Transcript IMHO CONFERENCE 2010

IMHO CONFERENCE 2010
Mental Health Services in Sri Lanka
Past Experiences
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Alan Krohn, Ph.D.
Clinical Psychologist; Psychoanalyst
University of Michigan, Ann Arbor, USA
[email protected]
Faculties of University of Michigan
Department of Psychiatry and Michigan
Psychoanalytic Institute
• Author of --• Books: “Hysteria: the Elusive Neurosis” and
“The Mind’s Eye”
• Articles on borderline personality, empathy,
adolescence, psychoanalysis and theater, and
disaster mental health
HOW I BECAME INVOLVED
• After Tsunami, through IMHO, learned of
UK-Sri Lanka Trauma Group
Two members I’ve worked with:
Dr. Shanthy Parameswaran, Sri Lankan/British Child
Psychiatrist
Dr. Harriet Calvert, British Psychologist and
Psychoanalyst
Also worked in Louisiana after Hurricane Katrina
TRAINING MENTAL HEALTH WORKERS
• Few Mental Health Professionals in SL
• Training at Samutthana; Shantiham (sites in
Colombo, Jaffna, Kandy, Vavuniya)
• My intensive program in University of
Colombo Graduate Program in Clinical
Psychology, stressing Psychodynamic
Psychology
TRAINING PROGRAM
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DIDACTIC PRESENTATIONS on:
Child development
General psychiatry
Psychodynamic/psychoanalytic principles,
ESPECIALLY NATURE OF DEFENSES
• Psychology of Trauma
• Child and Adolescent therapy
• GROUP SUPERVISION; EXPERIENTIAL GROUPS
OUR DISCOVERY
Trainees were themselves victims of trauma due to:
War
Atmosphere of Fear in the Society
Tsunami
Physical Abuse
Sexual Abuse
DOING COMBINATION OF TEACHING, CLINICAL
SUPERVISION AND BRIEF THERAPY
“PATIENTS” ARE EVERYWHERE
• NUMEROUS INFORMAL “THERAPEUTIC”
INTERCHANGES WITH PEOPLE –”IF YOU ARE A
THERAPIST, PEOPLE WILL TALK” – BE READY TO
LISTEN
• PEOPLE IN OUR TRAINING GROUPS, PEOPLE IN
POINT PEDRO AREA WHERE WE WENT, A
WAITER IN A HOTEL,
NATURE OF MY TEACHING
• Examples from my own life such as my working to
tolerate my affect of fear of some dogs in
Vavuniya vs becoming traumatized and
withdrawn
• Example from my two year old grandson’s ego
process as he came to terms with birth of his
brother
• Humor
• Ample vignettes to illustrate psychoanalytic
concepts
FORMS OF TRAUMA
• War: death of loved ones, injury, dislocation,
and LIVING IN A STATE OF DREAD AND FEAR
• Tsunami: death of loved ones, acute trauma at
time of tsunami (classic PTSD)
• STATE OF FEAR DUE TO ONGOING POLITICAL
ENVIRONMENT
Traumatized Country
• Dr. Daya Somasundarum: Concept of Mass
Trauma
• Dr. Vamik Volkan: Groups’ responses to
humiliation and defeat by other groups
• Dr. Henry Krystal: Affect (Emotional) Arrest in
Traumatized People
TRAUMA AS STATE OF
OVERWHELMING, UNRELENTING
PAINFUL AFFECT
• SOME EFFECTS:
• Affect regression, numbing, dissociation
• Aggression as defense against helplessness,
including violence as preferred solution to
problems – on a societal level, in the form of
physical abuse of children, of violence against
women
PSYCHODYNAMIC APPROACH
• HELPING MENTAL HEALTH WORKERS TO
LEARN TO LISTEN TO INDIVIDUAL NARRATIVE
ABOUT THEIR EMOTIONAL STRUGGLE – STORY
BEHIND THE STORY
• EXAMPLE: SUICIDE RATE – LOOK BEYOND
“STRESS” OR “TRAUMA” TO MEANING OF
INDIVIDUAL MOTIVATION FOR SUICIDE
CASE TWO: 16 YEAR OLD GIRL:
“TRAUMA” AND UNCONSCIOUS GUILT
• FAMILY IN BUNKER, GIRL ARGUES WITH BROTHER
ABOUT GETTING WATER, ANGER AT BROTHER,
THEN BUNKER HIT, FAMILY BURIED
• FEELS SHE SHOULD DIE, BE A NUN, GUILT OVER
SECRET THOUGHT BEFORE SHELL HIT BUNKER
• GUILT OVER “SECRET THOUGHT”: FEELS SHE IS
UNDESERVING OF LOVE, FAMILY, SEX. (AGAIN
UNCONSCIOUS)
• OVERWHELMED BY LOSS (TRAUMA) PLUS GUILT
CASE THREE:DEPRESSION IN YOUNG
WOMAN
• 25 YEARS OLD WOMAN WHOSE HUSBAND
MURDERED HER MOTHER OVER A FAMILY
FEUD GOING BACK TWO GENERATIONS
• VERY CONTROLLING, GROWTH STUNTING
MOTHER; VERY CONTROLLING HUSBAND
• MOTHER DEAD; HUSBAND IN JAIL
• FIRST TRAUMA OF LOSS, DEPRESSION, THEN
SOMETHING ELSE
• THERAPIST NEEDS TO SPEAK TO THIS
PSYCHODYNAMIC APPROACH –
RESEARCH SUPPORT
• COGNITIVE BEHAVIORAL THERAPY IS VIEWED
BY MANY AS THE ONLY MODERN THERAPY
WITH RESEARCH VALIDATION
• SHEDLER (UNIV OF COLORADO) REVIEWS
RESEARCH AND SHOWS THAT RESEARCH ON
PSYCHODYNAMIC THERAPY SHOWS IT TO BE
AS POWERFUL AS CBT AND MORE LASTINGLY
POWERFUL THAN CBT (THERAPEUTIC EFFECTS
INCREASE OVER TIME!)
VALUE OF “JUST TALKING” IN TRAUMA
TREATMENT
• “HOLDING ENVIRONMENT,” (MODELL)
“WITNESSING” (POLAND) – THERAPEUTIC
EFFECTS OF TRUSTING RELATIONSHIP WITH
THERAPIST.
• DEVELOPMENT OF AFFECT TOLERANCE
FOLLOWING TRAUMA, REVISING SEVERE,
TRAUMA DEFENSES
• WORKING WITH DISORDERED COGNITION
CAUSED BY TRAUMA – ACTUAL BRAIN EFFECTS
HAVE BEEN DISCOVERED – ADDICTION-LIKE
EFFECTS
LANGUAGE AND MASTERY
• PUTTING THINGS INTO WORDS HELPS TO
MASTER THEM, HELPS BRING “FROZEN” AFFECTS
BACK
• “MENTALIZING” (FONAGY) AND OBSERVING EGO
(SELF) (STERBA) – DEVELOPING CAPACITY TO
OBSERVE ONE’S OWN REACTIONS AND TO THINK
ABOUT MOTIVES IN OTHERS
• “THERAPEUTIC FRAME”: NON JUDGEMENTAL,
FOCUS ON PATIENT, EVERYTHING CAN BE TALKED
ABOUT
OBSTACLES
• LACK OF PSYCHOLOGICAL TRAINING FOR
PSYCHIATRISTS: PSYCHIATRY STRICTLY “MEDICAL”
(SIGN/SYMPTOM—MEDICATION); DIAGNOSING
“BIPOLAR DISORDER” IN 5 YEAR OLD AND
MEDICATING CHILD (SRI LANKAN COLLEGE OF
PSYCHIATRISTS MEETING)
• FEAR IN COUNSELORS TO WORK WITH TORTURE
VICTIMS AND FORMER LTTE (DESCRIBE)
• DISTRUST BY VICTIMS OF COUNSELOR
PROBLEM OF PHYSICAL ABUSE
• CORPORAL PUNISHMENT, DERISIVE, “SOUL
MURDERING” (SHENGOLD) TREATMENT OF
CHILDREN – CAN LEAD TO PASSIVITY, DEFERENCE
TO AUTHORITY AND LACK OF INITIATIVE (CASE
EXAMPLE OF MAN ROLLING TIRE IN THE ROAD)
• OR CAN LEAD TO IDENTIFICATION WITH
AGGRESSOR
• RECENT EXCELLENT STUDY BY DUKE UNIVERSITY
SHOWING SPANKING CAUSING AGGRESSIVENESS
IN CHILDREN
HISTORY OF SRI LANKAN CHILD
REARING
• RESEARCH BY PIYANJALI DE SOUZA
(PSYCHOLOGIST AT UNIVERSITY OF COLOMBO)
FOUND THAT WRITINGS FROM THE PERIOD
UNDER SRI LANKAN KINGS DESCRIBES A
DISTINCTLY NON-PUNITIVE APPROACH TO CHILD
REARING
• IT WAS WITH THE BRITISH COLONIAL ERA THAT
CHILD REARING CHANGED TO BECOME MUCH
MORE HARSH AND PUNISHMENT ORIENTED
GRACE CARE (ORPHANAGE AND ELDER
HOME)
• CONSULTED WITH PEOPLE THERE BUT ONLY IN
MARCH HAVE VISITED GRACE
• DID AN ASSESSMENT OF SOME OF THE
MENTAL HEALTH NEEDS OF THE CHILDREN
• Dynamic relationship between elders and
children very important in all children,
especially those separated from parents
GRACE CARE CENTER (CONT.)
• ONE OF VERY FEW PLACES ANYWHERE THAT
CONSIDERS MENTAL HEALTH NEEDS OF
CHILDREN SO HIGHLY
• SUPPORTS COMMUNITY OF GIRLS AS AN
ASSET, WHILE WORKING TO FOSTER
INDIVIDUALITY IN GIRLS
• PHILOSOPHY RESPECTS DIFFERENT RELIGIOUS
AND CULTURAL BELIEFS AND BACKGROUNDS
OF GIRLS