Dr Ruwan M Jayatunge

The Sri Lankan society experienced a 30 year prolonged armed conflict that changed the psychological landscape of the Islanders. A large number of combatants, civilians and the members of the LTTE underwent the detrimental repercussions of combat trauma. The concept of combat trauma was new to the Sri Lankans. ƒÆ’-¡ƒ”š‚ Through out ƒÆ’-¡ƒ”š‚ the history Sri Lankans experienced natural and man made disasters. The religion and culture provided great resilience to cope with trauma. ƒÆ’-¡ƒ”š‚  ƒÆ’-¡ƒ”š‚ Culture consist of traditions, values, customs, folklore, ƒÆ’-¡ƒ”š‚  rituals and artifacts that help to make meaning of physical world and its transmitted primarily through language and everyday interactions. ƒÆ’-¡ƒ”š‚ These cultural factors sometimes play as ƒÆ’-¡ƒ”š‚ are ƒÆ’-¡ƒ”š‚ trauma buffers to come to terms with psychological trauma.ƒÆ’-¡ƒ”š‚ 

The Americanization of Mental Illness

The author Ethan Watters examined trauma and cultural factors in depth. He expresses that the Western conception of mental health and illness might be shaping the expression of illnesses in other cultures is rarely discussed in the professional literature. Many modern mental-health practitioners and researchers believe that the scientific standing of Western drugs, Western illness categories and Western theories of the mind have put the field beyond the influence of endlessly shifting cultural trends and beliefs.

Dr Sing Lee a psychiatrist and researcher at the Chinese University of Hong Kong, watched the Westernization of a mental illness firsthand. In the late 1980s and early 1990s, he was busy documenting a rare and culturally specific form of anorexia nervosa in Hong Kong. Unlike American anorexics, most of his patients did not intentionally diet nor did they express a fear of becoming fat. The complaints of LeeƒÆ’‚¢ƒ¢-¡‚¬ƒ¢-¾‚¢s patients were typically somatic ƒÆ’‚¢ƒ¢-¡‚¬ƒ¢¢”š¬‚ they complained most frequently of having bloated stomachs. Lee was trying to understand this indigenous form of anorexia and, at the same time, figure out why the disease remained so rare. (The Americanization of Mental Illness – Ethan Watters)

Combat Trauma is not a Western based Concept

The concept of combat trauma dates back to the ancient times. Combat trauma has a profound historical, cultural, social, and religious significance to ƒÆ’-¡ƒ”š‚ Sri Lanka and the notion of combat trauma is not new to the Sri Lankans. The history of Sri Lanka dates back to 543 BC. Throughout the Sri Lankan history there were foreign invasions, internal conflicts and the Islanders had to confront fearsome battles. According to the Mahawansa ƒÆ’‚¢ƒ¢-¡‚¬ƒ¢¢”š¬…” the great chronicle history of Sri Lanka and one of the oldest chronologies in the world describes the devastating impact of the great Wijithapura Battle that occurred in 205 B.C. The triumphant King Dutugemunu experienced severe depressive feelings soon after the battle. This could have been a negative emotional reaction due to post combat depression.ƒÆ’-¡ƒ”š‚ 

The Western Nations arrived in 1505 AD and until 1815 AD the Sri Lankans fought against three Western Nations- the Portuguese, the Dutch and the English. Some of the local worriers who fought against the foreign invaders later became the victims of combat trauma.

According to the Western chronological records the first patients who showed PTSD like symptomatology were recorded in 1666. These records were based on Samuel PepyƒÆ’‚¢ƒ¢-¡‚¬ƒ¢-¾‚¢s diary which described the bizarre behavior pattern of ƒÆ’-¡ƒ”š‚  the survivors of the Great Fire of London. ƒÆ’-¡ƒ”š‚ Samuel Pepy vividly portrayed the nightmares, intrusions and flashbacks experienced by these survivors. ƒÆ’-¡ƒ”š‚ 

Although the Western World recorded PTSD like symptoms in 1666 the King Seethawaka Rajasinghe – the 16th century monarch of Sri Lanka believed to be suffered from combat related PTSD and his disturbed behavior pattern was recoded in ancient scripts. The kingƒÆ’‚¢ƒ¢-¡‚¬ƒ¢-¾‚¢s abnormal behavior pattern was described in the Chulawansaya and by the Portuguese historian ƒÆ’-¡ƒ”š‚ FernƒÆ’†’ƒ”š‚£o de Queyroz . ƒÆ’-¡ƒ”š‚ In his publication titled ‘Temporal and Spiritual Conquest of Ceylon Queyroz writes about the King Seethawaka Rajasinghe ƒÆ’‚¢ƒ¢-¡‚¬ƒ”¹…”s behavior in the later stages in detail. These writings came prior to Samuel PepyƒÆ’‚¢ƒ¢-¡‚¬ƒ¢-¾‚¢s diary. ƒÆ’-¡ƒ”š‚ 

The Portuguese came to Sri Lanka in 1505 and launched a massive armed campaign against the islanders. The King Seethawaka Rajasinghe (1544 A.D ƒÆ’‚¢ƒ¢-¡‚¬ƒ¢¢”š¬…” 1593 A.D) was a great warrior who came to the battle field at the age of 16. He fought against the Portuguese invaders and witnessed many deaths and destructions. He was a fearless fighter who used proficient war tactics and overpowered the fully equipped and fully trained Portuguese Army that was considered as a superpower in the 16th century World. The King Seethawaka Rajasinghe defeated the Portuguese in a number of decisive battles. His military campaigns prevented Sri Lanka becoming a Portuguese colony. ƒÆ’-¡ƒ”š‚  Following long years of combat the King Seethawaka Rajasinghe was exhausted and unquestionably suffered from battle fatigue. In the later years the King Seethawaka Rajasinghe showed outburst of anger, irritability, deep mistrust, alienation, emotional numbing and various other PTSD related symptoms. ƒÆ’-¡ƒ”š‚ 

PTSD Denial in the Modern Era

Over 200,000 members of the Sri Lanka armed forces and Police had been directly or indirectly exposed to combat situations during these years. These experiences include seeing fellow soldiers being killed or wounded and sight of unburied decomposing bodies, of hearing screams for help from the wounded, and of helplessly watching the wounded die without the possibility of being rescued. Following the combat trauma in Sri Lanka, a significant number of combatants suffered from Post-Traumatic Stress Disorder and many were undiagnosed and untreated. ƒÆ’-¡ƒ”š‚ ƒÆ’-¡ƒ”š‚ 

For a number of years the Sri Lankan authorities denied fact that combat related PTSD was emerging in the military. PTSD was regarded as an American illness and there was an unofficial taboo to use the term PTSD. The tension of combat trauma was mounting in the military over the years and there had been suicides, and self-harms reported from the battle fields. The soldiers affected by war trauma had behavioral problems and their productivity was plummeting. Many soldiers who had positive features of combat related PTSD without any physical disabilities were compelled to serve in the operational areas and engage in active combat. Some were charged with malingering when they tried to seek medical attention. Many traumatized veterans deserted the army or joined underworld criminal gangs. Until 2005 the Sri Lanka Army did not medically discharge any combatant on psychological grounds especially PTSD. The laborious work of Dr. Neil J Fernando- the former Consultant Psychiatrist of the Sri Lanka Army gave an insight to the authorities to think about war trauma and PTSD seriously. The first soldier who was able to get a medical discharge with PTSD was a Lance Corporal with malignant PTSD. He was a POW who was held by the LTTE for nearly 5 years. ƒÆ’-¡ƒ”š‚ ƒÆ’-¡ƒ”š‚ 

The culture and history of Sri Lanka reveal that PTSD type of illnesses were common in the ancient days and these concepts were not imported to Sri Lanka from the West. The Buddhist Jathaka stories that were ƒÆ’-¡ƒ”š‚ compiled in the period, the 3rd Century B.C. to the 5th Century A.D ƒÆ’-¡ƒ”š‚ narrate ƒÆ’-¡ƒ”š‚  posttrumatic symptomatalogy of the ƒÆ’-¡ƒ”š‚ trauma victims.ƒÆ’-¡ƒ”š‚ 

Combat Trauma and cultural factors

Psychological trauma is a very complex and ƒÆ’-¡ƒ”š‚  damaging factor to the human psyche. It is a unique individual experience and the individualƒÆ’‚¢ƒ¢-¡‚¬ƒ¢-¾‚¢s interpretation is mostly based on his subjective experience. Individual differences in posttraumatic response have been known to the mental health clinician for over many decades. ƒÆ’-¡ƒ”š‚ Numerous psychologists indicate the close association between trauma and the cultural factors. Some argue that the impact of trauma and trauma recovery sometimes depend on cultural factors as well. Therefore the victims of trauma should be treated culturally appropriate manner.

Batista & Wiese ƒÆ’-¡ƒ”š‚ (2010) argue that the trauma must be considered within a culture, because it is the cultural context that shapes the life experiences including the ones that are considered traumatic. ƒÆ’-¡ƒ”š‚ ƒÆ’-¡ƒ”š‚ ƒÆ’-¡ƒ”š‚  No culture is immune to the pain and suffering caused by catastrophic or life-threatening events, but there are important cultural differences in how these events are interpreted and dealt with. (Watters 2010)ƒÆ’-¡ƒ”š‚ 

The cultural impact of combat trauma in Sri Lanka significantly denotes from the beginning of the Northern conflict in early seventies in the 20th Century. The combatants and civilians experienced the aftermath of combat trauma. The religious believes played a key role in trauma management. Many Sri Lankan combatants believe in reincarnation and the effects of Karma. The victims believe that their physical and psychological symptoms are due to karmic actions in the past lives. Often these concepts help them to come to terms with their traumas.

Sri Lankan combatants have more somatic ailments when they manifest anxiety and depression. Many combat trauma victims with depression get treatment for migraine or joint pains before coming for psychological help. (Jayatunge 2004) ƒÆ’-¡ƒ”š‚ 

During the World War 1 Conversion reactions were in abundance. Even Freud wrote about these war hysteria reactions. His famous case study – the soldier of Dardanelles (from the battle of Gallipoli) had dissociative reaction (according to the modern DSM classification) which Freud termed as Traumatic Neurosis.ƒÆ’-¡ƒ”š‚ 

Although in Europe and in North America conversion reactions became minimal with the WW2, Vietnam War and the Iraq War the Eelam war in Sri Lanka has generated a large number of conversion reactions. (Jayatunge 2004) ƒÆ’-¡ƒ”š‚ It could be due to several factors. In the Sri Lankan conflict, soldiers had no psychological debriefing or similar trauma management soon after the traumatic combat events. The combatants were not informed about possible combat trauma reactions. Although the Sri Lankan Army had top surgeons and physicians throughout the war, for the last 30 years the Sri Lanka Army had no single combat Psychologist. The field military doctors had little knowledge about traumatic combat reactions and the effects of PTSD. The psychological victims were often charged with malingering. In addition, the soldiers were reluctant to show their fear mixed emotions which was considered as an act of cowardice. Therefore, many combat reactions were expressed through disociative channels.

Dissociative reactions have a cultural significance in Sri Lanka especially in rural areas. Some combat related dissociative reactions often interpret as the disturbances created by the bad spirits. Mostly in rural parts of Sri Lanka Psychogenic paralysis is considered as an act of black magic and traditional healers use a ritual called Thovilaya (the ancient ritual Thovilaya is a form of psycho drama) to treat the sufferers.

Possession state which is categorized under the Dissociative Disorders could be seen among the soldiers with combat trauma. In possession, the person enters an altered state of conscious and feels taken over by a spirit, power, deity, or other person who assumes control over his or her mind and body. In many rural areas the possession state which is often regarded as mediation with the gods and goddesses. ƒÆ’-¡ƒ”š‚ Some soldiers with possession state had left the military and they had become so called spiritual mediators.

On most occasions the cultural factors and religious believes have helped the victims of combat trauma to integrate the traumatic experience into a meaningful context. ƒÆ’-¡ƒ”š‚ It has worked against a buffer to prevent further traumatization. After exposing to the combat trauma many people have embraced their cultural and religious practices. These individuals interpret their posttraumatic symptomatology in spiritual terms. Somehow these traumatic experiences have been transformed into a meaningful attitude and non-self-destructive manner. ƒÆ’-¡ƒ”š‚ 

The relationship between trauma and culture is an important one because traumatic experiences are part of the life cycle, universal in manifestation and occurrence, and typically demand a response from culture in terms of healing, treatment, interventions, counseling, and medical care……… The concept of traumatic stress and the multidimensional nature of cultures requires a ƒÆ’-¡ƒ”š‚ conceptual framework by which to address ƒÆ’-¡ƒ”š‚ core issues that ƒÆ’-¡ƒ”š‚ have ƒÆ’-¡ƒ”š‚ direct ƒÆ’-¡ƒ”š‚ relevance ƒÆ’-¡ƒ”š‚ to ƒÆ’-¡ƒ”š‚ understanding ƒÆ’-¡ƒ”š‚ the ƒÆ’-¡ƒ”š‚ nature ƒÆ’-¡ƒ”š‚ of ƒÆ’-¡ƒ”š‚ trauma ƒÆ’-¡ƒ”š‚ as embedded within a culture and its assumptive systems of belief and patterns of behavioral regulation. ( ƒÆ’-¡ƒ”š‚ The Lens of Culture -John P. Wilson).

(Summerfield ( 1999) argues that ƒÆ’-¡ƒ”š‚ when it comes to the issue of cultural differences and ƒÆ’-¡ƒ”š‚ posttraumatic ƒÆ’-¡ƒ”š‚ syndromes ƒÆ’-¡ƒ”š‚ (e.g., ƒÆ’-¡ƒ”š‚ PTSD) ƒÆ’-¡ƒ”š‚ it ƒÆ’-¡ƒ”š‚ cannot ƒÆ’-¡ƒ”š‚ automatically ƒÆ’-¡ƒ”š‚ be assumed that advances in Western psychotherapeutic techniques can be exported ƒÆ’-¡ƒ”š‚ and ƒÆ’-¡ƒ”š‚ applied ƒÆ’-¡ƒ”š‚ to ƒÆ’-¡ƒ”š‚ non-Western ƒÆ’-¡ƒ”š‚ cultures. ƒÆ’-¡ƒ”š‚  ƒÆ’-¡ƒ”š‚ ƒÆ’-¡ƒ”š‚ 

Treating Combat Trauma in Sri LankaƒÆ’-¡ƒ”š‚ 

Combat trauma can be identified soon after a traumatic combat operation or exposure to a violent combat related event. Some combat reactions manifest as acute stress reactions and some take months and years to develop. Many victims have clinical features as well as behavioral issues after facing traumatic combat events. ƒÆ’-¡ƒ”š‚ Some go in to negative stress coping methods such as alcoholism, drug abuse, social violence or self-harm. Traumatic post combat reactions can cause significant discomfort to the victim and to his family and in the long run it could negatively affect the society.

In Sri Lanka the psychological victims of war trauma are treated with Allopathic medicine, traditional Ayurvedic medicine, Psychotherapy and Spiritual therapies.

Psychiatrists treat the war trauma victims with depression and PTSD and other anxiety related disorders with SSRI s and sometimes combine antipsychotics when there are signs of severe disturbed behavior with psychotic manifestations. Ayurvedic specialists use various types of traditional remedies to ease the anxiety.ƒÆ’-¡ƒ”š‚ 

Psychologists and Psychotherapists often use Cognitive behavior therapy which is an effective form of insight therapy. ƒÆ’-¡ƒ”š‚ Exposure Therapy is one form of cognitive behavior therapy unique to trauma. Treatment which uses careful repeated, detailed imaging of the trauma (exposure) in a safe controlled context, to help the survivor face and gain control of fear and distress that was overwhelming in the trauma. ƒÆ’-¡ƒ”š‚ 

Spiritual therapy frequently helps the war victims to reduce their depression and anxiety related symptoms. Many Sri Lankan clinicians have observed that the spiritual therapy diminishes the suicidal ideation in combat trauma victims. Many combatants and civilians with war trauma are encouraged to practice mediation and yoga. Meditation methods such as Methha Meditation (Meditation of loving-kindness), Vipassanna meditation (mindfulness mediation) are widely used in rehabilitation centers. ƒÆ’-¡ƒ”š‚ 

Every culture is unique and it has distinctive way of interpreting psychological trauma. The clientƒÆ’‚¢ƒ¢-¡‚¬ƒ¢-¾‚¢s religious and cultural believes play an important role in the treatment process. Using these innate factors in trauma management obviously give effective results.ƒÆ’-¡ƒ”š‚ 

References

American Psychiatric Association (APA) (1994) . Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association

Baro, M. (1994) . Writings for a liberation psychology, Harvard University Press.

Batista, P. & Wiese, E. ( 2010) . ƒÆ’-¡ƒ”š‚  Culture and Migration: Psychological Trauma in Children and Adolescents. ƒÆ’-¡ƒ”š‚ Traumatology ƒÆ’-¡ƒ”š‚ 16: 142-152

Fernando, N. & Jayatunge, R (2011) . Combat Related PTSD among the Sri Lankan Army Servicemen. Retrieved from

http://www.srilankaguardian.org/2011/02/combat-related-ptsd-among-sri-lankan.html

Jayatunge, R. (2004) . PTSD Sri Lankan Experience , ANL Publishers Colombo.

Jayatunge, R. (2008) . EMDR Sri Lanka experience: (Psychological trauma management through EMDR in Sri Lanka , Sarasavi Publishers Colombo.

Srinivasa Murthhy, R. & Lakshminarayana, R . (2006) . ƒÆ’-¡ƒ”š‚ Mental health consequences of war: a brief review of research findings. World Psychiatry. 5(1): 25ƒÆ’‚¢ƒ¢-¡‚¬ƒ¢¢”š¬…”30.

Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programs in war-affected areas. Social Science and Medicine, 48, 1449ƒÆ’‚¢ƒ¢-¡‚¬ƒ¢¢”š¬…”1462.

Watters, ƒÆ’-¡ƒ”š‚ E. (2010) . Crazy Like Us: The Globalization of the American Psyche. ƒÆ’-¡ƒ”š‚ Free Press.