Photo courtesy of Haribunda
Sri Lanka has a storied history filled with a rich tapestry of socio-cultural narratives around how people experience themselves and the world around them. Stories carried through lineages, passed on by our ancestors, embedded in the cellular makeup of those of us currently inhabiting the world are those of resilience, spirituality, family and community. However, imprints we carry from generations before us and the legacies we may transfer to future generations are also infused with oppression, trauma and an almost visceral sense of pain. Years of war and terrorism, natural disasters, economic insecurity and residual effects of colonialism that still provide grounds for marginalization of certain communities, contribute to the legacy I speak of while inherent sources of courage, resilience and tenacity embedded in our families and communities, continue to act as buffers. However, are these buffers sufficient?
The ubiquitous nature of trauma and pain often leads us as a society to grapple with it in fits and starts, punctuated by “episodes of amnesia” as psychiatrist Judith Herman describes it. Whereas contending with it head on would almost force us to question what we know of the world, to witness human suffering at its core and to confront our own vulnerability. There is also a mirroring of experiences like invalidation, invisibility and powerlessness that pervade through our health, mass communication and judicial systems, enveloping many of us in a “traumatic fog” to quote psychologist Karen Treisman, which can be exhausting and make some of us want to numb out our collective sense of what it really means to be human. The recreation of the impact of trauma through the same systems that are supposed to help, through policy, the use of language, the use and abuse of power and a general notion of “tough love” further activates already existing individual and collective wounds. While appreciating the complexity and the layered nature of trauma, especially in a context like Sri Lanka, I believe it is crucial to reflect on how we can create gradual shifts towards being trauma-informed, especially in healthcare, so that we can strive towards being responsive rather than reactive to promote healing and wellbeing not just for us but for those yet to come.
In exploring trauma and trauma-informed care further, I will lean on ecological systems theory first described by Bronfenbrenner in 1979, where there is an inside-out and an outside-in transmission of the impact of trauma. The word trauma derived from the Greek word traumata means according to Treisman, to wound or to pierce. Although often associated with events such as disasters and accidents, authors such as Gabor Mate likens trauma to an internal wound. Hence, trauma is often our body’s reaction to what happens to us and this penetrates through the individual onto layers such as family, peers, community and broader societal structures and vice versa. Trauma impacts one’s physical health including their immunity and chronic exposure to stress hormones such as cortisol is known to create changes in the architecture of the brain. The lens through which one views relationships, perceives the sensory world around them, their beliefs and narratives about themselves, others and the world, their executive functioning, their ability to learn, solve problems and feel safe are impacted by trauma. Having considered the widespread impact of trauma on a person’s life and how different ecologies around the individual interact with each other to either support or further oppress them, we now arrive at a place where trauma-informed care can be examined.
I will locate trauma-informed care within guiding principles provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) known as the four Rs and contextualize how these principles can be used as a framework within the Sri Lankan healthcare system. The first R is realizing and being aware of the complex, interwoven nature of the impact of trauma and adversity on individuals and communities and considering cultural and historical aspects such as ethnic conflict, racially motivated violence, insurgencies and disasters that has caused and continues to cause disruption and distress. I also have to acknowledge the loss of identity, language, knowledge, traditions and rituals through historical government policies, military rule, destruction of knowledge hubs and the forced assimilation of minority groups in the guise of eradicating terrorism. Daya Somasundaram, a distinguished psychiatrist from the North calls this a “cultural bereavement”. With this I emphasize the importance of being mindful that anyone a healthcare worker may interact with may have had traumatic experiences including medical trauma which I will delve into later.
The second R is about recognizing how distress, and adversity can present themselves as symptoms, coping strategies and behaviors in individuals and in wider ecologies around them. This could be in psychological and psychiatric services, general outpatient clinics, emergency departments and even in the judicial medical system. The third R is resisting re-traumatization by accepting the fact that systems themselves can induce and exacerbate trauma. A powerful example of how systems harm individuals, is narrated through participants interviewed for a study published in BMC Pregnancy and Childbirth on obstetric violence in the state health institutions in the Colombo district, Sri Lanka. The study authors quote the public health midwives saying that patients may perceive their “firm instructions” on how women giving birth “should behave” as humiliating, degrading and disempowering whereas for them obstetric violence seemed a trivial issue.
Another example of how trauma is induced in healthcare is captured in the quote captured from the above study. A participant is quoted saying “I still feel so upset to be reminded about what happened. That second sir (doctor) came to me and from the very first moment stared at me and asked me in a rude way to keep my legs in the ‘correct position’ (for him) to check (the progress of labor). I did as he asked. Oh god! How terrible! That was the moment I felt the most severe pain during the entire labor when he was checking me. I had no control and screamed loudly”. Another example based on cultural and religious stereotypes is highlighted in the study where a Sinhalese nurse is quoted saying to a Muslim woman “You are the people who bring headaches to us. We are the people who always face trouble because of you…you will produce children year by year starting from 19 (years), but we have to resolve all your problems”. The quote highlights a complex multitude of issues including a potential lack of cultural safety where the healthcare provider does not reflect on their own culture, identity and privilege, according to McGough and colleagues, leading to a lack of awareness on how their power as a health worker influences the individual under their care.
The final R is about responding in a proactive manner using the knowledge health workers have about trauma and distress and finding ways to infuse this knowledge into the culture and practices of healthcare institutions. For example, borrowing from the work of Somasundaram, western conceptualizations of how trauma may manifest in individuals, families and communities may differ significantly in collectivist, Eastern cultures like Sri Lanka. This is echoed in the words of Derek Summerfield, a renowned psychiatrist who says “Western mental health discourse introduces core components of western culture including a theory of human nature, a definition of personhood, a sense of time and memory and a source of moral authority. None of this is universal”.A part of being trauma-informed and responsive is considering historical and gender issues, while collaboration and peer support are vital cogs in the wheel.
An example from the North that other healthcare institutions can potentially learn from is the work of Dr. Jegaruban, a medical officer of mental health (MOMH) in the Kilinochchi and Mullaitivu areas, whom I have had the pleasure of meeting. Dr. Jegaruban trained a cadre of field workers who represent villages in the outskirts of Kilinochchi, some with the lived experience of trauma, to identify and support those with mental health problems in their villages. Similarly, Dr. Hiranya Wijesundara, who was once the psychiatrist at the Ampara District General Hospital, created a network of teachers, social workers, religious leaders, counsellors and nurses to support individuals and families in their communities, and Dr. Mahesan Ganesan, who was once the only psychiatrist in the East, built entire health systems, considering the needs of people in the community and moving beyond the pathologizing of distress. While it is easy and convenient to criticize and blame a system for the harm it potentially does, I believe it is important to identify and celebrate the strengths and potential in a system so that learning and reflection can take place.
The notion that trauma and distress can be viewed through multiple lenses then brings to the forefront the need for acknowledging the complex interweaving of personal meaning, socio-cultural-political concerns, the ecologies surrounding an individual and the impact of trauma, being key factors in deciding how healthcare and healing may be offered. Rachel Tribe from the University of East London invites us to consider health pluralism in a Sri Lankan context where those who are not certified or registered as healthcare workers (in a bio-medical sense) can still promote healing and recovery. Priests, traditional healers, medicinal systems like Ayurveda, Unani and Siddha and astrologers can play a crucial role. We need to advocate for voice and choice where the person is included in deciding how they want to address their distress and trauma. Being trauma-informed and trauma responsive includes developing the humility to accept that different people may need different interventions and that Western models of mental health, psychotherapy and psychiatry may not be the gospel truth.
Finally, as most people’s experiences of trauma are relational, healing needs to happen in a relational space, as we are biologically wired to thrive in safe and nourishing relationships. Being trauma-informed and responsive requires healthcare professionals to relate to those they care for with compassion, humility and respect. This requires the healthcare system to promote self-care and community care for health workers themselves, which may be perceived as a hard task but is a key ingredient in an institution and a system shifting from being trauma soaked to being trauma responsive.