In this article, I will tell you guys about my clinical experience in an extotic and remarkable country.
In November 2018, I completed a four-week Mental Health Foundation Placement in Sri Lanka, as a volunteer for the organisation SLV.Global.
When I decided to join this placement, I was extremely interested in the culture of this small country at the bottom of India, which I had often heard being referred to as “the Pearl of the Indian Ocean”. At the same time, as a final-year undergraduate Neuroscience student, I was looking for a more clinical, psychology-based experience, and was fascinated by the idea of volunteering in mental health, in a country that seemed to be in great need of such work.
A bit about Sri Lanka
Sri Lanka has an extraordinary cultural, ethnic and natural diversity, as well as a long and distinguished history.
Map of Sri Lanka
Religion is very important. This country is the home of one of the world’s oldest and purest forms of Buddhist traditions, approximately 70% of the population being Buddhist. 12.6% are Hindus, especially in the North and East of the country, 9.7% Muslims, and 7.4% Christians. In 2008, Sri Lanka was the third most religious country in the world according to a Gallup poll.
Ethnically, there are two main groups of population, with different languages, the Singhalese (most of them of Buddhist religion and speak Sinhala) and Tamils (mainly Hindus and speaking Tamil). Apart from these, there are also the Moor of Arabic descent, Burghers (descendants of European colonists), Malays and ethnic Chinese migrants who came to the island in the 18th and 19th centuries.
Another name of Sri Lanka is Ceylon. Many people around the world are familiar with this name, due to the Ceylon tea (green and black tea), from the vast upland plantations in Sri Lanka. But the Ceylon tea is just one of the many natural riches that make this tiny island a tropical paradise.
For tourists, Sri Lanka has it all – from very well-conserved ancient vestiges to beautiful beaches, amazing landscapes, impressive temples and incredible flora and fauna, many of which are endemic.
One of the entrances to the Temple of the Sacred Tooth Relic in Kandy. The interior of the temple is truly spectacular and quite intricate in its structures and decors.
Sigiriya (Lion Rock), one of the medieval Sri Lanka’s most remarkable royal palaces and an unforgettable landmark.
Dancers performing the famous Kandyan dance.
But many of those who visit this small Indian Ocean country only for touristic purposes sadly overlook the struggles of its inhabitants, reflected, among others, by the issues in the educational and health care systems, widespread poverty, socio-political confusion rising from the centuries-long colonial history (until Sri Lanka’s independence in 1948), and the ethnic problems.
Mental health problems in Sri Lanka
Sri Lanka deals with an increasing prevalence of mental illness and a high suicide rate. Suicide is the second biggest cause of morbidity and unnatural death. In 2016, Sri Lanka ranked number 31st in the world for the suicide rate. This situation is largely determined by poverty and the traumas caused by a 26-year civil war which only came to an end in 2009. In addition to these, in 2004 the country was devastated by a tsunami, which led to about 35,000 deaths and 516,000 displacements, and which has contributed to the high rate of PTSD, anxiety and depression. Schizophrenia affects around 210,000 people, based on a report by the World Health Organisation, in 1993.
By contrast, Sri Lanka has great deficit in mental health resources, funding and clinical staff. Only 1% of the government funds is directed to the mental health sector. Currently in Sri Lanka, there are only 89 psychiatrists serving a population of 21 million, and the number of other mental health professionals (psychiatric nurses, psychologists, occupational therapists etc.) is also extremely low.
One of the main causes for the lack of personnel is the stigma attached to mental illness which is perceived as shameful.
People with depression and attempted suicide are subject to discrimination, for instance when seeking a job. The relatives of the mentally ill themselves consider them a burden and abandon them. There are cases of patients after being discharged from the hospital and upon returning home, they were rejected by their own families and left homeless, which determined them to return to the hospital, as that became their only home. In fact, a friendly family environment and a society without the above-mentioned prejudices would allow a successful recovery of the patient.
Stigma affects not only the ill, but also the mental health professionals. The latter are being looked down upon, and so, many of them choose to leave the country and work abroad. Other significant consequences of stigmatisation are the lack of proper training of the mental health staff, as well as the very little advancement of the psychiatric treatment, which in Sri Lanka is mainly reduced to medication and electroconvulsive therapy.
There is need for a change in mentality, so that mental illness stops being considered shameful, and instead it is seen as any other disease, like cardiac or liver diseases. At the same time, it would be necessary that the government, too, take the problem of mental health more seriously, and allocate more resources to it.
It is remarkable the fact that some Sri Lankan psychiatrists have already taken steps in changing the mentality, by organising workshops about mental health in schools and for their patients’ families.
The projects run by SLV.Global, in partnership with the mental health charity Samutthana Kings College London Centre for Trauma, Displacement and Mental Health, support the very few local mental health professionals in their attempt to fight the stigma around mental illness, promote alternative therapeutic approaches, and help former patients reintegrate in their community after being discharged from the hospital.
Volunteers stayed at local Sri Lankan families at three different locations – Colombo, Kotte and a rural area called Horana and Bandaragama (I lived in Horana and Bandaragama). This was very important to us, because it helped us better understand Sri Lankan customs and mentalities.
We ran seven sessions per week. The first week was, however, dedicated entirely to the volunteers’ orientation. We participated in workshops with mental health professionals about working with service users, effective session planning, and the mental health situation in Sri Lanka. One of the workshops took place in a Buddhist Thai Temple, where a Buddhist monk gave us tips on meditation, which we were then able to include in some of the therapy sessions we ran.
The projects took place in a number of different facilities (centres for special needs, vocational training centres, schools, temples, psychiatric hospitals etc.), with service users having a variety of different diagnoses. The sessions we organised focused on enhancing the social skills, communication skills, motor and sensory functioning, and cognitive skills (e.g. short-term and long-term memory, sustained attention, learning, imaginative play) of the service users. Activities included performing dancing routines, yoga for relaxation and mindfulness, musical activities, movement therapy sessions, games (e.g. puzzles, board games).
The main goal of the sessions was to improve the quality of life of the service users, by increasing their general well-being, and supporting them to develop skills that they could use to become more financially and socially independent.
During my volunteering in Sri Lanka, one of the things I truly valued was the fact that the people we volunteered for were referred to as service users (not “patients” or “mentally ill”). This was due to the attempt at changing the mentality around mental illness, by helping the service users feel less like patients and more like any other human being, who deserves respect, love and appreciation.
It was also interesting to see that the sessions we ran included meditation (relaxation yoga, laughing yoga) and breathing techniques, rather than being solely based on Western forms of therapy, which indicated attempts at an integrative approach to mental health.
The projects we worked on were often challenging, as the service users suffered from a variety of conditions, from communication and intellectual impairments to schizophrenia and depression, and we did not have access to any individual service user’s diagnosis or history, since we were not members of the clinical staff. Therefore, we had to figure out by ourselves what best worked for each of them.
Aside from activities aimed at promoting mental health, volunteers also took part in English for Development projects, which took place in schools, temples, community centres and vocational training centres. These sessions focused on improving the spoken English and communication of students, which would prove very useful for studying or having a job in their home country, as well as abroad.
Creativity was the key
All volunteers had access to the session planning sheets, materials and ideas used in the past by previous volunteers, but were encouraged to be creative and come up with their own ideas.
During this placement, I decided to use classical music, particularly Baroque pieces, in sessions aiming at improving memory and social interaction. For example, in one session my group of volunteers had the service users at that respective facility (who were suffering from communication impairments, intellectual disability and depression) listen to several classical compositions, and then associate these with drawings of faces representing various moods or feelings. Service users were also encouraged to tell us why, to them, a musical piece evoked a certain feeling. The scope of this activity was to expose the service users to classical music (known for its benefits on the mental processes) and help them form associations between auditory and visual stimuli.
Another innovative idea, which two of my teammates had, was to use Kendama toys as a means of improving fine motor skills, coordination and forward planning, as well as a stress relieving mechanism. We soon discovered that certain service users suffering from depression and autism-spectrum disorders had become more receptive, more talkative and less aggressive after a few sessions combining Kendamas and classical music.
Ayurvedic medicine and modern medicine
The Golden Temple of Dambulla.
Sri Lanka relies heavily on traditional medical practices based on Ayurveda (Ayurvedic medicine), astrology and religion (mainly Buddhism).
The Ayurvedic medicine involves, among others, the use of herbs, meditation, massages and special diets, in order to prevent and cure disease, increase wellbeing, and decrease stress. The Ayurvedic belief is that health problems are due to a disharmony between mind, body and spirit, and that restoring the balance will restore and maintain health. Establishing one’s diagnosis is based on the person’s medical history, emotions, relationships with other people, and a close examination of different parts of the body. The treatment is then established according to what the practitioner decides best suits the individual.
Alongside traditional medical practices, there are of course modern Western forms of psychiatry and care. One of the largest institutions dedicated to mental health is The National Institute of Mental Health (NIMH) located at Angoda, Kandy District, founded in 1927 and having a capacity of 1,500 beds.
The two approaches, Ayurvedic medicine and Western medicine, should not be seen as opposites. It is clear that both of them have limitations, which is why mental illnesses still persist, and some are even rising. We have to admit that Western doctors are reluctant about ayurvedic medicine. Among the critiques they have provided of ayurvedic medicine are the fact that it is not very scientific, it can have severe side effects, and can interfere with conventional treatment. However, modern approaches, too, have offered neither conclusive answers to questions about the causes or triggers of mental disorders, nor definitive solutions to curing them. In my opinion, instead of rejecting ayurvedic medicine or ridiculing it, we should try to know as much about it as possible, and then decide whether it is suitable or not.
I believe that a great challenge is integrating the Occidental and Oriental views. Sri Lanka is one of the countries with a long-lasting experience in ayurvedic practices, which makes it one of the few ideal places where reconciling the two medical approaches could be successful.
I left Sri Lanka with the hope that one day I can go back to work in mental health there, and that I can convince more people to do the same. While volunteering there, it soon became clear to me that, in a land where where mental illness is still a taboo topic, volunteers contribute to the wellbeing of the service users simply by their presence. If more people with experience and knowledge in Psychology, Psychiatry and Neuroscience, and who have a genuine desire to help others, volunteer in Sri Lanka, the costs involved in psychiatric treatment there would decrease, alternative forms of treatment would start to spread, and more awareness will be raised about the importance of mental health.
To me, this experience was not only an opportunity to make myself useful, but above all, it was a learning and an eye-opening experience.
When volunteering in Sri Lanka, it is very important to understand the culture, the traditions and the customs there, and try to think outside of the box. An integrative approach, where modern Western forms of medicine and Eastern, more traditional, practices are combined, would benefit not only Sri Lankans, but the volunteers themselves and their own communities. As volunteers, we can bring back to our countries what we learn in Sri Lanka, and help improve our still-in-progress medical system.
I would like to thank Prof. Aravinda Ravibhanu Sumanarathna, Senior Research Development Scientist at Institute of Professional Studies & Skill Development Sri Lanka, CEO & Founder of Eco Astronomy Sri Lanka Research Unit, and Isuru Priyaranga Silva, BSc. Microbiology student and Eco Astronomy Researcher, as well as their lovely families, for making me feel like home when I was so far away from mine, for offering me valuable information about Sri Lanka, for showing me its beauties, and for revealing to me the well-known Sri Lankan hospitality.
I am also thankful to my homestay family, Uditha Dananjani and Sampath Dissanayake, and to all the Sri Lankan volunteers I had the great pleasure to work with, especially to Gayeshi Lakshika who helped me many times practise Sinhala.
I also thank Prof. Hugh Piggins, Head of School of Physiology, Pharmacology and Neuroscience, University of Bristol, for supporting and encouraging me to volunteer in Sri Lanka.
De Silva, D. (2002). Psychiatric service delivery in an Asian country: the experience of Sri Lanka, International Review of Psychiatry, 14:1, 66-70, DOI: 10.1080/09540260120114096
Hutter, C., Haputantri, M., Anver, G. (2016). Inside Sri Lanka’s National Mental Health Institute: A Photostory. Retrieved from: https://roar.media/english/life/reports/inside-sri-lankas-national-mental-health-institute-photostory/
Minas H., Mendis J., Hall T. (2017). Mental Health System Development in Sri Lanka. In: Minas H., Lewis M. (eds) Mental Health in Asia and the Pacific.International and Cultural Psychology. Springer, Boston, MA.
Uduman, N. (2018). Mental Health and Stigma in Sri Lanka. Retrieved from: https://groundviews.org/2018/02/19/mental-health-and-stigma-in-sri-lanka/