In 2005 and 2006, Shanthy Parameswaren, a psychiatrist originally from Sri Lanka, Harriet Calvert, a British clinical psychologist, and I went to Sri Lanka to do post-tsunami mental health work and to train others to do the same. A psychoanalytic perspective, including both Freud's topographic model (very relevant for post-disaster work) and his structural model, Henry Krystal's trauma/affect theory, Anna Freud's developmental theory, and Heinz Hartmann's ego psychology, all when flexibly applied, were very helpful.
We worked in a preschool in the tsunami affected area in northeastern Sri Lanka. We helped parents and preschool teachers understand the regressed behavior in their children after the tsunami. We talked about the value of listening to children, responding non-punitively to regressive behavior, and the importance of a gradual encouragement of phase appropriate autonomy.
We set up the first of a weekly series of meetings where parents could bring problems presented by older children. Such a child is described below. Her problems illustrate the indirect but profound impact of living in temporary camps with limited security and, as well, how psychoanalytic and cultural perspectives can be helpful in understanding this 14-year-old child's (and her mother's) particular response to a trauma that occurred in this unsafe environment.
About a month before I saw her, she was attacked from behind by a man, while she was urinating. He held a knife to her throat and grabbed for a chain he thought mistakenly she was wearing. By her account, he then forced her to hold some liquid in her mouth for a few minutes, so she wouldn't call out, while he ran away. She was frightened, often refused to go to school, and feared seeing the man who was still in the camp.
She had flashbacks and realistic fears. I talked with her about how her fear operates: Your body belongs to you, but he grabbed it away during the attack. I asked if anything sexual had happened, and she insisted that it had not, but I am not sure. She was just scared, she said, that he would kill her. Yes, I said, of course, that is the most awful kind of loss, loss of your own life.
I asked if she felt unprotected. No, she said, she feels protected. But then at just this point, interestingly, she told me that at eight in the evening, she faints.
Alan Krohn, Ph.D., is a member of the Michigan Psychoanalytic Institute and Society, and on the faculty of the University of Michigan Department of Psychiatry, Ann Arbor.
I asked her when the attack had occurred, and she said at eight. I said that sometimes something is just too much to feel. When you faint, you escape. Here was an hysterical symptom common during the Victorian era in the West. In this culture that has many physicalistic ideas about mental phenomena, just as in the Victorian era in the West, there is social and cultural support for this type of symptom.
One of the psychosocial worker trainees and I talked with the girl's mother about her daughter's responses to the trauma and suggested it would be helpful for her to walk her to school. The mother wanted to know if her daughter had some physical problem caused by whatever the man made her drink or hold in her mouth. Was the girl sick after it happened? No, the mother said, but maybe it went into her brain little by little. She was also concerned that the girl's problems had to do with her nutrition, she doesn't want to eat fish. I asked what else she eats, and her diet sounded fine, including other sources of protein. Here we see the mother presenting the physicalistic theories of psychological problems emblematic of the culture. The fainting reveals a use of the body as metaphor: What is within her mind is viewed as a physical force working on her body. This mother viewed her daughter's difficulties as coming from the liquid the man made her hold in her mouth or the food she eats. This promotes an avoidance of feelings about the trauma through an illusion of passivity: The cause of the girl's problems is not her feelings but a chemical that has entered her brain. (This hysterical dynamic is described in my book Hysteria: the Elusive Neurosis, International Universities Press, 1978.) We arranged for the girl to talk weekly with the psychosocial worker.
Much of what we did during both trips was to train psychosocial workers, psychiatrists, psychologists, and teachers in basic psychoanalytic child and adolescent development, stage specific responses to trauma, the therapeutic process, and loss and bereavement.
Much of what we did during both trips was to train psychosocial workers, psychiatrists, psychologists, and teachers in basic psychoanalytic child and adolescent development, stage specific responses to trauma, the therapeutic process, and loss and bereavement. We used Robertson's film on separation and a video of children of different ages speaking about their reactions to the death of a loved one. On each day of the training we set aside times for discussion of their cases and for their responses to the material presented. We discovered that the material we were presenting raised issues of their own. In the analytic tradition we followed the material, which went way beyond responses to the tsunami. It focused on responses to the 20-year long civil war and other much more individual and personal issues, which, in a country with virtually no “talking therapy,” they had nowhere to explore. We ended up doing an amalgam of teaching, supervision, and therapy.
A few vignettes: The trainees raised problems that highlighted a cross-cultural difference between the Western and Sri Lankan views of the individual self. In one example, a trainee talked of a friend who was promised as a child bride by her family to another family. She hated the boy, fell in love with another, but the family would not withdraw from the arrangement, and the girl committed suicide (Sri Lanka has one of the highest suicide rates in the world).
In another example, a trainee asked, “What if there are two cures?” and described a depressed 18-year-old boy. He wanted to study electronics, which he loved, but his mother wanted him to be a teacher, which he hated. What should the counselor do? Helping him actualize his vision for himself and separate from his family was one of the “cures” and clearly the more Western one. But the group felt this would be the poorer alternative, it would make the mother and the family unhappy and that would be bad for all. It highlighted for me how much in the West self-actualization is embedded in, and an implicit value promoted by, our psychoanalytic efforts.
Several psychosocial workers asked to discuss another population they work with: torture victims. One of the workers spoke of wanting to work regularly with a survivor tortured in a government prison but felt he could not. Why? With fear of even sharing this with me, he said being Tamil himself, if he works closely with this prisoner, probably a Tamil Tiger rebel, the counselor himself would be suspected by the government of being a Tiger. Another worker talked of wanting to help a torture survivor think out how he might stand up to the Tiger organization's effort to recruit him back, but the worker felt, again realistically, that to do so would antagonize the Tigers and put the counselor and his family under threat from them.
They asked what I would do. I said, first, I was impressed with their courage to work with these torture survivors. I said I know what I wish I would do, but I'm not under the threat they are. I can only try to empathize with their helplessness and fear when faced with these choices. Near the end of this discussion I said, I don't think I was of much help with this. The counselor of the first torture victim said, “No, you helped me, you listened, you are my counselor”—one of the most moving moments for me. He then went on to say how the fear from both the Tigers and the government “gets inside me.” This is, of course, the psychology of terror.
A minister from India who approached me at my hotel said helping tsunami victims in his part of India, Tamil Nadu, is difficult. There are different communities with no contact living side by side: the castes. We then spent two hours in what I can describe as very brief psychotherapy for him and an education for me about the personal effects of the caste system on someone from the
untouchable/outcaste group, of which he is a member. He talked about how imprisoned he feels being in his caste, and that his caste is “in my bones” (similar to the torture counselor). He spoke poignantly about his son, who was a gifted cricket player in a country obsessed with cricket. He had advanced through successive stages. The boy was then told that he could not, because of his caste, go further. The boy never played cricket or talked about it again. He closed it off as if a physical limitation had prevented him from progressing further. It was, to me, chilling and enraging. The minister was, of course, describing a defense his son was employing to adapt to this horrendous unfairness, a defense whose long-term effects one can only wonder about.
As he was talking about his son and himself, I said what seemed obvious: “It seems that part of the problem you and others in your caste have is that what the society says about you, you believe to be true. You've internalized what you've been told throughout your life.”
His eyes filled with tears, and he said, “Yes, it's inside me, that's right.”
“So you get this view of yourself from the outside and from the inside, too.” Analysts observe this with patients all the time—simple observation, but meaningful to this man.
He said, “I've never really put it this way to myself, but it's part of me.”
“It is a terrible, prejudicial, irrational, cruel idea about yourself, and you are being unfair to yourself in the extreme to believe it. This may be presumptuous to say about your culture, but the people need to know that this caste system is simply a sickness of the culture. It is abusive and has not the slightest shred of reality to it.” I found doing this work put me often at a complex and messy intersection of local values, human rights, and mental health.
I gained from my work in Sri Lanka as much as, or more than, I gave. I hope this article invites others in the analytic community to get involved in disaster mental health domestically or internationally.
As this article goes to press, sadly the cease-fire agreement between the Tamil Tigers and Sri Lankan government has broken down, and the country is descending once again into civil war.