trauma and transformation in sri lanka now: a blueprint for intervention and research dr shamil...

Trauma and Transformation in Sri Lanka now: a blueprint for intervention and research

Dr Shamil WanigaratneConsultant Clinical Psychologist and Hon. Senior Lecturer

South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King’s College London

Sri Lanka Psychiatrists Association (UK) Annual Academic Conference 3rd October 2009

Trauma and Transformation in Sri Lanka now: a blueprint for intervention and research

• Background• Estimation of need• Responding to need• Need for research • Opportunities for understanding and transformation • UK-Sri Lanka Trauma Group and appeal • Discussion

2Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

Background

• Historical context of trauma • Disasters and mental health • International NGO’s and mental health• Sri Lankan context


Historical context of trauma

• JVP insurrections in the 70’s• Civil Conflict since the 80’s• Riots and displacement of Tamils 1983• Tsunami 2004• Final phase of the war and end 2009


Response to disasters and trauma

• International NGO’s respond from a Maslowian hierarchical perspective – protocol driven

• Sphere Project (2003) minimum standards for disaster response

• Governments also respond along the lines of International response

• Driven by a public health agenda • Mental health has lower priority


Disasters and mental health


Sri Lankan Data

NATIONAL SURVEY ON MENTAL HEALTH IN SRI LANKA (Commissioned by the Ministry of health - conducted by the Institute of research and Development - 2007)

6120 participants (16 – 65), 365 from each district apart from North and East, interviewed using Primary Care Evaluation of Mental Disorders (PRIME-MD) - Patient Health Questionnaire (PRIME-MD/PHQ).

86.2% Sinhala, 7.7% Tamils, 6% of Muslims, and 0.1% each from Burgher and Malay

• Low prevalence of PTSD (1.7%)• Mood disorders (10%)• Medically unexplained symptoms (3%)• Alcohol abuse (7%)

Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009 7

Sri Lankan context

• Disaster model alone is not enough• Multiple trauma’s war-tsunami-displacement

• Collective trauma (Somasundaram & Sivayokan 1994, Somasundaram,1998)

• ? Religious and cultural factors as mediators • End of the war presents an unique opportunity for taking

stock and intervention• From a mental health perspective whilst there is an

infrastructure in the country there is inadequate capacity hence need for preventive interventions and capacity building


Loss & grief

• Loss of life - children, siblings, family• Home and property• Loss of livelihood• Loss of dignity


Estimation of need Who is traumatised?


New IDP’s

• Estimates around 250 – 300, 000• Experienced multiple and prolonged trauma• One MOMH providing mental health cover for

entire area• Local NGO’s (eg. Survivours) doing some

sterling work• Most workers and volunteers suffering form

burnout Dr Shamil Wanigaratne King's Health

Partners & UK-Sri Lanka Trauma Group 3rd October 2009

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Combatants

• Serving combatants (combat stress, non- combat stress)

• Ex-LTTE carders• Child Soldiers • Injured and disabled combatants (26,000 before final phase of war)

• De mobbed security personnel • Deserters (18,000)


Focus on children

• Estimated 40% in IDP camps are under 16.• Child soldiers• Working towards normalisation has to be a

priority

13Dr Shamil Wanigaratne King's Health

Partners & UK-Sri Lanka Trauma Group 3rd October 2009

Support workers & burnout

• NGO workers, hospital workers, CSO’s, drivers• Lot of containing work with minimum

resources and support• Can be treated as a vulnerable group (direct

and vicarious trauma) and burnout • Great need for training, supervision and

support structures

Estimation of need and mental health problems

• PTSD • Complex PTSD (DESNOS – Disorder of Extreme Stress Not Otherwise Specified- Luxenberg

et al 2001) – Collective Trauma

• Depression • Anxiety Disorders• Substance misuse problems • Medically unexplained disorders (somatisation)

• Psychosis• Range of behaviouaral problems (antisocial behaviour, criminality,

domestic violence, etc)


Public Safety Public

PolicyPublic

Education Service Coordination

Training/Education

Family Education

Clinical TreatmentTraditional Healing

Capacity Building

Family, Self-Help Networks

SOCIETAL

COMMUNITY

Village

FAMILY

INDIVIDUAL

Types of Intervention

Levels of Intervention

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Intervention from a mental health perspective

• Scope is immense and possibilities endless• Short term well intentioned but not well thought

through responses and replication – could be wasteful and potentially damaging (don’t rush to do counselling)

• ? Need for co-ordinated approach• Advantages of creative individual projects


Infrastructure

• Government departments and ministries (Ministries of: health and nutrition, Education, Disaster Management and Human Rights, Rehabilitation, Defense)

• International NGO’s (eg. UNHCR, WHO, Red Cross, UNICEF)

• Consortium of Humanitarian Agencies (CHA)• Other NGO’s (eg.Sarvodaya, Basic Needs, Survivors, FRC, Shanthiham, TRO)

• Established Religions and their infrastructures (Catholic, Anglican and Methodist churches, Council of Mosques, Buddhist temples and Hindu Kovils)

• Professional bodies (SLMA, College of Psychiatry)


Capacity building

• Volunteers • NGO workers• Nurses • Teachers • PHI & Midwifes • CSO• MOMHS• Psychologists• Psychiatrists


How can one help?

• Direct work• Involvement in training and capacity building• Involvement in psychosocial interventions

aimed at prevention • Fundraising to support initiatives • Collaboration in research (evaluation

research) • Direct work with Diaspora


Research

• Collecting good epidemiological data (on going monitoring not just snapshots)

• Collecting phenomenological and epidemiological data on collective trauma

• Measuring factors associated with resilience and adaptation • Investigating adjustment and coping with disability • Evaluating interventions

– Effectiveness of preventive interventions – Evaluating societal level interventions

Needs co-ordinated ethical framework


Co-ordination?

• Lessons from the tsunami response • Presidential task force• Co-ordinating body? • Database of initiatives • Support initiatives• Good small scale initiatives could make a big

difference • Co-ordinated ethical clearance for research


Transformation – reconciliation – healing

• War against memory• Confidence building • Small individual initiatives (eg. Sunera Foundation)

• Understanding and reconciliation though training• As well as applying what has been learnt from South

Africa and Northern Ireland – there is potential for unique Sri Lankan solutions

• Peace Museum (mental health section)


UK-Sri Lanka Trauma GroupTHE UK WORKING GROUP TO FACILITATE WORK TO

MINIMISE PSYCHOLOGICAL IMPACT OF TRAUMA IN SRI LANKAUK Charity Registration Number 1074746

Why was it formed ?• To do some thing about the psychological impact of the civil

conflict in Sri Lanka • Co-ordinate efforts to maximise impact

How were we going to do this? • By working towards increasing awareness• By influencing policy development• By helping to increase the skills of front-line workers in Sri

Lanka • Helping develop mental health infrastructure


Formed in 1996 (Dr Athula Sumathipala and Dr Shamil Wanigaratne)

First conference on Psychological aspects of Trauma in Colombo 1996

Registered as an UK Charity in 1999 Numerous conferences and training workshops in Sri

Lanka between 1996 and 2005 on civil conflict related trauma

Involvement in early post tsunami work


History

2005 lobbied for grant to establish a resource centre in Sri Lanka for skills training in mental health

With the help of King’s College and South London and Maudsley NHS Trust obtained a Grant from CAFOD

Established Samutthāna with UK and Sri Lankan partners (Forum for Research and Development, Mangrove, BasicNeeds)

Continued


Current executive:

• Chair: Dr Anula Nikapota

• Hon. Secretary: Mr Kuhan Satkunanayagam

• Hon. Treasurer: Dr T Rasamuthiah

• Committee: Dr Harriet Calvert, Mr Sam Goonetileke, Dr Kanthi Karalliedde, Dr Vinetha Perera, Dr Shanthy Parameswaran, Professor Rachel Tribe, Dr Shamil Wanigaratne, Ms Dilanthi Weerasinghe and Professor William Yule


A brief introduction to Samutthāna

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What is Samutthana?

Samutthana, is the King’s College London Resource Centre for Trauma, Displacement and Mental Health. Samutthana means “renewal” or “regeneration” in Sanskrit. The project was established with the help of a grant from CAFOD by volunteers from the UK-Sri Lanka Trauma Group, Institute of Psychiatry, King’s College London and the South London and Maudsley NHS Trust in the UK. During its first year of existence the Forum for Research and Development, Mangrove Network and Basic Needs were its local partners.

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The main objectives of Samutthāna

1. Training and skills development2. Creating a supervision infrastructure 3. Research 4. Conflict resolution & policy development

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Mission Statement

The mission and objectives of Samutthana is encapsulated in the following section. All individuals and organisations who wish to work Samutthana are required to sign a declaration agreeing to these principles and objectives and expected to adhere to them

Read

www.samutthana.org.lk

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http://www.samutthana.org.lk/

http://www.smautthana.org.lk/

http://www.samutthana.org.lk/

http://www.smautthana.org.lk/

Samutthāna the King’s College London Resource Centre for Trauma, Displacement and Mental Health

Samutthāna meaning “renewal” or “regeneration” in Sanskrit has the following objectives:

• Training and skills development• Creating a supervision infrastructure• Providing a resource on mental health books and information • Research

• Conflict resolution (peace building) & policy development


The structure of Samutthāna The King’s College London Resource Centre for Trauma, Displacement and Mental Health

23, 17th LaneColombo 2 Centre Manager: Ms Shikanthini Varma-Atthanayake + 2 staff

Batticaloa OutpostIn partnership with Mangrove Network

Resource Person:Mrs Selvika Sahathevan

Jaffna OutpostIn partnership with Shanthium

Resource Person:Mr Radnam Jegananthan

Hambantota OutpostResource Person:

Mr Duminda Wanigasekare

Colombo Resource Centre

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The structure of Samutthāna The King’s College London Resource Centre for Trauma, Displacement and Mental Health

• Registered in Sri Lanka as a non profit company • UK-Sri Lanka Trauma Group acts as sponsor and main fund raising body • Board of Directors: Dr Anula Nikapota, Dr Shamil Wanigaratne, Mrs Isuri Roche

Mrs Manori Muththetuwegama and Dr M. Ganesan

• Centre Manager: Ms Shikanthini Varma-Atthanayake • Outpost resource persons, accountant p/t, receptionist and x 2 office

assistants (Colombo and Hambantota) • Voluntary workers


Recent achievements of UK-Sri Lanka Trauma Group and Samutthana

• More than 6000 mental health workers and volunteers have attended training workshops

• Held international conference “Renewal and Regeneration” in 2007 in Colombo

• Helped establish the first Clinical Psychology training course in Sri Lanka at the University of Colombo in 2008

• Programme to develop Mental Health Nursing in Sri Lanka


Workshops Conducted- selected (2009)

• Stress Management -Prof –Rechel Tribe• Child Psychology - Dr Anula Nikapota • Cognitive Behaviour Therapy for Psychosis -Prof. Philippa Garety • Physical, Sexual, & Psychological Abuse of Children -Prof Alan Khron• Intellectual Disabilities and Learning Difficulty -Dr Anna Eliyathambi • Assessment & Management of Children & Adolescent with Mental Health Problems - Dr Anula Nikapota • Child Mental Health - Dr Anula Nikapota • A Clinical update on Cognitive Behaviour Therapy (CBT) for Anxiety Disorders - Prof. Paul Salkovskis• Curriculum Development - Mr Bill McGowan• Dealing with fear of rejection - Mr Duminda Wanigasekera • Well-being & Mental health - Dr Suman Fernando • Mental Health Problems in People with Disability -Dr Mallika Ganasinghe• Working with Alcohol & drug misuse -Dr Shamil Wanigaratne

Activities

• Past activities and external evaluation please see website www.smautthana.org.lk

Future:• Continue to do skills training with different groups• Continue work towards building networking and supervision frameworks • Support research • Peace building work


Some Feedback “Excellent people involved in Samutthāna. Shamil, Anula and Padmal are very skilled experts in the field of

mental health. Anula has done a lot of work in the North East and is leading by example. Samutthāna seems to have a clear strategy and understanding of the local cultural context. They have involved the WHO from the beginning in all stages of their activities and developed some effective interventions to build local psychosocial capacity”.-Dr. John Mahoney, WHO

“Samutthāna has provided our staff with practical training on various aspects of mental health including cognitive behaviour therapy, psychotherapy and motivation interviewing techniques. I encouraged my staff to attend the courses and gave study leave to some of the nurses to attend” Dr. Hiranthi de Silva, Directorate of Mental Health, MoH

“Samutthāna is building local research capabilities in the field of mental health through its PhD students. The international conference helped to share experiences about issues related to conflict and reconciliation and start a dialogue between conflicting communities”. -Neil Fernando, Angoda Mental Hospital.


Fundraising Targets

• After the end of CAFOD grant numerous unsuccessful grant applications – totally ran out of funds early this year.

• South London and Maudsley Charitable Trust threw in a lifeline on condition of implementing a new fundraising strategy.

• To keep Samutthana running at current level of activity = £30,000

• Keep the centres open = £1,600 pcm (£3,500)• Clinical Psychology Course for next year only = £5,000• Nursing development work stream = £2,000 • Total target for the year = £37,000


UKSLTG and SLPA

• History of working together • Have overlapping objectives • ? How can we work together in future


trauma and transformation in sri lanka now: a blueprint for intervention and research dr shamil...

Documents

ministry of health

mental health perspective

trauma international

institute of research

loss grief loss of life

research opportunities

disaster response governments

displacement of tamils