Prem Giri was only six years old when he saw the mutilated body of his father, who was killed by the Maoists in Dhangadi. His state of mind deteriorated. Generally a jolly boy, he changed into a quiet and aloof person who refused to talk even with his mother. He didn't have an appetite and was haunted by nightmares. At night, he paced up and down the house because he couldn't sleep.

His mother started to worry that her son was losing his mind and thought his condition would improve if she sent him away from the village. She reluctantly sent her youngest child to Kathmandu with help of a local social worker. Today, Prem is eight but he still has nightmares. With help of counsellors at a shelter in the capital, the boy has started to speak more but he still has problems mixing with other children. He suffers bouts of violence and ends up beating up children who try to make friends with him.

Psychologists and social counsellors are worried that Nepal's trauma-exposed population is on the rise, yet they don't consider it a serious health concern. Donor agencies, international charities and local child-help groups seem to think that the Nepali people are resilient and have the inner strength and family support to endure emotional hardships. But with killings and torture being everyday events in the news, many Nepalis appear to be numbed by the shock.

This is worrying. "When people become desensitised about news of killing and start to accept that violence is part of life and society, it is a very dangerous sign," says Bhogendra Sharma, director of Centre for Victims of Torture, Nepal (CVICT), which specialises in rehabilitating children and women traumatised by violence and bereavement.

Identifying and dealing with trauma victims is quite new for Nepal's few psychiatrists and psychologists, who tend to use textbook knowledge of clinical practices to treat traumatic stress. "I learnt more in Nepali villages than what I was taught in the universities abroad," says eminent psychiatrist Vidya Dev Sharma, chief of the Department of Psychiatry at Kathmandu's Teaching Hospital.

There are no more than 50 psychologists in Nepal, out of which only six are qualified clinical psychologists. Every year, less than 10 students pass with a master's degree in psychology from Tribhuban University (TU) and most of them end up working in non-related commercial jobs. Only a handful actually focus on conflict-related trauma.

"One way to start addressing trauma is by producing more psychologists. This is possible only when the government and non-governmental organisations create more jobs for them," says Rebekah Bajracharya, who recently completed her master's in psychology from TU.

CVICT and a few other groups are training social workers to be psychosocial counsellors, and their numbers have grown. Their role is to identify people affected with post-traumatic stress disorder (PTSD) and give them basic counselling and refer them to counselling service centres run by non-government groups. Most government-run clinics deal only with mentally handicapped patients with severe brain disorders and epilepsy cases.

Social counsellors have been playing a key role in Nepal to help traumatised individuals get out of depression. "I was always obsessed with revenge but now I realise that will not benefit me," says Nirmal Bista from Kalikot. He was only 18 when he saw his friends killed by the police during the government's Kilo Sierra II operation in 1997. But Nirmal's mental state worsened after the Maoists brutally beat up his uncle and abducted his father. His family sent him to Kathmandu when they realised Nirmal was determined to take revenge on the Maoists in his village. He received counselling at the activist group, Nagarik Awaj, and today he helps other victims of psychosocial trauma.

"Counselling helps a lot, not only by talking sense but also through the care and support of other people," says Min Bahadur Raoul, also from Kalikot. The 18-year-old was abducted twice and forced to attend Maoist trainings, but managed to escape the second time. Today, with help from Nagarik Awaj, Raoul is more at ease and wants to help others like him through a new organisation called Orphanage for Terror Victims in Nepal.

Small initiatives like these fill a gap left by the government's neglect of the issue, but the need is much greater than what individual groups can do. In conflict regions, hundreds of thousands of Nepalis are coping with a level of violence that they have never been used to. And while the stress is on the physical harm caused by war, there is less attention paid to the psychological after-effects.

"The women and children are most vulnerable. They don't know anything about trauma affecting their lives or about the psychosocial treatment available," says Sushma Regmi, a psychologist.

If trauma is treated, there are serious physical health consequences as well. There may be loss of appetite, sleeplessness and sometimes even suicide attempts. "Timely orientation reduces the level of trauma and helps to lessen physical symptoms as well," says Bidur Osti, a medical doctor who heads the rehabilitation section of CVICT.

Unexplained somatic complaints are quite common but medical workers end up giving sleeping pills and pain killers without properly investigating the history of the patients. "The problem is that our health system is curative oriented and most of the health professionals can't link the aches and pains with mental illness. The patient won't say he is traumatised," says Sharma.

Sharma and his team at the psychiatry department developed a Nepali model for community counselling, in which grassroots social mobilisers, teachers, community medical auxillary workers and health assistants would be trained in 'first-aid' psychological care and would then refer patients to counsellors at district hospitals. This model worked effectively in treating teachers and students of the Sharada Secondary School in Doti, where several children were killed and wounded in crossfire during a skirmish last year. ('This is not a school. It is a cemetery\', Nepali Times, #169). When Sharma proposed the idea of an integrated program to several donor agencies, it was turned down.

Psychologists accept that psychosocial intervention is more effective if community counselling and support to form a stable social environment is made. In Nepal's case, there are already examples of teachers, traditional healers and local village leaders coming together to address the problem jointly. Says Dutch psychologist Mark Jordan: "The great thing about Nepal is that there is a culture of helping each other and we should take the strength of the community into account."

(Names of some patients have been changed on request.)

Menuka is coping

Menuka Koirala does not regret losing all her property in Gorkha. The only thing she is sorry about is losing her husband.

He joined the Maoists and used to torture her constantly. He often threatened to kill her if she refused to work with the rebels, but she never thought he would actually do it. But after he started making serious threats, she decided to leave. Staying with her family in Gorkha was not safe either, so she came to Kathmandu. But even here, Menuka constantly lives in fear that her husband will track her down. "I was so mentally tortured that I did not even have the strength to live," recalls Meunka, trying hard to control her tears. Although impoverished, counselling has taught her how to cope with the pain.