PSYCHOLOGICAL CONSEQUENCES AND COPING MECHA-NISMS OF BOMB BLAST SURVIVORS: THE EXPERIENCE OF SIX CIVILIAN VICTIMS IN THE CITY OF COLOMBO

During the last few years, civilian centered bomb explosions have been a common occurrence in Sri Lanka. These bomb blasts do not seem to target an individual or any authority. Rather, they are designed to create economic damage, cause general fear among people and commit mass murder. As such, bomb blasts have proven to be a strategy that promotes a constant fear of its possible occurrence in the minds of civilians that are not exposed to active combat in their daily Lives.

Whereas war between nations traditionally focussed upon battles between armies, developnlents in the twentieth century have led to a concept of total war where the civilian population has increasingly become victims of war activities. Civil war seems to have affected the civilian population to a degree as never witnessed before.
During the last few years, civilian centered bomb explosions have been a common occurrence in Sri Lanka. These bomb blasts do not seem to target an individual or any authority. Rather, they are designed to create economic damage, cause general fear among people and commit mass murder. As such, bomb blasts have proven to be a strategy that promotes a constant fear of its possible occurrence in the minds of civilians that are not exposed to active combat in their daily Lives.
Over the last several years, several major bomb explosions occurred in the country's capital city, Colombo. The more prominent of these may be the Centra.1 Bank bomb blast, the Torrington bomb blast and the Dehjwela train bomb blast. Many persons were seriously injured and several sustained varying degrees of physical andlor mental suffering due to these explosions. Other than regular bomb blasts such as the above, people living in the country's capital city do not get exposed to constant war activities.

War a n d its Psychological Consequences
The relationship between a war and its psychological consequences are complex. There is no linear relationship between the severity of the exposure and the consequent psychological ramifications. Yet, i t is invariably seen t h a t the effects of intense stress may have severe traumatic implications for the persons concerned.
A war often enforces an alteration in the meaning of life and death through the exposure to life threatening situations. In times of war i t is the military profession t h a t runs severe risks to life and actual loss of life. However, in times of war, the risk of harm to civilians increases. In fact, we generally see a n increase in psychological problems in a society ravaged by war. Violence, theft and other forms of unhealthy societal pathologies are often seen. In the lives of civilians toowhether being constantly exposed t o combat or whether living in combat free areasthe war is a n ever-present hazard, constantly looming in their minds. In such a context, when civilians are actually affected by a war strategy such as a bomb blast, the psychological ramifications are very complex. It would be dependent on several factors, such as: The person's pre-trauma personality (i.e. premorbid personality); The person's pre-trauma coping style; ' The person's current social support system;

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The person's political/religious ideology; The person's personal views on war, democracy, freedom etc.

Psychological Disorders Resulting f r o m Exposure t o Severe Traumas
We all encounter stressors ( physical, emotional, and mental pressures) in our daily lives. These may be physical, psychological and /or social. All types of stress place a certain demand on us and require us to adapt to it. When we have difficulty in adapting, we experience this as stress. The intensity with which we experience stress varies depending on a variety of factors. These include (Bisbey, S. and Bisbey L. B., 1998):

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The nearness of the stressor; The perception of the threat level of the stressorincluding beliefs abo~xt our ability to cope with the stress; The stress tolerance of the individual;

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The availability of external resources and support; The number of stressors; The period of time in which the stressors occur.
Most people experience periods of heavy stress. Larzarus (1966) refers to these periods as a "crisis" and defines stress as a critical period during which an individual or group is exposed to threats or denlands which are a t or near the limits of their resources. During a crisis, people are often challenged to develop new coping skills to come . through the crisis and readjust.
A traumatic experience is an abnormal experience. i.e. the individual does not have any pre-existing mental structure t h a t allows himlher to assimilate the experience into h i s h e r memory. Data or experiences for which a n individual has no pre-existing understanding require the creation of an entirely new set of mental structures which, if i t contradicts an already existing old one, may be experienced as confusing or traumatic.
There a r e two psychological disorders (as stated in the Diagnostic a n d Statisticcrl Manual of Mental Disorders -IV, 1994) pertaining to stress: Post Traumatic Stress Disorder and Acute Stress Disorder. The diagnostic criteria for these two disorders are cited in the annex. Acute Stress Disorder is distinguished from Post Traumatic Stress Disorder because the symptom pattern in Acute Stress Disorder must occur within four weeks of the traumatic event and resolve wltllin that four week period. If the symptoms persist for more than one month and meet the criteria for Post Traumatic Stress Disorder the diagnosis is changed from Acute Stress Disorder to Post Traumatic Stress Disorder. Thus, Post Traumatic Stress Disorder is a more long term condition than Acute Stress Disorder. In this paper we are primarily concerned with Post Traumatic Stress Disorder due to it being a more long term psycho-pathological condition.

Culture, Stress & Post Traumatic Stress Disorder (PTSD)
Much has been written about the cultural aspects of mental health and ill health. Research writings have shown t h a t there are specific culture-bound psychological illnesses. The presentation of universally found psychological illriesses might have cultural manifestations. In fact, the concept of mental illness varies from culture to culture and the nature of traditional therapies used to treat such illnesses may also vary from culture to culture.
There are several issues that need to be addressed with regard to the relevance of culture to the study and understanding of Post Traumatic Stress Disorder. De Silva (1999) h a s presented the following: 1. Perception of trauma and the reaction in society-the socio-cultural meaning of the traumatic event, whatever the event may be, is a crucial variable;

2.
Social support is an important mediator of the impact of the traumatic eventsas cultures differ markedly in the extent to which support systems existsuch as the extended familythis factor should be considered seriously;

3.
Role of the military culture in war with regard to the soldiers in combat situationsi t h a s been argued t h a t t h e prevailing culture in the military organization as well as the national culture of the country, can have a n effect on the soldiers' vulnerability to stress reactions and thus to PTSD;

4.
Cultural and national differences in response to traumathe kind of empirical, up-to-date information needed for any conclusions to be drawn about national differences in vulnerability to stress and in the manifestations of stress reactions is limited.
Janoff-Bulman (1985,1992) refers to the notion of 'shattered assumptions'. According to her, the experience of a major trauma shatters the individual's belief that (i) the world is benevolent, (ii) the world is meaningful, and (iii) the self is worthy. This shattering of assumptions may lead to traumatic reactions possibly in the form of PTSD. The core assumptions identified by Janoff-Bulman (1985,1992 are representative of a western civilization or culture. What of people of a very different culture which do not propagate such assumptions about t h e world they live in and themselves? Do persons in such cultures experience similar stress reactions in facing traumatic situations? I t is indisputable that, even in countries where the predominant world view accepts hardships and disasters as entirely in the nature of things (e.g. the concept of "karma" in some Indian religions), those who experience major traumatic events are no more protected against PTSD than their western counterparts (de Silva, 1999) The above discussion points out the notion o f the cultural sensitivity of the diagnostic criteria of PTSD t o non-western countries, such as Sri Lanka. Specifically, it is possible to use the diagnostic criteria of PTSD to understand and thus identify the individuals in our cult~lre who have experienced traumatic events.

Psychological Consequences of Bomb Blasts: an Insight to the S r i Lankan Experience
During the past few years, several bomb blasts have occurred in Colombo and its suburbs. Most of the victims have been civilians who have been attending t o their daily activities when the unfortunate incident occurred.
In order to understand the psychological ramifications and the consequent long-term coping strategies used by survivors to overcome the trauma, the second author personally interviewed a group of six bonib blast survivors. The interview was based on the criteria for assessing Post Traumatic Stress Disorder, 111 accordance with t h e Diagnostic and Statistical M a n u a l -IV specificatiolzs (1994).
The age range of those interviewed was 36 -53 years. All interviewees were males. One interviewee was a Buddhist, and the other five were Christians. These bomb blast survivors were either affected by the Central Bank bomb blast, the Torrington bomb blast or the Dehiwela train bomb blast.
A brief description of the interviewees and how the incident had affected them is presented below:

Interviewee 170. 1 (age-53 years)
He was injured in the Central Bank bomb blast. He is completely blind and has sustained injuries to his arms and some disfigurement to his face. He had amnesia for a period of eight days after the incident and was then taken to India for treatment. He used to constantly dream that he, dressed in a white suit, was looking down at himself. He did not have these dreams at the time of the interview. He feels marginalised from society and does not wish to discuss his blindness. Whenever he hears a noise he gets overly startled. He is currently unemployed and js heavily dependent on others, even for small tasks such as getting from one place to another in the house.

Interviewee 720. 2 (age-36 years)
He was injured in the Dehiwela train bomb blast. His left arm was injured, left ear lobe damaged and face disfigured. He had lost consciousness on admission to the National Hospital of Sri Lanka and was there for 40 days for skin grafting. He feels intense fear even a t the sound of a tyre puncture blast. He feels much discomfort when in the midst of others, especially when travelling. He avoids all places and situations that remind him about the bomb blast and feels estranged from society and disgusted with himself due to the disfigurement in his face. He has difficulty concentrating and is unable to remember day to day matters. Despite these difficulties h e is able to fu%ction as a storekeeper and maintain reasonably acceptable social relationships.
He was thrown to the ground and sustained injuries to his forehead, during the Central Bank bomb blast. From a distance he saw gunmen sl~ooti~lg at the Central Bank. He still has flashbacks of these gunmen, especially when there js the sound of firecrackers and a t times of traffic congestion. At these times he feels helpless and extremely fearful. When he is jn the midst of a crowd, he is very vigilant of any possible danger. Apart from these difficulties he is able to operate reasonably well in social, personal and occupatiorlal settings.

I7zteroiewee no. 4 (age-37 years)
He became completely paralysed and bedridden due to the Dehiwela train bomb blast. On the day of the explosion, he fell to the rail tracli froin the train compartment and was crying out for help and was taken to the Kalubowila Hospital. He had lost consciousness on the way and lost the ability to spealr for about four days. He received treatment at the National Hospital of Sri Lanlra for nearly six mo~lths. For a period of about three months after the bomb blast, even the sound of coconuts belilg cracked made him shiver uncontrollably. For about seven months after the incident the scene of the train used to come back to him, leaving hiin dizzy with fear. He avoids seeing wounds or blood in televlslon or pictures and has an intense anger towards the terrorists. He has difficulty falling asleep a t night and is irritable with his family members, especially his children. He does not expect to live long and states that the little social support he has had is also diminishing. HIS wife is the breadwinner now, and she operates a small boutique. He feels ecollonli cally burdened.

I7lZternietuee 110. 5 (37 years)
He sustained damage to the cervical spine due to the Central Bank bomb blast. He has continuous pain in the right sl~oulder and has spasms in the right shoulder, fingers, legs and spine. For at least a period of six months he used to have flashbaclcs of the event, especially in times of thunder and lightning. He used to eat excessively after the incident, but has now brought it under control. For about a year, he avoided talking about the event and avoided any person that may have any resemblance to terrorists or gunmen. He feels irritable, especially with his father, and has lost interest in things he used t o like (e.g. cricket and football).

Interviewee no. 6 (age-44 years)
He was injured in the Torrington bomb blast and is now bedridden. He spent about a year i? the hospital where he had to undergo an operation (due to some particles lodged in the stomach) and was in intensive care for about 20 days. For about a period of five months, he used to feel that the hospital would burst and that he was floating. When there a r e loud noises or crackers being lit, he used to get flashbacks of t h e incident. He feels irritable with others and h a s difficulty falling asleep. He is unable to do any form of work and his wife is the breadwinner now.

Concept of Coping
Coping strategies have been defined in many different ways, usually along dichotomized dimensions, as person based vs. environment based, stable coping styles vs. flexible coping styles, conscious coping vs. unconscious coping, adaptive vs. pathology producing coping, and coping as a general adaptive response vs. task related coping ability (Freud 1967;Eitinger 1974;Murphy 1976;Haans 1977;Roth and Cohen 1986;Kahana, Hare1 and Rosner 1998;Vaillant 1977;Aldwin 1994 Coping is a dynamic process that changes over time and is transactional in nature. I t is seen in the first author's clinical experience that survivors of traumas invariably react in confusion during the short aftermath of the traumatic incident and then adopt various coping strategies in the long term. These coping strategies depend heavily on the individual's pre-trauma personality and social support system to which s h e belongs.

Coping Strategies of Bomb Blast Survivors: the Experience of Six Civilian Victims in the City of Colombo
The coping strategies employed by the study sample were classified as: Psychological coping strategies; ": Social coping strategies; Spiritual coping strategies.
A description of the coping strategies used by the participants in the study is indicated below:

Psychological coping strategies
In this sample the more therapeutic or cathartic forms of psychological coping techniques were not observed. While psychological coping strategies were noted only in the case of two interviewees, they were also the more common sense, simple, layman's strategies of immersing oneself in one's job (case no: 3) or consuming sweets to distract oneself from the intensity of the pain (case no: 5).
Social coping strategies ., , Most of the interviewees (except case no: 3) had some form of social o support. Four intemiewees (case no: 1, 2, 4, 6) stated that they had support from their spouse and children and in one intemiewee's case it was indicated that this support and his positive relationship with them had been very helpful in managing his difficulties. Interviewee no: 4 indicated t h a t he had support from friends.

Spiritual coping .strategies
All the victims got some solace by turning towards religion and getting involved in religious activities or religious beliefs which afforded meaning to their traumatic experiences. Four interviewees (case nos. 2, 3,5 and 6) strongly believed in God's protection of them and in God's will. These beliefs gave them comfort and provided a meaning to what had happened to them. One interviewee (case no. 1) practised Buddhist meditation regularly and this offered him some comfort. Interviewee no. 4 believed t h a t what had happened to hjln was due to sins committed in a past life and that his wife had sufferred due to her own karmic sins.

Post Traumatic Coping
In the case studies presented, the bomb blast survivors showed the entire range of post traumatic indications of depression, anxiety, hyper-vigilance, social withdrawal and outbursts of anger. This is not to say that all individuals having faced a traumatic event such as a bomb explosion would necessarily develop characteristics of Post Traumatic Stress Disorder (PTSD). As indicated elsewhere in the paper, having experienced a traumatic situation is not necessarily an indication of future psychological djfficulties. In fact, we have met extreme resourcefulness, courage and bravery with which people face physical and psychological difficulties (as well as economic difficulties, arising out of inability to hold ajob due t o blindness, deafness, paralysis etc.) caused by traumatic events.
The coping strategies used by the survivors were categorized as psychological, social and spiritual. It is seen that spiritual coping strategies are resarted to more than psycl~ological coping mecl~anisn~s aild social support. Every person in the studyirrespect,ive of their religiontried to attach a religious mearling t o their traumatic experience and that -assisted them to understand and assimilate the traumatic event into their already existing belief system. According to the notion of Janoff-Bulman (1985,1992, an individual has certain core assumptions about the universe and self as, (i) the world is benevolent, (ii) the world is meaningful and (iij) the self is worthy. This is more a Christian outlook t o life. Such individuals consider explanations such as "God's will", "destiny" etc. in helping them t o assimilate the stressful experience to their existing mental schema. These explanations help them in their coping process. In persons belonging to Buddhist and Hindu religionswhich believe in a karmic outlook to lifeexplanations based on concepts such as "karma", "past sins" and "God's desirelpunishment" may be used. They would resort t o various religious rituals and practices such as praying and meditation to overcome the psychological discomfort and thus cope with the traumatic incident.
In the persons interviewed, psychological coping strategies seem to be less used than spiritual coping strategiesj.e. the individual does not seem to be doing much internallywithin himherself, to overcome the emotional discomfort. Psychological coping strategies such as emotional self-disclosure, hope and the viewing of the (traumatic) event as a challenge for growth are some of the resilient psychological coping strategies that may be used by survivors of extreme stress. In fact, it has been documented in research that social sharing and emotional self-disclosure a r e the best predictors for good mental health after a trauma (Paez e t a l , 1995). Yet, we did not see any of these positive psychological coping strategies in our interviewees. In fact, the two participants who did show psychological coping strategies used unhealthy techniques such as overeating and immersing himself in office work, rather than confronting the core issue of the trauma.

Conclusion
I t is in this area of traumatic stress due to the civil war in Sri Lanka, t h a t mental health professionals, i n co-operation with other professionals, have a major function in this country. Through support, counseling and psychotherapy, it is possible to help people confined within their own suffering and self destructive small world to alter their cognitive, emotional and behavioral coping, to accept support and sympathy from others, rely on themselves, plan for the future and create better conditions for themselves arld thus the society at large.
( 5 ) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and' numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, feelings or conversations associated wit11 the trauma (2) efforts to avoid activities, places or people t h a t arouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities ( 5 ) feeling of detachment or estrangement from others (6) restricted range of affect (e.g. unable to have loving feel ings) (7) sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty in concentrating (4) hypervigilance ( 5 ) exaggerated startle response.
E. Duration of the disturbance (symptoms of criteria B, C and D) is more than 1 month.
F. The disturbance causes clinically significant distres:s:or impairment in social, occupational, or other important areas of functioning.

Specifi if
Acute: if duration of symptom is less than 3 months