• Lack of capacity, skilled personnel and dedicated services to respond effectively to addiction-related issues 
• Culturally, judging people harshly for seeking treatment for addiction and substance abuse, poses a serious challenge 

Applied cognitive behavioural therapy (CBT) is a structured, evidence-based form of psychological treatment that looks at how a person’s thoughts, emotions and behaviour are linked in their day-to-day life. According to the literature available on CBT and international clinical guidelines, applied CBT is a structured, evidence-based approach used in the assessment and treatment of conditions such as obsessive-compulsive disorder, substance use disorders and trauma-related conditions. It has been described as ‘applied’ because it focuses on practical methods that people can use to manage distress, change unhelpful behaviour and improve how they function on a daily basis. Rather than concentrating only on past experiences, applied CBT is collaborative and goal-focused, helping individuals develop skills that they can practice both during therapy and in their everyday lives.

In this backdrop, The Daily Morning spoke to Consultant Clinical Psychologist and the Chairperson of the United Kingdom-Sri Lanka Trauma Group (UKSLTG), Dr. Shamil Wanigaratne who is currently visiting Sri Lanka. 

Following are excerpts of the interview:

How do you view Sri Lanka’s mental health situation and the level of services provided? 

Sri Lanka is a developing country, but, our mental health problems are not very different from those in other countries. We have experienced the war, the tsunami and events such as cyclone Ditwah, so, there are significant mental health issues among the population. We are not at the highest level, nor are we at the bottom. We are somewhere in the middle and we do have a range of facilities, interventions and services, but, they are never enough.

In many countries, physical health is given priority, while mental health receives the smallest share of resources. Yet, there is a clear link between physical and mental health. Mental illness can lead to physical illness and stress-related conditions. Unfortunately, these are issues that policymakers need to address. Over the years, much has been spoken about mental health, but often, it has been little more than lip service.

My own involvement in this area spans more than 30 years, during which I have worked on building capacity in the mental health sector. In 1996, we formed the UKSLTG to help Sri Lanka deal with the psychological impact of the war. At that time, some leading figures in Sri Lanka claimed there was no such thing as psychological trauma, arguing that trauma only referred to physical injury. Dr. Athula Sumathipala and I formed the Group, which worked gradually with the medical profession. Compared to 30 years ago, the situation has improved considerably.

The 2004 tsunami marked a major turning point. Even developed countries would have struggled to cope with such a disaster, and Sri Lanka certainly did not have the capacity, expertise or trained personnel at that time. Due to goodwill, mental health professionals from around the world volunteered to help. Many tried to provide counselling despite not speaking the language of those affected.

We were involved from the very beginning and witnessed the chaos. The World Health Organisation (WHO) asked how many psychologists were available in the country. At that time, there were only six people who could call themselves psychologists and around 36 to 38 psychiatrists — clearly inadequate. One of the first clinical psychologists produced by Sri Lanka, Dr. Padmal de Silva and I had already spent about 15 years trying to establish a psychology course, facing strong resistance.

Former President Chandrika Bandaranaike Kumaratunga was the first to recognise the importance of psychology and trauma and to include them in national policies. One of our achievements was persuading the legislators to incorporate mental health into the policy framework.

The WHO initially agreed to provide funding to develop a psychology course. The then Dean of the Colombo University’s Graduate Studies Faculty, Professor Lakshman Dissanayake efficiently guided the course through the university system and secured approval. However, the WHO later informed us the funds had already been spent. Members of the UKSLTG, some of whom were affiliated with the King’s College London (KCL), England, then lobbied for alternative funding. The KCL helped prepare a proposal for submission to the UK’s Disasters Emergency Committee. Of the 10 organisations represented in the latter, the Catholic Agency for Overseas Development approved a substantial grant. This led to the establishment of Samutthana in 2006 as a resource centre for training and capacity building.

With this funding, we opened four centres — in Colombo, Jaffna, Batticaloa and Hambantota. Unfortunately, when the grants ended, we were unable to sustain all centres and had to close those outside Colombo. The KCL remained a key donor, allowing Samutthana to continue operating from Colombo while serving the entire country.

During this period, the Clinical Psychology postgraduate course was also launched with support from a Canadian funder. The course began in 2008 and, over the past 20 years, has produced more than 70 clinical psychologists, most of whom have remained in Sri Lanka.

In addition to the degree programme, Samutthana conducts training workshops for people with varying levels of qualifications. Those with no formal background receive basic training in counselling skills and mental health awareness. Nurses and doctors with limited mental health training but an interest in the field receive intermediate-level training, while psychiatrists receive advanced-level training.

As a result, when the 2019 Easter Sunday bombings occurred, almost everyone involved in the frontline psychosocial response had attended at least one Samutthana workshop.

This does not mean that Sri Lanka has sufficient services. However, compared to many countries, we do have some strong mental health services, especially outside the Government sector. Organisations working with people with disabilities and groups such as the Lanka Alzheimer’s Foundation are services that many Western countries would be proud to have. The Government sector, however, remains weak.

The greatest need for mental health services is in the North and the East of Sri Lanka. When the country is viewed as a whole, this region has the highest demand. Our charity carried out extensive work in the North, but, 10 years ago, there were more services in Jaffna than there are today. Many of these services were run by organisations such as Shanthiham and the Family Rehabilitation Centre, which depended on foreign funding. With support such as the United States Agency for International Development now being withdrawn, the impact is being strongly felt.

How serious is the issue of addiction in Sri Lanka, and what gaps do you see in the country’s ability to respond to it?

Another issue that is closely linked to mental health, and cannot be separated from it, is addiction. Substance misuse, including drug and alcohol use, is high in Sri Lanka, particularly among young people and in many parts of the country. Although there are no accurate statistics, the prevalence appears to be very high among certain age groups.

The situation is similar in Jaffna and the wider Northern region. There is a lack of capacity, skilled personnel and dedicated services to respond effectively to addiction-related issues. This remains a significant gap. One example of a good practice is a voluntary organisation based in Colombo, Mel Medura (the Sumithrayo Drug Demand Reduction Programme). It provides counselling, assessment and referrals in a structured and systematic way. This model should be expanded and replicated across the country.

In Government hospitals, there may be one or two individuals with an interest or some skills in addiction care, but, the scale of the problem is far greater. People with addiction and serious mental illness need sustained support. While access to psychiatric services is relatively better in Colombo and Kandy, it is uneven across the country. Although Sri Lanka’s Government services compare favourably with those in some other countries, there is still a strong need to expand services and allocate more resources to ensure access for all.

With Sri Lanka’s ageing population growing, are current services adequate to protect the mental well-being of older people, and what needs to be improved?

In the Sri Lankan culture, the elderly are usually cared for at home. This does not mean that the State should take over family care or rely only on Government institutions. Services do exist, but, they are not enough, and there is a shortage of trained and skilled personnel with experience in working with older people.

With ageing comes conditions such as dementia, but, there are ways of supporting these individuals. Skilled interventions can significantly improve their quality of life. Depression is also very common among older people. Compared to some Western cultures, our society is generally more caring towards the elderly, which is a strength that we can build on.

There is a need to develop centres of excellence that can set standards and act as models of good practice. Improving the quality of life for older people should not be limited to physical care alone; mental well-being must also be addressed.

At the policy and Governmental level, population trends clearly show the need to allocate more resources, expand services and strengthen planning. Old age psychiatry is a specialised area within mental health, and Sri Lanka needs more professionals trained in this field.

How does stigma affect people’s seeking help for mental health and addiction problems in Sri Lanka? 

Stigma is a major obstacle to mental healthcare. Many people do not want to be seen accessing mental health services or to be known as having mental health problems. As a result, they avoid seeking help even when services are available.

This is why continuous awareness programmes, supportive Government policies and public education are essential. Reducing stigma requires long-term effort and consistent messaging.

Stigma is especially strong when it comes to addiction and substance abuse. There are very few other health conditions where people are judged harshly for seeking treatment. Although this is not unique to Sri Lanka, it is rooted in our culture and poses a serious challenge.

What role does mental health have in the suicides that the country has seen?

Sri Lanka has a very high suicide rate. The last statistics I saw placed us at the higher end globally. Not all suicides are directly related to mental illness. Often, untreated depression leads to suicide, but, in Sri Lanka, many cases involve young people who lack the skills to handle conflicts or broken relationships. They may act impulsively, attempting suicide without fully intending to die. In other countries, this is often called ‘para-suicide’ — where someone might threaten to harm themselves to scare others or teach someone a lesson. These impulsive attempts contribute significantly to the overall figures.

Access to pesticides, which was once a common method, has been reduced, and this appears to have helped lower suicide rates. Young people need to know that support is available through counselling and other services. While suicide is linked to mental health, cultural factors and impulsive behaviour play a major role in Sri Lanka.

In the UK, assisted dying and do not resuscitate orders are widely discussed, but, these options are unavailable or banned for the terminally ill in Sri Lanka. Should this situation be changed?

At present, discussions are taking place in the UK, including in the House of Lords, and a Bill is being considered in the Parliament. However, it is still a long way from becoming the law. I cannot offer a personal opinion on this issue as it is a deeply personal matter and depends on individual beliefs.

Those who advocate assisted dying argue that it is a fundamental human right. They also emphasise that it is different from suicide. In this context, a person may make a living will, stating that if they reach certain medical conditions, they wish to be allowed to end their life with dignity.

This is part of a wider international movement, and in some countries assisted dying is already legal. 

Gender-based violence (GBV) and scams often affect the elderly and the youth. How can these be addressed?

These situations are traumatic and distressing. But, this is something that happens globally. Support should be available to help them cope. However, the internet presents a growing challenge. Many young people are addicted to video games, which affects their ability to focus on other responsibilities. Addiction to online pornography is another major issue. These are emerging problems, and there is very little that Governments can currently do to fully control them. Social media use among young people is also a concern. For example, Australia has banned social media for children under 16, and I believe that this is the kind of approach that we should be considering.

We say that children under 16 should be banned from using the internet and at the same time adults seem to be unable to do without it? 

Children at a very young age get into all this and by the time they are 16 they become more knowledgeable and assume that there would be a degree of maturity. The WHO’s International Classification of Diseases 11th Revision has included ‘Gaming Disorder’ as a disease. In Far Eastern countries, young people are playing games and foregoing their food, and dying after having had no food or water for days. These are all modern problems. 

Do you think the Sri Lankan health authorities are aware of all these issues?    They should be. I think that newspapers do carry articles, and at the same time tele-dramas and all these should create awareness about the dangers of this. Any human behaviour can be addictive if excessive. People should be advised on taking the middle path.

Most of the alcohol and drug rehabilitation facilities are in the private sector. What should the State intervention in this be? 

There are probably good and bad rehab facilities. But, the National Dangerous Drug Control Board has licensed these premises and they have been issued criteria. That is how the Government controls it. But, there are possibilities that they could be open to abuse. Therefore, there should be more scrutiny. There are international standards on what should be provided in rehabs. The UN Office on Drugs and Crime and the WHO quality standards documents should be implemented in Sri Lanka through the Government. 

The private sector offers the most psychological services and some clients leave with their issues unresolved or worsened. How can this be improved?

This is the case in most countries, but, in Sri Lanka, while there are positions for psychologists in Government hospitals, the pay and working conditions are very low. It is not treated as a proper graduate-level profession.

The Government should create more positions and improve pay and conditions for this category of service. Cadre positions have existed for years. Psychologists are licensed by the Sri Lanka Medical Council (SLMC) and must follow a professional code of conduct. The SLMC currently licenses only clinical psychologists.

However, the title ‘psychologist’ is not legally protected in Sri Lanka, meaning that anyone without proper training could potentially use it. This is an issue that needs to be addressed. There should be a professional psychology association with the authority to regulate and oversee psychologists in the country.

The number of psychiatrists in Sri Lanka has also dwindled. How do you think the service could be developed? 

There have been efforts to stop the brain drain in the medical field. But, there are larger issues which need to be dealt with to improve the quality of life so that more psychiatrists would decide to remain in the island. The recent economic crisis had a flood of people leaving. These are issues to be flagged up and someone making policy should support in strengthening the service. 

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The views and opinions expressed in this column are those of the interviewee, and do not necessarily reflect those of this publication

Addiction - PoV

• Addiction is closely linked to mental health and can't be separated from it
• North and East region has the greatest need and highest demand for mental health services
• Suicide is linked to mental health, cultural factors and impulsive behaviour play a major role as many youth lack the skills to handle conflicts or broken relationships
• SL should consider the approach of banning social media for under-16s
• The pay and working conditions for psychologists in Govt. hospitals are very low as it isn't treated as a proper grad-level profession
• The title 'psychologist' is not legally protected in SL