The Cultural Perspectives on Psychological Trauma in Sri Lanka

A nation's culture resides in the hearts and in the soul of its people.

Mahathma Gandhi

Dr Ruwan M Jayatunge M.D. 

The Sri Lankan society experienced 30 year prolonged armed conflict and the 2004 Tsunami that changed the psychological landscape of the Islanders. A large number people underwent the detrimental repercussions of these manmade and natural disasters. The victims exhibited various types of trauma reactions. These traumatic reactions were unique and expressed it in different psychosomatic channels. Some victims used traditional healing methods and the cultural components to ease the suffering.  The Western experts who came to treat the psychological victims of the War and 2004 Tsunami in Sri Lanka noticed the cultural   traditions   symbols, narratives that had been used to treat the victims.

The Cross-cultural studies indicate that human expression of grief is strongly linked with culture. Psychological reactions to death, disability and material losses differ from culture to culture beyond biological level. Every culture has its own way of dealing with mourning and grief. The relationship between trauma and culture is significant. Because traumatic experiences are part of the life cycle, universal in manifestation and occurrence, and typically demand a response from culture in terms of healing, treatment, interventions, counseling, and medical care (The Lens of Culture: Theoretical, and Conceptual Perspectives, in the Assessment of Psychological, Trauma and PTSD, John P. Wilson). Cultural differences can also be found in the beliefs about how people use healing methods. Many Sri Lankans for instance, hold that repeatedly talking about distressing experiences is a sign of weakness. When they talk about the dead, they often talk  good things rather than bad things about the deceased. The dead are respected and commemorated. People killed following violent traumatic circumstances are viewed with compassion.

Natural and manmade disasters experienced by the Sri Lankans over the past two millennia had been documented in the historical chronicles. Combat trauma is in Western culture the experience was described some 2 500 years ago in the Iliad and the Odyssey, which can be read as accounts of combat trauma and its sequelae (Shay, 1995, 2002) whereas the effects of combat trauma in Sri Lanka is discussed in the ancient chronicle -the Mahavamsa that was   written in the 6^th Century A.D.,   by Ven. Mahanama. Therefore, the concept of psychological trauma was not new to Sri Lankans.  The religion and culture provided great resilience to cope with trauma.

Culture and Trauma

Culture consist of traditions, values, customs, folklore,   rituals and artifacts that help to make meaning of physical world and its transmitted primarily through language and everyday interactions.  These cultural factors frequently play as trauma buffers   and help the victims to come to terms with psychological suffering. The essential point about the concept of culture is that culture constructs our reality. It is the template that guides our perceptions (Marsella, 2010). 

Psychological trauma is a very complex and a damaging factor to the human psyche. It is a unique individual experience and the individual’s interpretation is mostly based on his subjective experience. Individual differences in posttraumatic response have been known to the mental health clinician for over many decades.  Numerous psychologists indicate the close association between trauma and the cultural factors. Some argue that the impact of trauma and trauma recovery sometimes depend on cultural factors as well. Therefore, the victims of trauma should be treated in a culturally appropriate manner.

Batista & Wiese  (2010) argue that the trauma must be considered within a culture, because it is the cultural context that shapes the life experiences including the ones that are considered traumatic.  No culture is immune to the pain and suffering caused by catastrophic or life-threatening events, but there are important cultural differences in how these events are interpreted and dealt with. (Watters 2010) 

The Interpretations of and reactions to trauma can vary by culture. Some psychologists view PTSD symptoms as a social construction more than a description of a medical fact.  According to Ed Tick, the author of the groundbreaking book “War and the Soul,” PTSD is soul wound, and he has counted over eighty terms from languages around the world to describe what we now call PTSD. The clinical psychologist Roger Brooke (personal communication, 2012) says that what we call PTSD is the   social construction of a universal human experience misguidedly constructed as a psychiatric issue.

For authors such as Shay, Tick, Hillman, Brooke, and others, the psychological wounds of war are in essence moral and spiritual wounds to that sustaining ground of human life people have traditionally called the soul. According to Tick, traditional warrior cultures understood traumatized combat veterans as initiates in need of further initiation so that they could be spiritually transformed into warrior elders and cultural guardians. They need the traditional healing themes of purification, making peace with the dead, restitution in community, and honored status as veteran warriors.

According to Tick and Brooke, PTSD is only a chronic condition if it is iatrogenically (mis-)treated as only, or primarily, a psychiatric issue. According to Brooke, psychotherapy works best if it picks up those traditional themes in new and appropriate cultural ways, both in therapeutic conversations, and in groups. The presence of civilians in such groups is sometimes resisted by veterans but is more helpful than they typically imagine it will be. The presence of civilians bridges the gap to the civilian world, and is a process in which the civilian community shares the burden of the violence that has been done in its name. Another crucial aspect of healing is, for Brooke, that the veteran "own" his experience in combat, and take it up as a task to understand the lessons learned and to integrate these into the rest of his or her life.

The relationship between trauma and culture is an important one because traumatic experiences are part of the life cycle, universal in manifestation and occurrence, and typically demand a response from culture in terms of healing, treatment, interventions, counseling, and medical care……… The concept of traumatic stress and the multidimensional nature of cultures requires a  conceptual framework by which to address  core issues that  have  direct  relevance  to  understanding  the  nature  of  trauma  as embedded within a culture and its assumptive systems of belief and patterns of behavioral regulation. (  The Lens of Culture -John P. Wilson).

Summerfield ( 1999) argues that  when it comes to the issue of cultural differences and  posttraumatic  syndromes  (e.g.,  PTSD)  it  cannot  automatically  be assumed that advances in Western psychotherapeutic techniques can be exported  and  applied to  non-Western  cultures.     

The Americanization of Mental Illness

The author Ethan Watters examined trauma and cultural factors in depth. He expresses that the Western conception of mental health and illness might be shaping the expression of illnesses in other cultures is rarely discussed in the professional literature. Many modern mental-health practitioners and researchers believe that the scientific standing of Western drugs, Western illness categories and Western theories of the mind have put the field beyond the influence of endlessly shifting cultural trends and beliefs.

                                                  

Dr Sing Lee a psychiatrist and researcher at the Chinese University of Hong Kong, watched the Westernization of a mental illness firsthand. In the late 1980s and early 1990s, he was busy documenting a rare and culturally specific form of anorexia nervosa in Hong Kong. Unlike American anorexics, most of his patients did not intentionally diet nor did they express a fear of becoming fat. The complaints of Lee’s patients were typically somatic — they complained most frequently of having bloated stomachs. Lee was trying to understand this indigenous form of anorexia and, at the same time, figure out why the disease remained so rare. (The Americanization of Mental Illness – Ethan Watters).

The Western  Conceptualizations of PTSD

The Western models have also been criticized for their strict consideration of the person as a self-contained unity, an individual completely independent of others (Bracken, Giller & Summerfield, 1995).

The author Ethan Watters is a popular author and his viewpoint includes how rational is to apply the Western based PTSD concepts in other cultures. Ethan Watters writes:

After the 2004 tsunami in Asia, many mental-health experts agreed that a ''second tsunami'' of mental illness in the form of post-traumatic stress disorder would strike the region. Like doctors rushing to the outbreak of an epidemic, American counselors and trauma researchers soon arrived on the scene hoping to pass on useful knowledge about PTSD. A few years on, however, their efforts have raised a troublesome question: Were they bringing the wrong treatment to the wrong people?

At issue is not whether tragic events like the tsunami trigger debilitating psychological distress and even mental illness -- everyone agrees that they can. The question is over the extent to which survivors' cultural beliefs shape their symptoms. If culture has the impact that some researchers suggest, the PTSD diagnosis may be of little help (and even do potential harm) when applied wholesale in other countries. (The Way We Live Now: Idea Lab; Suffering Differently -Ethan Watters / New York Times. August 12, 2007   ).

An Ancient Hospital in Sri Lanka 

Deviations from the DSM based PTSD Check  list.

People from different cultures understand and react to trauma in different ways. These reactions are unique. Each culture has its own symptoms of trauma, its interpretation and they have distinct healing methods. Therefore, it is difficult to categorize common symptoms of trauma in to one unit. The anthropologist Allan Young of McGill University argue that ''PTSD has become psychiatric Esperanto and interventions pressure other cultures to adopt Western beliefs about the meaning and impact of trauma.

Ethan Watters gives numerous examples on how PTSD is expressed in different cultures.

Ken Miller, a psychology professor at Pomona College, reached similar conclusions in his work on war-related trauma in Guatemala, Bosnia and Afghanistan. His study of Afghans who experienced trauma yielded 23 symptoms, including many that were not on the PTSD symptom list and several that had no ready translation into English. There was, for instance, ''asabi,'' a type of nervous anger, and ''fishar-e-bala,'' the mental sensation of internal stress or pressure. (The Way We Live Now: Idea Lab; Suffering Differently -Ethan Watters / New York Times. August 12, 2007)

In Sri Lanka PTSD like symptoms are often expressed in different psychological and somatic routes. The victims frequently complain of the heaviness in their chest and tension in the head. The fatigability they explain as : Angata Pana Nathi Gathiya,

and anhedonia  as: Mona De Karath Hithe Sathutak Nathi Gathiya. Apart from these common anxiety and depression related symptoms Sri Lankan suffers have a number of symptoms that is not highlighted in the DSM based PTSD checklist.

Dr. Gaithri Fernando of the  California State University argues that the deepest psychological wounds for Sri Lankans were not on the PTSD checklists; they were the loss of or the disturbance of one's role in the group.''

                        Sigiriya Frescoes  5 th Century A.D.

The Concept of  Trauma in the Ancient Sri Lankan  Societies

According to the archaeological evidence, the island was inhabited as early as 10,000 B.C.  The Sri Lanka’s ancient cultural heritage dates back over 2,500 years. The Buddhism was introduced to Sri Lanka in the 3ed Century. The Buddhism became an integral part of Sinhalese culture and civilization.  Sri Lanka became one of the few countries with a very vast and rich cultural diversity. The Sri Lankan culture was influenced by India and subsequently by Europe. The European influence was a result of invasion from the Dutch and Portuguese and finally the British in the 19^th Century. 

The concept of combat trauma dates back to the ancient times. Combat trauma had a profound historical, cultural, social, and religious significance to Sri Lanka and the notion of combat trauma is not new to the Sri Lankans. Throughout the Sri Lankan history, there were foreign invasions, internal conflicts and the Islanders had to confront fearsome battles.

According to the Mahawansa – the great chronicle history of Sri Lanka and one of the oldest chronologies in the world (a German translation of Mahavamsa was completed by the Deutsche Academic Wilhelm Geiger in 1912) describes the devastating impact of the great Wijithapura Battle that occurred in 205 B.C. The triumphant King Dutugemunu experienced severe depressive feelings soon after the battle. This could have been a negative emotional reaction due to post combat depression. The King had guilty feelings over the men that perished in the war. He felt that he was personally responsible for these lives. Later the King’s emotional suffering was healed by a monk.

From 103B.C to 89 B.C, Sri Lanka faced a series of foreign invasions from South India. The King Walagamba fought against the invaders for a long period. When he reestablished his kingdom, the King Walagamba was exhausted following long battles. The enemies had destroyed the irrigation systems, the economy had been collapsed and the country was suffering a starvation. The population manly consisted of war widows and orphans. The King Walagamba took unmourns measures to heal the land that was tormented by 14 year war.

In 110 A.D, South Indian Sovereigns invaded Sri Lanka and took 12,000 people as prisoners. The Bhilla tribal men kidnaped young healthy Sinhala males to work in the South Indian paddy fields. The men suffered immensely in these ancient day gulags. The King Gajaba conquered these kingdoms and rescued the POWs. Up-to-date the fear of Bhilla tribal men remains in the Sri Lankan collective unconscious. Even today, if a child does a mischief parents often say Billa the boogeyman will come and get you.

The King Wijayabahu who ruled Sri Lanka from 1055AD to 1110 AD had to fight   against the  Chola  invaders. His military campaign lasted for 17 years. During these years, he faced numerous war related stress conditions.

The Western Nations arrived in 1505 AD and until 1815 A.D, the Sri Lankans fought against three Western Nations- the Portuguese, the Dutch and the English. Some of the local warriors who fought against the foreign invaders later became the victims of combat trauma.

According to the Western chronological records, the first patients who showed PTSD like symptomatology were recorded in 1666. These records were based on Samuel Pepy’s diary which described the bizarre behavior pattern of   the survivors of the Great Fire of London.  Samuel Pepy vividly portrayed the nightmares, intrusions and flashbacks experienced by these survivors.  

Although the Western World recorded PTSD like symptoms in 1666 the King Seethawaka Rajasinghe – the 16th century monarch of Sri Lanka is believed to have suffered from combat related PTSD and his disturbed behavior was recorded in the ancient scripts. The king’s abnormal behavior pattern was described in the Chulawansaya – the ancient chronicle and by the Portuguese historian Fernão de Queyroz .  In his publication titled ‘Temporal and Spiritual Conquest of Ceylon Queyroz writes about the King Seethawaka Rajasinghe ‘s behavior in the later stages in detail. These writings came prior to Samuel Pepy’s diary.  

The Portuguese came to Sri Lanka in 1505 and launched a massive armed campaign against the islanders. The King Seethawaka Rajasinghe (1544 A.D – 1593 A.D) was a great warrior who came to the battlefield at the age of 16. He fought against the Portuguese invaders and witnessed many deaths and destructions. He was a fearless fighter who used proficient war tactics and overpowered the fully equipped and fully trained Portuguese Army that was considered as a superpower in the 16th century World. The King Seethawaka Rajasinghe defeated the Portuguese in a number of decisive battles. His military campaigns prevented Sri Lanka becoming a Portuguese Colony. Following long years of combat, the King Seethawaka Rajasinghe was exhausted and unquestionably suffered from battle fatigue. In the later years, the King Seethawaka Rajasinghe showed outburst of anger, irritability, deep mistrust, alienation, emotional numbing and various other PTSD related symptoms.

The Collective Trauma Following Foreign Invasions  

The Portuguese Army unleashed many cruelties against the people of Sri Lanka.  They committed a number of atrocities that were considered as genocide in the modern day standards.  They vandalized the religious buildings burnt ancient books and looted the wealth. They tortured the natives and forced them to renounce their traditional religion. The General Don Jeranimo De Azavedu is still remembered as a symbol of a bloodthirsty villain who ordered the Portuguese Army to launched brutality against the indigenous people. The Portuguese soldiers committed unspeakable horrors in their occupied territories in Sri Lanka. The infants were thrown to crocodiles in the Kelani River and the women were subjected to gang rape. The men were tortured and entire villages left for starvation. These ruthless inhuman actions created deep psychological scars in the natives.  Even today, these psychological horrors prevail in the collective unconscious of the Sri Lankan People. The  Portuguese invasion brought guns and germs. The waves of Leprosy started spreading among the indigenous people in the  16^th Century Sri Lanka. The local people called the disease Parangi - the same name used to call the Portuguese invaders.

On the 18^th  of November 2005 complete 500 years after Portuguese invasion in Sri Lanka. One prominent Sri Lankan Politician called the Portuguese Prim- Minister to celebrate this event. Many Sri Lankans protested against this idea of celebration and asked for National day of mourning. These actions show that even after 500 years   people have not forgotten the psychological anguish.

The Dutch rule in Sri Lanka started in 1640 and ended in 1796. The Dutch East India Company (VOC) controlled a large coastal area in Sri Lanka. The Dutch Forces launched several unsuccessful attacks on the Kandian Kingdom during these years.

In 1803, the British invaded the Kingdom of Kandy.  But the attempt was a failure. Then they changed the tactics.  With the help of the aristocrats, the British succeeded in taking over the kingdom in 1815.  A few years after the Kandyan Convention in 1818 natives stood against the British colonial rulers. Martial Law was declared and the revolt was suppressed in a vigorous manner. The British Army committed a number of atrocities in Sri Lanka during the Great Rebellion of 1817-1818.

Major MacDonald of the British Army set fire to the houses, burnt the grain and killed the cattle as an act of retaliation. The Army could shoot any native male over 14 years of age. Many collaborators were shot and some were exiled. Even the family members were taken prisoners. Keppetipola Disawe- the prominent leader of the Uva rebellion of 1918 was executed and his family was deported. Keppetipola Disawe ’s  son died under the captivity. After 30 years the British Army used the same cruel fist to defeat the 1848 revolt that was headed by Gongalegoda Bada and Puran Appu . Inhuman and sadistic punishments were inflicted on the villagers and the Army destroyed the fertile social fabric. Many people became the victims of hostile actions and starvation.

1915 :The Hundred Days of Terror

In 1915 race riots broke out in  Gampola (a town, located in Kandy District) between the Sinhalese and the Muslims. The Colonial representatives of the British Government declared Martial Law from June 1915 to August 30, 1915. During this period the military forces commanded by the Brigadier General H.H.L.Malcolm, executed 63 people (according to some reports the number of people shot by the militia were 140 or more). Many were arrested mealy on suspicion and shot without fair trials. Some of the executions were conducted in front of the public. The Government arrested 8736 people and 4497 were imprisoned. Most of the rural villages and urban towns in Sri Lanka experienced the 100 days of terror. Mr. Armand de Souza - a newspaper editor and a social activist documented the terror and horror that was unleashed by the colonial rulers in 1915.  This dreadful period changed the psyche of the Sri Lankans. The people could not trust the Colonial Government anymore and the national leaders headed for a movement towards an independent Sri Lanka.

The Natural Disasters that Occurred in the Ancient Sri Lanka

The ancient Sri Lanka suffered several huge natural disasters that caused damage in astronomical propositions. According to the Mahavansa during the King Kelanitissa's reign (around 190 B.C) a gigantic sea wave (Tsunami) destroyed hundreds coastal  villages in the Western part of Sri Lanka.  The sea flowed up to nearly 28 miles inside the Kingdom causing enormous devastation.  The survivors became so desperate and feared. They urged the King to sacrifice his daughter the young princess Vihara Maha Devi to the sea God. The princess was placed inside a   boat and set adrift on the sea. The boat reached the shore, at   Kirinda in the southern part of Sri Lanka. The King   Kavantissa the regional monarch rescued the princess and later married her.

The Rajavaliya – the 17^th century historical chronicle of Sri Lanka narrates a vast famine that occurred during the King Valagamba’s period known as Baminithiya Saya  (around  89 BC) and this famine lasted for 12 years. Thousands of men women and children died due to starvation and many fled the country. The history reports several other famines named Bulu Ke Saya , Eknali Saya  that killed thousands of people in the subsequent years. These famines were directly connected to the foreign invasions and civil war conditions in the country.

Psychological Trauma Described  in the Ancient Sinhala Language

The culture and history of Sri Lanka reveal that PTSD type of conditions were common in the ancient days and these concepts were not imported to Sri Lanka from the West. The ancient chronicles like Mahavamsa ,Dipavamsa,  Rajavaliya etc.  give comprehensive accounts on distressing periods that the populations experienced.

According to the Archaeologist Dr. S.U. Deraniyagala the oldest Sinhala inscriptions found are from the 6th century. Some experts point out that the oldest extant prose work in Sinhala dates to the tenth century and is attributed to King Kassapa the 5^th  in   913–923 A.D. The ancient texts vibrantly describe the human melancholies in literary form. For instance, The Buddhist Jathaka stories that were compiled from the 3rd Century B.C narrate the dynamics of the human psyche in different situations. The Buddhist Jathaka stories describe various types of mental disorders and how it affects the individual as well as the society.  The Jathaka storyteller describes the symptomatology of a monk (in the Maranabheruka Jātaka) that is well similar to the modern day PTSD.

The said monk had fear feelings, being panicked for a slightest sound (the ancient text describes that the monk was terrified even hearing a sound such as a drop of a leaf from a tree  - which is modern day viewed as hyper-arousal) , fearing the places where he received terrible experiences and reluctant to visit them (avoidance)  , troubled by the fearful mental images  (flashbacks?)  , morbid fear, unable to meditate (lack of concentration), sweating and heart pounding (activation of the sympathetic nervous system), lack of happiness (depressive feelings), mental worry etc.  The clinical picture, which is given in the Maranabheruka  Jātaka much similar to the present day DSM description of PTSD. The word Maranabheruka roughly translates into English as fear of death. For centuries, these stories helped the people to view individuals with mental illnesses with a compassionate eye.

The term for the PTSD in Sinhala language is Pschath Viyasana Klamatha Akramathavaya, which is   relatively a new term. But the ancient Sri Lankan texts describes numerous trauma related conditions using wide vocabulary. The old texts use many words that describe the psychological pain and anguish. Some of the words are…

Umathu - Being   insane, 

Ukatali - Lack of motivation 

Chithha  Viyadhi - Mental worry / mental disease 

Vishada - Depressive 

Bhithiya - Fear 

Dhomnas- Unhappiness

Unmadaya - Mania 

Ullasaya - Manic state 

Rudhuru Svapna   - Nightmares 

Koopa - Anger 

Viyaapada - Rage 

Chithha Rupa -Mental images / flashbacks?

Vikshiptha  - Confusion 

Rujava  - Pain (body pain)

Laya Palena Sookaya – Severe Heartache

Thrasthava – Terrified

Divi Thora Kara Ganime Chithhaya – Suicidal idea

The Treatment of Trauma in the Ancient Days

The earliest system of medicine that prevailed in Sri Lanka was Deshiya  Chikitsa or Sinhala Vedakama,  which was a truly indigenous system of medicine that was handed down from generation to generation(Uragoda ,1997). The ancient Sri Lankans treated body and the spirit including the living environment of the patient. They did not separate body and mind as two different entities. For the treatment of psychological ailments, medicine (extracted from plants) and rituals had been used.

Kolam and Traditional Healing Ceremonies

The ancient Sri Lankans used Kolam or dancing rituals to heal the mentally and physically ill people. Kolam Dances are traditional comic folk plays that bring purification to the patient. It was geared to treat the patient as well as his surroundings – immediate family and the community. Hence, the ancient healers had more holistic view than present day individual psychotherapy.

 Kolam is a dancing tradition rooted in the eastern and western coastal belts of Sri Lanka and is performed in a Kolam Maduwa specially constructed with special foliage.. Although the tradition is believed to date back to the early 19th century, anthropologists believe that kolam has a history beyond that. Over the years, the traditional kolam dance consisting of diverse stories and characters have been enriched by political, economic, social and religious factors. While anthropologists debate over the birth of kolam dance in Sri Lanka, folklore traces its origin to a craving of Mahasammatha Bisawa (Queen Mahasam-matha) who yearned to see masked dancers. ( Unmasking a craft By Naomi Gunasekara Sunday Times)

Sanni Yakuma

The ancient Sri Lankans identified demons as agents of illness.  This concept has nothing to do with the Christian view of Satan and Satanic influences on evil. Some of these traditions date back to before the birth of the Christ. In Sanni yakuma healing ritual, various demons causing illnesses are summoned and demand them to leave the patient without causing further harm. This method has profound hypnotic effect and it gives series of autosuggestions to the mentally ill. The patient strongly believes that the demon that caused the illness had been banished and he has been cured.  The patient’s family and the other community members too share this belief and this common belief help the mentally ill to become functional.

Sinhalese Cosmology and the Eighteen Sanni Yakku (Devils)

The cosmology of traditional Sri Lankan beliefs is a complex mixture of native Vedic gods, spirits, and demons, overlaid with imported Hindu and Buddhist deities, beliefs, and practices. This pantheon is vast, filled with hierarchies and sub-hierarchies which the uninitiated finds nearly impossible to grasp. The synthesis is a spiritual landscape where Buddha reigns supreme, but where the day-to-day is fraught with danger from the yakku (devils) and other malignant forces (vas) which seem all too ready to afflict man with scourges of every description. In this word, life is a constant struggle against these forces.

Paul Wirz, in his seminal work Exorcism and the Art of Healing in Ceylon (1954), lists the following demons and their effects: Kana-sanniya (blindness), Kora-sanniya (lameness/paralysis), Gini-jala-sanniya (malaria), Vedda-sanniya (bubonic plague), Demala-sanniya (bad dreams), Kapala-sanniya (insanity), Golu-sanniya (dumbness/muteness), Biri-sanniya (deafness). Maru-sanniya (delirium). Amuku sanniya (vomiting), Gulma-sanniya (parasitic worms), Deva-sanniya (epidemic disease, i.e. typhoid, cholera), Naga-sanniya (evil dreams particularly with snakes) (7), Murta-sanniya (swooning, loss of consciousness), Kala-sanniya (black death), Pita-sanniya (disease related to bile) (8), Vata-sanniya (shaking and burning of limbs), and Slesma-sanniya (secretions, epilepsy).

Surveys by individuals such as Alain Loviconi and E.D.W. Jayewardene, have demonstrated significant differences between various areas and the impossibility of creating a universally recognized list. One area might include 0lmada sanniya (babbling) and another area Avulun sanniya (breathing difficulties, chest pains). Contemporary ethnographers such as Obeyesekere have also noted the addition of certain more contemporary maladies to the list. For example Vedi sanniya as relating to gunshot wounds, dramatically reflecting the change in times and the adaptability of this indigenous system. ( The yakun natima - devil dance ritual of Sri Lanka -  by Alan Pate ) 

Kohomba Kankariya

Kohomba Kankariya is a very old healing ritual that dates back to 500 BC. The Kohomba Kankariya is performed to achieve freedom from ailments, restore the sense of community identity  and to invoke blessings from the heavenly beings for prosperous and healthy life.  The kankariya consists of more than thirty discrete acts and includes the building of the ritual hall and altars, offerings to the gods, solo and group dancing, drumming, chanting, comedy and dramas. (Kohomba Kankariya Ritual - Susan A. Reed)  In Kohomba Kankariya dances, the most common instrument for the background music is called Geta Beraya (traditional drum) that evokes bilateral auditory stimulation.

The ancient Sri Lankans believed that the bilateral auditory stimulation has some trauma healing effect and traditional drum sounds had been incorporated in healing ceremonies such as Kohomba Kankariya.

The Creator of EMDR (Eye Movement Desensitization and Reprocessing) Dr. Francine Shapiro believes that the traumatic experiences and persistent unmet interpersonal needs during crucial periods in development can produce blockages in the capacity of the adaptive information processing system to resolve distressing or traumatic events. The combination of EMDR procedures and bilateral stimulation results in decreasing the vividness of disturbing memory images and related affect, facilitating access to more adaptive information and forging new associations within and between memory networks.

Thovilaya

The ancient ritual Thovilaya is a form of Psychodrama and it has been used to treat mentally and physical ill. It creates action methods, role training, spontaneous dramatization, and group dynamics to alleviate illnesses. For Thovilaya the entire village gets to gather and help. Hence, the community connections are strengthened and soothing atmosphere is created around the patient and his outer environment. The patents with Dissociate Disorders and various phobias were successfully treated in the old days using the ancient ritual Thovilaya.

The  Buddhist  Psychotherapy in Treating Trauma

The Buddhism was introduced to Sri Lanka in 236 BC. The ancient civilization of Sri Lanka emerged and flourished with the Buddhism. For centuries, the Buddhist Philosophy helped people to deal with trauma. 

The Buddhism teaches the universal truth of human suffering and impermanence.

The Buddhism declares that in this world there is nothing that is fixed and permanent. Everything is subject to change and alteration. (The Concept of Impermanence in Buddhism - Jayaram V)  

In the Buddhist point of view, suffering is not caused by external, traumatic events, but by qualities of mind, which shape our perceptions and responses to events. These same words were repeated by the Psychologist Albert Ellis in 1953 when he introduced his action oriented therapeutic approach – Rational Emotive Therapy. According to Ellis not the event, that causes psychological distress but the belief held by the client. He further argues that one's emotional distress is actually caused by one's catastrophic thinking in appraising stressful events. Ellis theories that unrealistic appraisals of stress are derived from irrational assumptions.

The Lord Buddha used numerous kinds of cognitive therapies in trauma situations. In the story of Kisagotami the Buddha used   cognitive mode of interventions to give insight to a young mother who had lost her infant son. The young mother Kisagotami was devastated with grief. She went to the Buddha carrying the dead body of her son and asked for medicine that would restore her dead son to life. The Buddha told her to get some mustard seeds from a house where there had been no death. Kisagotami went from house to house but she could not find a single house where death had not occurred. She gradually got the insight and the meaning of death. She realized death is a universal phenomenon.

Patachara a young woman developed an acute stress reaction when she witnessed the death of her husband two children and the parents. She came to the Buddha with weeping and with utter confusion. After she became rational, the Buddha explained her true meaning of suffering and the nature of impermanence. The story of Patachara reveals an excellent case study of trauma counseling. 

Existential Psychotherapy is a form of psychotherapy that aims at enhancing self-knowledge. In the Buddha's teaching existentialism is widely described. The Buddhism brings up questions about ethics and the nature of our existence. The goals of existential therapy are to enable people to become more truthful with themselves, to widen their perspective on themselves and the world around them, to find clarity on how to proceed in the future while taking lessons from the past and creating something valuable to live for in the present. In addition, it helps to explore the client's physical, social, psychological and spiritual dimensions. The story of Mattakundali (in the Buddhist Jathaka stories) narrates the existential analysis that had been used by the Buddha.   

In the Buddha's teaching meditation has a special place. Meditation can be used for personal growth. Buddhist meditation is a process of mental clarification and geared to direct perception. The purpose of Buddhist meditation therefore is to gain intellectual understanding of the universal truth. Buddhist Vipassana meditation gives realization of impermanence, suffering and non-self. The Mettha (loving-kindness) meditation helps to reduce anger and a perfect way to control aggressive feelings. Generally, meditation helps to reduce stress and anxiety.  For generations the ancient Sri Lankans used mediation as a stress breaker.

Trauma and Search for Meaning

The Neo Psychoanalyst Erich Fromm argued that the human being needs to find an answer to his existence and this urge to search for meaning differs human from other animals. In addition, he highlights that human has an inner dynamism that directed towards personal growth. He viewed that living is a process that starts at birth and does not end at death. Fromm states that most of the people die before they are fully born. The notion of fully born according to Fromm is becoming fully functional as a human being.

The search for meaning has become the main theme of religion and philosophy. The meaning of life constitutes a philosophical question concerning the purpose and significance of life or existence in general. Dr Viktor E. Frankl in his influential book Man’s Search for Meaning states that the meaning of our existence is not invented by ourselves, but rather detected. (Man’s Search for Meaning- p.157) In 494 B.C, the Prince Siddhartha renounced his wealth and went in search for meaning. He spent six years travelling, exchanging ideas with different mentors and practicing meditation. 

The people struck by trauma often try to find answers for their suffering. They often ask “Why Me? ” Inability to link and find the reason for their suffering could make the trauma related symptoms worse. Many Sri Lankan veterans with PTSD whom we have interviewed   tried to find the meaning of their suffering via religion or cultural factors.

Combat Trauma Management in Ancient Time

The ancient Sri Lankans used the teachings of the Buddha to heal trauma. The Sri Lankan history illustrates that after major battles that caused many lives the ancient Kings were able to restore peace and then built large religious monuments. After the   Great Wijithapura Battle that occurred in 205 B.C., the King Dutugamunu built Ruwanwelisaya stupa in Anuradhapura. The stupa is one of the world's oldest and tallest monuments, standing at 300 feet (91 m) and with a circumference of 950 ft (290 m).

The King Valagamba launched 14-year war campaign against the foreign   invaders and regained his throne in 89BC. The country was in ruins, a large number of people were perished in the wars and communities were displaced. Post war traumas were mounting. Nevertheless, the King Valagamba was able to bring harmony and prosperity. Between 89-77 BC the King King Valagamba builds Abhayagiri stupa and temple complex that becomes a Buddhist University Center in the ancient world in later years.

The King Vijayabahu 1 (ruled 1055- 1110 AD) faced 17 year prolonged war following invasion from South India. After restoring peace, the King Vijayabahu 1 took numerous measures to uplift the war-wreaked society. He renovated and constructed irrigation systems to increase the food production.

These historical events show that in the ancient days the county had an effective mode of combat trauma management system and rebuilt the civil societies.

  

 The  Cultural and Social  Perceptions of Trauma in Modern Day

Culture influences what type of threat is perceived as traumatic and how we interpret the meaning of the traumatic event. Culture also influences how individuals and communities express traumatic reactions. While reactions to trauma seem to be common throughout all cultures and based in the physiology of human beings, manifestations of responses may differ significantly. Culture forms a context through which the traumatized individuals or communities view and judge their own response. . (Cultural Perspectives on Trauma and Critical Response -  Kris Sieckert ) 

Wilson & Tang (2007) argues that the concept of traumatic stress and the multidimensional nature of cultures require a conceptual framework by which to address core issues that have direct relevance to understanding the nature of trauma as embedded within a culture and its assumptive systems of belief and pat-terns of behavioral regulation.

The cultural influence and regulating the perception of trauma is often stronger than the biological perception.  The two-factor theory of emotion introduced by Schachter states that emotion is a function of both cognitive factors and physiological arousal.

The victims see their suffering from a cultural perspective. 

The word suffering has a deep philosophical meaning to Sri Lankans. The Buddhist Philosophy analyses the nature of suffering and the cessation of suffering.  According to the Buddha, the word suffering has a deep existential meaning. It is an universal explanation of the true human condition.

Mr.RXXC65 lost his son who was an Army Officer. He died in action and several years  Mr.RXXC65 experienced symptoms of pathological grief. When his grief reaction was at peak, he started reading books on Buddhist Philosophy. He was able to realize the meaning of death and could relate it to his son’s untimely death. 

L/Cpl HXXV34 lost his leg due to an antipersonnel mine in 1997 went in to severe depression. Later he was able to come to terms with the disability. I am paying for my Karma says L/Cpl HXXV34. I have committed sins in my previous birth and in this life. Therefore, I am paying my debts and again I will be a free man.

Cpl WXXB32 sustained a gunshot injury to his abdomen in Sarasalei. His bowels came out and he was in deep pain. He was evacuated immediately and laparotomy was done at the Palali Military Hospital. After his recovery, he became more religious and gave up smoking and consuming alcohol. He relates his gun shot injury to bad Karma that he committed. In his own words, he described his experiences thus.

“When I was posted to the Elephant Pass Camp our food rations were not palatable. So we used to hunt wild boar and cattle that were abandoned by the fleeing civilians. I used to cut and clean the carcasses. I used to remove the bowels and then separate the meat. I have seen animal bowels many times while cleaning carcasses. But my experience at Sarasalei was dreadful. I saw my own bowels coming out. I was in shock seeing it. It was retribution and a warning from the sky. After the Sarasalei incident, I committed no sin , never killed even a mosquito and I will maintain that principle until my last breath. ”

Sgt. THXX42 was diagnosed with PTSD and had pessimistic view of his life. He saw no future for him and felt that his life had come to a standstill. Several times, he contemplated to commit suicide. In 2004, Sgt. THXX42 participated in spiritual therapy session and it changed his life forever. He started meditating and then to analyze his suffering in a philosophical angle. Our lives are short and the psychological agony cannot be everlasting says Sgt. THXX42. He started meditating and was able to concentrate for a longer period. By 2006, his depression subsided and he was free of suicidal ideation. His hyper -arousal reaction was significantly reduced.

Mr. TXX46 lost his house and several family members following 2004 Tsunami disaster. He was in mental pain for some time. After this tragic incident, he became an active member in his community helping needy people. He started reading Buddhist philosophy in depth. The life is impermanent and it is a universal truth says Mr. TXX46. Everyone is going to die someday and nothing is permanent. The world is constantly changing;   thinking about this unchanging philosophy, I was able to come to terms with my loss and trauma” he further expressed. 

The Cultural Impact of Combat Trauma in Sri Lanka

The cultural impact of combat trauma in Sri Lanka significantly denotes from the beginning of the Northern conflict in early seventies in the 20th Century. The combatants and civilians experienced the aftermath of combat trauma. The cultural values and religious believes played a key role in trauma management. Many Sri Lankan combatants believe in reincarnation and the effects of Karma. The victims believe that their physical and psychological symptoms are due to karmic actions in the past lives. Often these concepts help them to come to terms with their traumas.

Sri Lankan combatants have more somatic ailments when they manifest anxiety and depression. Many combat trauma victims with depression get treatment for migraine or joint pains before coming for psychological help. (Jayatunge 2004)  

During the World War 1 Conversion, reactions were in abundance. Even Freud wrote about these war hysteria reactions. His famous case study – the soldier of Dardanelles (from the battle of Gallipoli) had dissociative reaction (according to the modern DSM classification) which Freud termed as Traumatic Neurosis. 

Although in Europe and in North America conversion reactions became minimal with the WW2, Vietnam War and the Iraq War, the Eelam war in Sri Lanka has generated a large number of conversion reactions. (Jayatunge 2004)  It could be due to several factors. In the Sri Lankan conflict, soldiers had no psychological debriefing or similar trauma management soon after the traumatic combat events. The combatants were not informed about possible combat trauma reactions. There was no effective psychological treatment system until the later years.  The soldiers were reluctant to show their fear mixed emotions that were considered as acts of cowardice. Therefore, many combat reactions were expressed through disociative channels.

Dissociative reactions have a cultural significance in Sri Lanka -especially in rural areas. Some combat related dissociative reactions often interpret as the disturbances created by the bad spirits. Mostly in rural parts of Sri Lanka Psychogenic, paralysis is considered as an act of black magic and traditional healers use a ritual called Thovilaya to treat the sufferers.

Possession state that is categorized under the Dissociative Disorders could be seen among the soldiers with combat trauma. In possession, the person enters an altered state of conscious and feels taken over by a spirit, power, deity, or other person who assumes control over his or her mind and body. In many rural areas the possession state which is often regarded as mediation with the gods and goddesses.  Some soldiers with possession state had left the military and they had become so called spiritual mediators.

On most occasions the cultural factors and religious believes have helped the victims of combat trauma to integrate the traumatic experience into a meaningful context.  It has worked against a buffer to prevent further traumatization. After exposing to the combat trauma many people have embraced their cultural and religious practices strongly. These individuals interpret their posttraumatic symptomatology in spiritual terms. Somehow, these traumatic experiences had been transformed into meaningful and non-self-destructive plains.

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 SSRI s 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 Cognitive behavior therapy, which is an effective form of insight therapy.  Exposure Therapy is one form of cognitive behavior therapy unique to trauma.

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 mediation and yoga. Meditation methods such as Methha Meditation (Meditation of loving-kindness), Vipassanna meditation (mindfulness mediation) are widely used in rehabilitation centers.  

Still the Sri Lankans use ancient methods of healing trauma. It has cultural as well as traditional value.  In trauma related dissociative symptoms in some areas Thovilaya is being performed.

Every culture is unique and it has distinctive way of interpreting psychological trauma. The client’s religious and cultural beliefs play an important role in the treatment process. Using these innate factors in trauma management obviously give promising results.