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Outsiders miss cultural differences when trying to help

Life has returned to normal for many Sri Lankans, even those on the beach, more than three years after a massive tsunami killed nearly 30,000 Sri Lankans. Ruins and slabs still dot the landscape, but idyllic scenes like these fishing boats on the beach in Madiha highlighting the country's overwhelming beauty are easily found.
Life has returned to normal for many Sri Lankans, even those on the beach, more than three years after a massive tsunami killed nearly 30,000 Sri Lankans. Ruins and slabs still dot the landscape, but idyllic scenes like these fishing boats on the beach in Madiha highlighting the country's overwhelming beauty are easily found. SUN HERALD

Almost exactly eight months before Hurricane Katrina, Sri Lankans faced one of the worst natural disasters in modern history.

About 30,000 Sri Lankans perished when a tsunami created by an undersea earthquake crashed ashore December 26, 2004. Tens of thousands more were injured or lost property.

Yet today, nearly all say they have recovered from the trauma of the disaster. The answer to their recovery lies in their community, most say, specifically their sense of community and not in the deluge of aid organizations that promised relief from grief after the disaster.

A.D. Sithumini, 15, lost her sister to the tsunami. She said she was terrified of the ocean, but it faded as time went on. Her sister was one of the most popular students, Sithumini said, and it was her classmates and teachers who helped talk her through the grieving.

Yet as disasters keep happening, like the cyclone in Myanmar and earthquake in China, the inevitable response of some good-intentioned people always involves sending counselors and psychiatrists to tend to survivors' mental health. The example of Sri Lanka's recovery from the trauma of the tsunami may show that current assumptions regarding the necessity of disaster mental health intervention are not necessarily the best thing.

"If you talk to the mainstream core mental health professionals, they're somewhat skeptical about it," said Dr. Nalaka Mendis, the founder of the Sahanaya National Council for mental health. "It doesn't mean that it is not there or that it is unimportant. It could be the people (that have been) identified (as needing help) have traditional mental health problems."

Mendis said in general there are cultural differences that get missed when people from the outside come in to help. There are exceptions of course, said Mendis, like the Community Stress Prevention Center, based in Israel, which has done post-disaster mental health work in Biloxi post-Katrina and Colombo, Sri Lanka, post-tsunami.

CSPC members came in and trained locals in techniques for dealing with stress and the release of anxiety through things like art therapy. Of all the post-tsunami mental health efforts, Mendis said this was generally the best example of what could be done.

Ruvie Rogel, deputy CEO of CSPC, said their work internationally in the last decade tends to indicate that some intervention has to happen to people who survive disasters, without exception.

"If you talk to the people in Israel two years after the war (with Lebanon's Hezbollah terrorist organization,) if you slam a door in Kiryat Shmona (on Lebanon's border,) everybody is going to jump and ask what happened," Rogel said. "That's a post-traumatic symptom. Do they stop living? Most of them didn't. But, are they avoiding anything? Are they preventing themselves and their families from doing some stuff? Probably they do on a certain level. The serious cases need help. It sits on other traumatic experiences also. One crisis enhances other crises."

Sri Lankans are no stranger to crises, coming into the 25th year of the civil war between the Tamil Tigers and Singhalese majority government.

Still, the country's professionals did not after the tsunami and do not to this day treat mental health issues directly. They have largely ignored the notion that traumatic stress requires head-on confrontation. Instead, post-tsunami, there has been a focus on establishing a formal network of psychosocial support centers, based indirectly on the collectivism that already exists in society.

In other words, they do not treat just mental health issues, but also help you find work, have a solid roof over your head, etc.

Dr. Mahesan Ganesan helped pioneer this idea in the northeastern province, which was severely devastated post-tsunami.

He said he knew early on it was not his job to tell people what to feel or how to feel. Instead, he said he wanted to use the area's limited resources to help people put their lives together and simply rely on the resiliency residing inside most people to take care of the rest. Ultimately, Ganesan said he believes that so long as someone does not feel neglected, they are capable of recovery on their own.

"When I say that you have depression, or when you have some other (mental health) disease, basically what I am saying (is) you are helpless to solve it," said Ganesan, who prior to the tsunami was the only psychiatrist available to 1.4 million residents of the northeastern province.

"Problem is, I can't really solve the problem for you. Medicalizing (sic) loss, I don't think is a good idea. Most can cope. This trauma (response) thing has gone too far. By medicalizing it, basically what we are saying is this is a specialized area and there is nothing you can do."

For Mendis, this assumption of post-disaster helplessness among a select few is a purely Western idea, and is misguided.

"In 1998 or 1999, we had a very big bomb blast in central Colombo," Mendis said. "Central Bank was bombed. Some 70 or 80 people died. And right in front of Central Bank was an American Express bank and there about 5 (or) 6 people died. Americans being American, they immediately flew two counselors from America. I met them just before they left. They said, 'We don't know whether we helped. All of them wanted to come to America.'"

The series

Post-disaster mental health, like mental health in general, is a dark art. While there is a lot of research and many years of practice in both, there is no guaranteed, positive way to handle post-disaster mental heath issues like there is, say, a broken bone or a cut.

The general agreement among American professionals is that disasters necessitate some sort of mass public mental health intervention. However, figuring out exactly who will be affected and how they are affected exactly is still anyone's guess.

This three-part series examines what has happened in Sri Lanka since the tsunami in terms of mental health issues through the lens of the post-Katrina experience.

Sunday: The Sun Herald looks at the response itself. There was a troupe of organizations that rushed in to lend a hand, to rebuild homes and rebuild allegedly fragile psyches. What did they do? What did they offer?

Monday: The Sun Herald looks at how individual Sri Lankans are recovering today. About 30,000 people died in the tsunami in Sri Lanka, so nearly everyone either lost someone they knew, or knew someone who lost someone they knew. At the same time, the population is dealing with an ongoing 25-year civil war and has dealt with large-scale trauma repeatedly. Prior to the tsunami, Sri Lanka had one of the highest suicide rates in the world. What kind of effect did that have on their mental health recovery from the tsunami, if at all?

Tuesday: The Sun Herald looks at what Sri Lankans have to say to their Gulf Coast counterparts as they glimpse into the future of disaster mental health. Mentally, why and how did the Sri Lankans get to where they are today?

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