University of Kentucky UKnowledge Theses and Dissertations--Anthropology Anthropology 2020 WE DIED AND WERE REBORN: AN ANTHROPOLOGICAL STUDY OF HEALTH-SEEKING STRATEGIES FOR MENTAL AND EMOTIONAL DISTRESS IN POST-WAR EASTERN SRI LANKA Daniel Ball University of Kentucky, [email protected] Digital Object Identifier: https://doi.org/10.13023/etd.2020.369 Right click to open a feedback form in a new tab to let us know how this document benefits ou.y Recommended Citation Ball, Daniel, "WE DIED AND WERE REBORN: AN ANTHROPOLOGICAL STUDY OF HEALTH-SEEKING STRATEGIES FOR MENTAL AND EMOTIONAL DISTRESS IN POST-WAR EASTERN SRI LANKA" (2020). Theses and Dissertations--Anthropology. 50. https://uknowledge.uky.edu/anthro_etds/50 This Doctoral Dissertation is brought to you for free and open access by the Anthropology at UKnowledge. It has been accepted for inclusion in Theses and Dissertations--Anthropology by an authorized administrator of UKnowledge. For more information, please contact [email protected]. STUDENT AGREEMENT: I represent that my thesis or dissertation and abstract are my original work. Proper attribution has been given to all outside sources. I understand that I am solely responsible for obtaining any needed copyright permissions. I have obtained needed written permission statement(s) from the owner(s) of each third-party copyrighted matter to be included in my work, allowing electronic distribution (if such use is not permitted by the fair use doctrine) which will be submitted to UKnowledge as Additional File. I hereby grant to The University of Kentucky and its agents the irrevocable, non-exclusive, and royalty-free license to archive and make accessible my work in whole or in part in all forms of media, now or hereafter known. I agree that the document mentioned above may be made available immediately for worldwide access unless an embargo applies. I retain all other ownership rights to the copyright of my work. I also retain the right to use in future works (such as articles or books) all or part of my work. I understand that I am free to register the copyright to my work. REVIEW, APPROVAL AND ACCEPTANCE The document mentioned above has been reviewed and accepted by the student’s advisor, on behalf of the advisory committee, and by the Director of Graduate Studies (DGS), on behalf of the program; we verify that this is the final, approved version of the student’s thesis including all changes required by the advisory committee. The undersigned agree to abide by the statements above. Daniel Ball, Student Dr. Erin Koch, Major Professor Dr. Richard Jefferies, Director of Graduate Studies WE DIED AND WERE REBORN: AN ANTHROPOLOGICAL STUDY OF HEALTH- SEEKING STRATEGIES FOR MENTAL AND EMOTIONAL DISTRESS IN POST-WAR EASTERN SRI LANKA DISSERTATION A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the College of Arts and Sciences at the University of Kentucky By Daniel David Ball Lexington, Kentucky Director: Dr. Erin Koch, Professor of Anthropology Lexington, Kentucky 2020 Copyright © Daniel David Ball 2020 ABSTRACT OF DISSERTATION WE DIED AND WERE REBORN: AN ANTHROPOLOGICAL STUDY OF HEALTH- SEEKING STRATEGIES FOR MENTAL AND EMOTIONAL DISTRESS IN POST-WAR EASTERN SRI LANKA Since the early 2000s, Sri Lanka has made major gains in decentralizing and expanding state-based mental healthcare access and services outside of Colombo. However, little evidence exists related to on-the-ground experiences of Sri Lankans who access these services, the quality and sustainability of services, and the effects services have on individual therapy management of mental and emotional distress. In addition to an extensive historical review of mental health service provision, this dissertation explores strategic health-seeking practices among Tamil- speaking communities in eastern Sri Lanka—an area ravaged by high rates of poverty, 26 years of civil war, and the 2004 tsunami catastrophe. Across 21 months of ethnographic research, I observed psychiatric, traditional, and religious mental healthcare practices and client interactions with both doctors and healers. I also conducted 58 semi-structured interviews with clients, family members, mental health doctors and staff, and traditional healers. I analyze clients’ life histories, local pluralistic therapies, as well as socioeconomic changes in post-war eastern Sri Lanka shaping experiences of suffering, treatment practices, and accessibility to resources and knowledge. I document the origin of mental health services in the east, subsequent barriers associated with increased demand for services, organizational changes, and a significant decrease in resources. Such social changes led to a heavy reliance on inexpensive biomedical drugs to alleviate mental illness and emotional distress. Given these shifts, and stigma associated with state-based mental healthcare, clients find strategic ways to associated with psychiatric treatments. This research positions local expressions of distress as tied to South Asian cultural ideas about mental health, and social inequalities linked to changing gender roles, transnational labor, sexual morality, and family economic status. Evidence collected from this research builds on existing contextually-based analyses to inform global health campaigns aimed at improving access to mental healthcare. Research and practice must adopt a more nuanced view of historical features, cultural processes, and socioeconomic changes that present challenges and/or opportunities for doctors and residents seeking out mental healthcare in post-war settings. KEYWORDS: Health-Seeking Strategies, Anthropology of Medical Pluralism, Global Mental Health, Sri Lanka, Social Suffering Daniel David Ball_________________ ___June 25, 2020_________________ Date WE DIED AND WERE REBORN: AN ANTHROPOLOGICAL STUDY OF HEALTH- SEEKING STRATEGIES FOR MENTAL AND EMOTIONAL DISTRESS IN POST-WAR EASTERN SRI LANKA By Daniel David Ball _______________Dr. Erin Koch ___________ Director of Dissertation ______________Dr. Richard Jefferies_______ Director of Graduate Studies ________________June 25, 2020___________ Date ACKNOWLEDGEMENTS I would first like to express my deepest gratitude to my advisor, Dr. Erin Koch, for cultivating my own intellectual curiosities, while keeping me grounded to evidence and academic professionalism. Your quality scholarship and perseverance throughout this process enabled me to develop my skills as a writer, researcher, and scholar. Without your help, this project would not have been realized. I also gratefully acknowledge the assistance of my dissertation committee, Dr. Mary Anglin, Dr. Mark Whitaker, and Dr. Clare Batty, for all their time, feedback, and unique contributions to my studies of medical anthropology, the anthropology of South Asia and Sri Lanka, and the philosophy of mind. Prior to my PhD studies at University of Kentucky (UK), I was mentored by Dr. Carl Kendall at Tulane University’s School of Public Health and Tropical Medicine. I wish to thank him for his willingness to engage in long discussions and nurture my interests in medical anthropology. His guidance strongly encouraged my anthropological graduate studies and subsequent dissertation research. I am grateful to my parents, Margaret and David Ball, and best friend, Connor Hanan, for decades of encouragement and support in my academic and life pursuits. I wish to also thank my advisors, colleagues, and friends while at Tulane University and UK, especially helpful during this period were Aeleka Schortman, Emily Capilouto, and Dr. Carmen Britton for their emotional support and assistance with writing, editing, and making deadlines that ensured my progress with this PhD process. This dissertation would not be possible without financial and intellectual support from U.S. Fulbright, American Institute of Indian Studies (AIIS), American Institute for Sri Lankan Studies, and the Department of Anthropology at UK. I want to thank Nasrudeen Buhary who spent numerous hours with me interviewing clients and discussing relevant issues to this dissertation project. Dr. Tissa Jayatilaka and other colleagues helped me navigate Sri Lankan institutions and channels of authority to carrying out this research. I am grateful for this assistance. Thanks also to organizations and various language tutors at AIIS in Madurai, South Asian Summer Language Institute, and in Batticaloa District who tirelessly worked with me to improve my Tamil language proficiency. I wish to show my sincere gratitude to all the Sri Lankan mental health staff, clients, family members, and other research participants. With kindness and hospitality, these individuals spent countless hours telling me their stories, sometimes describing terrible circumstances living under the conditions of war and poverty. I do not list these people individually in order to protect their privacy. I hope this research sheds light on both challenges and achievements of local therapies that residents use to manage mental and emotional distress in eastern Sri Lanka. iii TRANSLITERATION All Tamil words and expressions are transliterated with an English spelling that closely imitates the Tamil pronunciation without the use of diacritical marks. These words, when first used, are italicized. All Tamil interviews were completed using a research assistant, Nasrudeen Buhary, a psychiatric social worker in eastern Sri Lanka. I solely carried out all English medium interviews with mental health physicians, staff, and key informants.