Trauma and Beyond: The Evolving Field of Mental Health and Psychosocial Support after Disaster and Conflict in Sri Lanka
The field of post-emergency mental health & psychosocial support is commonly represented as being about the provision of psychological support to people in terrible emotional distress after experiencing a traumatic event. The images in the popular imagination and in the media often are of counsellors or psychiatrists compassionately listening to or treating victims of violence, or survivors of disaster. Whilst these forms of help are still crucial to the field of mental health and psychosocial support in the context of conflict and disaster, they are now by no means the only way in which it seeks to assist people affected. This article attempts to sketch some of the key shifts that have taken place in this field over the past decade in Sri Lanka, which has been affected by chronic conflict over several decades and a major disaster in December 2004. These will be illustrated through examples from work that I have been a part of since I entered the field in 1996. At that time, because of the continuing war between the government of Sri Lanka and separatist militants in the North and East of the country, and also a recent failed but bloody insurrection in south, western and central Sri Lanka, numerous services had arisen to deal with the psychological consequences of this violence — mostly provided by non-governmental organisations and to a much lesser extent by the state. Due to the globalized nature of the field (that is, in terms of knowledge, technical expertise and financial resources typically flowing from North America and Western Europe to poorer conflict-affected countries), the approaches in Sri Lanka closely mirrored those in other similar contexts. Whilst this trend continues today, the development of local expertise and consolidation of experience within the island is beginning to change this dynamic.
The Clinical Model
If we examine the popular stereotype of the field of post-emergency MHPSS work; this representation has its roots in the origins of work in this area. When the field of mental health work with refugees first emerged in the 1980s, as a part of the new professionalised humanitarian interventions with refugee populations affected by war and disaster in the developing world, the perspective that dominated this work was that of psychiatry and clinical psychology. It was recognised that civilians affected by the terrible events of war or disaster often had consequences that went beyond material loss or physical injury. Psychological problems like depression, overwhelming grief reactions, anxiety and post-traumatic stress were identified as key issues to address. As a result, the psychotherapeutic and medical approaches that had been developed in Europe and North America to address these same issues in civilian and war-veteran populations were deployed through clinics or community mental health programs in conflict-affected countries. In Sri Lanka, this meant the establishment of programs to train counsellors and medical staff to identify people with the symptoms of particular mental disorders and provide them with talk-therapies or drug treatment. Their services were provided through hospitals, centres in the community and home-visits. For children, there was an added concern that their stressful experiences might impair their psychosocial development and pre-dispose them to later mental health problems, or that exposure to violence could lead to antisocial or violent behaviour in the future. In Sri Lanka, this again led to the development of programs for children to work through their experiences using art or play, as well as to many training initiatives for teachers to better help their conflict-affected pupils. These approaches often took the form of ‘stand-alone’ psychologically oriented programmes or sometimes deployed a ‘psychosocial plus’ structure where other practical services were delivered in conjunction with those that were explicitly therapeutic.
Examples of the Clinical Model in Sri Lanka
In the early 1990s, an intervention for women whose husbands had been killed or disappeared during the recent ‘Southern’ insurrection often sought to identify women who suffered from unresolved grief or intrusive post-traumatic symptoms such as nightmares or recurring disturbing memories. The grassroots counselling services that were offered in response involved basic psycho-education and reassurance that symptoms were normal reactions, and not signs that they were going ‘mad’. Occasionally, mental health professionals from Colombo would conduct clinics in affected districts, providing advice on managing symptoms through relaxation exercises and referring people with psychiatric disorders to the nearest government mental health clinic (which often involved several hours travel to another district). Clients were also encouraged about their positive coping strategies and encouraged to communicate more effectively about their problems with their family-members and others close to them.
In the East of the country in the mid 1990s, a project to support children affected by war focussed on bringing routine to children’s lives through regular activities at village play centres. These activities facilitated by locally recruited animators used art to help process traumatic memories and engage children about fears they had of aerial bombing or fighting between armed actors. Cooperative games were also employed to encourage pro-social behaviour. Children were also given a daily snack to improve their nutritional status.
When I first entered this field in 1996, as a volunteer with an organisation supporting survivors of torture in Sri Lanka, this was very much the paradigm within which we worked. Our clients were provided with sessions with counsellors to help them talk through the various emotional, existential, relational and practical problems that they encountered. Although the model of care was relatively progressive in that it recognised that our clients and their families had many difficulties beyond the purely psychological, and attempted to provide a ‘holistic’ care package, these services were all compartmentalised. Medical care and physiotherapy for physical injuries, provision of assistance in job-seeking or grants for income-generation, legal assistance in seeking justice and counselling for psychological difficulties were each delivered separately and with little interaction with each other. What we did not see at the time was that many of the different problems of torture survivors were actually inter-related, and that our attempts to assist them could have been more meaningfully integrated.
Although clinical and psychologically-oriented interventions continued to dominate the interventions in the field in the mid 1990s, these had also begun to draw criticism internationally. One argument was that they focussed too narrowly on trauma and individual psychological states and ignored the broader social circumstances and problems that produced and shaped distress. It was also claimed that the ‘medicalized’ approach emphasised the role of external experts, failed to recognise or make use of the local resources available to affected persons and communities, and undermined survivors’ roles in effecting their own recovery. The focus on ‘vertical’ specialist services targeting small well-defined groups (ie. torture survivors, people with PTSD, survivors of sexual violence, etc) was also argued to be at the cost of more ‘horizontal’ general support that could be provided to entire populations, and which would avoid the stigmatisation or differentiation of particular individuals. Lastly, there was a suggestion that the Euro-American concepts such as post-traumatic stress disorder were not appropriate to use in capturing or addressing the suffering of people in non-western settings.
The debate this criticism provoked between what has been described as the ‘trauma’ and ‘resilience’ camps was quite vigorous and at times even bitter. Whilst these exchanges mostly conducted in European and North-American academic and humanitarian policy arenas, their effects were felt in terms of the design and financing of programmes in conflict-affected countries. In Sri Lanka, whilst practitioners were aware of the specific disagreements taking place, their concerns about the clinical model were first shaped by the practical experiences of implementing it. Clients were not always comfortable with or convinced of the value of talking-treatments, preferring practical interventions around the concerns associated with their psychological distress. Often there was divergence in the way that clients and service providers conceptualised or prioritised problems. Limitations in resources for training and supervision meant that the quality of ‘barefoot’ counselling or ‘psychiatry-lite’ being offered was often low. The fact that most clients continued to live in communities that continued to be afflicted by violence, social conflict and deprivation also presented challenges to therapeutic progress.
Understanding Social Suffering and Integrating MHPSS
By the end of the 1990s, several colleagues in Sri Lanka had begun trying to articulate alternative visions of what support to individuals and communities might look like. We drew inspiration and insight from our unsatisfactory experiences with the institutional and theoretical elements of the clinical model, from snippets we read of the Euro-American debates within the field or the emerging work of medical anthropologists on social suffering, and most significantly from research and reflection on the nature of women’s suffering Sri Lanka’s conflict zones.
Whilst conducting research and being involved with service delivery, my colleague Gameela Samarasinghe and I were confronted with the realities of women’s lives under conditions of ongoing war in Northern Sri Lanka and also in the disadvantaged South-Eastern part of the island where an armed insurrection had been suppressed some years earlier. The impacts that they described caused us to look beyond purely psychological disorders and effects, and adopt a more ‘psychosocial’ perspective that aimed to acknowledge how events and circumstances shaped both their inner psychological and external social worlds, and how these two domains continued to interact with each other. For instance, the murder of her husband might not only cause a woman grief, a sense of powerlessness and existential doubts, but also new challenges in terms of material and economic survival, increased vulnerability to sexual violence or exploitation, and changes in social identity and relationships with her children, relatives and neighbours. It was clear also that these impacts had knock-on effects many years down the line, and that the suffering of conflict lay on a continuum with other forms of violence and hardship that women experienced even when the fighting was over. The powerful way that poverty undermined women’s abilities to cope with losses or threats was also evident. The lack of disposable assets like jewellery or savings to mobilise in a crisis, not owning land or livestock from which to make a living, the lack of salaried income, and the absence of skills or connections to be able to find work and negotiate the public domain were all often associated with greater difficulty and distress. The insights gained from these women’s lives were crucial in our understanding the contours of the suffering of adults and children in disadvantaged and chronically affected communities.
If the psychosocial consequences of conflict were mediated and shaped by the social and structural conditions of people’s lives, it seemed to follow that our interventions to support survivors had to engage with these, and not only the symptoms of individuals affected. Similar views were eloquently expressed in 1994 by Daya Somasundaram and S. Sivayokan, who wrote that they did not wish to, “individualise and make medical the problem, while diverting attention from the socio-economic determinants as well as the political attitudes that make massive trauma possible,” and suggested that the, “responsibility of the medical profession is to alleviate the suffering of individual patients as well as to address these larger issues”. By the end of the 1990s, small groups of practitioners had declared their intention to integrate approaches conducive to enhancing psychosocial wellbeing into mainstream development and humanitarian work, and since then have worked to put this into practice. From 2002, MHPSS practitioners began to dialogue with and lobby policy-makers and mainstream development practitioners, whilst also striving to better understand the linkages between long-term and large-scale development processes and the wellbeing of individuals and groups affected by these. This work also fit into a broader trend within the field globally, as illustrated by authoritative guidelines on mental health and psychosocial support interventions in situations of emergency issued by the Inter-Agency Standing Committee (the key humanitarian coordination forum established by the United Nations General Assembly) in 2007, which emphatically argues for the need to support individuals and populations through activities directly related to provision of shelter, education, food and information — but which impact strongly on psychosocial wellbeing and mental health.
The integration of MHPSS objectives into other aspects of humanitarian and development work can take place in many different ways, as is illustrated by several popular models (adapted from IFRC, 2009). In the ‘Bundled Integration’ Model, MHPSS services are delivered in ways that are closely coordinated and related to other side-by-side interventions. The ‘PS Support as Organising Principle’ Model sees the use of MHPSS services as the basis for organizing or guiding the provision of other required services. In the Model of ‘Integrated PS Princples’, the mental health and psychosocial objectives are achieved entirely through the provision of other services in ways that promote wellbeing, and in the ‘Integrated PS Principles Plus’ Model, these are complemented by stand-alone therapeutic interventions to meet needs that require targeted services.
This incarnation of mental health and psychosocial support work looks remarkably different from the popular image that I invoked at the start of this article. Whilst it still retains and values the individual therapeutic workers doing one-to-one or group work with affected people, increasingly the emphasis is also on less obviously therapeutic processes. These might typically involve any of the following: the way in which people being resettled are well informed about the place to which they will go, their ability to choose their neighbours (relatives or people they knew before as opposed to strangers) or influence the layout of their house; ensuring that orphans can find foster homes within their own communities (rather than be institutionalised), helping teachers prevent discrimination against orphan children in school or reuniting siblings who have been separated after the loss of their parents; helping widowed women become more skilled in running home-businesses, ensuring a match between their products and market demand, and creating opportunities for new friendships and partnerships between them and other women in the community; establishing clear complaint and advocacy mechanisms in refugee camps, ensuring that camp administrators don’t privilege particular individuals and groups, or coordinating the way different agencies interact with and provide assistance to a single camp.
Examples of the Integrated Approach in Sri Lanka
In January 2005, after the Indian Ocean tsunami disaster, there were many people who were left searching for family members who had been swept away by the waves. The process of searching through the photographs of the dead at local police stations was extremely distressing. In two districts, it was arranged that special identification tents were set up to give family members a private and calm environment to view the pictures of the often damaged bodies of tsunami victims. Counsellors accompanied families throughout the process — from preparing them to view the upsetting photos, to explaining the legal process for confirming a death, to arranging for follow-up emotional support if necessary.
In the early 2000s, a resettlement programme in Northern Sri Lanka appointed a psychosocial worker as the team leader and primary liaison with the newly established community. Whilst the programme included components of housing construction, starting of new livelihoods and building community governance mechanisms, it was the psychosocial practitioner’s interactions and work with individuals and groups that guided the direction and process of all development activities.
Another intervention in 2002 engaged a rural children’s club in a social service project at their local hospital, where they read newspapers to bedridden patients. Amongst the club members were many orphaned children for whom this was a rare opportunity to be valued as helpers, rather than being viewed socially only as being dependent on others. The project also expanded the children’s social networks and connections, for example giving them direct access to hospital staff outside clinic hours in case of illness.
A few years ago , a Task Force for Gender Based Violence in Eastern Sri Lanka integrated the services of several government (mental health support & policing) and non-government agencies (safe shelter, legal aid, livelihood assistance & community-based support) through cross-agency case work systems that placed psychosocial considerations at the centre of efforts to support affected women.
Learning to Integrate
The new approaches described above now have their own challenges. The greatest of this is that these new strategies require new skills on the part of those who wish to intervene — who continue to make use of the clinical techniques offered by the professions of psychiatry and psychology, but need to go beyond these. There is a need to draw in persons with skills in the areas of poverty-alleviation and micro-credit, community-building and social mobilisation, local social and healing practices, camp-management, protection and legal aid, education, healthcare and shelter, providing them with new understandings of how their actions in these fields can contribute to enhancing psychosocial wellbeing and mental health. People who wish to specialise in this increasingly multi-disciplinary area of work require broad training and must have a willingness to innovate and collaborate. In Sri Lanka, as in other locations around the world, we have started running courses on mental health and psychosocial support for professionals and community workers, both in our universities and in affected areas. There are attempts to ensure that learning that emerges from new initiatives and developments in the field, especially in our own contexts, are quickly reflected in the curricula of the training on offer.
Working in relatively unmapped territory also requires that practitioners continue to re-think and critique their assumptions about the field, even as they try to consolidate and formalise our learning into concrete guidelines on good practice. At the moment, there is renewed interest in Sri Lanka to better understand local socio-cultural frameworks of psychosocial wellbeing, as well as to find better ways of measuring the impact that our interventions have on the dimensions that affected communities consider to be priorities. Practitioners are challenged to improve the quality of the dialogue with the individuals and groups whom they are trying to assist, and to give them greater opportunities to participate in the decisions that shape interventions. There are also attempts to find ways of understanding and responding to suffering and difficulties on a collective level — exploring whether the overall impacts may be greater than merely the sum of their parts.
There have also been attempts to build inter-disciplinary alliances and better partnerships with other sectors of humanitarian response and development practice. These linkages and collaborations need to take place at the level of front-line service provision, but also at that of regional or national programmes and policy. At an individual case level, a psychosocial worker may work together with a primary health midwife to support a displaced woman suffering from postpartum depression; at the level of local programmes, psychosocial practitioners and school administrators may collaborate in getting school drop-outs to re-enter education; local government and humanitarian managers may be encouraged at a regional level to adopt standard policies and processes for consulting with affected populations; interventions at the level of central government may include working with the Ministry of Education to develop national curricula and training for teachers on supportive classroom practices for disaster-affected students, or helping to frame policy that diverts children from incarceration within the justice system.
The experience after the tsunami disaster of 26th December 2004 has taught Sri Lankan practitioners many valuable lessons about coordinating services within and across sectors in an emergency context. Granted what we learned in the context of the tremendous and unruly post-tsunami response was as much from our mistakes and narrow misses as from our more successful efforts. Still, valuable skills and experience in cooperative action has been developed within the field, which can be harnessed for future work.
New Challenges for the Field in Sri Lanka
At the end of the long and brutal war between the Sri Lankan state and armed Tamil nationalist movements in 2009, the field of MHPSS faces several challenges. In many ways, the field has grown beyond its roots as a response to the suffering caused by armed conflict and disaster, becoming relevant to wider social problems within and beyond conflict zones, such as child abuse or violence against women. However, in the North of the country, where the field first emerged in Sri Lanka, psychosocial interventions were perceived as politically ‘sensitive’ in the post-war period, to the extent that they have been discouraged or restricted. This situation is both unfortunate and ironic, given that most MHPSS interventions in Sri Lanka have historically avoided overtly political approaches (in contrast, for example, with the field in Latin America) in order to be able to provide services under difficult and contentious conflict conditions.
The sustainability of innovations and multi-dimensional systems of support that developed during the years of conflict and disaster are current threatened by a decline in the grants available for financing community services. As international donors withdraw emergency-specific funding, or redirect resources towards building of major infrastructure, livelihoods and economic regeneration, the networks of services have begun to dwindle — in the non-government sector, and crucially in terms of adjunct services to the public sector (which so far do not receive government financing). Alternative models for sustaining and extending these services are urgently required.
Regrettably, the momentum within the field of MHPSS intervention to engage other larger areas of development and humanitarian practice has dwindled in recent years. Following the Indian Ocean tsunami, the field expanded very rapidly with a wide range of non-specialist agencies entering this area of work. Unintentionally, this has brought about what I would characterise as a ‘bureaucratisation’ of the field in Sri Lanka — with administrative and management imperatives increasingly overshadowing technical or professional concerns within the sector. The emphasis within coordination and management is often on compliance with guidelines, minimum standards and stereotyped modes of intervention, rather than on substantive learning, innovation and thoughtful extension of a still young field. In the mainstream of development work too, there appears to be a reduction in responsiveness to beneficiaries at the frontline. Bureaucratic tendencies are seen within the new arrangements for service delivery, with grassroots providers often acting as short-term contractors for larger organisations or the state, with increasingly centralised administrative and regulatory systems. A renewed emphasis on large scale infrastructure development at a national level, and a return to internationally-set development goals at the global level also creates new challenges for horizontal integration of MHPSS concerns. There is a need for ongoing empirical data-gathering and critical theoretical work to monitor the status of individual and collective psychosocial wellbeing, to measure the efficacy of MHPSS interventions and to direct developments in both policy and practice.
Even as we try to enhance the technical capacity of practitioners, adopt new financing mechanisms and develop the institutions and structures to deliver psychosocial and mental health support, we have to remain doubly aware of the human element that is integral to this area of work. Most of what we do is ultimately not very complicated, but our success often hinges on the ability to maintain sensitive and genuine relationships between the persons providing support and those who receive it. Whilst this work requires that practitioners engage closely with survivors and their suffering, this often takes an emotional toll that can easily result in workers feeling ineffective, jaded or disinterested — which can spell disaster for our clients. Maintaining healthy, ethical and committed relationships with the people we aim to assist can be greatly aided by the building of small teams and networks of practitioners who reinforce positive professional values practices, as well as provide personal support when needed. In my own view, this is often the most important ingredient for successful services.
Changing Relations to the Global Field
When I first entered the field in Sri Lanka in the mid 1990s, the flows of knowledge and expertise were almost exclusively uni-directional from outside the island. At its best, this meant that services in Sri Lanka benefited from wise and influential international advisors sensitively transferring insights and successes from other parts of Asia, Africa, Europe or North America. At its worst, it meant that initiatives were introduced in Sri Lanka with little attention to how they would interact with local structures, social practices or knowledge systems. However, the long-standing and sometimes pioneering work in Sri Lanka has now meant that a level of experience and expertise has been built up in relation to post-emergency mental health and psychosocial work. This is bringing an increased sophistication and coherence to Sri Lankan MHPSS work, which is increasingly shaped by local practitioners. This is also true for other similar contexts of disaster and chronic conflict, with the result that practitioners from these arenas are beginning to make their mark on the field globally. It is no longer uncommon to have practitioners from Jaffna working in Cambodia, or from Gampaha working in the Democratic Republic of Congo. That there is increasing direct exchange between practitioners from emergency contexts is very exciting, considering that this has been sorely lacking in the past. It is encouraging to note that initiatives with roots in local practice are seeking to improve global participation in knowledge exchange. The journal Intervention (www.interventionjnl.com) that actively seeks contributions from practitioners working in situations of adversity was founded in collaboration with Shanthiham, in Northern Sri Lanka, but now has a global reach. Similarly, the online platform for the Mental Health and Psychosocial Network (www.mhpss.net) connects practitioners around the world, but is maintained by ‘hosts’ based in Sri Lanka and Manila, amongst other places. A full ‘democratization’ of the field is still far off, but the voices and priorities of practitioners who live and work in situations of war and adversity are increasingly shaping the direction of the field, both locally and beyond.
References:
IFRC (2009) Psychosocial Interventions: A Handbook, International Federation of Red Cross and Red Crescent Societies Reference Centre for Psychosocial Support.
Somasundaram DJ, & Sivayokan S (1994) “War trauma in a civilian population”, British Journal of Psychiatry, 165: 524–7.
Ananda Galappatti is a medical anthropologist based in Sri Lanka. He is the Director of Strategy at The Good Practice Group, a Managing Board Member of mhpss.net and also a member of the editorial board of the journal Intervention.
[An earlier version of this article was published in Somasundaram, Daya (2014) Scarred Communities, Sage Publications].
