The word counselling became much popular in Sri Lanka after the 2004 Tsunami. Along with the word ‘counselling’, there was another buzz word that came to the fore. That was Post traumatic Stress Disorder (PTSD). Another assumption also followed these words, the myth that everyone who undergoes a traumatic event should have counselling.

There was a renewed interest about trauma and counselling, especially after the cricket team was attacked by terrorists in Pakistan. Now the spotlight is on post-war counselling. Therefore it is timely to take this window of opportunity to examine closely about counselling and trauma. It is very important to revisit the notion of trauma because an undue emphasis has been placed on trauma and its consequences especially on PTSD and what to do after a traumatic event. No one talks much about the resilience. The other reason why such a discussion is needed at present is because of the potential danger that post-war interventions may be dominated by undue emphasis on trauma, counselling and PTSD. It is clear that dubious NGOs will not be able to be in a commanding position in the North and East, they will not be able to channel material support to the LTTE. So the way forward will be to flag the need for counselling. Hence, it is also possible that as in the aftermath of the Tsunami, international organizations may come in offering counselling without any understanding of Sri Lankan culture.

This article aims to explain about the normal psychological reaction following any traumatic event, clarify that this reaction is not an illness, and provide scientific evidence to dismiss the fallacy that everyone facing traumatic events warrants compulsory counselling.

Any catastrophic situation, or a major disaster; may it be ‘man made’ or ‘natural’ will result in bringing out expressions of grief for losses suffered through either by death or material loss manifesting in a variety of ways and with varied symptomatology. Sleeplessness, nightmares, tremors, agitation, undue reaction to noise, flashbacks, avoidance of social interaction, withdrawal from family and usual activities, chest pain, and many other physical symptoms will be commonplace.

Under the circumstances, these are natural reactions and are not signs of weakness or illness. Most of these ‘normal psychological reactions’ or the common symptoms and the people who are experiencing these symptoms will get better with time, generally within a few weeks than months.

As most of these are self-limiting, no specific intervention is needed. However, some may continue to have interpersonal problems; family, sexual relationship problems, etc. alcohol dependence and other psycho-active substances abuse. A minority will be affected by mental illness, including ‘Common Mental Disorders’ such as depression, anxiety. Some may develop psychosis which in lay term is ‘madness’. Another extremely important but less well recognised category is those who will have increased perception of medical symptoms but without any significant medical illness (what we call ‘medically unexplained symptoms’ or somatisation). This last category is particularly important as they will present to many different disciplines in medicine, and has a significant implications in terms of disproportionate consumption of healthcare resources.

An island-wide mental health survey commissioned by the Ministry of Health and carried out by us at the Institute for Research and Development, shows that in Sri Lanka 10% is affected by mood disorders, mainly depression, while 3% has medically unexplained symptoms, but shows that only 1.7% has PTSD.

Considering that a great majority will get better with time, offering counselling to everyone is not indicated. In fact the present scientific evidence is that compulsory counselling for everyone is not indicated and even can be counterproductive. However, all these will be helped by psycho-social inputs, such as providing basic necessities, reassuring and providing information to get rid of uncertainty. Those who are affected by relationship difficulties and also alcohol abuse or dependence issue will need specific counselling programmes (‘brief interventions’) and other relevant treatments, including medication. Those who suffer from mental illness will need more than counselling, for example much greater psychological inputs, including cognitive behaviour therapy (CBT). In addition they will need medications. Most of them, however, could be managed in the community. Only a small percentage will need in-patients care, even that as an initial step. In the detection and management of patients with medically unexplained symptoms, the most crucial thing is to increase awareness of this category among general doctors to whom they will present and then to manage them at the level of detection.

Extending mental health or psychological functioning beyond mental illness, broader psychosocial interventions also have a role to play. The Oxford English Dictionary defines ‘psychosocial interventions’ as pertaining to the influence of social factors on an individual’s mind and behaviours. This is also interpreted as ‘social intervention that has secondary psychological effects and psychological interventions that have secondary social effects’.

In that sense, a great amount of work will be needed to re-establish the trust lost over three decades. Deeds, not words will take away the destruction. If any one believes that three or four session of counselling, particularly at the inexperienced hands that lacks adequate amount of skills, will do the job, will be a huge mistake.

A toy will do a lot for a kid than talking. Normalising children’s life through providing some form of educational opportunity as early as possible (which is already happening in some IDP settlements), providing a toy or allowing kids to express their feelings through drawing, will offer a lot.

A sincere national awakening to support those who have been liberated from the LTTE controlled areas, the so called IDPs, will go a long way to re-establish the national harmony.

To support what I say, I would like to reproduce some of the text published in a newsletter titled ‘insights health’ published by id21 with the titled "Prioritising mental health care in war-torn countries (2005 Feb) written by an eminent psychiatrist, Professor Derrick Silove Director of the Psychiatry Research and Teaching Unit, University of New South Wales. "There is emerging evidence from studies amongst Vietnamese refugees and in East Timor to suggest that PTSD-type symptoms may recover of their own accord if the political and social situation is stabilised. Mass psychological interventions (debriefing) are not necessary, nor are such broad-based strategies affordable and feasible in many countries affected by conflict. The best ‘therapy’ is sound social policy aimed at building peace, supporting the reunion of families and communities, promoting justice, providing opportunities for work, and re-establishing institutions that bring meaning and coherence to political, religious, spiritual and social life".

He continues to say "Trauma interventions need to occur at the right time. Rushing in to provide trauma therapies or awareness programmes soon after the conflict has ended is not needed. However, services should be alerted to the likelihood that some people with acute stress reactions, and later, chronic and disabling PTSD, will need attention.

He reiterated the importance of "establishing a network of community-based mental health services that is capable of dealing with a wide range of problems, including severe mental illness and severe or chronic traumatic stress disorders. These services need to interact with other areas of the health sector, traditional care systems and other services. In keeping with experience worldwide, developing and maintaining the necessary mental health skills is an incremental task requiring extensive in-service mentoring".

Therefore it has to be concluded that current undue emphasis on counselling or medicalising the psychological, sociological and political implications of the "IDPs" should not be promoted. What they need is not the ‘therapy’ but provision of basic needs, care with dignity, respect, reassurance to avoid uncertainty and move them to accommodation as soon as possible so that they will have some privacy and also the opportunity to reintegrate to ‘normal’ life as soon as possible. The best therapy will be a sound social policy.

I am confident, the impressive and unprecedented steps taken by the Sri Lankan government in the right direction can be further strengthened to achive a long lasting and honourable peace in Sri Lanka.

I am also confident that as in post-tsunami Sri Lanka, a wealth of experience will be left behind by the Sri Lankans, for those who are genuinely engaged in the management of post-war and conflict situations in other parts of the world.

= PTSD symptoms may not be disabling or seen as a major problem in developing countries.

= The re-establishment of safety and security can allow for natural recovery.

=Local systems of healing and traditional cultures may be effective in healing psychological wounds.

= Standard treatments for PTSD devised in the developed world, such as cognitive behaviour therapy, require specialist skills or expensive medications and may be difficult to access.

= Other severe mental health problems, such as psychosis, severe depression, organic disorders (delirium, brain injury, dementia), and epilepsy, need attention.

.........

Why this series and why Dr. Sumathipala

This is the first in a series of articles on post-war health challenges, mental health consequences after trauma, role of counselling, mental heath service development in Sri Lanka, place of research and ethics in the context of disaster, role of research and development in post-war Sri Lanka, reconciliation and reintegration, normalization, children needs, role of NGO, post traumatic stress disorder and resilience.

We have invited Dr. Athula Sumathipala to pen this series for several reasons. He is a psychiatrist, widely known locally and internationally for his academic and research work. Internationally, he is best known for his work on medically unexplained symptoms.

His research work on patients with medically unexplained symptoms and psychological intervention applicable to those patients (cognitive behavioral therapy), is globally recognized. His publication have appeared in leading international journals, books and the book chapters published by leading international publishers. His works cover areas such as culture and mental health, disaster related issues, and bio ethics; on research ethics from developing country perspective.

The Sri Lanka Medical Association’s CNAPT prize for the best publication of the year was awarded twice (2001 and 2008) to his work. After the tsunami, based on this work, he was commissioned by the WHO for a training programme in Sri Lanka. His work is now incorporated in to the Inter Agency Standing Committee (IASC) guidelines on mental health and psycho social support in emergency settings

He was also invited by University of Sichuan to train doctors in the aftermath of the earthquake in China and also by the University of Aga Khan to train doctors after the Pakistani earthquake.

He was invited by the American Psychiatric Association, the World Health Organization, and the National Institutes of Health to be a member of a team for refining the research agenda for classification of psychiatric disorders and I was one of them.

He received the HB Williams travelling professorship by the Royal Australian and New Zealand College of Psychiatrists in 2007. This award is an internationally acclaimed fellowship which is awarded once in two years to a distinguished leader in psychiatry and allied sciences.

Dr. Sumathipala has also been a keynote, or guest speaker, at many leading international conferences held in the US, the UK, France, Spain, Belgium, Canada, Finland, Brazil, Malawi, India, Pakistan, Bangladesh, Thailand, China, Japan, Vietnam, and South Africa.

In addition to his mental health background, his work in bioethics has earned him recognition and has been validated as an expert in bioethics by the UNESCO.

In recognition of these achievements, last year the Sri Lankan College of General Practitioners awarded an honorary fellowship.

He originally graduated with MBBS from the Faculty of Medicine, University of Colombo, then obtained a Diploma in family Medicine and to follow a MD; a doctorate through research. Then he left the to UK with his own funding and was trained at the prestigious Maudsley and Bethlem Royal hospital to obtain specialist qualifications, MRCPsych, Certificate in higher training. Then he obtained a PhD from University of London.

Currently, he works as the Senior Lecturer at the Institute of Psychiatry (IoP), Kings College, University of London. IoP is the largest psychiatric research centre outside the USA, providing post-graduate education and carrying out research in Psychiatry, Psychology, and allied disciplines, including basic and clinical neurosciences. The Institute is world renowned for the quality of its research. It achieved the highest possible "Five Star" rating in the 2001 Research Assessment Exercise and was rated as the most cost-effective mental health research organization in the world (Science Watch).

He founded and has led the development of the Institute for Research and Development, a national Sri Lankan research institution exclusively devoted to research and development focusing on policy impact. It is in the final stages of incorporation by an Act of Parliament. It provides an effective framework for conducting research, providing research governance, and for capacity building. He is the honorary director of the institution. The IRD was commissioned by the Ministry of Health to conduct the first ever island wide mental health survey which has now been successfully completed.

Dr. Sumathipala also headed the psychosocial section of the Centre for National Operations, set up by the Presidential Secretariat post-tsunami.