Dr. Alan Krohn PowerPoint Presentation 2010

IMHO CONFERENCE 2010 Mental Health Services in Sri Lanka Past Experiences

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Alan Krohn, Ph.D. Clinical Psychologist; Psychoanalyst University of Michigan, Ann Arbor, USA drakrohn@comcast.net Faculties of University of Michigan Department of Psychiatry and Michigan Psychoanalytic Institute

• Author of --• Books: “Hysteria: the Elusive Neurosis” and “The Mind’s Eye” • Articles on borderline personality, empathy, adolescence, psychoanalysis and theater, and disaster mental health

HOW I BECAME INVOLVED • After Tsunami, through IMHO, learned of UK-Sri Lanka Trauma Group Two members I’ve worked with: Dr. Shanthy Parameswaran, Sri Lankan/British Child Psychiatrist Dr. Harriet Calvert, British Psychologist and Psychoanalyst Also worked in Louisiana after Hurricane Katrina

TRAINING MENTAL HEALTH WORKERS • Few Mental Health Professionals in SL • Training at Samutthana; Shantiham (sites in Colombo, Jaffna, Kandy, Vavuniya) • My intensive program in University of Colombo Graduate Program in Clinical Psychology, stressing Psychodynamic Psychology

TRAINING PROGRAM • • • •

DIDACTIC PRESENTATIONS on: Child development General psychiatry Psychodynamic/psychoanalytic principles, ESPECIALLY NATURE OF DEFENSES • Psychology of Trauma • Child and Adolescent therapy • GROUP SUPERVISION; EXPERIENTIAL GROUPS

OUR DISCOVERY Trainees were themselves victims of trauma due to: War Atmosphere of Fear in the Society Tsunami Physical Abuse Sexual Abuse DOING COMBINATION OF TEACHING, CLINICAL SUPERVISION AND BRIEF THERAPY

“PATIENTS” ARE EVERYWHERE • NUMEROUS INFORMAL “THERAPEUTIC” INTERCHANGES WITH PEOPLE –”IF YOU ARE A THERAPIST, PEOPLE WILL TALK” – BE READY TO LISTEN • PEOPLE IN OUR TRAINING GROUPS, PEOPLE IN POINT PEDRO AREA WHERE WE WENT, A WAITER IN A HOTEL,

NATURE OF MY TEACHING • Examples from my own life such as my working to tolerate my affect of fear of some dogs in Vavuniya vs becoming traumatized and withdrawn • Example from my two year old grandson’s ego process as he came to terms with birth of his brother • Humor • Ample vignettes to illustrate psychoanalytic concepts

FORMS OF TRAUMA • War: death of loved ones, injury, dislocation, and LIVING IN A STATE OF DREAD AND FEAR • Tsunami: death of loved ones, acute trauma at time of tsunami (classic PTSD) • STATE OF FEAR DUE TO ONGOING POLITICAL ENVIRONMENT

Traumatized Country • Dr. Daya Somasundarum: Concept of Mass Trauma • Dr. Vamik Volkan: Groups’ responses to humiliation and defeat by other groups • Dr. Henry Krystal: Affect (Emotional) Arrest in Traumatized People

TRAUMA AS STATE OF OVERWHELMING, UNRELENTING PAINFUL AFFECT • SOME EFFECTS: • Affect regression, numbing, dissociation • Aggression as defense against helplessness, including violence as preferred solution to problems – on a societal level, in the form of physical abuse of children, of violence against women

PSYCHODYNAMIC APPROACH • HELPING MENTAL HEALTH WORKERS TO LEARN TO LISTEN TO INDIVIDUAL NARRATIVE ABOUT THEIR EMOTIONAL STRUGGLE – STORY BEHIND THE STORY • EXAMPLE: SUICIDE RATE – LOOK BEYOND “STRESS” OR “TRAUMA” TO MEANING OF INDIVIDUAL MOTIVATION FOR SUICIDE

CASE TWO: 16 YEAR OLD GIRL: “TRAUMA” AND UNCONSCIOUS GUILT • FAMILY IN BUNKER, GIRL ARGUES WITH BROTHER ABOUT GETTING WATER, ANGER AT BROTHER, THEN BUNKER HIT, FAMILY BURIED • FEELS SHE SHOULD DIE, BE A NUN, GUILT OVER SECRET THOUGHT BEFORE SHELL HIT BUNKER • GUILT OVER “SECRET THOUGHT”: FEELS SHE IS UNDESERVING OF LOVE, FAMILY, SEX. (AGAIN UNCONSCIOUS) • OVERWHELMED BY LOSS (TRAUMA) PLUS GUILT

CASE THREE:DEPRESSION IN YOUNG WOMAN • 25 YEARS OLD WOMAN WHOSE HUSBAND MURDERED HER MOTHER OVER A FAMILY FEUD GOING BACK TWO GENERATIONS • VERY CONTROLLING, GROWTH STUNTING MOTHER; VERY CONTROLLING HUSBAND • MOTHER DEAD; HUSBAND IN JAIL • FIRST TRAUMA OF LOSS, DEPRESSION, THEN SOMETHING ELSE • THERAPIST NEEDS TO SPEAK TO THIS

PSYCHODYNAMIC APPROACH – RESEARCH SUPPORT • COGNITIVE BEHAVIORAL THERAPY IS VIEWED

BY MANY AS THE ONLY MODERN THERAPY WITH RESEARCH VALIDATION • SHEDLER (UNIV OF COLORADO) REVIEWS RESEARCH AND SHOWS THAT RESEARCH ON PSYCHODYNAMIC THERAPY SHOWS IT TO BE AS POWERFUL AS CBT AND MORE LASTINGLY POWERFUL THAN CBT (THERAPEUTIC EFFECTS INCREASE OVER TIME!)

VALUE OF “JUST TALKING” IN TRAUMA TREATMENT • “HOLDING ENVIRONMENT,” (MODELL) “WITNESSING” (POLAND) – THERAPEUTIC EFFECTS OF TRUSTING RELATIONSHIP WITH THERAPIST. • DEVELOPMENT OF AFFECT TOLERANCE FOLLOWING TRAUMA, REVISING SEVERE, TRAUMA DEFENSES • WORKING WITH DISORDERED COGNITION CAUSED BY TRAUMA – ACTUAL BRAIN EFFECTS HAVE BEEN DISCOVERED – ADDICTION-LIKE EFFECTS

LANGUAGE AND MASTERY • PUTTING THINGS INTO WORDS HELPS TO MASTER THEM, HELPS BRING “FROZEN” AFFECTS BACK • “MENTALIZING” (FONAGY) AND OBSERVING EGO (SELF) (STERBA) – DEVELOPING CAPACITY TO OBSERVE ONE’S OWN REACTIONS AND TO THINK ABOUT MOTIVES IN OTHERS • “THERAPEUTIC FRAME”: NON JUDGEMENTAL, FOCUS ON PATIENT, EVERYTHING CAN BE TALKED ABOUT

OBSTACLES • LACK OF PSYCHOLOGICAL TRAINING FOR PSYCHIATRISTS: PSYCHIATRY STRICTLY “MEDICAL” (SIGN/SYMPTOM—MEDICATION); DIAGNOSING “BIPOLAR DISORDER” IN 5 YEAR OLD AND MEDICATING CHILD (SRI LANKAN COLLEGE OF PSYCHIATRISTS MEETING) • FEAR IN COUNSELORS TO WORK WITH TORTURE VICTIMS AND FORMER LTTE (DESCRIBE) • DISTRUST BY VICTIMS OF COUNSELOR

PROBLEM OF PHYSICAL ABUSE • CORPORAL PUNISHMENT, DERISIVE, “SOUL MURDERING” (SHENGOLD) TREATMENT OF CHILDREN – CAN LEAD TO PASSIVITY, DEFERENCE TO AUTHORITY AND LACK OF INITIATIVE (CASE EXAMPLE OF MAN ROLLING TIRE IN THE ROAD) • OR CAN LEAD TO IDENTIFICATION WITH AGGRESSOR • RECENT EXCELLENT STUDY BY DUKE UNIVERSITY SHOWING SPANKING CAUSING AGGRESSIVENESS IN CHILDREN

HISTORY OF SRI LANKAN CHILD REARING • RESEARCH BY PIYANJALI DE SOUZA (PSYCHOLOGIST AT UNIVERSITY OF COLOMBO) FOUND THAT WRITINGS FROM THE PERIOD UNDER SRI LANKAN KINGS DESCRIBES A DISTINCTLY NON-PUNITIVE APPROACH TO CHILD REARING • IT WAS WITH THE BRITISH COLONIAL ERA THAT CHILD REARING CHANGED TO BECOME MUCH MORE HARSH AND PUNISHMENT ORIENTED

GRACE CARE (ORPHANAGE AND ELDER HOME) • CONSULTED WITH PEOPLE THERE BUT ONLY IN MARCH HAVE VISITED GRACE • DID AN ASSESSMENT OF SOME OF THE MENTAL HEALTH NEEDS OF THE CHILDREN • Dynamic relationship between elders and children very important in all children, especially those separated from parents

GRACE CARE CENTER (CONT.) • ONE OF VERY FEW PLACES ANYWHERE THAT CONSIDERS MENTAL HEALTH NEEDS OF CHILDREN SO HIGHLY • SUPPORTS COMMUNITY OF GIRLS AS AN ASSET, WHILE WORKING TO FOSTER INDIVIDUALITY IN GIRLS • PHILOSOPHY RESPECTS DIFFERENT RELIGIOUS AND CULTURAL BELIEFS AND BACKGROUNDS OF GIRLS