section - 3
CARING FOR CARERS
 STRATEGIES FOR WORKING
CHAPTER 1 WITH VULNERABLE GROUPS

Who can be trained as psychosocial caregivers

Role of psychosocial caregivers

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Role of psychosocial caregivers pre-disaster

Role of psychosocial caregivers post-disaster

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 MENTAL HEALTH AMONG
CHAPTER 2 CAREGIVERS IN DISASTER

Reactions post-disasters and necessary actions

Stress during disasters

Common reactions experienced by caregivers

Psychological

Physical

Interpersonal

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 Contributors to distress among caregivers

Work related Trauma related

Common reactions among caregivers experiencing burnout

Work

Relational

Psychological

Physical

Behavioural

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Secondary traumatic stress

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 MENTAL HEALTH PRESERVATION
CHAPTER 3 STRATEGIES

Before During

After

130
Dear Buddy

Steps to initiate Buddyship

Enhancing resilience among caregivers

Risk Factors Protective Factors

Pre-Disaster

During Disaster

Post-Disaster

131
Wells of coping

132
Reference
1. Benedek, D. M., Fullerton, C., &Ursano, R. J. (2007). First responders: mental health
consequences of natural and human-made disasters for public health and public safety workers.
Annu. Rev. Public Health, 28, 55-68.

2. Brannen, D. E., Barcus, R., McDonnell, M. A., Price, A., Alsept, C., & Caudill, K. (2013).
Mental health triage tools for medically cleared disaster survivors: an evaluation by MRC
volunteers and public health workers. Disaster medicine and public health preparedness, 7(1),
20–28.

3. Geldard, K., Geldard, D., & Foo, R. Y. (2017). Counselling children: A practical introduction.
Sage.

4. IASC Reference Groups MHPSS. IASC Guidance on Operational Considerations for

Multisectoral Mental Health and Psychosocial Support Programmes during the COVID-19
P a n d e m i c ; I A S C : G e n e v a , S w i t z e r l a n d , 2 0 2 0 ; Av a i l a b l e o n l i n e :
[Link]
psychosocial-support-emergency-settings/iasc-guidance-operational-considerations-
multisectoral-mental-health-and-psychosocial-support (accessed on 6 May 2022)(In Multiple
Languages).

5. National Disaster Management Guidelines: Psycho-Social Support and Mental Health Services
in Disasters, 2009. A publication of the National Disaster Management Authority, Government
of India. ISBN 978-93-80440-00-2, December 2009, New Delhi.

6. NDMA. (2021). Annual Report. New Delhi: National Disaster Management Authority.

7. New South Wales (NSW) Health, Disaster mental health response handbook. North Sydney,
NSW: NWS Health, 2000.

8. Roxane Richter, E. M. T., & Flowers, T. (2008). Gendered dimensions of disaster care: critical
distinctions in female psychosocial needs, triage, pain assessment, and care. American journal
of disaster medicine, 3(1), 31-37.

9. Seto, M., Nemoto, H., Kobayashi, N., Kikuchi, S., Honda, N., Kim, Y., ...& Tomita, H. (2019).
Post-disaster mental health and psychosocial support in the areas affected by the Great East
Japan Earthquake: A qualitative study. BMC psychiatry, 19, 1-13.

10. World Health Organization. (2011). Psychological first aid: Guide for field workers. World
Health Organization.

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Project Advisory Committee
1. Shri. Krishana S Vatsa, Member, National Disaster Management Authority,
and PSC Chairman, New Delhi.
2. Dr. Nimesh Desai, Director, Institute of Human Behavior and Allied Sciences
(IHBAS), Delhi.
3. Dr. Jacqueline Joseph, Professor, Centre for Disaster Management, Jamsetji
Tata Institute of Social Sciences, Mumbai.
4. Ms. Sindhuja Khajuria, UNICEF, Communication Consultant, New Delhi.
5. Dr. Atreyi Ganguli, National Professional Officer, Mental Health and
Substance Abuse, WHO, India.
6. Dr. Saurabh Dalal, National Professional Officer, Emergency Risk and Crisis
Management, WHO, India.
7. Shri. Maître Mukerji, Senior Consultant, National Disaster Management
Authority, New Delhi.

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Project Team
Dr. K. Sekar, Former Prof. and Head, Department of Psychosocial Support in
Disaster Management, National Institute of Mental Health and Neuro Sciences,
Bangalore.
Dr. Jayakumar C, Associate Professor, Principal Investigator, Department of
Psychosocial Support in Disaster Management, National Institute of Mental Health
and Neuro Sciences, Bangalore.
Dr. Patrick Jude, Project Coordinator, Department of Psychosocial Support in
Disaster Management, National Institute of Mental Health and Neuro Sciences,
Bangalore.
Dr. Veena Sree, Project Coordinator, Department of Psychosocial Support in Disaster
Management, National Institute of Mental Health and Neuro Sciences, Bangalore.
Mrs. Jayashree, Project Associate, Department of Psychosocial Support in Disaster
Management, National Institute of Mental Health and Neuro Sciences, Bangalore.
Mrs. Aleena Mathai, Project Associate, Department of Psychosocial Support in
Disaster Management, National Institute of Mental Health and Neuro Sciences,
Bangalore.
Ms. Irien Joe, Project Associate, Department of Psychosocial Support in Disaster
Management, National Institute of Mental Health and Neuro Sciences, Bangalore.

135