Friday, October 31, 2014

The Psychological Impact of the Armed Conflict in Sri Lanka






Dr. Ruwan M Jayatunge M.D.


The Sri Lankan society experienced a 30 year prolonged armed conflict that changed the psychological landscape of the Islanders. A large number of combatants, civilians and the members of the LTTE underwent the detrimental repercussions of combat trauma. Following the armed conflict in Sri Lanka over 90,000 people lost their lives and thousands of families are still grieving. A large numbers became physical and psychological casualties of the war.  The war trauma still echoes in the Sri Lankan society. 

War has serious consequences for both short-term survival and longer-term recovery and development (Sørensen, 1998). War trauma represents a horrendous experience to the Sri Lankans. The Sri Lankan society is still struggling with the negative aftermath of the 30 year armed conflict.  If not addressed effectively the psychological scars following combat can stay behind for many years. It can change the psychological markup of people making them more dysfunctional.

Londoño and colleagues (2012) indicate that exposure to violence in general and to armed conflict in particular has been consistently associated with an increased prevalence of mental illness.  Although mental disorders are a major public health problem, the development of mental health services has been a low priority everywhere, particularly in low- and middle-income countries (Minas, 2012).

War trauma has impacted the Sri Lankan society in every level. The social fabric has been severely damaged. It has become a part of social experience and memory.  As the Salvadorian psychologist Martin-Baro wrote of his own country, what was left traumatized were not just Salvadorian individuals, but Salvadorian society. This expression is totally applicable to Sri Lanka.  

During the post war period interpersonal violence, child abuse, rape, alcohol and drug abuse, social violence have been increased in significant numbers. Many of these social maladies have direct or indirect connections with war trauma.  Deplorably Psychological wounds of the Eelam war were not adequately addressed and the deleterious effect of combat trauma impacts the post war Sri Lankan society. 
   

  
 Brief History of the Conflict
The armed clashes in Sri Lanka dates back to as far as 1972. In 1972, a group of undercover Tamil militants planted several bombs at the   Duraiappah Stadium in Jaffna. In 1974, a hand bomb was thrown at the Kankesanturai Police Station.  On the 27th  of July 1975, the Mayor of Jaffna Mr. Alfred Duraiappah  was gunned downed by the LTTE  leader Velupillai Prabhakaran,The tension was escalating in the North and the security forces were repeatedly on high alert.

The Eelam War started in 1983 and lasted until 2009. Over the years, the Sri Lankans saw a bloody war that destroyed thousands of lives. Many civilians as well as the members of the armed forces became the physical and psychological casualties of the war.

From Independence in 1948 to until 1971, Sri Lanka had a relatively small Army that was less professional and regarded as a ceremonial army.  With the 1971 JVP insurgency, the Armed Forces had been mobilized for combat operations for the first time. The Northern conflict demanded more manpower to the Armed Forces. In late 1987, the army had a total estimated strength of 40,000 troops, about evenly divided between regular army personnel and reservists on active duty. The approximately 20,000 regular army troops represented a significant increase over the 1983 strength of only 12,000. Aggressive recruitment campaigns following the 1983 riots raised this number to 16,000 by early 1985. (Global Security.org). In the year 1986, the Sri Lanka Army had 30,000 personnel.  By 2008, the Sri Lanka Army had force strength of 162,000. 

From 1981, the LTTE intensified its attacks on the security forces. In 1981, the LTTE killed two members of the Sri Lanka Army on the Kankesanturai road in Jaffna. In 1983, the LTTE ambushed a Sri Lanka Army patrol killing 13 soldiers.  The LTTE launched its first suicide attack in 1987 at the Sri Lanka Army camp in Nelliady killing 40 soldiers. The Sri Lankan Armed Forces launched a number of military operations against the Tamil Tigers. On May 26th  1987 the Operation Liberation (Vadamarachchi Operation) was launched against the LTTE.


 The Nature of the Sri Lankan Conflict
The Sri Lankan Conflict was the longest-running armed conflict in Asia.  It was a conflict between the Government Forces and a rebel separatist group better known as the LTTE (The Liberation Tigers of Tamil Eelam).  The LTTE was regarded as the most lethal terrorist group in the world. In the subsequent years the LTTE was banned in UK, US and in Canada. The LTTE   attacked   the Sri Lankan armed forces with modern high tech weapons. In addition the LTTE used numerous unconventional methods to fight the Sri Lankan Forces using child soldiers and suicide bombers. The Northern conflict consumed many lives and caused damage to the property worth of billions of dollars. 


Sri Lankan Combatants and War Trauma
Sri Lankan military forces deployed its entire bayonet strength for nearly 30 years.  During this critical period the Sri Lankan military launched nearly 20 major military operations against the LTTE. Over 200,000 members of the Sri Lanka armed forces and Police had been directly or indirectly exposed to combat events during these years.  They were exposed to hostile battle conditions and many soldiers underwent traumatic battle events outside the range of usual human experience.


In 2009 May the Sri Lankan government declared that the country won the war against the LTTE. Although the armed forces were able to gain a decisive victory it came with a huge social cost. The Eelam war affected the psychosocial health of the combatants. Significant numbers are still impacted by combat trauma. During the post war era high numbers of desertions and suicides have been reported among the combatants.  According to the Military Spokesperson of the Sri Lanka Army from 2009 to 2012 postwar period nearly 400 soldiers had committed suicide (Sriyananda, 2012).


The Social Impact of Combat Related PTSD

The experts believe that the circumstance of war can produce a range of emotional, psychological and behavioral stress reactions among soldiers and officers that can lead to a condition known as PTSD (Post Traumatic Stress Disorder). Posttraumatic stress disorder (PTSD) is a condition that engenders both symptomatic distress and severe disruption in interpersonal and social functioning (robertson et al. 2004).

During the Eelam War many soldiers experienced combat related psychologically distressing traumatic reactions. Most of these acute traumatic reactions were not appropriately diagnosed or treated. Some soldiers were emotionally overwhelmed as a result of war trauma. There were no apparatus to identify these distressing reactions and offer psychological first aid without delay. Some soldiers lived with the traumatic ruminations for years while serving in the operational areas. These victims were later diagnosed with combat related PTSD.

For a number of years the Sri Lankan authorities were reluctant to believe that combat related PTSD was emerging in the military. PTSD was regarded as an American illness and there was an unofficial taboo to use the term PTSD. The tension of combat trauma was mounting in the military over the years and there had been suicides, and self-harms reported from the battle fields. The soldiers affected by war trauma had behavioral problems and their productivity was plummeting. Many soldiers who had positive features of combat related PTSD without any physical wounds were compelled to serve in the operational areas and engage in active combat. In the early days of the war soldiers were sometimes charged with malingering when they tried to seek medical attention. Many traumatized veterans deserted the army or joined underworld criminal gangs. Until 2005 the Sri Lanka Army did not medically discharge any combatant on psychological grounds especially PTSD.

Combat related PTSD has impacted combatants hugely.  The wounds that they received from war were not confined to the battlefield. It was not an individual trauma anymore.  The war trauma frequently transformed to their domestic environments. Domestic and community violence, child abuse addiction issues, self harm etc. became massive social problems. War trauma has turned in to a vicious cycle affecting   individuals as well as the entire society.



The Residual Effect of Combat Trauma
It is important to know that in the post war era late reactions of combat related PTSD can emerge. Combat stress has residual effect on some veterans. For some soldiers combat related traumatic reactions can emerge at a later date. Posttraumatic stress disorder (PTSD) may develop as a serious long-term consequence of traumatic experiences, even many years after trauma exposure (Lecic-Tosevski et al. 2013). There is a risk of emergence of late reactions of combat related PTSD in the post war Sri Lankan society.



Palali Syndrome
A new form of battle stress began in Sri Lanka mainly after 1983. Many Psychiatrists point out that a number of psychiatric illnesses have been increased as a result of the Northern Conflict. For a combat soldier in World War 2 who served for 4 years the average time spent in actual combat was approximately 40 days. In Vietnam, soldiers spent an average of about two thirds of their 12 or 13-month tours over 250 days in combat. But in Sri Lanka a large number of soldiers have spent 10-15 years in combat with short intervals.

For nearly three decades, Sri Lanka experienced a social calamity following an armed conflict and people were deeply traumatized. The echoes of the war trauma will affect Sri Lanka for generations. Although the origin and the history of this conflict was very complicated and carries many versions and explanations, after all it is a collective trauma for the Islanders. The North and South suffered from this conflict creating a large number of physically and psychologically traumatized victims. The combatants who experienced the war firsthand became profoundly affected by the physical and psychological consequences of the armed conflict. Many became the victims of the Palali syndrome. Unfortunately the International media has overlooked the magnitude of combat trauma experienced by the Sri Lankan combatants and often portrayed them as the perpetrators of violence.   

Palali Syndrome describes post traumatic reactions and post war re-adjustment problems experienced by some Sri Lankan combatants.  It narrates the psychological aftermath of the Eelam War in Sri Lanka. Even though the Eelam War is over  combat trauma is still hounding the Sri Lankan society rising as social violence, political violence, political extremism, criminal activities, domestic violence, suicides, homicides, alcohol and drug abuse, cruelty to children and various other forms.


Combat Related PTSD Study in Sri Lanka
The first combat related PTSD study in Sri Lanka was conducted during 2002 – 2006 period at the Military Hospital Colombo. This study was headed by Dr. Neil J Fernando Consultant Psychiatrist of the Sri Lanka Army and the former acting Director of Mental Health – Ministry of Health Sri Lanka.
From August 2002 to March 2006, 824 members of Army infantry and services units who were referred to the Psychiatric ward Military Hospital Colombo were interviewed. This study was conducted while the soldiers were still on active duty. The study group included 824 soldiers and officers. These soldiers were administered the PTSD Check List based on DSM 4 with a structured interview. This schedule designed from similar trauma questionnaires used elsewhere in the world to detect PTSD. The presence or absence of PTSD was evaluated with the use of the PTSD Checklist. 

This was a convenient sample that was referred to the Psychiatric Unit Military Hospital Colombo. Mainly the referrals were done by the medical officers of the OPD, Consultants in the Medical and Surgical units, Palali Military Hospital, Victory Army Hospital Anuradhapura and other military treatment centers. The affected combatants had behavioral problems, psychosomatic ailments, depression and anxiety related symptoms, self-harm, attempted suicides, alcohol and substance abuse, and misconduct stress behaviors.

In this study among the 824 Sri Lankan combatants 56 were found with full blown symptoms of PTSD and 6 soldiers were found with partial PTSD. The PTSD rate was found as 6.7% following analysis of DSM 4 based questionnaire.


Combat Trauma among the ex LTTE Carders

Combat Trauma among the ex LTTE Carders is least discussed. Very few studies are available on the mental health factors relating to the ex militants. Many surviving members of the former LTTE either now live in Sri Lanka or live abroad. Most of these ex militants joined the movement as children and throughout the war they underwent the harsh realities of war trauma.

As children these members witnessed and engaged in violence. While spending time in the battlefield they turned in to adults. As adults they continuously lived through battle stress until the end of the conflict in 2009.

Mental health experts believe that psychological trauma experienced by people during their childhood have a higher tendency to manifest mental health problems in later life.   According to several mental health experts some of the ex LTTE members suffer from malignant PTSD (Disorders of Extreme Stress Not Otherwise Specified or DESNOS). These victims live with rage, guilt, alienation and suicidal ideation. They lack social skills and unable form families due to lack of parental skills and intimacy. Although a number of rehabilitation projects were launched by the Sri Lankan government to rehabilitate the former militants some of them still live with scarred minds. Those who managed to flee and live as refuges in the Western countries do not receive culturally fitting psychological rehabilitation therapy. These individuals need psychosocial rehabilitation in order to re integrate in to society.


The Child soldiers in the Sri Lankan Conflict 
Over 7000 children were forcibly recruited and sent to war by the LTTE during 1983 – 2009 (Human Rights Watch). Children were abducted and forced into weapon training and they were subjected to torture, indoctrination, sleep deprivation and often forced to commit atrocities.   During the Eelam War these children witnessed absolute carnage that would impact their future adult lives. 

Former child soldiers have numerous mental health issues. Children who survive traumatic events exhibit   diverse set of symptoms and physical signs   often meet with diagnostic criteria for attention-deficit hyperactivity disorder, anxiety disorder etc (Perry, 2003). 

In 2009 the Sri Lankan Government liberated all the child soldiers that were held by the Tamil Tigers. These child soldiers were reunited with their families and they were offered rehabilitation.  Among   the conflict ridden countries Sri Lanka became the first state to free all the child soldiers that were held by the rebel group.  Today Sri Lanka is free of child soldier menace.  This is a major victory to the civilized world that sternly condemns the military use of children.

Today these ex-child soldiers undergo rehabilitation. Most of them go to schools and receive vocational training.  But still many are trapped with their dreaded combat memories. According to the local clinicians a considerable numbers of Sri Lankana child soldiers   are suffering from depression, PTSD, somatization and adjustment disorders. They need effective long term rehabilitation and acceptance by the society.


The Civilians Affected by the War  
In armed conflicts civilians have little protection from collateral or incidental damage and often they become vulnerable. Among the consequences of war, the impact on the mental health of the civilian population is one of the most significant (Srinivasa Murthi & Laksminarayana , 2006). The recent military conflicts in Afghanistan and Iraq had a large numbers of civilian casualties.  The Eelam war in Sri Lanka was no exception. A large number of civilians from the North and South   became innocent victims of the war in Sri Lanka. Many became casualties due to the colorectal damage following military offensives against the rebels (in the North) and due to suicide bombing by the LTTE (in the South). 

According to the International Institute for Strategic Studies (2003) between 1980 and 2000, the LTTE carried out 168 suicide attacks causing heavy damage on civilian, economic and military targets. Suicide bombings and other form of explosions can cause long-term repercussions on survivors. Bashir and colleagues (2013) highlight that  civilian victims of suicidal and improvised bombings present with a wide range of neurological symptoms and injury patterns, which often differ from the neurological injuries incurred by military personnel in similar situations, and thereby often require individualized care.

The Sri Lankan conflict caused mass displacements. At the end of 2006, at least 520,000 people in Sri Lanka were victims of conflict-induced displacement in a country of 20 million, making up one of the largest displacement crises in Asia in absolute terms and particularly in terms of the proportion of the population displaced (Civilians in the way of conflict: Displaced people in Sri Lanka September 2007).  Many civilians who became displaced   lived in shelters for long years and fled the country. Adverse mental health consequences have been reported among the displaced people.

The war trauma in Sri Lanka destroyed the social fabric and a large number of civilians underwent hardships of war. People lost their loved ones. They lost their property and livelihoods.  It affected individual as well as in collective level.  For the most of the Sri Lankans the war became a collective trauma. Tens of thousands of Sri Lankans still face the bitter consequences of the war. They live with their traumas suffering silently.

The civil society has been degraded by war trauma. Hostility, suspicion, alienation, emotional numbing, indifference, scapegoating became the common components in the war ridden Sri Lankan society. Empathy, tolerance and compassion gradually disappeared as the war progressed. There is a noticeable lack of quality in civil society, partly due to the crippling brain drain, but also due to the devastating effect of the war. There is also widely reported perception in northern Sri Lanka that there has been a marked deterioration in social values evidenced by changing sexual and social behaviours. (Somasundaram 2007) 

The researches indicate that armed conflict can have long term consequences. Nandi (2013) investigated to what extent the soldiers and young women of World War II were affected by PTSD symptoms over the course of their lives and in this study the researchers recruited 52 male and 20 female Germans aged 81-95 years and interviewed regarding war experiences and PTSD symptoms. Of the men 2 % and 7 % met the criteria for current and lifetime PTSD diagnoses, respectively, as compared to 10 % and 30 % of the women, respectively. These researches show that the impact of war trauma can affect the Sri Lankan society for long years.

  
The Eelam War and the War Widows
One harsh reality of the war is that the every soldier killed in war leaves behind grieving family and relatives. It has been a reality since the Trojan War. The women who were left widows as a result of the Sri Lankan conflict are facing radically altered circumstances. There are estimated thousands of war widows who still experience grief reactions. Many widows young and with the death of their husbands these women have become a psychologically and socially vulnerable group. Most of the women who underwent severe emotional pain still have not completely recovered. Many have become the victims of pathological grief and were clinically diagnosed with Prolonged Grief Disorder or PGD.

They are unable to work through their grief despite the passage of time. With the widowhood, they experience identity change, role adjustment and change in social status.

Many researches concur that the mental trauma of the war widows can last for long years. Depressive reactions are common among the Sri Lanka war widows. Many LTTE carders who died in action left their wives in grief-stricken situations. The war widows of the Northern part of Sri Lanka too experience the similar plight. 

In the conservative Asian societies, widows face social, economic and legal handicaps. Widow as its name denotes is associated with some form of socio-cultural stigma and humiliation. They are considered as bad omen in many Sri Lankan rural areas. They are marginalized by their own communities. These   factors affect their self-esteem. In some events, the accusations were made by the in laws stating that the husband’s death occurred because of the unluckiness of the wife and they are partially answerable for the husband’s death. They experience lack of social support and loss of their social possession in their own family circles.

The war widows face a number of mental health problems. They have suffered bereavement as a result of the violent deaths of their husbands and these traumatic memories hound them for long years. They are often subjected to extreme forms of discrimination and physical, sexual, and mental abuse. Therefore, widowhood represents a form of “social death” for these women.



Treating  Trauma Victims based on Cultural Components

In the modern day Sri Lanka, the psychological victims of   trauma are treated with Allopathic medicine, traditional Ayurvedic medicine, Psychotherapy and Spiritual therapies. Psychiatrists treat the war trauma victims with depression and PTSD and other anxiety related disorders with SSRIs (Selective serotonin re-uptake inhibitors) and sometimes combine antipsychotics when there are signs of severe disturbed behavior with psychotic manifestations. Ayurvedic specialists use various types of traditional remedies to ease the anxiety. Psychologists and Psychotherapists often use Person-centered (Rogerian) therapy, Cognitive behavior therapy and EMDR.  

Spiritual therapy frequently helps the war victims to reduce their depression and anxiety related symptoms. Many Sri Lankan clinicians have observed that the spiritual therapy diminishes the suicidal ideation in combat trauma victims. Many combatants and civilians with war trauma are encouraged to practice meditation and yoga. Meditation methods such as Methha Meditation (Meditation of loving-kindness), Vipassanna meditation (mindfulness mediation) are widely used in rehabilitation centers.  


Conclusion 
Sri Lanka faced a prolonged armed conflict that caused paralyzing impact on the society. War trauma in Sri Lanka has generated a large number of victims with PTSD and other forms of psychological ailments. A study done with the Sri Lanka Army servicemen during 2002-2006 reveals that combat related PTSD is prevailing among the members of the armed forces. The victims of war trauma experience problems in their living, working, learning, and social environments. In Sri Lanka there are numerous measures to treat the war victims using traditional and modern treatment measures. In overall effective psychosocial measures have to be implemented to treat victims of the Sri Lankan armed conflict.

War Trauma Presentation : (contains graphic images) Link 

https://www.youtube.com/watch?v=SN6cgq1vGu0 



References

American Psychiatric Association (APA) (1994) . Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association

Baro, M. (1994) . Writings for a liberation psychology, Harvard University Press.

Bashir, M.U., Tahir, M.Z., Bari, E., Mumtaz, S. (2013).Craniocerebral injuries in war against terrorism --- a contemporary series from Pakistan. Chin J Traumatol.  16(3):149-57. 

Batista, P. & Wiese, E. ( 2010) .   Culture and Migration: Psychological Trauma in Children and Adolescents.  Traumatology   16: 142-152

Child soldiers global report (2009) .

Fernando, N. & Jayatunge, R (2011) . Combat Related PTSD among the Sri Lankan Army Servicemen. Retrieved from

Human Rights Watch. (2004) .  Sri Lanka: Tamil Tigers Forcibly Recruit Child Soldiers.  November 12, 2004 Retrieved from    

Jayatunge, R. (2004) . PTSD Sri Lankan Experience , ANL Publishers Colombo.


Lecic-Tosevski, D.,Pejuskovic, B., Miladinovic, T., Toskovic, O., Priebe, S.2013). Posttraumatic stress disorder in a serbian community: seven years after trauma exposure.J Nerv Ment Dis. 040-4. doi: 10.1097/NMD.0000000000000051.

Londoño,A,.   Romero,P.,    Casas , G.(2012).The association between armed conflict, violence and mental health: a cross sectional study comparing two populations in Cundinamarca department, Colombia.Confl Health.6: 12. 

Minas,H (2012). The Centre for International Mental Health Approach to Mental Health System Development. Harv Rev Psychiatry.20(1): 37–46.

Nandi,C. (2013).War trauma and PTSD among German war survivors : A comparison of former soldiers and women of World War.

Perry, B.D. (2003) Effects of Traumatic Events on Children. Retrieved from http://www.mentalhealthconnection.org/pdfs/perry-handout-effects-of-trauma.pdf

Robertson, M., Rushton, P.J., Bartrum, D., Ray ,R. (2004).Group-based interpersonal psychotherapy for posttraumatic stress disorder: theoretical and clinical aspects.

Somasundaram , D. (2007) .  Collective trauma in northern Sri Lanka: a qualitative psychosocial-ecological study.   International Journal of Mental Health Systems 2007, 1:5

Sørensen, B. (1998).  Women and Post-Conflict Reconstruction.  Retrieved from http://www.unrisd.org/unrisd/website/document.nsf/0/631060b93ec1119ec1256d120043e600/$FILE/opw3.pdf

Srinivasa Murthhy, R.,Lakshminarayana, R . (2006) .  Mental health consequences of war: a brief review of research findings. World Psychiatry. 5(1): 25–30.
Sriyananda, S. (2012 September 24). Nearly 400 soldiers commit suicide in peacetime. The Island Newspaper. Retrieved on February 14, 2013, from  http://www.island.lk/index.php?page_cat=article-details&page=article-details&code_title=62302
Tribe, R., & Silva, P. D. (1999). Psychological intervention with displaced widows in Sri Lanka. International Review of Psychiatry, 11, 184-190. 

Watters,  E. (2010) . Crazy Like Us: The Globalization of the American Psyche.  Free Press.

3 comments:

  1. Really appreciate this post as an Infantryman actively participated in the ethnic conflict of Sri Lanka for nearly 25 years. What my belief is there are a number of Military Personnel and LTTE Cadres as well to be redressed with their mental agonies. It's the total responsibility of relevant authorities to take prompt action without any delay, as this situation could be developed to a national issue.

    ReplyDelete
  2. Thank you Mr. Wicharaka , you had been an Officer and a Gentlemen in the SLA . Engaged in many combat situations never left your men at critical moments. I want to do an interview with you one day. I know you are very humble and do not want to talk about your past heroic acts . However your story must be told. RMJ

    ReplyDelete
  3. Thank you for sharing such wonderful information! In my opinion, Keep a healthy life by consuming healthy food and doing exercise regularly is the best healthy formula.

    Nurse Jobs

    ReplyDelete

Appreciate your constructive and meaningful comments

Find Us On Facebook