How do we help children and families in the midst of collective trauma in Sri Lanka?

This paper will explore an approach to the training of psychosocial workers engaged in ongoing work with children and families in Sri Lanka, rather than direct work. By approaching it this way it is hoped to reach as many of the trauma victims as possible, where direct work would reach only a fraction of the population for a very limited time.

As a member of the UK-Sri Lanka Trauma Group I have had the privilege of paying several visits to Sri Lanka as a mental health/psychosocial trainer, providing mental health training to psychosocial workers at every level in the country. These workers have ranged from people with only the most basic, or even no, training in ‘mental health’ to trained professionals like doctors, psychologists and other academically trained professionals.  All these workers have been engaged in providing help and support to traumatized children, families and adults.

I should like to start by sharing my impressions of arriving in Sri Lanka.  My first visit to Sri Lanka was in spring 2005, just a few months after the tsunami had devastated large parts of the coastline of the country. This was also during the ceasefire between the warring factions, the government and the Tamil Tigers, and it meant that we were able to conduct our first training in Jaffna in the North, which is now again inaccessible due to the war situation. If that situation has changed yet again is not clear.  I arrived in Jaffna on a small aircraft which had to share its runway with a large number of stray dogs, an omnipresent feature of Sri Lanka.   I arrived at a military airfield which was surrounded by soldiers with machine guns in bunkers.  The houses close to the airfield were full of bullet holes and people wandered about with their heads bowed; the atmosphere was tense. Not only had this area been devastated by the recent tsunami, it had also suffered from a very long civil war.

What could I possibly contribute to this broken society? Mental health needs had been seriously neglected in general and those of children and families even more so. For instance, post-traumatic reactions were not recognized.  After the tsunami there had been considerable ‘help’ from the international community, but a lot of this had been felt to be inappropriate. Thus, I was very aware that the task of providing something useful was a truly daunting one. I had some helpful advice given to me before leaving which went something like this: ‘Have a plan but be willing to change it or throw it out. Be realistic about what you can accomplish as it will not be as much as you expect. Don’t not go just because you think that you can’t do very much. Just going communicates to the professional community and the victims a message of professional caring that the world has not forgotten you’. I wanted to add to this that if we could only enable the psychosocial workers to keep working, bearing in mind that they were also ‘victims’ of the numerous disasters that the country had experienced, then we had accomplished something.

The context

The issues facing the traumatized population in Sri Lanka have to be understood in the context of the long civil war and in the context of the aftermath of the tsunami.  Sri Lanka has been embroiled in a bloody civil conflict for nearly 30 years.  Since 1983, there has been an intermittent civil war, predominantly between the government and the Liberation Tigers of Tamil Eelam (LTTE, also known as the Tamil Tigers), a separatist militant organization which fought to create an independent state named Tamil Eelam in the North and East of the island. It is difficult to get reliable figures for the number of casualties but it has been reported that since 1983 up till 2008 around 80,000 people have lost their lives in the war, which has been described as one of the world’s deadliest armed conflicts. The tsunami claimed 38,000 lives, and made 1 million people homeless. Needless to say, a significant proportion of these were children. It has been reported that one third of the 80,000 internally displaced people were children. Right now, we don’t know how many civilians are living in fear and distress at this time, in camps erected after a large number of the Tamil population had to flee from the fighting in the last days of the conflict (which has now come to an end). According to UN estimates, many thousands of people, excluding the actual Tamil fighters, have died here in the past couple of months.

Sri Lankan society has undergone huge changes as a result of the above-mentioned traumatic events. During this period it has changed radically, sliding towards disintegration, fragmentation and, in some places, catastrophic breakdown.  These external political events are, of course, inseparably intertwined with internal psychological processes as presented by either the psychosocial workers themselves or by their client population.

Somasundaram (2007) (a well-known Sri Lankan Tamil psychiatrist from Jaffna) describes what has happened in terms of a ‘Collective Trauma’ as follows:

‘Fundamental changes in the functioning of the family and the community have been observed. While the changes after the tsunami were not so prominent, the chronic war situation caused more fundamental social transformations. At the family level, the dynamics of single-parent families, lack of trust among members and changes in significant relationships and child rearing practices are seen. Communities tend now to be more dependent, passive, silent, without leadership, mistrustful, and suspicious. Additional adverse effects have included the breakdown of traditional structures, institutions, familiar ways of life and deterioration in social norms and ethics.’ Somasundaram argues that exposure to conflict, war and disaster situations impact on fundamental family and community dynamics, resulting in changes at a collective level. Relief, rehabilitation and development programs, in order to be effective, will need to address the problem of collective trauma, particularly using integrated multi-level approaches. Primitive defences can be observed on the societal level.

Freud describes a belief as ‘an illusion’. When it is motivated essentially by wish-fulfilment, then the reality principle is suspended and objective verification becomes irrelevant. Ron Britton puts it as follows: `A belief attached to a fantasy or idea is treated as a fact, i.e. ‘natural` The political theorist Antonio Gramsci caught the essence of this when he wrote that ideologies create ‘the belief about everything that exists (about them) that it is natural, that it should exist, that it could not do otherwise than exist. Belief ‘naturalizes’ its tenets to such an extent that for the believer to question them becomes unthinkable. There is a belief in a natural order which needs to be restored`.  Both parties in the bloody conflict in Sri Lanka hold onto a version of this ‘natural order that needs to be created or restored’, in defiance of external reality.

The Sri Lankans have lived in an atmosphere of uncertainty and fear, especially the Tamil minority.  They have grown accustomed to living with high anxiety, including annihilation anxiety- as if this were part of the, in many ways, very real normality of their lives. A split state of mind has become the norm. and, in their efforts to maintain psychic equilibrium, the Sri Lankans have taken to employing primitive mechanisms with increasing frequency and severity. Surface expressions of psychopathological processes have come to be taken for granted.   Some of these mechanisms include distortions of memory, pathological splitting and projection, as happened in Cyprus during their extended conflict, described by Catia Galatariotou (2008). As these mechanisms have taken root, moderate voices have become silenced. In both communities, as the result of sustained and prolonged splitting and projection, a frighteningly clear part-object world has emerged. Badness is being projectively evacuated and violently inserted from the collective self into the object/other; the now part-object is inevitably experienced as denigrated and murderously persecuting, while the self is idealized as the innocent victim of the other’s unjustified aggression. The human ability for empathy suffers massively.   In all such situations, to quote Galatariotou, the ‘part’ that is removed from the whole is its humanity. This situation has now continued for at least 25 years and a form of trans-generational transmission of ‘chosen traumas’ and `chosen glories’, as described by Vamyd Volkan, is taking place.

There are, of course, many complex consequences to the tragic state of affairs in Sri Lanka, most of which are beyond this presentation. I have already mentioned the devastating effect on the family and, as Somasundaram described, for instance, a curious difficulty in mourning. In many instances, to relinquish the lost object becomes impossible, either because it is too overwhelming, shame-inducing such as if the lost object has disappeared and been a member of the LTTE, and often because the loved object has been missing but no death has been confirmed, such as happened after the tsunami and keeps on happening as a result of the civil conflict.  It might even be that for some not to relinquish the lost object is a matter of pride. Families enter into a form of frozen grief in which, in the absence of absolute confirmation of death, of a body to mourn and bury according to their culturally determined customs, mourning is held at bay for a number of reasons, such as shame, survivor guilt and a wishful fantasy that the missing person is still alive. This contributes to many entering instead into a melancholic and helpless state of mind.

What has happened to the family?

Although the traditional family unit as the basic social institution has often survived, its function has been irrevocably changed by the chronic conflict. The cohesiveness and traditional relationships are no longer the same. Compared with before the war, it is a common complaint that children no longer respect or listen to their elders, including teachers. These changes, attitudes and perceptions, like many others, may have ante-dated the war but could have been accelerated by it. A foreign NGO worker who had served in Jaffna for a long period made the observation of a common day-to-day occurrence at the pervasive check points in the North and East. Tamil parents quickly change their behaviour and tone (in contrast to what the child has seen at home or elsewhere) when dealing with the security forces. They, perhaps unconsciously and with the best of intentions (to safeguard their children and to avoid unnecessary hassle), assume a submissive posture (removal of hat, bent head and body, low and almost pleading tone of voice, pleasing manner with a smile) when accosted by the security forces (e.g. at check points). The children will observe this change without comprehending the full purpose (perhaps to avoid the child being detained), comparing it with their parents` demeanour at home and, in time, lose faith in those parents.

A strong influence has been the contemptuous way elders and community leaders have been treated by the authorities and the submissive way they have responded. Elders are perceived as being powerless and incompetent in dealing with war and its consequences, a point often made by the young militants. Parents were careful about what they discussed in front of their children as the child could inadvertently have let this out in school or during play.

In the case of the tsunami, there were more women who died compared with men as perhaps the women were less capable of surviving, not having the skills needed in the sea, and women’s clothes, such as saris, would have made it much harder to swim. Women may also have been at home when the tsunami struck. This left many widowers who found it difficult to cope with the remaining families, not having the skills to look after children, prepare food or do routine household chores; some took to alcoholism. Suicidal ideation, attempts and suicide, was reported to be high. In time, some re-married, creating problems for the children - and often the children were given to other relations to look after. Cases of child abuse were reported in some of these arrangements and attempts to adopt children who lost one or both parents or to put them in institutions were resisted by child protection authorities. Initially, there had been reports of the abduction of orphans, so-called tsunami babies, as well as interest from people abroad to adopt tsunami orphans. The cumulative effect of all these devastating events and ecological contexts on the community is described by Somasundaram as Collective Trauma.

Is psychic reparation possible and, if so, how?

The Work carried out by me and my colleagues from the UK-Sri Lanka Trauma Group

The UK-Sri Lanka Trauma group is a non-partisan organization working with any traumatized community in Sri Lanka. In practice this means that we have worked with the Singhalese and Tamil and with other population groups and organizations.   We work in collaboration with local professionals who have been able to identify groups of psychosocial workers and also other untrained, or almost untrained, psychosocial workers who are in touch with large numbers of traumatized children, families and adults at the grass roots level. By providing training at this level our work fits in with the model described by Somasundaram, as follows:

Training

According to Somasundaram, training of grass root community level workers in basic mental health knowledge and skills is the easiest way of reaching a large population. They, in turn, would increase general awareness and disseminate the knowledge as well as do preventive and promotional work. Thus, there would be a multiplication effect where the information would spread to the general population. The majority of minor mental health problems following disasters could be managed by community level workers and others, referred to the appropriate level. In our case, groups of 20 to 30 participants have been identified as benefitting from brief but intensive mental health training. The trainings have lasted between one to five days. Any one individual may be offered participation in several trainings; the need for these has been identified on the basis of feedback received.

The challenge has been to discover how can we deliver something of some lasting value during such a short space of time with such varying groups of people. In addition, we have been very mindful of the fact that all of our ‘trainees’ have themselves been subject to the traumas and changes described above.  A psychoanalytic training model has proved to be most helpful as this has enabled us directly and indirectly to address both some of the theoretical as well as some of the emotional needs of our trainees.

We have adopted a three-pronged approach to the teaching, with good results (at least as measured by feedback forms, distributed both immediately after each training as well as some months afterwards).

1. Theoretical

This has varied according to the groups in question, but has been focused on trauma in its wider meaning.   Specifically, we have included teaching sessions on such topics as child development, the nature and meaning of trauma, grief in children and adults, understanding of suicides and suicidality, basic understanding of the ‘helping relationship` etc.  Approaching these topics from a psychoanalytic perspective has made it possible to explore these themes from a dynamic angle rather than bringing to the students rigid Western ‘ready packaged’ treatment modalities.

2. ‘Supervision’

A significant part of the time has been assigned to discussing the ongoing work of the participants. This has taken the form of case discussions and role play. Both the case discussions and, in particular, role plays have been very successful in bringing the material to life in the sessions.

3. Experiential component

Needless to say, it became clear very soon when working with these groups of people that their own experiences shape their understanding and their working practices.  The psychoanalytic approach has also enabled us to do some more direct therapeutic work with our trainees. This part has been an unexpected success and has been much appreciated by the participants. This component, more than the others, has enabled us to promote and explore ways in which the ‘trainees’ may be able to find their own answers, both to their personal issues as well as to their professional dilemmas.

Who are the patients?

In a society like Sri Lanka the population as a whole has been traumatized. This creates a challenge:  how to empower ‘our trainees’, while being mindful of the fact that they have, more often than not, suffered significant, often multiple, trauma themselves. This can be observed by listening to the ‘students’ and providing space and time to hear about their trauma, but it also expresses itself in the kind of relationships that get created with the trainers. We are seen to be ‘rescuers’, or people with the answers. The ‘idealization/denigration’ paradigm can be seen at work, with us the trainers seen to have ‘all the answers’ while the trainees view themselves as having very little to contribute. You are confronted with a powerful feeling of helplessness in the psychosocial workers. This passive attitude has its origins in the culture reinforced by the ongoing frightening conflict. Losi (2002) describes how it is imperative to resist stepping into this idealized role and instead to provide a forum for the trainees to find their own strengths, maybe even through a ‘trial and error’ process. 

In a recent training with a number of professionals from Jaffna, the constellation ‘victim-rescuer’ played out in the following way:

In one of our first experiential groups at the end of the day`s teaching, which had included talks on trauma and grief, the group sat in silence. I explained the purpose of the group, which was to think about what the topics we had covered meant to us personally. The silence continued. Then one of the participants said, ‘We don’t often talk about how we feel’.   The participants looked at each other briefly but mostly at me, expecting answers. Then a very intense-looking young man, said, ‘We are not allowed to kill dogs in this society.  Why are they then allowed to kill us?’    This comment was again directed at me.  A discussion flowed about how the participants had to adapt to living under curfew; one story after another emerged of fear and helplessness. My counter-transference was also one of feeling ‘helpless’ and I had to resist the temptation of coming up with ‘comfort’ of some kind.  The concerns expressed by the participants moved from expressing this ‘total sense of helplessness` to thinking of, for example, how to deal with a difficult colleague in their places of work. No longer did they look to me to provide the answer for by now the group was working as one to provide helpful suggestions to each other.

We came across many very dramatic stories during our case discussions/supervisions.   Let me give you some examples:

A counsellor working for the Family Rehabilitation Centre wanted to think about her work with a six-year-old girl whom I shall call Anula, who used to live close to the border between the rebel-held North and the government-controlled South. She lived with her parents, siblings and grandparents, and some aunts and uncles.  People in this neighbourhood lived in constant fear of an attack and many people preferred to sleep in the jungle as they felt this was safer.

One night, Anula`s family was woken up by gunshots; the LTTE were attacking the village. The family ran out into the jungle for safety, away from the bullets. Before they managed to get out, the LTTE entered the house and killed many members of this family. The grandmother hid Anula under her clothes and ran towards the jungle.   The LTTE, however, shot the grandmother in the back. This bullet entered the grandmother, killed her and then entered the child. The bullet did not kill Anula but left her seriously injured and she was finally taken to hospital for intensive care. Her parents, uncles, aunts and baby brother were killed but her grandfather, one aunt and uncle and two brothers survived the attack.

The counsellor, my student, started visiting Anula in hospital. The child was frightened and mute, clinging to a male nurse during the visits. The counsellor despaired and felt she was never going to be able to establish contact with her. After Anula was discharged, the counsellor continued to visit her but Anula would not communicate with her in any other way except crying.  But, almost by chance, the counsellor discovered that Anula was showing some interest in the children next door so my student started to give some small gifts and sweets through the neighbour’s children. After some weeks of regular visits, Anula was able to form a stronger relationship with the counsellor and they started to draw pictures together.

To start with, the drawings were just scribbles, black lines crossing red lines. Anula was given toys, she was given bricks with which she built towers and houses, and then destroyed them. The worker took the child to the clinic to play with other children and provided a form of play therapy for her. After six months she started drawing pictures of her family. Anula drew pictures of her father, her mother, her brother and herself. She was particularly worried about her baby brother who was six months old at the time of the attack. She spoke about him as though he were alive and she was very concerned about him. Gradually, Anula was able to say that her parents had been killed; her mother and father had been shot. After a year, Anula was able to return to school and is, according to the counsellor, doing well.  The counsellor who was working with her had to move into another area, but remains in telephone contact with this child. Initially, Anula said she couldn’t remember anything of the events. It took a long time before she could mention her grandmother who had saved her life. She often returns in her stories and in her play to thoughts about her baby brother.

Although Anula`s was not an ongoing ‘case’, we were able in the group to explore the issues raised, linking the child’s behaviour to our theoretical teaching on trauma, child development, attachment theory and play therapy. The counsellor was able to explore how her own trauma had contributed to her response to the child; she was herself a war widow.

What we focused on most was to examine and think about the transference and counter-transference highlighted by Anula`s case. Indeed, the counter-transference of the whole group. I was impressed with the sensitivity and persistence of the counsellor, who was able to use ‘child psychotherapy’ techniques without much training.  This case, not surprisingly, stirred a lot of strong feelings in the participants. People asked how to cope with feelings of helplessness and hopelessness, created by this case and others. No doubt these feelings are exactly those described by Somasundaram above, but they were also generated by working with these trauma victims.   Eventually, this counsellor, a woman in her mid-fifties, dissolved into tears thinking about her own and Anula’s loss.  The purpose of the discussion was to explore this remarkable piece of work, both from a theoretical and, above all, from a relationship point of view; the role of the transference and the role of the counter-transference. I hope that our discussions were able to strengthen our counsellor`s already remarkable therapeutic skills.

Another case was presented by a young male counsellor. He had been asked to counsel an 18-year-old female torture victim from Jaffna whom I shall call Lalita.  She had gone to another town to go to the authorities to get some documents to support her visa application to Switzerland, where she was intending to join her fiancé who was living there.

Sometime earlier Lalita met a boy who had fallen in love with her, but she had not reciprocated his feelings. Later, this young man had joined the Tamil militants on the government side (a faction of the LTTE, which split off and joined the Sri Lankan army).  One day while in this town applying for her visa Lalita met this man again. He was so angry with her about her not showing an interest in him that he informed the criminal investigation authorities and told them that Lalita was a member of the LTTE. The criminal investigation people came to arrest her and kept her for 14 days without trial. During those days she was tortured by the army, before being released. She was released only after her uncle went to what was described as the Human Rights Authorities, after which pressure was put on the army to release her. The uncle later took her to the hospital in Trincomalee from where she was referred to the counselling agency.   At first the counsellor said that he had a problem dealing with Lalita because she so reminded him of his sister. He felt as though his sister had been tortured. Lalita was in both severe mental and physical pain, she had nightmares, poor sleep and had no appetite.

By the second session, Lalita already felt a little bit better and she told the story of the man who had informed the criminal investigation people that she was supposed to be a member of the LTTE.  In discussing this case we were able to explore the meaning and impact of the counter-transference in some depth.  In this case, as in the case above, the young counsellor’s own experience of trauma became central. Many of his family members had been either killed or otherwise affected by the attack of government forces. The difficulty in retaining a therapeutic attitude, of not getting drawn into the intensely felt anger and the need to be caught up in the splitting and projections described above, was explored.

The impact of personal experiences by the traumatized psychosocial workers was dramatically illustrated by the story of another young male psychosocial worker in Jaffna, told in one of our experiential groups. 

During this group session the psychosocial worker said he was going to tell us something else which he had wanted to talk about for some time (he had previously told us about a disappointing love affair). The theme for this experiential group on this day was ‘What trauma means to me’.  He told his story about what had happened to him when he was 10 years old. I shall call him Arjun. Arjun was in the house with his grandfather. There was some noise outside; both his grandfather and he went outside where his grandfather was shot by the army. He was standing behind him and he described in detail how he watched a flower fill with the blood from the bullet wound; his grandfather had been shot in the head. When he spoke, it was clearly difficult for him to talk and he was close to tears.  He then described his anger and how all he then wanted to do was to join the LTTE (you may have heard that the LTTE also recruit child soldiers). He then went on to explain how grateful he was to his parents, who were good to him and supportive to him, persuading him not to join the insurgence (these were his actual words). Everybody in the group was moved by this story. We were able to talk about this as an extreme example of the difficulties that adolescents and young people face. As I have mentioned, there was a lot of concern expressed about what is happening to adolescents. The students were wondering why adolescents were drawn to join either the army or the LTTE, depending on from which community they came.  We were also talking about how this painful experience might be something Arjun might be able to use in his work.

Cultural issues and dilemmas encountered during the work

Sri Lanka is not only a different culture from my own, in fact it is a collection of many cultures. The main ones are the Singhalese Buddhist majority, the Tamil Hindu minority and other minorities, such as the Muslims, Christians etc. All these cultures have, in addition, been changed along the lines described above, involving primitive defence mechanisms, resulting in extreme polarization of communities who have previously lived side by side. How can I then provide something helpful, given that I am - in a very important sense – an outsider?

I have mentioned above how one gets recruited into an idealized position, ‘the one with the answers’, and how important it has been to resist the temptation to occupy this position. Firstly, because these training events are not, in an important sense, an opportunity to deliver a Western ‘ready packaged’ treatment modality and, secondly, this could soon lead to disappointment and disillusion - and the prevalent projective mechanisms would soon come into play. Many attempts to deliver ‘aid’ have stumbled just because of these dangers and potentially successful partnerships have been terminated, with the protagonists switching from mutual adoration to mutual accusation.  In these situations, we have not found that any preconceived guidelines or recipes are of much use.  What is required is sensitivity and respect at all levels in a way unique to the given situation and to the individuals concerned.  This has meant in practice that we have both respected local customs, allowing our students and local colleagues to act as advisors and interpreters, and we have not shirked from entering into debates about, for instance, punitive child care practices.  I was also struck by how, in spite of the superficial cultural differences presented in the students’ material, psychoanalytic thinking could be applied without violating cultural sensitivities. The following case demonstrates this point.

In one of our supervision groups a young counsellor wanted to discuss the following case:

The theme of the day was adolescence.  The client was an adolescent boy who had recently attempted suicide.   I shall call him Seelan.  He was the result of a relationship between a Brahmin and his unmarried mother. The Brahmin abandoned Seelan’s mother when he was three days old.   He grew up with just his mother, under a cloud of ‘shame’.  This boy had always been very angry with his father and had a very conflictual relationship with his mother. He was now putting pressure on her to find the father and marry him so that she could then divorce him.  Seelan was described as a very arrogant young man. Significantly, there had been some difficulties in engaging him in the counselling relationship.  The discussion in the group centred on how to handle the counselling relationship in general and the meaning of the transference in particular as he frequently rang up and cancelled his sessions, saying that he had ‘more important things to do’.  I was very struck by how similar this case was to many of the cases we see in our consulting rooms in the West. The ingredients were similar.  This was possibly a young man with a narcissistic disorder with significant omnipotent features, Oedipal complications etc. The central problem seems to have been the difficulties with identification with the ‘imaginary father’; Ruszczynski (2007) talks about the inability to mourn the absent father. If Seelan had been able to tolerate the loss of the father and mourn him, he might have been able to integrate the father as an internal object. The ‘internal father’ could then have been made use of intra-psychically as and when required when managing the ‘core complex’ oscillation between abandonment and annihilation in relation to the mother.

Another example of a ‘culturally specific trauma’ was discussed when a student counsellor was puzzled about how to help the parents of an adolescent who had committed suicide.  Besides the grief work, the situation was complicated as it was claimed that the parents’ grief work was affected by their Buddhist belief that their son could never be reincarnated as a human being because of his suicide. The group discussed this clinical vignette and, apart from emphasizing how these parents could be helped in their grieving, they also felt that it might be helpful to consult a Buddhist priest in the matter.

Conclusions

It is hard to do justice to the rich experience that providing these trainings has been. It is almost impossible to do direct work with children and families as the time I can spend in Sri Lanka is very limited. Thus the ‘direct work’ has happened with the students who have attended these trainings. We are hoping to provide follow-up, and continued training and supervision using, for instance, Skype. The aim has been to harness the compassion and enthusiasm which we encountered in our trainees to a remarkable degree.  We have continually monitored our performance using feedback forms, sometimes on a daily basis, as we wanted to deliver what the students felt they could use. The responses we have had have been overwhelmingly positive. In order to explore if our teaching has had an enduring effect we have also given out feedback forms some months after the training event, and – again - the response has been very positive.

I feel that work in Sri Lanka has enabled me to stretch my psychoanalytic skills in a unique way.  I have had to think on my feet, and use my counter-transference together with my theoretical understanding when I have been confronted with a multitude of challenges and moving life stories, both in relation to the psychosocial workers’ clients and relating to their own lives. There has been an opportunity to think about the ‘helping relationship’ from both the perspective of the psychosocial worker and from that of the child and his/her family, as we do in psychoanalytic training. 

I think it would not be an exaggeration to say that I found myself getting as much or more than I was able to give. In spite of the tensions in the society, there is a very special gentleness, kindness and warmth in the Sri Lankan people from all communities which had a profound effect on me.