Transcript Trauma and Transformation in Sri Lanka now: a blueprint

Sri Lanka Psychiatrists Association (UK) Annual Academic Conference
3rd October 2009
Trauma and Transformation in Sri Lanka now:
a blueprint for intervention and research
Dr Shamil Wanigaratne
Consultant Clinical Psychologist and Hon. Senior Lecturer
South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King’s College London
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
3
Background
•
•
•
•
Historical context of trauma
Disasters and mental health
International NGO’s and mental health
Sri Lankan context
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
4
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
5
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
6
Disasters and mental health
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
7
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 (PRIMEMD) - 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
8
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
9
Loss & grief
•
•
•
•
Loss of life - children, siblings, family
Home and property
Loss of livelihood
Loss of dignity
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
10
Estimation of need
Who is traumatised?
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
11
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
12
Combatants
• Serving combatants (combat stress, noncombat stress)
• Ex-LTTE carders
• Child Soldiers
• Injured and disabled combatants
• De mobbed security personnel
• Deserters (18,000)
(26,000 before final phase of war)
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
13
Focus on children
• Estimated 40% in IDP camps are under 16.
• Child soldiers
• Working towards normalisation has to be a
priority
Dr Shamil Wanigaratne King's Health
Partners & UK-Sri Lanka Trauma Group 3rd
October 2009
14
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)
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
16
17
Levels of Intervention
SOCIETAL
Public
Safety
Public
Education
Public
Policy
Service
Coordination
COMMUNITY
Capacity Building
Village
Family, Self-Help Networks
Training/Education
Family Education
FAMILY
Traditional Healing
Clinical Treatment
INDIVIDUAL
Types of Intervention
18
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
19
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)
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
20
Capacity building
•
•
•
•
•
•
•
•
•
Volunteers
NGO workers
Nurses
Teachers
PHI & Midwifes
CSO
MOMHS
Psychologists
Psychiatrists
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
21
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
22
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
23
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
24
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)
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
25
UK-Sri Lanka Trauma Group
THE UK WORKING GROUP TO FACILITATE WORK TO MINIMISE
PSYCHOLOGICAL IMPACT OF TRAUMA IN SRI LANKA
UK 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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
26
 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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
27
History
Continued
 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)
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
28
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
29
A brief introduction to
Samutthāna
30
www.samutthana.org.lk
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.
Read More
The main objectives of Samutthāna
1. Training and skills development
2. Creating a supervision infrastructure
3. Research
4. Conflict resolution & policy development
Read More
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
31
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
32
The structure of Samutthāna
The King’s College London Resource Centre for Trauma, Displacement and Mental Health
Jaffna Outpost
In partnership with Shanthium
Resource Person:
Mr Radnam Jegananthan
Colombo Resource Centre
Batticaloa Outpost
In partnership with Mangrove Network
23, 17th Lane
Colombo 2
Centre Manager:
Resource Person:
Mrs Selvika Sahathevan
Ms Shikanthini
Varma-Atthanayake +
2 staff
Hambantota Outpost
Resource Person:
Mr Duminda Wanigasekare
33
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
34
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
35
Workshops Conducted- selected (2009)
•
•
•
•
•
•
•
•
•
•
•
•
•
Stress Management
Child Psychology
Cognitive Behaviour Therapy for Psychosis
Physical, Sexual, & Psychological Abuse of Children
Intellectual Disabilities and Learning Difficulty
Assessment & Management of Children &
Adolescent with Mental Health Problems
Child Mental Health
A Clinical update on Cognitive Behaviour
Therapy (CBT) for Anxiety Disorders
Curriculum Development
Dealing with fear of rejection
Well-being & Mental health
Mental Health Problems in People with Disability
Working with Alcohol & drug misuse
-Prof –Rechel Tribe
- Dr Anula Nikapota
-Prof. Philippa Garety
-Prof Alan Khron
-Dr Anna Eliyathambi
- Dr Anula Nikapota
- Dr Anula Nikapota
- Prof. Paul Salkovskis
- Mr Bill McGowan
- Mr Duminda Wanigasekera
- Dr Suman Fernando
-Dr Mallika Ganasinghe
-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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
37
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.
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
38
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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
39
UKSLTG and SLPA
• History of working together
• Have overlapping objectives
• ? How can we work together in future
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
40