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Mental Health Project in Sri Lanka (Jaffna and Colombo, May -- June 2005)

Alan Krohn, Ph.D. Psychoanalyst; Clinical Psychologist Adjunct Associate Professor of Psychiatry, University of Michigan

From late June to late July Dr. Shanthy Parameswaran, a British child psychiatrist, originally from Sri Lanka, Dr. Harriet Calvert, a British clinical psychologist, originally from Finland, and myself, Dr. Alan Krohn, an American clinical psychologist and psychoanalyst conducted two training projects for mental health workers in Sri Lanka (in Jaffna and Colombo). After the two other members of my team returned to England, I stayed on and did some direct work with tsunami victims, mostly children, in northeast Sri Lanka. The focus of Drs. Parameswaran’s, Calvert’s, and my work was on training mental health workers to deal with mental health problems in children and adolescence, especially problems that result from trauma and loss. We knew we would need first to provide training in normal childhood and adolescent development for our teaching on trauma and loss to be effective. Though we came to Sri Lanka thinking we would be training mental health workers to deal with problems related to the tsunami, we encountered, as well, major mental health problems that have resulted from the years of civil war. We learned, too, that we needed to train the mental health workers to deal with the psychological effects of torture. Finally we learned that we needed to help these mental health workers to manage their own psychological reactions to the turmoil that has beset the country. How I became involved: After the tsunami, a group of mental health professionals in the Detroit, Michigan area who had previously received Red Cross disaster mental health training got together to explore what we could do to help victims of the tsunami with their mental health needs. We were told that the Red Cross position was “don’t go” to the affected areas. Based on what I learned when I arrived in Sri Lanka, this was both good and bad

advice. I heard in Sri Lanka about some poorly trained mental health people who had come in an uncoordinated way to the area soon after the disaster. But at the same time NGO’s like the Red Cross were doing almost nothing in the mental health area. In the tsunami affected area I worked in, which is not true everywhere in Sri Lanka, the NGO’s had made progress building transit camps, shelters, latrines, bringing in water, and digging channels for fishing boats. At the guesthouse where I was staying in Jaffna I met people working for a number of NGO’s, including Oxfam, Care, and the Red Cross. There was little or no attention paid to mental health needs. In the tsunami village I worked in, there was an enormous hunger in the people to talk about their problems, especially those connected with their children. Whether mental health people should go to a disaster area immediately is open to discussion, but it seems to me that the NGO’s should be encouraging people, soon after a disaster, in a well planned way, to go. When I asked a man from Oxfam who was doing needs assessment throughout Sri Lanka why his organization was not paying much attention to mental health, he referred broadly to “cultural problems” working in this area. He is certainly right that there are “cultural” challenges working in the mental health area, more than in rebuilding infrastructure or even providing medical treatment. However, these cultural issues should be understood and not be used as a reason to do little or nothing in the mental health area. We learned how doing mental health work and training of mental health workers raises cultural, social and cross-cultural challenges. These are challenges that can be dealt with and learned from. I became involved in the Sri Lanka effort after my girlfriend, Colleen Flynn, who has been incredibly helpful at many points in this effort, and like me is a committed National Public Radio listener, heard the President of the IMHO on “All Things Considered” say that the mental health needs in Sri Lanka were “huge.” So we found his email address on the NPR website, emailed him, told him that I have for many years had a special interest in trauma and teach courses on it at the Michigan Psychoanalytic Institute and in the University of Michigan’s Psychiatry Department. I had read the IMHO task force report on medical and other needs in northern Sri Lanka. I found the report impressive and comprehensive and made some observations about the importance of work with trauma in the medium and long term phases after a disaster, drawing on Dr. Henry Krystal’s work. Several people responded, including Dr. Rajam, from New

York City and Dr. Somasundaram, world renowned expert on trauma and author of a book on Sri Lankan war trauma, “Scarred Minds.” They liked my observations about the long term affect-stunting effects of trauma, loss, bereavement, and dislocation. Through this email networking within IMHO, I learned that Drs. Parameswaran and Calvert in Britain, members of the UK-Sri Lankan Trauma Group, were looking for someone with expertise in adolescence to join them to train psychosocial workers in Sri Lanka and to work directly with tsunami victims. They wanted to emphasize in the training mental health in children and adolescents, an area even more neglected that the already neglected area of mental health in general. We began email correspondence with Dr. Somasundarum of the Jaffna Teaching Hospital and with people at Shanthiham, a counseling and teaching facility connected with the Jaffna Teaching Hospital Psychiatry Department devoted to health and mental health counseling and training. We had a brief setback while planning the training: After fairly regular contact with Dr. Somasundaram in Jaffna, we heard nothing from him for almost two weeks. We all sent emails asking what had happened. We then received an email from him telling us that the medical students at Jaffna Medical School had gone on strike and locked the faculty out of their offices, preventing Dr. Somasundaram from accessing his emails. A couple of days later, we received word, “The strike is over!” We never learned what the strike was about, but having later learned that strikes by medical students are not uncommon.

Attending the IMHO Annual Meeting Before going to Sri Lanka, at the encouragement of the Dr. Rajam, I went to the annual IMHO meeting in New Jersey. Physicians of many specialties, nurses, people working to build infrastructure, and psychologists were there. There were people who had been to Sri Lanka since the tsunami and others, like myself, who were preparing to go. Several useful things emerged from this meeting. I met Dr. Rajam who was very helpful in a variety of ways, I learned some about Sri Lankan culture, and talked to people about about previous missions. I took a few things away from the meeting: Most of all, be flexible. Have a plan but be willing to change it or throw it out. Be realistic about what you can accomplish, it will not be as much as you expect. Don’t not go just because you think you can’t do very much. Just going communicates to the professional community and to the victims a message of professional caring – that the world has not forgotten you. Also what you may think is modest help, based on the limited resources in northern Sri Lanka, may be much more. I found all of this advice to be sound.

Constructing a Training Program for Psychosocial Workers By email we put a training program together. Email turned out to be invaluable for exchanging, editing, and critiquing drafts of our training materials. There were many unknowns such as level of experience of the trainees, prior mental health education, even how long we would have with them. So a program was constructed that we knew might have to change. Another unknown was how I would mesh with the other two whom I had never met in person, no less worked with. Before meeting in Colombo a few days before our training began, I had had one phone call each with the other two members of our small team. Especially working in the mental health area, it is important for there to be a basic sense of compatibility among the members of a small team working in what was for two of us a foreign culture. It turned out that we worked very well together. We put together an intensive child and adolescent mental health course (one five and the other two days long): The course consisted of lecture/discussion modules on behavioral developmental milestones (walking, talking, etc.), developmental phases (drawing mostly on Anna Freud and augmented by general developmental psychology), phase specific nature of trauma and what to do about it, loss and bereavement, communication with children and adolescents (including the rudiments of play therapy with children and talk therapy with adolescents), assessment of bio/psycho/social fields of a child or adolescent’s life (general child psychiatric perspective). We showed and discussed two videos: children talking about loss of parents and the famous Robertson tape of a toddler separated for nine days from his mother. In the afternoons we broke the larger group into thirds and discussed children and adolescents they had dealt in the field, in schools, wherever they were working. This was like group psychological/clinical supervision. Finally in these same smaller groups we conduced experiential sessions in which the trainees were invited to respond personally to whatever was the topic of the day, development, trauma, loss, etc. For example after discussing loss, we invited them to talk about a loss of their own, or when talking about developmental phases to describe for the group a memory that illustrates something about a specific developmental phase. These groups were an amalgam of supervision and group therapy. This turned out to be an unexpectedly rich experience. It was so in part because many of these counselors had themselves been traumatized, in their case less by the

tsunami and more by the trauma of the decades long civil war that was going on around them during their childhoods. None of them had ever had any sort of psychological counseling or psychotherapy.

In Sri Lanka

As most people do traveling to Sri Lanka, I flew into Colombo, a bustling, vibrant city whose streets are clogged by traffic and its air by pollution. Three wheelers whine through the streets, and the cacophony of horns is everywhere. I met the other members of my team and we spent a day doing final planning for the training programs. We flew to Jaffna from Ratlamana airport, with a hand lettered sign at its entrance and several military checkpoints to enter. The airport we arrived in Jaffna was in a security area controlled by the Sri Lanka Army. We conducted the training in Jaffna at Shanthiham, “Center for Health and Counseling” set up by Dr. Somasundarum, the trauma expert. The center is run by Mr. Wije, a sixty something, bright, well-read, world-wise, wirey man, fluent in five languages, once an entomologist, then trained as a social worker, who has worked all over Asia. He was enormously helpful throughout our work there. We did our training in a pavilion with a sign “Lecture Hall” over its entrance. The “Hall” is an open air structure with a thatched roof, sand floor and the ubiquitous ceiling fans. Dogs and cats wandered in as did a beggar, the momentarily deafening noise of poorly muffled buses regularly interrupting whatever was going on. For someone who teaches in airless, often windowless, hospital conference rooms, this was a marvelous change. I know it sounds like some requisite guest politeness to say this, but I mean it when I say that everyone connected with our project -- trainees, staff of Shantiham, and those we met at the guesthouse -- were wonderful, friendly, incredibly hospitable, generous people. People were highly respectful in an old-fashioned (by Western standards) way and very appreciative of what we were doing. Pleasing others runs deep in the culture. This is connected, it seems to me, with the culture’s subordination of the self to the needs of the other, the family, the community, or a guest. But the appreciation has also to do with Jaffna having been cut off for so long. Just the presence of foreigners represents a reconnection with the outside world and an endorsement by that world of the value of this community. People would come up all the time to talk with me, children joined me when I went

running at a stadium, and when I had my camera with me, people would stop me to take their picture.

“Patients” Were Everywhere I found that I needed to be alert to opportunities to be a mental health worker at moments when I was not expecting to. Sri Lanka, I found, was a place where much of the population has been traumatized: by the tsunami, by the war, by the uneasy truce, and by living among complex political currents. In Colombo at the hotel I was staying for several periods, people heard I was a psychoanalyst soon to go to Jaffna to do post-tsunami disaster work. A waitor approached me and began talking of his experience: he had had a restaurant on the beach in southeast Sri Lanka and was caught in the tsunami. He and the young men who worked for him were swept away by the wave but managed to cling to the top of a palm tree for hours and all survived. He talked about his reactions to what happened, including classic PTSD symptoms of flashbacks, sleep difficulties, hyperalertness, but beyond this he talked about the loss of his way of life, his community, his livelihood, and then about the people he knew who had died. I also pointed out what was between the lines in what he was saying to me; that he had a powerful feeling of unfairness that this had happened. We talked off and on over several weeks about his reactions. He told me he had never talked about his feelings about this before and felt better that he had. Pressing people to talk about what they experienced during a disaster (Critical Incident Debriefing) has been found not to be helpful, but being available to people during the second post-disaster phase to those who wish to explore what they went through can be invaluable. It can help unfreeze people’s emotional lives, allowing them to move forward with life and especially to connect and reconnect with people. The kind of talking I did with people in Colombo and later in the tsunami villages also stressed helping them to rediscover themselves, to remind them of who they were before the tsunami, and to support the most mature ego coping skills they had available within themselves. This can strengthen a sense of mastery. There is in this kind of therapeutic listening what has been called “witnessing” and creating a “holding environment” within which memories, worries, and private thoughts about troubling matters can be expressed. Another “patient”: a bellman working at the hotel approached me and talked with tears coming to his eyes of holding his eight month old daughter under his arm and with his wife at his side literally outrunning the wave that he could see a 100 or so meters behind him. The three of them all survived, but many people did not, and there are many orphans in his area. He lost his

house which he had built himself with money he had saved working in Dubai. The house was too close to the water to get insurance which is not widely available anyway in Sri Lanka. Again he ventilated feelings of panic, as he looked back and saw the wall of water ready to engulf him and his family. For months he thought about it all the time and said repeatedly to me that he’ll remember it every day for as long as he lives. I talked with him as I did others about the value of putting these feelings into words. I did with him and others some emotional education: explaining that to put feelings into words helps to master them and that if a person doesn’t do this the feelings become generalized into a mood they can’t shake and can lead to physical problems. A person can also become scared of feelings themselves and then stop feeling anything. Fear of feelings can lead to an emotional shut down that creates distance from people, even those one loves. He said he knew what I was describing and that this had happened to him. Another man, a minister, had overheard me at the same hotel in Colombo talking to a physician I had approached who was doing some community centered work with tsunami victims. A little later the minister approached me in the dining room of the hotel while I was eating breakfast and said he’d heard my conversation and that the approach of the physician I was speaking with would never work in his community. I invited him to sit down, and he said where he is working with tsunami victims there is no community. There are many people in the same area, but there are different communities that have no contact with each other. Where is this, I asked. Chenai, in Tamil Nadu, on the southeast coast of India. The different communities are the different caste groups within the same geographical area. We then spent two hours in what I can only describe as an education for me and psychotherapy for him learning about the very personal effects of the caste system, especially on someone from the untouchable/outcaste group of which he is a member. I had read about the caste system, but he told me what the experience is like on a very personal level to be in the untouchable caste. He is a Christian minister who works as a counselor/social worker with, by his own admission, almost no training. He talked about how imprisoned he feels being in his caste. The caste system, he told me, is still very strong and spoke of his disappointment in Ghandi for his tacit support of the system. He spoke of the external restrictions on what one can do, but just as significantly he talked about how the idea of being an outcaste is inside him, “in my bones.” He spoke poignantly about his son, who was a gifted cricket player in a country that is obsessed with cricket. The boy advanced from his local school team, a county team, to district competition,

with his record actually improving at every stage. He was then told that he could not, because of his caste, go further. The boy never played cricket nor talked about it again. That was that. He just closed it off, as if he had been told he had a physical limitation that would prevent him from progressing further. It was one of the most chilling, and to me enraging, things I had ever heard. He was, of course, describing a defense the boy was employing to adapt to this horrendous unfairness, a defense whose long term effects one can only wonder and speculate about. I found myself wondering what effects this would have on this boy’s assertiveness, ambition, and view of his future. He said this caste system follows him and will follow his son to any place in the world, especially in Indian communities. His sense of its power would extend, in his opinion, to efforts to advance himself even if he were working in a non-Indian community in the West. While this last perception may be an exaggeration of the reach of the caste culture, it at least reflects his sense that he and his family are forever completely trapped by and imprisoned by their caste. It was to these internal effects of the caste system that our conversation turned. As he was talking about his son and himself, I said what seemed obvious, but important to say: Part of the problem you and others in your caste have is that what the society says about you, you believe to be true. You’ve internalized what you’ve been told over your whole life. You may not think rationally that it’s true, but you also do. His eyes filled with tears and he said yes, it’s inside me, that’s right. So you get this view of yourself as worthless from the outside and you get it from the inside, too. For an analyst this phenomenon is one we observe with patients all the time. It was a simple observation, but it was, at least for that moment, the key in the lock for this man. I’ve never really put it this way to myself, he said, but that’s it, I can’t get away from this, it’s part of me. I said, it is a terrible, prejudicial, irrational, cruel idea about yourself, and you are being unfair in the extreme to yourself in believing it. We went over this in various ways. He asked what he could do with his community to help them with this, they all feel this way. I said that is a very challenging question, and I have no simple answer to it, but one goal may be to facilitate recognizing as the two of us were just now doing how much those in your caste have bought into this degraded view of themselves. I said that this may be presumptuous to say about his culture and society, but the people he works with need to know that this caste system is, plain and simple, a sickness in the culture. It is cruel, abusive, and has not the slightest shred of reality to it. Being a

stranger to his culture, like being the “other” for our patients, gave me and what I was saying some special, though irrational power in his mind – part of an idealization of a foreign doctor. I don’t know what ultimately made what I said to him effective, nor how long lasting the effects will be. I do know that at the end of this 2 hour conversation in a hotel dining, looking out the window on ancient trains running between Colombo and Galle, with the Bay of Bengal just beyond the tracks, this man told me he had been through something important for him and that he felt very close to me. I said I was glad to have been able to help him, and that I had learned a great deal from him and enjoyed getting to know him. We exchanged email addresses, shook hands, and parted. I learned later in Jaffna that there are remnants of the caste system there, too, more subtle and unspoken, but a psychological and social force nevertheless. Another example: In Jaffna one late afternoon in front of the guesthouse at which we were staying, after I returned from my bike ride, the manager of the house began talking about the hardships of the twenty year civil war. He talked of how resourceful people were, running motorbikes and cars on kerosene (after a shot of petrol to start them), using shampoo for brake fluid, powering radios by hooking them to bicycle generators and manually spinning the wheels. Once he had gone through some of these resourceful, interesting, and humorous accounts, the emotional pain began to emerge. His father, who still at the age of 81 rides his bike everywhere, had been wounded by an Indian soldier. He talked about an alliance that had been formed for a time between the Tigers and India. India sent troops to support the Tigers. A rift developed, and the Indian soldiers went on a rampage, indiscriminately killing, stealing, and raping. Around the same time Nepalese Ghurkas came, and they were even worse. Again I mostly listened and at times helped him to articulate some of his feelings, especially some of the revengeful feelings he doubtless has. This is simple, seat of your pants psychoanalysis. It involves the holding environment of Dr. Arnold Modell, the witnessing of Dr. Warren Poland, the life space interview of Dr. Fritz Redl, affect tolerance of Dr. Henry Krystal, and the ventilation of painful emotions of Sigmund Freud. It is the necessary medium and long term work that must be done post disaster (in this case war), an area that is neglected by much disaster mental health psychology which stresses repression and suppression

and focuses almost exclusively on adaptation and “normalizing� in the immediate post disaster phase. As you can see in this last example, the tsunami was only indirectly connected with this man’s struggles and trauma. This turned out to be true of many of the people that the psychosocial workers brought to the case discussion sessions during our trainings and of the people we provided direct aid to in the field. This brings me to the next topic.

What is the Disaster? Just as a patient comes to a psychotherapist complaining of one problem and the therapist comes to recognize there are others or even that the original complaint was not the most important part of their struggle, we found that the tsunami was not the only problem the people were contending with. As important was the war, torture survivors, and the ongoing state of fear of both the government and the Tigers. “Patients” are everywhere, because this is a traumatized population and one that is also living in an atmosphere of threat. So we needed to broaden our focus. The psychosocial workers work with torture survivors, with widows and orphans of men killed in the war, and people caught in Faustian choices from which there seems to be no exit. These were all “disasters” we were confronted with. As in other areas, the work of Dr. Henry Krystal and Dr. Leonard Shengold provided valuable ways of understanding the psychological challenges confronted by torture survivors, war survivors, and those under political threat. Being the object of someone trying to destroy the self is, of course, distinctly different from being the victim of a natural disaster (though of course in some people with animistic or other religious beliefs, that line can be blurred). Living in daily and nightly threat of being shelled by the Sri Lankan Navy is yet a third kind of traumatic threat. In this last case no one is out to destroy you as a specific person, but you are so completely insignificant that if the Navy thinks there are Tigers in your midst, you will be shelled. Much of the northeast tsunami coast, the area we worked in, was shelled for years. The husband of a preschool teacher at a school we consulted at was killed. She was another of the “patients” who I talked to – and arranged in her case for her to talk regularly with one of the psychosocial workers who has an ongoing connection with the her village.

The Mental Health Training Itself Our approach, which was at its heart developmental, drew on the work of Sigmund Freud, Anna Freud, Erik Erikson, Jean Piaget, general developmental psychology, ego psychology and object relations. The first section was on normal child and adolescent development. For this I described what happens in each developmental phase in the areas of behavioral developmental milestones, drives, dominant defenses, general ego functioning, superego development, object relations and core conflicts. So for the anal phase, for example, I talked about the ascendance of the aggressive drive, the conflict with parental and other reality pressures to curb and socialize the child, the self differentiating function of the child’s use of the word “no,” the development of self worth through internalizing the parents’ attitudes towards the child’s words and actions (secondary narcissism), the dominant defense of turning feelings into their opposite (reaction formation) to avoid loss of love of the parent. Drs. Parameswaran, Calvert and I then used many illustrations to build a conceptual bridge between the concepts and actual behavior of children. This helped the students to understand the concepts and, as well, provided some ways they could counsel parents about what is normal in their children, toward the goal of helping parents be more empathic with their children’s experience. This empathy can help parents, as well, be more appropriately limit setting and, in some cases, less punitive with their children. For example, when the counselors understand the function of oppositionalism in the anal phase child, in child guidance meetings with parents, they can explain this to help prevent harsh, sometimes physically abusive, parenting behavior. In the oral phase, for another example, we explained to counselors how they could help parents understand that there is no superego (conscience) developmentally possible during the first year and a half of life. Parents knowing this can help prevent them trying to “discipline” babies and toddlers and in some cases can help prevent such physically abusive behavior as “shaken baby syndrome.” The concept of “transference” was explained. It was readily understood when it was explained as a “carrying over” of feelings, attitudes, perceptions, and behavior from one relationship to another or one person to another. We illustrated this by inviting the students to think about how they may be experiencing us, older people, teachers, possibly like parents. The concept of inner conflict between strong desires such as hateful feelings and

the social, family and personal prohibitions against these desires was also explained simply and understood by most of the trainees. The effects of trauma, especially the way certain mental self protections (defenses) are set up were also explored. For the section on bereavement and communication with children Dr. Calvert gave a talk about how children try to process loss, the kinds of fantasies they often have about a loss, and the ways these struggles can emerge in play therapy. She brought some play therapy toys and illustrated a configuration of toys that a child she had treated used to express his feelings about the death of a parent. Also she presented drawings this child had done. She also used some hypothetical play configurations that one might see in a child traumatized by the tsunami, setting up a family in a house and then with a big sweep of the hand leveling everything. We also showed a video of the famous Robertson film made in the 60’s of a toddler’s reactions to the nine day absence of his mother. Dr. Parameswaran gave a very comprehensive talk on how one does a bio/psycho/social evaluation of a child. She stressed the importance of assessing the whole life situation of the child along with doing an in-depth interview with the child him/herself. She described with illustrations the ways PTSD, depression, and other psychiatric conditions manifest themselves in children of different ages. Dr. Parameswaran was tremendously important to our whole effort, know the culture intimately, helping with translation, and bringing a wealth of clinical experience with children to the whole effort. At many points during the presentations of concepts she would break in to handle questions, clarify concepts, and focus the discussion. I would say, without question, that she was the most important member of our team. As I mentioned earlier, the training included a smaller group discussion of cases the students had encountered and an experiential group that invited them to talk about their own reactions to the material we had presented and related issues in the lives of their patients and themselves. Here, too, the possibility of communication about cases, even through translators, was better than expected. The three of us facilitated/taught each of the three groups. The differences in the cultures were interesting and often surprising. A few examples: one young counselor asked what should one do if there are “two

cures.” The case was of a 16 year old boy who presented with thoughts of suicide. Suicide has been, long before the tsunami, a significant problem in Sri Lanka – the suicide rate is high. This boy talked of wanting to take pills to kill himself. When the counselor asked the boy what he might be upset about, the boy said he wants to study electronics (for which there is a growing demand) which he has always loved and is passionate about, while his mother wants him to be a teacher. He feels depressed, he said, that he won’t be able to do his electronics. Teaching has never appealed to him. Psychoanalysis, indeed much of western psychology and psychiatry, contains assumptions that mental health means actualization of the self. Indeed adolescent separation-individuation we often see as a process leading to the formation of an individual identity. Identity formation, one of the key goals of the adolescent phase, does contain complex connections to ethnic and religious self reference and self defining groups, but we still see in the West identity formation as an essentially individual act, an individual creation. As we discussed this case, the possibility was explored that the counselor could work to support this boy’s very personal passion for electronics and help him essentially stand his ground with his mother. When I discussed the possibility that it would not be such a bad thing for the mother to be angry at the counselor for doing this, there was nervous laughter and disbelief. This would make the family, particularly the mother, unhappy which was viewed as a harmful thing for the counselor to do. Clearly when the counselor talked about two cures, he had also the alternative in his mind that a counselor might support the boy’s individual passion and the goals that arise from it, but there was a huge conflict between these two alternatives, these “two cures.” The role of the self, the very salience of the self, is subordinated to the role prescriptions of the society. While any society, of course, including American culture, exerts all kinds of complex and powerful forces on how we live, how we see ourselves, and how other people see us, in the more traditional culture of northern Sri Lanka, the external world seems to exert, by our standards, a much greater pressure to live out expectations from the environment. Marriages are mostly arranged, family unity is considered sacrosanct, the role prerogatives and the rights of a woman are very different if she is single, married, or widowed. The status of men is higher than women and the social class of the family via the dowry system further restricts the “free” choices of people as to choice of spouse.

An example of the role prescriptions of women: widows rarely remarry as they are viewed as damaged goods. If they do remarry it is with a lower status man who “ will have them.” In one example I heard of an intelligent woman with some college education who had been married to a school principal. When he died young, the only man who showed interest in her she married, a man who was illiterate. Religious beliefs entered prominently into case discussions. In one case a child of 5 was terrified of ghosts. An aunt had died and the boy could not sleep, his appetite, which had been good, was now very poor, and he looked anxious much of the time. I talked about the common fear of monsters and ghosts in children from 3 to 6 years. Fear of retaliation for what the child thinks are his/her bad, aggressive, hostile wishes result often in fears that someone will do something destructive to the child. The students affirmed that this made sense, but then one said that ghosts are considered very real. The belief is that if someone who loves you dies, you will be especially likely to be haunted by the dead person. Also when anyone dies it is believed that a child is given a torch to light the way along the path to heaven. I could imagine, putting myself in the mindset of young child, that a child would worry that he/she might end up too far down that path and not get back. Cross cultural issues emerged around translating certain words or terms. When we were talking about “magical thinking,” the word “magic” itself posed translation problems. The concept of the “unconscious” was understandable to them, but there was a struggle to find a word for it. Language itself in this culture is a very politically and culturally sensitive matter (as is true in other parts of the world and other eras historically). The Sri Lankan civil war was fought, of course, partly over language. While we were at first encouraging the trainees to find Tamil words for the concepts we were presenting, we came to understand that they preferred to learn in Tamil the meanings of the terms we were using, but wished to use the English terms so they would become familiar with them when they read them in the psychological literature, most of which is in English. Very little general psychological, psychiatric, or psychoanalytic literature has been translated into Tamil.

Even working the tempo with translators took some work (such as how long to speak before breaking for the translator to translate). You become a team with the translator, and he/she becomes an extension of your verbal self.


Working in the Tsunami Village Driving out to the tsunami ravaged areas, we saw immediately why there was such devastation: the land is very flat and very low. As you look, it is hard to discern where the land ends and the sea begins. Though there had been some rebuilding in the area where we worked (near Point Pedro), there was still much evidence of destruction. While you see some fairly large smashed boats far from the beach and the remains of buildings destroyed by the tsunami, destruction is evident also in what you don’t see, in vacant lots and slabs where houses and shops once stood. I cannot imagine what it was like the day of tsunami, but only if you’re there do you even begin to get a sense of the scale of these waves. When someone points to the top of a thirty foot high palm tree and describes hanging there for hours, you begin to see why there was such devastation and why everyone is still so frightened of the water. (Incidentally people spoke of three distinct waves, the last of which was the worst. All spoke of the sea pulling way back before the first of the waves. It is also impressive how resilient these palm trees were under the enormous force of the water and how many lives these trees saved). The people, adults and children alike, wanted and needed to talk about the experience. Many of the children are still terrified of the water, as are some adults. Many adults have an animistic view of the sea as something that gave them life and then turned against them and took it all away. On our first visit to the village there were many questions from parents about their children’s reactions and behavior after the tsunami, so I suggested to the counselors that on a later visit the parents be invited to the preschool for a parent guidance/question and answer session. I also had toys that people in the U.S. had given me to give to the children. It was quite a scene in the preschool when I returned the next week: the preschool was packed with about forty children and their parents. Though the children knew that the toys we were giving to them would stay at the preschool and not owned by them personally and individually, most of the kids, when their names were called, came up to me, like in a graduation ceremony, and received some combination of little toys that the counselors were speedily bundling for me to distribute. Once the gifts were distributed, we opened things up for discussion of issues with children. Envision the

scene: the children were all talking excitedly about the toys, while the parents shout questions, the translator translates and I shout out an answer which the translator then shouts back to the group. I talked to them about the way words can help them and their children to contain and master the effects of the tsunami, the value of listening to children, of not assuming they are “too young to understand,” One of the preschool teachers asked about a little girl who had become very clingy since the tsunami. Should she just somehow train her not to do that by ignoring the behavior or pushing the child to be independent. I talked to them about regression, that the little girl seems scared she’ll lose important people because she heard about people dying, so she worries people close to her could die. She probably wants to stay very close to care giving adults like parents or teachers to make sure she doesn’t lose them. I explained that children, and adults too, sometimes have to move back to move forward, that she is acting like a younger child to go back to what feels to her like a more secure situation, being something like a baby. You need to allow her to do this for a while, while reassuring her in words that you and her parents will protect her and take care of her. Yes, the tsunami came, but that doesn’t mean it will come again soon or ever come again there. You can explain, I said, that now stronger houses are being built further back from the water (both true). But, of course, it is important still to communicate to the child that you know she’s scared. Take the child’s fear seriously, don’t dismiss it, but normalize it, name it, and let the child gradually learn to reassure herself by staying close to you for a while. If you push her to stop clinging, this may feel like the very thing she fears, being abandoned, and she will cling even more. A better way is through gradual separation and encouragement to be more independent supported by a lot of reassurance, coupled with talk about her fears and the facts of the external reality. The issue of spanking and hitting children came up and I talked to them about how children identify with what parents do more than what they say. So if a parent tells a child not to hit, but then punishes the child by doing so, the child may use hitting as a method with other kids, in school, and later in adulthood with other adults and with their own children. Again words are much more effective in the long run, for it helps children control their own aggression. Using words takes longer than physical punishment but pays off in the end. The child learns to exert control over himself or herself and is less likely to consider violence a reasonable alternative to solving problems.

This is very relevant as this society is having major problems with violence, vandalism, threats against parents in its adolescents. I asked the fathers who, as is the custom, were sitting in a little knot together on the side of the room, if they had questions about their children. No, one father said, they are out working so they don’t know what goes on in the home. I said that I understood that, but that it can be important, especially after a disaster like the tsunami, for both parents to be involved. I was again here running into a cultural attitude: it seems men are not supposed to have too much nurturing contact with small children. In fact, I learned while there that there is a major problem with widowers whose wives were killed in the tsunami, because they feel both unequipped and psychologically invalidated for taking care of children (by their own sense of what it is to be a man and by the society’s view of masculinity from which it comes).

Rural One Day Mental Health Clinic – Maybe a Start Two of the psychosocial workers from Shantiham drove one day out to a two room clinic to which the counselors had invited people whose children were having problems to come. First we (myself and one of the psychosocial workers who participated in the interview and translated for me) met with a 13 year old girl who was attacked from behind by a man while she was urinating. The man held a knife to her throat and grabbed for a chain he thought she was wearing. She wasn’t wearing it, but he forced her to hold some liquid in her mouth for a few minutes so she wouldn’t call out while he escaped. She is still frightened, sometimes can’t go to school, fears being alone, fears seeing the man who is still in the community and has not been arrested. She has what might be called flashbacks (or just frightening memories and realistic fears), when she sees him. I talked with her about how her fear operates, that she had her body assaulted, her body which should belong to her was, during that terrible incident, grabbed away from her. She’s trying to get it back. It is terrible for a person to have anyone take control of her own body. I asked if anything sexual happened, and she insisted that it didn’t, but I’m not sure. She was just so scared, she said, that he would kill her. Of course, I said, that is the most awful kind of loss of control, loss of one’s own life, fear that he would take that away. I asked her if she had people to talk to about this and she said, yes, her mother and her friends. I asked her if she felt unprotected because this happened and yet the man is still out in her town. No, she said, she feels she does have support. But then at just this point, interestingly, she told me that at certain times, especially at 8 in the evening, she feints. I asked if she feints at other times, too. Yes, but mostly at 8. That was the time when she was attacked. When we met separately with the girl’s mother, she described her daughter being phobic about going to school for several days and then returning. We talked with the mother about how the girl is still very much caught up with aftereffects of the attack and that it would be helpful for her to walk her daughter to school for a while to help her transition back to it. She talked about trying with difficulty to bring this man to justice. I said that whether or not she can do this, and I hope she can, this is a very important effort for her to share with her daughter, because it communicates to her that you, her mother, are determined to protect her.

The mother then wanted to know if her daughter had some physical problem caused by whatever the man made her drink or hold in her mouth. Was the girl sick after it happened, I asked? No, the mother said, but maybe it went into her brain little by little. She was also concerned that the girl’s problems had to do with her nutrition, the girl doesn’t want to eat fish. I asked what else she eats and it sounded like she eats fine, including other sources of protein, including pork and chicken. We see the mother’s physicalistic theories of what are actually psychological and emotional problems. The feinting (like the headaches the trainees described having after doing too much self-awareness work with me on my second trip to Jaffna) reflects a form of an hysterical view of the body – a use of the body based as metaphor, that something that is truly within one’s mind -- thoughts and emotions -- is viewed as happening to the body. Here this mother views her daughter’s difficulties as coming from the liquid the man made her hold in her mouth. This promotes an avoidance of feelings about the event and instead a focus on the cause of he girl’s problems being based on an illusion of passivity, in this case that something chemical got into the girl’s body and went to her brain. This case, incidentally, illustrates an often neglected postdisaster mental health issue: the effects of living in shelter or temporary living environments that lack the usual legal and social protections. We then met with a group of orphans and other children and some adults who have some caretaking roles with them. We did what can only be described as a combination of emotional education, responding to emotional currents, a little interpretation of some unvoiced issues, and support. One girl’s father had committed suicide (a significant problem in Sri Lanka as I mentioned), and I asked if she thought about him and she said resolutely and it seemed defensively “ille, ille,” no, no. We talked about her feelings of loss, and I said that sometimes kids feel after a parent dies that the parent has abandoned them. I said that when someone suicides this abandoned feeling can be even more severe, because the person has chosen to take themselves out of life. She shook her head in agreement. There was a boy of about 7 who had lost an eye, and I asked his name, which he gave. I asked what had happened to his eye, and the woman who was caring for him said he’d lost it to cancer. I asked how he was doing in school, and the woman said he was doing well. After some talk with him about his wondering how he’ll be able to do in life with one eye, I told him that I knew a man who played polo (which they knew about) who had only

one eye and outplayed most players. People can compensate; they can learn to use other visual cues to see how far something is away. A girl of about 10 spoke up that she has not been able to sleep. Just from the look of her, very neatly dressed, hair very much in place, sitting very straight, you could see she was a very compulsive child. I asked if she thought about anything as she lay awake (this simple question is likely to never have been asked. If she had seen a doctor, if he treated this problem at all, it would be with medication). She talked with a lot of energy and intensity about how she worries about school tests. That you won’t do perfectly on them, I asked. Yes, yes. This, I said, can be a burden, I’ve felt this way at times in my life, too. It seemed to me that modeling that people can have feelings and problematic ideas would help her to feel more comfortable and less stigmatized talking about anxieties. (In this culture going to a psychiatrist or any mental health person is still very stigmatized) Needing to be perfect makes everything so pressured, doesn’t it? Yes, she said. I said that I don’t know her really at all, but sometimes people feel they must do everything perfectly, because they think that if they don’t, something terrible will happen, some catastrophe. We needed to get to our next meeting, and I asked the people if this had been helpful. Though what we did was simple, they enthusiastically said it had been very helpful, no one had talked to them or their children like this. I came to realize that many NGO’s have the attitude that until all the physical needs are taken care of, the mental ones need to be put aside. There is the unfortunate attitude that it is neglectful and maybe even irresponsible to do direct mental health counseling until they are thoroughly taken care of physically. This means that when there is so much rebuilding of infrastructure that needs to be done, the mental health challenges are never really addressed. I took the two psychosocial workers aside and said to them that they have a real opportunity here to do some group and maybe individual counseling with these people. They brought up that these people are from areas serviced by other NGO’s. I said that that may be so, but what we have done today those NGO’s aren’t doing. What would stop them from simply coming here at a set time every week or every other week. They said they would like to set this up and before the end of the meeting set a time for the next meeting. These were here some very simple, but psychoanalytically inspired, interventions that I could model for the counselors.

Home Visit to Very Poor Woman We visited a woman who the counselors had briefly talked to the week before. She was the mother of a child by a man with whom she had had an affair. The wife of the man had threatened her even though the man has now returned to the wife. She talked to us about feeling very abandoned, but spent most of the time feeling apologetic about her home. The woman lived essentially outdoors with her daughter and aged father, beneath a thatched roof supported by bamboo. She has an open pit where she cooks, no plumbing, no electricity. There is no furniture and what can only be described as low, molded, slightly raised clay about a foot off the ground that serves as a bench. When I asked her, she said they do have enough to eat, that has not been a problem. She and her daughter were dressed in clean clothes. Though the clothes were, of course, not new, they were neither tattered nor torn. Though pretty, the woman is in much need of both dental and orthodontic care. Though she didn’t say it, she was evidently embarrassed about her teeth, trying to close her mouth when she smiled. She very poignantly said at some point during the visit, “I’m smiling, but I’m crying inside.” I said I understand. It is very hard not to distance yourself from this kind of pathos and pain. I asked her about her daughter, and she said her daughter does go to school and does well there. Her father, however, is 81 and has been sick. He sat quietly in a squatting position with a loincloth and no shirt during the visit. He looked gaunt and ill. I asked what she felt like crying about right now, and she said she feels embarrassed that I’m a big man and there’s nowhere for me to sit. I’m the first white man who has ever been to her home, in fact I was the first white man she has ever talked to. She talked of wishing she could do more for her daughter. She said that it’s hard not having the protection of a man. She worried about what do I think of her. I said to her that I was impressed with how she lives her life given what she has. I said that living my life is so easy, that she has reason to be much more proud of what she’s done for her daughter and for the care she takes of her father than do people who have more money or possessions. I wish, I said, she had more, but you have much reason to be proud because of what you do everyday to keep yourself, your daughter, and your father safe and fed.

I though again of the positive value of really listening, witnessing in Dr. Warren Poland’s terms, psychological holding in Dr. Arnold Modell’s. Here again I felt that what I could provide was so little compared to the material things that would make her life easier and better, like a better dwelling, electricity, running water. I felt that talking about her feelings and her emotional struggles was somehow condescending, that it should wait until the “important” things are provided. I had the attitude I described above that material things are what she needs, that emotional, psychological support was some kind of indulgence or frill that should wait until later. This attitude, which I know is irrational, can rob someone like her of the chance to talk and be listened to. I felt also there is something about the power of me being a stranger, someone not of her world, like a Western therapist is not part of the Western patient’s personal world, that made it more possible for her to talk to me. I recognized in myself at many points my own rescue fantasies. These are invited by situations like this. I found them in myself and in co-workers in Sri Lanka and during my work with the Red Cross in Louisiana after Katrina. I think the emotional challenge for anyone trying to work in these deprived and/or disaster environments is to avoid a variety of defensive positions: becoming inured to one’s emotions, avoiding the whole situation, or trying to work out one’s guilt and helplessness by trying to rescue. When this last effort fails there can be both severe criticism of the self and paradoxically anger even at the people one is trying to help. The unconscious, angry theme is: why don’t these people improve to validate my usefulness and to assuage my guilt.

Home Visit in Remote Area With the psychosocial workers we went for a home visit in a very remote area. This is an area that the NGO’s refuse to go because of the history there of inter-family, intra-community violence, mostly knife fights between men of feuding families. Foreigners have never been involved. About five women and a man were told we were coming and met with us. The home of the woman who hosted this meeting was a fairly substantial stone structure, no glass windows, cloth drapes instead of doors, no electricity or indoor plumbing. Water was from a communal well. The woman of the house had a little chicken farm in her backyard which she gave us a tour of. Also in the backyard was a mound of smoldering ash from the slow burning of some vegetation that is then sold as tooth powder. Though I explained that I was not a medical doctor, the women still wanted to ask me about problems with their menstrual periods and the man about his bad knee. After a couple of times re-explaining what I could do and not do, they shared some of their emotional experiences of their life: that they are very glad the war is over, that they wish they had electricity (which they have never had), they wish they had more material things for their children and that they were less cut off. They have enough food to eat and, when I asked, they described themselves as generally happy. I felt here that just visiting these people had a meaning. I was told at the IMHO meeting in New Jersey that just having foreign interest in these remote areas is very important to the people. The whole community feels ostracized and my being there had some validating effect, as if the culture outside had recognized them. They were interested in what life is like in the US and in my family. When I told them I had a daughter, they began to talk about a match with their teenage son. There was here, as with the Tamil Nadu Indian man I met in Colombo, a way in which they had internalized what they perceive (probably accurately) to be an attitude of the society: that they are tainted. One wonders if the internecine conflicts might in some displaced way be an expression of their rage at the world outside for this ostracism, but this is a speculation.

A Sea of Nurses When I returned myself to Jaffna during my last week in Sri Lanka, the Director of Shanthiham asked if I would do a presentation/consultation with nurses at the Jaffna University Teaching Hospital. There was a problem with nurses being critical and, at times, verbally abusive with patients. Would I do something that very afternoon on communication with patients. I went back to the guesthouse where I was staying and put together about 16 pages of overheads on the subject. The areas I covered were: feelings generated in nurses and doctors by patients, especially if a patient is presenting with a medical problem the professional or someone in his/her family has struggled with; how patients may carry over feelings from another relationship into the relationship with the nurse; how a negative spiral can occur where a nurse gets frustrated with the demanding behavior of a patient – the patient feels neglected and gets more demanding and/or angry – the nurse gets even more frustrated, critical, harsh, or withdrawn and so on; I talked about active, listening and empathy, looking beyond the patient’s anger or demandingness to what lies behind. In very simple terms I explained how overt behavior may be a defense against what the patient is more basically struggling with, such as anger hiding feelings of fear of the implication of a bad medical diagnosis or prognosis. I talked about how vulnerable hospitalized patients often feel and that trying to control those around them is often done out of a need to feel more in control and less passive and vulnerable. I gave many illustrations of these points. The Teaching Hospital in Jaffna reminded me of the film “The English Patient,” it was of that era. The light in the wards was low, the beds were constructed of thick white steel pipe, some patients were lying in the open air walkway that snaked through the hospital, and the hospital, as far a I could see, had nowhere any air conditioning. There was, however, a very warm, caring feeling about the place. In a large lecture room with the ubiquitous ceiling fans whirring quietly and a raised platform for the teacher were what looked like a sea of young nurses (mostly women), all dressed in impeccably neat uniforms with large, pointed starched collars and winged hats. When I entered, they immediately stood up with almost military formality and greeted me with the Tamil greeting, Vaanakam, which I said back to them. The nursing tutor translated my presentation. When I finished I asked for questions or comment. While there were none, there was much discussion among themselves. When I

asked the nursing tutor what they were saying, she said that they were talking about the presentation, but that there is a negative attitude about asking a question or speaking up because that might be seen as trying to look good, to stand out. This feels like both an individual problem with aggression as well as a cultural inclination to subordinate the self to the group. “Showing off” promotes the individual, while quieting those individual competitive strivings enhances the unity and power of the group. The group was especially responsive when I described studies that have shown that ward staff personnel treat patients the way the staff themselves are treated by superiors (Stanton and Schwartz). I illustrated this with an example of administrative staff treating ward staff harshly leading to staff treating patients in the same way. Making the connection to their own situation, they all laughed and applauded. This reflects what are surely some underlying institutional problems. I wonder how these may effect the medical students and residents and whether the frequent strikes have something to do with these institutional tensions. After the talk I met with the two “tutors” one of whom had been at the hospital for many years and other was much more junior. As was the case everywhere, the older nurse was of the generation that was taught English in school and spoke it quite well.

Afterthoughts The work we did in Sri Lanka was rich and rewarding. The people we were training and the people at Shanthiham, who were facilitating the training, were all unusually gracious and generous. The people of Sri Lanka whom I had contact with, from the kids who ran along with me during my morning runs at a stadium in Jaffna, to the people who ran the guesthouse, to the drivers who took us out to the tsunami village, to the psychosocial worker who invited me to dinner with her husband at her home – everyone – was warm, helpful, and engaging. I hope we made some difference. During the two training programs we gave out daily evaluation forms. The responses were overwhelmingly positive. There were constructive comments on how we might improve the training, including even more opportunity to talk about their cases. They wanted, too, somewhat more concrete recommendations on what to do with the troubled people they were working with. The work in the tsunami village and at the rural clinic, though very time limited, I think also contributed in some small way to the welfare of the people there. As several people said at the IMHO conference of their work in Sri Lanka, I found myself getting as much or more than I was able to give. There is a gentleness, kindness, and warmth in the people and in the culture that deeply influenced me and changed me for the better. I look forward to returning and plan to do so in 2006 (tentative plan is June, 2006). Ann Arbor, Michigan February, 2006

Mental Health Projects in Sri Lanka  

Report on Mental Health Projects in Sri Lanka

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