Annai Illam : Using Lay Counselors to Serve the Trauma-Related Mental Health Needs of Remote Sri Lanka

Sri Lanka, a beautiful island nation, was once called the “Pearl of the Indian Ocean.” Its beauty, however, has been marred by the 30-year ethnic war that ended in May 2009. Human rights organizations around the world have accused the Sri Lankan government of killing more than 40,000 Tamil civilians in the course of the so-called “final war” in which the Sri Lankan government forces defeated the Liberation Tigers of Tamil Eelam. Although the ethnic conflict between the majority Sinhalese and the minority Tamils has been ongoing for many decades, the armed conflict between the Sri Lankan government forces and the Tamil Tigers escalated only after 1983, when countless Tamils living in Sinhalese areas were killed in a pogrom. The Tamil people who live predominantly in the north and east of Sri Lanka have experienced multiple displacements as a result of the military operations carried out by the Sri Lankan forces opposing the Tamil militants. October 30, 1995, is an unforgettable day in the history of Tamils living in the north of Sri Lanka, particularly in the Jaffna Peninsula. When the Sri Lankan government forces began military operations to bring the Jaffna peninsula under their control, almost half a million Tamils fled their villages and began moving south. The Tamil Guardian of November 2, 2005, remembered this mass exodus in the following manner: Ten years ago, the entire town of Jaffna, the largest Tamil population centre in Sri Lanka, streamed out of their homes ahead of a major offensive by government troops against their town. On October 30, 1995, half a million men, women and children walked several miles east, crossing the Navatkuli bridge into the neck of the peninsula. Many then made the dangerous boat journey on to Kilinochchi in the Vanni as to the north of Jaffna, heavy fighting raged as

Sri Lanka, a beautiful island nation, was once called the "Pearl of the Indian Ocean." Its beauty, however, has been marred by the 30-year ethnic war that ended in May 2009. Human rights organizations around the world have accused the Sri Lankan government of killing more than 40,000 Tamil civilians in the course of the so-called "final war" in which the Sri Lankan government forces defeated the Liberation Tigers of Tamil Eelam.
Although the ethnic conflict between the majority Sinhalese and the minority Tamils has been ongoing for many decades, the armed conflict between the Sri Lankan government forces and the Tamil Tigers escalated only after 1983, when countless Tamils living in Sinhalese areas were killed in a pogrom. The Tamil people who live predominantly in the north and east of Sri Lanka have experienced multiple displacements as a result of the military operations carried out by the Sri Lankan forces opposing the Tamil militants.
October 30, 1995, is an unforgettable day in the history of Tamils living in the north of Sri Lanka, particularly in the Jaffna Peninsula. When the Sri Lankan government forces began military operations to bring the Jaffna peninsula under their control, almost half a million Tamils fled their villages and began moving south. The Tamil Guardian of November 2, 2005, remembered this mass exodus in the following manner: Ten years ago, the entire town of Jaffna, the largest Tamil population centre in Sri Lanka, streamed out of their homes ahead of a major offensive by government troops against their town. On October 30, 1995, half a million men, women and children walked several miles east, crossing the Navatkuli bridge into the neck of the peninsula. Many then made the dangerous boat journey on to Kilinochchi in the Vanni as to the north of Jaffna, heavy fighting raged as the Liberation Tigers of Tamil Eelam (LTTE) battled to keep the massed might of the Sri Lanka Army at bay.
As a result of this mass exodus a large number of people had moved into Kilinochchi and many other towns in the Vanni region, which is located to the south of Jaffna peninsula. Although much larger than the Jaffna peninsula, the Vanni region was not as developed and did not have the infrastructure to cope with such an exodus of people. The displaced were forced to live under trees and in makeshift tents.
Although the physical hardships they had to endure were severe, the psychological effects were even greater. The Tamil people regard their homes as an important part of their heritage. Having to abruptly leave their homes, their villages, and their kith and kin, left many of these people psychologically vulnerable.

A COLLECTIVE DEPRESSION
The trauma of being uprooted from their villages in the Jaffna peninsula, where they had lived for many generations, brought about a collective depression among the refugees. There was a consensus among the humanitarian organizations that something had to be done to address the psychological needs of the displaced population in Vanni. The Kilinochchi Association for the Rehabilitation of the Differently Abled (KARDA), a humanitarian organization in Vanni, created an Oxfam-funded project to train lay counselors. (Oxfam is a worldwide development organization that mobilizes the power of people against poverty.) Fifteen young men and women were recruited in February 1996 and a two-week long training program was conducted in Kilinochchi, providing initial training in counseling skills. Having been trained by Father Selvaratnam, who had led such programs in Jaffna before the displacement, I was one of those conducting the training program for the recruited young people. Sister Christobel, who had also received counseling training in Jaffna, contributed to the training along with many others.
In April 1996, a second group of young people was recruited for training. I permanently moved to Vanni and decided to participate in the new counseling initiative geared toward the displaced people from Jaffna. Although KARDA was financially responsible for the project, Sr. Christobel and I became more involved in the training of these young men and women.

EMPOWERING LAY COUNSELORS
Once trained, the lay counselors visited the camps and houses of the refugees, listened to their stories of displacement, and provided supportive counseling. Some officers from KARDA expressed skepticism and wondered how these very young and inexperienced men and women could provide effective help.
As the counseling work progressed, Sr. Christobel and I began to conduct what we called "follow-up" sessions for the lay counselors. We decided to meet with the lay counselors in small groups once a month and provide them ongoing training in counseling skills. These follow-up sessions slowly became an essential part of the training and were continuously conducted despite the many challenges we faced.
The lay counselors were gradually taught to take detailed notes of their counseling sessions, which were then discussed in follow-up sessions and feedback was provided by both trainers and trainees. This process became an important part of the training experience.
While providing professional help to the lay counselors during these sessions, we also provided individual counseling assistance to them, enabling them to cope more effectively with their personal issues.
In order to further my own knowledge and to become a better trainer, I enrolled at the Columbia campus of Loyola University in Maryland and earned my Master of Science degree in pastoral counseling in May 1999.
By the time I returned to Vanni in September 1999, CAFOD, a Catholic humanitarian agency in England, had begun to fund our project. Following my request, this counseling project developed into an organization with the name Annai Illam: Association for Counseling and Psychological Education (in the Tamil language, "Annai Illam" translates to "the house of the mother").
Sr. Christobel and I put our hearts and souls into empowering the trainees to become resilient individuals who could provide effective assistance to the displaced people.
Training for the lay counselors was conducted in Tamil, which presented a significant challenge as teaching resources in this language were sorely lacking. As a result, we began to translate relevant material.

A COUNSELING APPROACH TAILORED TO THE PEOPLE AND CULTURE
The lay counselors reached out to the displaced people housed in camps, in schools, and with relatives and often had to walk or use bicycles to reach them. They encountered numerous other challenges related to the specific culture and societal norms of the region. One of these challenges was convincing people of the benefits of counseling. In Tamil society it is the custom to seek help from religious leaders and elders in times of need.
Contrary to practices of Western counseling, however, this help centers mostly on advice given by the elder or leader. And although Tamil society handles social conversations with ease, intimate conversations laden with emotional content are rather unusual. Additionally, there is an unwritten understanding to not discuss one's family issues with strangers. It was the sensitivity and perseverance exercised by the members of Annai Illam that helped overcome these very difficult challenges and lead to an acceptance of their work in Vanni society.
The history of Annai Illam is intertwined with the history of people in Vanni. Annai Illam was born out of the response to the trauma experienced by these people in the aftermath of the mass exodus that took place in 1995 and 1996. When Kilinochchi came under military occupation in July 1996, the people were forced to move to interior villages. Annai Illam responded to this event by transferring its headquarters to a small village called Arokiyapuram, where it remained until 2003. At that time, the so-called period of peace, it returned to a 3-acre land in Kilinochchi.

COUNSELING AT PUBLIC HOSPITALS: A BREAKTHROUGH
Almost 2 years after its inception, Annai Illam was invited to provide counseling services at the Kilinochchi District Hospital where the medical director had begun to understand the importance and value of counseling to community members. Given that many of the patients presenting to the hospital displayed psychosomatic symptoms, the doctors began to comprehend the role of psychological counseling in treating these patients. The hospital setting provided a new and unique challenge to the lay counselors of Annai Illam who were provided with additional support in order to learn to work with this particular patient population. The work in this new setting marked a milestone for Annai Illam and attracted the attention of other medical professionals in various medical institutions serving the people of Vanni. As there were no psychiatrists at hospitals in Vanni during that period, the presence of counselors represented a great help to the physicians serving these hospitals. Whenever they deemed psychological assistance necessary, the physicians referred their patients to Annai Illam counselors. Gradually, Annai Illam staff reached out to other public hospitals in Vanni and began to extend their services to those patients as well. Given the large number of displaced people in the region, demand for both physical and psychological aid in the local hospitals was high.
Following its entry into public hospitals, the counseling work of Annai Illam became widely known in the Vanni region. As years went by, Annai Illam became an important stakeholder in contributing valuable service to the local medical sector.

COUNSELING AT PUBLIC SCHOOLS AND CHILDREN HOMES
After introducing counseling to public hospitals, Annai Illam began providing counseling assistance to public schools in the region. As a result of the prolonged war between the Sri Lankan government forces and the Tamil Tigers, hundreds of children had lost either one or both parents and had endured multiple traumatic displacements. Annai Illam counselors regularly visited selected schools and provided individual and group counseling to children who had been affected by the war.
While providing counseling to children in public schools, counselors also reached out to children living in numerous group homes, which had been established to care for war-affected children. The services that Annai Illam counselors provided at various homes in Vanni were not only invaluable in the rehabilitation and healing of these children, but also represented a great support to the children's caregivers.

COUNSELING INTERVENTIONS IN THE POST-TSUNAMI PERIOD
Sri Lanka was one of the many countries affected by the south Asian tsunami of December 26, 2004, which killed more than 35,000 people. The coastal areas of northern and eastern Sri Lanka were more affected by this disaster than any other areas of the country. Sadly, people who were affected by the tsunami in the north and east had already been affected by the prolonged ethnic war that had ravaged the country for more than 3 decades.
Having had no prior experience with tsunamis in Sri Lanka, it took us several days to realize the extent of the effect of the disaster on the lives of the country's people. By this time, Annai Illam had grown into a bona fide counseling institution, and the only one in the Vanni region. When the tsunami struck the coasts, we wanted to respond immediately by organizing counseling for the affected population. During the first week of 2005, 2 groups of 7 counselors were sent to the most affected areas, Mullaitheevu and Vadamarachchi East.
We began post-tsunami counseling interventions in public schools, where the victims of this natural disaster had found refuge. Annai Illam counselors began to meet with the affected and displaced population individually, as well as in groups. Some people who had difficulty talking about their pain and loss in individual sessions found it easier to share their stories in groups. Separate groups were formed for women, men, and children.
Although most of the affected people found it difficult to talk about their pain and losses at first, the presence and the empathic listening of Annai Illam counselors encouraged them to share their stories and express their feelings of grief.
Although our capacity to help did not match the vast needs of the population, other aid organizations took note of the importance of our work. Many other local and international organizations began to organize counseling services for the individuals affected by the tsunami. Given the rising number of organizations in the area, there was a need to coordinate between the various efforts. A special committee was set up in Vanni to specifically help coordinate the psychological aid being delivered and Annai Illam worked side by side with these other organizations. After almost a year, Annai Illam itself, assisted by some other institutions, took on the role of coordinating psychosocial activities in the area.

CONTACT WITH DISASTER PSYCHIATRY OUTREACH
In the aftermath of the tsunami, Annai Illam welcomed national and international mental health professionals. Dr. Craig Katz, a psychiatrist and cofounder of Disaster Psychiatry Outreach, was one of those professionals from the United States, who visited Annai Illam in the aftermath of the tsunami. After discussions with the Annai Illam team, Dr. Katz organized a team of mental health professionals from the United States to provide special training to Annai Illam counselors. As a result of this initiative, a team of psychologists and psychiatrists arrived in Kilinochchi in April 2005 and provided special training in trauma counseling to Annai Illam staff. This was a memorable experience for the Annai Illam staff and we were very grateful to Disaster Psychiatry Outreach for providing such effective training.

OTHER PROGRAMS AND COLLABORATIONS
In addition to providing counseling services, Annai Illam also provided educational services. Scores of seminars and workshops for people from all walks of life, including schoolteachers and medical professionals, were conducted in Vanni from 1996 to 2009. Annai Illam also conducted many training programs for health professionals who were involved in fieldwork. Through its educational activities, Annai Illam was able to disseminate knowledge about psychological counseling and mental health to diverse groups of people. In fact, through its broad work and efforts, the word counseling became a household term in the mainland of Vanni.
Annai Illam partnered with various organizations and institutions over the years, such as Victory Home, a mental health institution for women affected by the war and other traumas. Another institution called Santhosham, meaning "happiness" in Tamil, was later established in Kilinochchi to care for men who were affected by mental illnesses. Annai Illam came forward to provide counseling assistance to the members of this institution as well.
Many United Nations (UN) and other nongovernmental organizations took note of Annai Illam's work, and in 2001, we began to work very closely with UNICEF to provide counseling and psychosocial assistance to the war-affected children in Vanni. Through its funding and support, UNICEF, more than any other organization, helped Annai Illam to improve its resources and to develop into a well-equipped counseling institution.
In the aftermath of the tsunami, Annai Illam also began to collaborate with many other UN organizations, including the UN High Commissioner for Refugees and the UN Development Programme. Later, Annai Illam also began working with other international organizations, including FORUT, a Norwegian development organization, and World Vision, an Evangelical Christian humanitarian aid, development, and advocacy organization.

CHALLENGES
The following is a list of challenges Annai Illam has faced.
During the first 5 years, Annai Illam operated out of a cadjan-thatched cottage without electricity or other basic amenities. All the training for the counselors was conducted in Tamil, the local language. Given the limited teaching material on counseling available in Tamil, Annai Illam needed to translate relevant material as well as develop its own teaching resources. As Annai Illam counselors had to initially provide services in schools and camps, maintaining the coveted privacy of an individual therapy session was nearly impossible. Initially, the mode of transportation for counselors was by bicycle, making it difficult to reach more remote areas and the individuals located there. Annai Illam staff needed to convince the people of Vanni of the benefits of psychological counseling and overcome significant cultural barriers to sharing one's innermost thoughts and feelings. Annai Illam staff were forced to manage financial strain.
There was a lack of support and other staff to help train counselors. Annai Illam counselors were faced with high client-tocounselor ratios.

CONCLUSIONS
When a group of young people came together to begin an Initial Training in Counseling Skills program on February 16, 1996, in Kilinochchi, none of us anticipated that this initiative would slowly evolve into an effective counseling organization. Neither did we envisage that it would leave an indelible impact on the lives of people it sought to serve during its 13-year existence in the mainland of Vanni.
In fact, an official from Oxfam, which had pledged to fund the initial phase of this counseling project, expressed a few days later his skepticism about this counseling initiative. He pondered how such an inexperienced group of young men and women could provide effective help to a group of people who had been traumatized by the consequences of an ongoing ethnic war that was taking place in their country.
But contrary to the initial assessment, the project evolved and developed into a multifaceted organization providing comprehensive counseling and psychosocial help to the war-affected people of the Vanni region. What the Oxfam official considered a weakness of the project became the strength of this counseling initiative: the young individuals involved proved to be openminded and were thus able to transcend some of the cultural barriers that may have prevented older individuals from buying into the concept of counseling. For instance, we were able to convince them of the value of sharing one's innermost thoughts and feelings-a concept that stands in direct conflict with the Tamil's idea of protecting information about one's family.
Our slow, patient, and determined effort to train these young people into effective listeners became a successful endeavor as years passed. And as they grew as counselors, we ensured their personal growth by helping them process their own feelings and supporting them in times of need.
The second factor that helped Annai Illam become an influential counseling organization was its close link to the life of the people it sought to serve. Annai Illam counselors and staff shared the same experiences as our clients: When citizens had to move into interior villages following the capture of Kilinochchi by the Sri Lankan military, Annai Illam moved with them. When most of the people were forced to live in cadjan-thatched cottages, Annai Illam did the same.
When the people of Vanni were badly affected by the tsunami in December 2004, Annai Illam was there to provide much needed support for those grieving the loss of their loved ones. Whenever people were killed as a result of the war, Annai Illam was there to provide emotional support. Annai Illam continued to serve the people of Vanni, even as the final war was being fought in May 2009. Today the grounds of Annai Illam function as an important location where humanitarian assistance to the war-affected people, organized by the religious Congregation of the Oblates of Mary Immaculate, is coordinated. The original training hall, which was destroyed during the final war, has been rebuilt, and a new, wellequipped library serving the children of Vanni, was declared open on February 16, 2013, on the 17th anniversary of its foundation.
Annai Illam was initially founded to provide assistance to the people of Vanni who had faced the consequences of war. This service continues today by the members of the religious congregation, of which the writer is a member.