This quarter I am enrolled in Refugee & Immigrant Health, a core class in the global health department taught by Bechara Choucair. The class discusses a wide range of topics related to the health challenges of these population groups including infectious disease, access to care, and mental health. Last week Mary Fabri, a trauma & mental health specialist, came to speak with us about trauma treatment and her work with former Sri Lankan child soldiers.
The Sri Lankan Civil War started in 1983, when an independent military organization known as the Liberation Tigers of Tamil Eelam (LTTE) wanted to create an independent Tamil State. The war waged for 27 years, during which an estimated 80,000-100,000 people perished. The LTTE also heavily recruited an estimated 6,000 child soldiers, both for use on the front lines and to be taken as “wives.”
How do we rehabilitate and reintegrate children that have experienced such atrocious trauma? The Professional Psychological Counseling Centre (PPCC), a local organization in Sri Lanka, and Heartland Alliance, a service-based human rights organization based in Chicgao, IL, sought to tackle this issue through Cuckoo’s Nest, a 6-month residential rehabilitation service for former LTTE child soldiers in Batticaloa, Sri Lanka. With the ultimate goal being reintegration, this program took a multifaceted approach: vocational training, basic language and literacy skill training, and trauma-informed group and individual counseling. The vocational training included tailoring, carpentry, electrical wiring, welding, and beauty services. The trauma-informed components psychoeducation, cognitive restructuring, problem solving, and anger management.
The results were rather dramatic. Children who met the criteria for Post-Traumatic Stress Disorder dropped from approximately an 80% baseline to just over 20% at graduation. Rates of moderately severe to severe depression also dropped, with a baseline of approximately 60% for girls and 30 % for boys, but little to none at graduation. One of the children stated, “These activities have changed me into a human person, have given me happiness and confidence, and have given me a desire to live.”
However, the top three activities that the children listed as most helpful would not traditionally be thought of being associated with mental health treatment: vocational training, meditation and yoga, and literacy skills. The vocational training could have also given the children a profound purpose in their home once they returned. Child soldiers can often be harshly stigmatized when they return to their homes post-conflict, being seen as criminals or sexually unclean. However, having a utility within the likely poverty-stricken home environment could help lessen the shame cast upon them. Meditation and yoga are a culturally sensitive way that the children could work on relaxation training and the mind-body connection. Additionally, literacy skills could have increased the children’s sense of control and self-esteem.
I believe that Cuckoo’s Nest is a prime example of how we should take more multidisciplinary approaches in mental healthcare. Our behavioral and emotional well-being are not separated from our daily lived experience, so perhaps they should not always be treated like they are. Treatments such as individual counseling unquestionably have benefits, but may be too abstract for a child to fully utilize to their benefit. Cuckoo’s Nest is an interesting example of a comprehensive, culturally-specific, and effective treatment plan for a specific patient population. It also raises further questions such as, if and how can we seamlessly integrate mental health supports into primary care models that may seem less formal than individual therapy. Because of the harsh stigma regarding mental health, policy may need to focus on how it can be assimilated into other forms of healthcare, and even daily activities.