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Trauma and Transformation in Sri Lanka now: a blueprint for intervention and research Dr Shamil Wanigaratne Consultant Clinical Psychologist and Hon. Senior.

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Presentation on theme: "Trauma and Transformation in Sri Lanka now: a blueprint for intervention and research Dr Shamil Wanigaratne Consultant Clinical Psychologist and Hon. Senior."— Presentation transcript:

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

2 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 3Dr 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 4Dr 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 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 6 Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

6 Disasters and mental health 7Dr 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 ) 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 20098

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 9Dr 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 10Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

10 Estimation of need Who is traumatised? 11Dr 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

12 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) 13Dr 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 14 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

15 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) 16Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

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17 Public Safety Public Policy Public 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 18

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 19Dr 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) 20Dr 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 21Dr 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 22Dr 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 23 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 24Dr 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) 25Dr 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 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 26Dr 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 27Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

27 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 28Dr 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 29Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

29 A brief introduction to Samutthāna 30

30 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

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 32Dr 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 23, 17 th Lane Colombo 2 Centre Manager: Ms Shikanthini Varma-Atthanayake + 2 staff Batticaloa Outpost In partnership with Mangrove Network Resource Person: Mrs Selvika Sahathevan Jaffna Outpost In partnership with Shanthium Resource Person: Mr Radnam Jegananthan Hambantota Outpost Resource Person: Mr Duminda Wanigasekare Colombo Resource Centre 33

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 34Dr 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 35Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

35 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

36 Activities Past activities and external evaluation please see website Future: Continue to do skills training with different groups Continue work towards building networking and supervision frameworks Support research Peace building work 37Dr 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. 38Dr 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 39Dr 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 40Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009


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