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Friday 2 September 2011

Readings. Crazy Like Us. Part Two: PTSD in Sri Lanka.

We’ve been considering Ethan Watters’ idea (2010, Free Press) that the spread of Western notions of mental illness can actually shift the way problems manifest in other cultures.

In the second of four case examples in his book, Watters examines the impact of a tsunami of mental health workers that descended upon Sri Lanka after the earthquake-generated tsunami of Boxing Day 2004.

Accounts of this type of international disaster response, at least as they appear in Western media, have a heroic quality. The wealthy West pitches in with its superior knowledge and mental health resources to lift disaster survivors out of their misery – often while holding the society's "untrained providers" at bay.

The reality may be somewhat different.

Several years ago I attended a talk by several psychologists who volunteered to be sent to a refugee zone in Africa. They spoke in glowing terms of their experience and were eager to return.

But as they described their experiences, it seemed clear that little of their western-based knowledge applied in the refugee camp. Western one-to-one psychotherapy was out, and no one was going to fill in any personality questionnaires. People were ill and dying. They had lost contact with family members. There wasn’t enough food. Sanitation was poor.

These psychologists wound up running errands, tracking down family, digging latrines, holding the hands of the dying, and helping organize bandages. Sometimes they would listen to people’s stories of their experiences. And that seemed to be about as close as they got to performing like psychologists.

Despite this, and perhaps because of it, they felt their contribution was valuable, and this really seemed to be true. But I couldn’t help thinking “Why do we need to talk about this as a psychological aid initiative?” The needs of the people in the camps had little do with the services that a Canadian psychologist is trained to provide. A latrine is a vastly more significant contribution than a vocational test battery. If we want to go, great. But practicing as though a refugee – or a Sri Lankan tsunami survivor – is interchangeable with an urban Canadian is likely to do as much or more harm than good.

A relative of mine was an executive with EMI, a Brtitish entertainment and technology firm that was involved in the development of the early CAT scanners. He told me about visiting an African country lacking all but the most basic medical facilities. He was given the grand tour of a dusty hospital, the crowning glory of which was a brand-new million-dollar EMI scanner purchased with aid dollars. This was obviously intended to impress him. Instead, he was furious. The country needed a vaccination program and mosquito nets, not a diagnostic tool designed to find problems the medical staff would never be able to treat. Some forms of Western counselling aid strike me as similar.

Watters recounts the stories of westerners who flew to Sri Lanka, and the local practitioners who watched the invasion. Try as he might, he is unable to extract from the clinicians any descriptions of specific psychological interventions that helped specific individuals. At best it appears that the play therapy, puppet shows, and group sessions were a distraction from the tedium of the evacuation centres. The children enjoyed playing with the toys. Some of the clinicians reported jettisoning any attempts at western-style treatment and focusing on more practical issues of survival and family reconnection.

But there are troubling examples as well. One clinician, when pressed to say how her services helped, said it came down to simply being there, showing the Sri Lankans that blonde people from the other side of the world cared about them. A British expert declared that PTSD symptomatology was universal and seemed to feel that the country had no expertise in trauma (apparently ignoring Sri Lankan history).

Watters contrasts western and Sri Lankan ideas about trauma. In the western view, trauma manifests as an injury to the individual. The person may need to withdraw from their social roles to engage in self-care. For the Sri Lankans, he reports that the worst aspects of the trauma for survivors was the disruption of social roles, and the most valuable approach was to help people reconnect and contribute, not isolate and withdraw. He implies that western-based trauma “assistance” was not just ineffective, but potentially harmful.

Could this be true? Well, consider that the assistance in question involves the application of services designed for one population and culture, transplanted wholesale into another. This kind of cultural insensitivity is often likely to cause problems.

In addition, considerable evidence suggests that western-developed trauma assistance programs are harmful even when applied to western populations.

The 1990s practice of critical incident stress debriefing is a case in point. The idea was to intervene with affected groups as soon as possible following a tragedy, with the aim of heading off lasting psychological trauma. The idea made so much intuitive sense to policy-makers that it was implemented prior to adequate testing. Subsequent evaluations have indicated that trauma debriefing actually results in more problems, not fewer. The challenge now is to extract (or correct) traumatic stress intervention programs that have become entrenched within social systems such as schools and emergency response professions.

The application of western trauma interventions, insufficiently validated in their home cultures, exported to other cultures without adaptation, testing, cultural sensitivity, or an awareness that most cultures have already developed procedures for dealing with upheaval, seems like yet another manifestation of western cultural narcissism.

Can we help other countries through trauma? Yes, probably. But food is probably more valuable than encounter groups, and helicopters may be more useful than counsellors.

Next:  Schizophrenia in Zanzibar, followed by Depression in Japan. Previously: Part 1: Anorexia in Hong Kong.

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