A silver lining in strife torn camps of Bodoland , Assam : a case study intersecting gender , disaster , and mental health

A case of a 40-year-old, Muslim woman, educated up to class IV, homemaker by profession, hailing from a lower socioeconomic background of Chirang district of Assam was referred to medical camp, with symptoms of reduced interest in daily activities, increased tension, fearfulness, with decreased amount of sleep and appetite. Psychiatric social work assessment showed that she had a frictional and confl icting relationship with her husband. Due to which her quality of life was compromised. On further assessment it was found that the client was having moderate level of functioning. Impact of Event Scale score suggested cutoff for a probable diagnosis of posttraumatic stress disorder (PTSD), consider consulting a mental health professional. The client was referred to a psychiatrist for further assessment and treatment, and she was diagnosed as PTSD. Later individual, marital, and group interventions were provided and moderate improvement in terms of self-esteem, reducing anxiety, and enhancing coping mechanism. The present case study prompts us to look at the intersection of mental health, disaster, and gender. Disasters have been taking place since time immemorial and will continue to occur. A signifi cant percentage of survivors develop profound, debilitating posttraumatic stress reactions requiring extended mental health intervention. These extreme stress reactions include fear and irrational behaviour, shock, immobilisation, withdrawal, denial and intrusive thoughts, hyper-vigilance, easy startle, insomnia, decreased attention and concentration, and psycho-physiological reactions. The social work professionals have long been involved with disaster relief work, both at individual and community level.


Introduction
India is prone and vulnerable to natural and manmade disasters; [1,2] prolonged confl icts and other complex situations impede the country's overall development, and oft en infl ict the right of a citizen to live in peace.North Eastern states have witnessed number of prolonged confl icts for the past few years.Similarly in July 2012 a riot broke out in the state of Assam between Bodos and Muslims, and the centre of confl ict was the Bodoland Territorial Autonomous Districts (BTAD).Th e riot has changed the lives of innumerable people and has changed the overall scenario of the inhabitants of the region.As reported in number of print and electronic media, over hundreds were killed and over four lakhs rendered homeless in BTAD.Months aft er the communal disturbance that took place many people are still unable to return to their normal lives.Th e scenario witnessed in the post riot camps are an ocean of unfathomable tragedy.Stories of death, destruction, and destitution were found to be abounded.

Case report
RB, a 40-year-old Muslim woman, educated up to class IV and from a lower socioeconomic background of Chirang (Assam), a home maker by profession was referred in a medical camp organised by an NGO in the relief camp for assessment and treatment.A detailed social history taking with the client provided with an insight of her previous and present conjugal life.RB mentioned that she had been married when she was just 15.She was an obedient daughter and thus committed herself for an arranged marriage with a farmer who was six years older to her.Initial three years of marriage as described was pretty easy going for her apart from few confl icts with her in-laws.Her husband did spend quality time with her and fulfi lled all her desires.Soon the couple was blessed with their eldest son.Th e whole family was in the state of merry making but RB's life was shaken.From confi dential source she heard about her husband's extra-marital aff air.On confronting him, he clearly denied the allegations and instead labeled her insane for suspecting him.As revealed by RB though they OJPAS | Volume 7 | Issue 2 | July-December 2016 had three more off -springs aft er the episode of confrontation yet the 'intensity' , the 'purity' of their marriage was losing its essence with time.It was refl ected by her husband's attitude towards her.He did not spend much time with her and there began a spate of physical and verbal abuses, that too in front of other family members.Th e worse happened when he started consuming alcohol and came in to the open about his status of having illicit relationships with other women, which RB described as the most heart breaking reality of her life.As mentioned by RB, her husband spent the major part of his earning on other women and on alcohol.Th us, with time where a family should progress and move forward their situation degraded.She saw no hope of his amelioration and accepted it as her fate.Th e riot out broke and thus she experienced the turmoil of a disaster.Houses were set on fi re, crops were destroyed, and people were injured and killed.Alike her, individuals around her lost their normal pace of life.Th e violence around changed her life too.RB along with her family had to take refuge in a camp.She started complaining of reduced interest in daily activities, fear along with intrusive thoughts of the communal disturbance, increased tension, fearfulness, and hyper-vigilance along with decreased amount of sleep and appetite.Th e family members reported that she had nightmares and fl ashbacks about the communal riots, had diffi culty falling asleep, and felt detached or alienated, and these symptoms started impairing the client's daily life.
Psychiatric social work assessment was done in the medical camp by administering socio-demographic and clinical datasheets, as well as daily functioning checklist and Impact of Event Scale [3] were administered.Th e daily functioning checklist score suggested that the client was having moderate level of functioning.It is a semi-structured interview schedule developed for the purpose of assessment.Impact of Event Scale score suggested cutoff for a probable diagnosis of posttraumatic stress disorder (PTSD), consider consulting a mental health professional.Th e client was referred to a psychiatrist for further assessment and treatment, and she was diagnosed as PTSD.According to the individual need brief psychiatric social work intervention was planned and implemented.Th e client was provided three individual sessions, two group sessions, and two follow-up sessions.A conjoint session was held with her husband.Th e individual session focused rapport building, supportive counselling, teaching relaxation technique and healthy coping mechanism skill.Group session was conducted to enhance community support system for one another and to educate the group members about mental illness.Th e initial session was focused on gathering information and building a therapeutic alliance and establishing goodwill between the psychiatric social worker and the patient.During this session she was informed about the importance of intervention and the benefi ts she would gain through the process of intervention.Confi dentiality was emphasised upon and reassurance and positive attitude towards the patient was accentuated.Psycho-education was provided to instill hope, educating about signs and symptoms, enhancing selfesteem, and engaging in treatment.Supportive counselling was rendered to the client for building self-esteem, reducing anxiety, and enhancing coping.Reassurance, empathetic listening, and unconditional acceptance were skillfully used to support her. Th e client was taught PTSD symptoms making her aware about her thoughts and feelings.She was taught about the skills to challenge her thoughts and feelings (cognitive restructuring), and making her understand the common changes in beliefs that occur aft er going through trauma.In the relaxation session the client was taught diaphragmatic breathing (deep breathing exercise) to help her relax and to manage her distress to get control of her thoughts and feelings.In conjoint session marital issues were addressed to enhance communication between the husband and the wife.Group intervention was provided for sharing of experiences, building relationships to deal with emotions, and to build self-confi dence and trust.Group session also focused mainly on expressing of individual distress and enhancement of support among each other.Two follow-up sessions were conducted focusing mainly on the feedback and reviewing of the previous session, and coping and problem solving skills were taught.Patient revealed of moderate recovery and was interested in further sessions with the psychiatric social worker.Th e case was terminated aft er two follow-up sessions.

Discussion
It has been recognised that the most of the disaster-aff ected persons experience stress and emotional reactions aft er a disaster as a normal response to an abnormal situation.While some of the survivors would be able to cope by themselves, a signifi cant proportion of them may not be able to do so eff ectively.Studies have shown that normal and pathological grief, acute stress reaction, depression, generalized anxiety disorder, PTSD, alcohol and drug abuse are prevalent among the survivors.Emotional reactions such as guilt, fear, shock, grief, hyper-vigilance, intrusive memories are universal responses in people experiencing unforeseen disastrous events beyond their coping capacity.[4][5][6][7] Under Section-6 of the Disaster Management Act.2005, the National Disaster Management Authority (NDMA) is, inter alia, mandated to issue guidelines "for preparing action plans for holistic and coordinated management of all disasters".Th e guidelines focus all aspects of Psycho-Social Support and Mental Health Services (PSSMHS) with an emphasis on prevention, mitigation, preparedness, response, relief, and rehabilitation in disaster scenario.[8] Riots aff ect women in versatile ways.Th e repercussions of the riots are manifold and at the same time unique to women.In the prevailing discriminatory attitudes towards women, during riots there are socio-cultural fallouts like women becoming widows, destitution of single women, increased vulnerability and responsibilities.Political issues like lack of legal help for women, coercion to keep quiet about assault.In the case discussed above the individual has undergone monumental pain, loss, betrayal and injustice in her conjugal life.With the progress of time in her life she faced an undesirable event-riot.As it is well-known that mastering changes in life situations is part of human existence and that is what RB has tried all throughout.RB was shaken with the communal disturbance and she was having complains of reduced interest in daily activities, increased tension, fearfulness, with decreased amount of sleep and appetite.A number of studies has documented that exposure to human-made disasters is linked to PTSD.[6,[9][10][11][12] Yet the unforeseen event helped the client in the present case to get back her husband.Th e psychosocial intervention provided to the client helped her to cope with the situation.Psychosocial interventions are eff ective in addressing PTSD.[13][14][15][16] Further enhancement of social support which is the core area for psychiatric social work intervention can facilitate in the recovery process in persons suff ering with PTSD.Various studies have shown that availability of social support can help individual in recovery of trauma.[17][18][19]

Conclusion
Psychosocial intervention helped the individual and community people to reduce their level of distress, build resilience, and assisted them to cope in a better way to overcome the trauma of an undesirable incident which changed their lives to a great extent.Disaster shattered the peace and notion of security among the inhabitants of the fore said area.With the active involvement of Government and non-governmental organizations (NGOs) and international NGOs (INGOs), BTAD is in the process of recovery and rehabilitation of the aff ected group of people.