Cultural brokers in mental health care in Sri Lanka’s North

Sri Lanka’s conflict and mental health context

The defeat of the Liberation Tigers of Tamil Eelam (LTTE) in May 2009 brought a formal end to the violent history of civil conflict in Sri Lanka. The war resulted in more than 100,000 deaths and the displacement of 800,000 people at the peak of the conflict in 2001 (Siriwardhana and Wickramage, 2014: 2). In the years following the end of the conflict, there has been much rhetoric focused on reconstruction and reconciliation. The conflict produced immense humanitarian problems that included mass displacement, loss of lives, property and resources, arbitrary arrests, detention, involuntary disappearances, curtailment of the freedom of expression, association and mobility as well as the social and economic destruction of infrastructure in the country, fuelling intensified disillusionment and perpetuating suffering (Uyangoda, 2006). Inevitably, these problems have left an indelible legacy, colouring post conflict social and political experiences, placing a significant burden on the mental health of the country’s population, especially in the North East province (Muraleetharan, 2016).

Furthermore, Sri Lanka has one of the highest suicide rates in the world (Somasundaram, 1998). The 2014 figures of rates in Sri Lanka indicate that 28.8 per 100,000 people per year commit suicide, resulting in approximately 6000 deaths annually (Siva, 2010). These statistics rank Sri Lanka within the ten most suicidal countries in the world. However, there is a significant lack of comprehensive epidemiology, particularly at a provincial level, which ultimately does not provide a robust view of regional fluctuations.

From the perspective of global health statistics, Sri Lanka has made significant developments in healthcare, despite relatively low health expenditure and many of the indices regularly challenge the more developed countries in the region (World Health Organization, 2018). This status is strongly buttressed by the provision of free, universal preventative and curative healthcare, delivered through a public system. As at 2017, there are 89 consultant psychiatrists in the country servicing a population of 21 million (Minas et al., 2017). With the introduction of two categories of trained medical doctors with short term mental health training placed mostly in under-resourced areas, provisional psychiatric treatment services provided by medical doctors is now theoretically accessible throughout the country (Mental Health Directorate, 2015).

The statistics do not, however, represent the significant issues that the public system faces in terms of capacity, specialist treatment, service standards and accessibility (World Health Organization, 2014). Services for specialist care in the public sector are concentrated in the capital Colombo along with a small number of large hospitals in major cities. All these specialist services have significant wait lists. Further, elaborating on the disparity of care between rural and urban areas, health infrastructure and services in the North of the country are comparatively poor and under-resourced, following the conflict (World Health Organization, 2014).

Despite having less infrastructure and resources, rural hospitals continue to service the majority of the population. Moreover, sixty per cent of psychiatrists live in the country’s three largest cities in the district of Colombo in the South (Mental Health Directorate, 2015). As such, health professionals in rural areas experience less desirable working conditions and a heavier workload than their urban counterparts, and fewer opportunities for career development because educational facilities and training are concentrated in cities (Ministry of Finance and Planning, 2012). Thus, mental health system and administration control are relatively disconnected from the local issues of the rural villages like Kavitha’s small, coastal village. This disconnection of the mental health system and administration from local realities has the potential to delegitimise community agency by denying recognition of local interpretations of illness and distress, impeding post conflict recovery measures in the North of the country. Broker-clinicians working in villages like Kavitha’s, therefore, have a particularly significant role to play in translating global concepts to national and local contexts, navigating local concepts of health and engaging with individuals and communities to support their social, cultural and emotional well-being. In other words, through a broker chain, these clinicians mediate within and between specific localities, national agendas and transnational mental health paradigms. In so doing, differences in interpretation are disambiguated and made more accessible to local, national and global stakeholders. To mobilise my stance, in the following, I leverage on two defining features of a broker that I argue describe the broker-clinicians whom I worked with.

Characteristics of clinician-brokers

The two key characteristics of the broker that I focus on are their ability to control second order resources (i.e. information) (Boissevain, 1974) and the perceived moral ambiguity (Merry, 2006) of the broker role. These features of brokerage are informed by anthropological conceptualisations and understandings of the broker and influenced by significant political developments like decolonisation and nation-building (Lindquist, 2015), which make them particularly relevant to clinicians working in post-colonial and post-conflict Sri Lanka. As Koster and Van Leynseele (2018: 806) contend ‘virtually all literature on brokerage situates actors in contexts of rapid societal change, mapping how they straddle different social worlds and combine different repertoires, languages of development and organisational styles’. This was also demonstrated much earlier by Wolf (1956) and Geertz (1960) whose ethnographic observations of decolonisation emphasised how brokers navigated the space and interrelationship between community-based local voices and the structural translocal transformations that were taking place. Through their ethnographic inquiry, these studies enabled the explicit consideration of social change more broadly (Press, 1969).

Leveraging on this context of social change, from one point of view, brokerage can enhance social dynamics, positively influencing economic activities, empowering political development and create spaces to hear voices that would otherwise be suppressed. Auerbach (2016) claims that communities with a wider presence of brokers have greater success in lobbying for responsive change to public services. In this example, broker-mediated interactions provide access to second order resources, like information, to connect individuals and communities to existing state-sanctioned rights, resources and services that they otherwise may not be able to access. From the other point of view, brokerage can also exploit social dynamics to perpetuate or create social, economic and/or political inequalities, leading to the establishment of informal systems of power. With a dependency on brokers for access to information, services and other resources, individuals’ behaviour can be more easily manipulated leading to the broker role being morally ambiguous (Stokes et al., 2013). CSOs have significant influence over how narratives of mental distress are interpreted, including what and how information is shared with the medical doctors in the NGO and also government agencies which, if not sensitively handled, can misrepresent local realities.

Interrogating trauma

In communities’, like Kavitha’s, there is no concept of an individual as a single entity divorced from the kin and community so the impact of traumatic events is also experienced and manifested at the family and community level. Somasundaram (2007: 2) elaborates that in post-war recovery efforts, the focus needs to extend beyond the individual to the ‘family, group, village, community and social levels if we are to more fully understand what is going on in the individual’.

This recognition of the significance of the socio-cultural matrix was reflected in my post conflict work with the NGO. Activities were not individualised and instead focused on social initiatives to engage communities through sport or livelihoods programs, creating a symbolic space to develop social inclusion narratives about mental health. The tension occurred when authoring reports and evaluations for back donors in Australia. These back donors required essentialised information about post-traumatic stress disorder (PTSD) and mobilised efforts and resources on the basis of pathologised notions of trauma. Although there is increased morbidity associated with exposure to extreme violence and trauma, the emphasis on individual development, behaviour and responses to traumatic events along with interventions that are individually focused disputes the validity of the transcultural applicability of PTSD as a diagnostic category (Somasundaram, 2007). For back donor reporting, idioms and narratives about social connectivity and bonding, relevant in the cultural context of the village, were not adequately scientific and did not demonstrate universal conceptions or approaches in which PTSD is diagnosed, treated and represented. This actively shifted the focus of the narrative away from community or group dynamics, weakening the political space for local community responses to the distress and upheaval caused by war and violence.

Further, there was little acknowledgement by back donors of the diverse manifestations of distress and suffering. As Kleinman and Kleinman (1996: 2) assert, ‘individuals do not suffer in the same way, any more than they live, talk about what is at stake or respond to serious problems in the same way. Pain is perceived and expressed differently, even in the same community’. Despite the variety of ways trauma and suffering can be physically and psychologically expressed, a failure to understand and function in the world has become aligned with the concept of trauma (Fassin and Rechtman, 2009). In narrating her experiences, Kavitha’s story of experiencing war had to be captured in conventional terms and aligned with the bio-medical language of PTSD in order to gain back donor legitimacy and continued program support. Consequently, this process was also intensely politicised, and had particularly strong impact in legal or bureaucratic contexts, particularly in the case of individuals looking to seek asylum (Malkki, 1995; Smith, 2012). Consequently, trauma and the codification of suffering through PTSD, embedded new forms of social inequality and structural vulnerability. In other words, back donors recognised trauma only presented through the framework of PTSD as a diagnostic category along with the universally legitimised methods of treating trauma. This, then, restricted the political space in which local responses to suffering could emerge, usurping it with an individualistic, pathologised framework to identify, express, chronicle and manage suffering. Exploring the way Kavitha and other individuals in her community expressed and made meaning of their suffering could not be articulated in these neat categories. So, this reinforced further how broker-clinicians were required to translate between these universally accepted clinical categories of illness while concurrently navigating how Kavitha, and others in her community, made sense of their suffering through locally relevant ways, in so doing, informing their own response to their clients’ distress. This recognition of the broker-clinician’s role of intermediary cultivates a greater understanding of the way in which they, through their everyday work, interpret, make connections and contextualise illness narratives to ultimately influence social networks.

Vernacularising distress and meaning making

It was clear, in my interactions, that Kavitha had a fundamental desire to understand and conceptualise her pain in order to navigate the distress that her suffering brought. However, conflated clinical aetiologies and neatly ordered diagnostic categorisations that bio-medicine offered simply did not address Kavitha’s intrinsic need to make meaning of her suffering and provided little understanding of the everyday realities that Kavitha and her community faced. These are also themes that Merry (2006) explores in her use of the term vernacularisation. She highlights how local actors relocate the universalised claims of the international human rights framework to the local context to address gender violence (Merry, 2006: 221). By using this notion of vernacularisation, I am exploring the interpretation, navigation and translation that occurs in the interaction between broker-clinician and client, illuminating how international norms about mental health journey across borders and are appropriated into national and local mental health systems, practices and diagnoses in the North of Sri Lanka. After all, for successful implementation of universal norms, the norms have to make sense locally.

Mobilising and extending on Kleinman’s (1977, 1988) explanatory models of illness, Kleinman et al. (1997) assert that narratives of illness, and the language of emotion allied to the pain or the emotionally expressive body, enables an individual not only to make sense of the illness experience, but also to transform the individual from a place of inexpressible pain and suffering to one where the pain is articulated (Das, 1996; Kleinman, 1988; Kleinman and Kleinman, 1995; Kleinman et al., 1997). ‘Suffering becomes a process of social mediation and transformation. It is experienced within nested contexts of embodiment: collective, intersubjective, individual. It absorbs into the body-self the moral world’s contradictory obligations/rights and the norms/contestations of the body politic’ (Kleinman et al., 1997: xix). The pain or suffering exists because the emotion or feeling is expressed through the body, providing a language or narrative.

Nichter’s (2010) theoretical framework elaborating on culturally derived expressions of illness or cultural idioms of distress reinforces that individuals make sense of illness through a culturally-mediated road map. Physical symptoms and somatic complaints may have no identifiable biological source, however are a physical manifestation of the individual’s psychological distress. Feelings and thoughts can manifest in bodily events and processes and amplify the ‘semantics and pragmatics of how languages encode ideas about emotions’ (Lee et al., 2007: 5). In other words, articulating and locating an individual’s experience of violence, pain or distress is often through the body; an embodied expression, channelling an individual away from a private, ineffable pain. The significance of how illness is manifested physically or the embodiment of distress is emphasised by Scheper-Hughes and Lock (1987). They introduce the Three Bodies construct, where the individual body, the social body and the body politic, each possess a different layer of meaning and network in the way in which humans navigate and make sense of the world. This framework clearly conceptualises how the body concurrently locates the individual experience along with the broader social and political landscape. As So (2008: 167) also elaborates ‘we filter, mediate, negotiate and otherwise interpret the signs and symptoms processed by our bodies through lived experiences, shaped by our social and relational worlds’.

In so many ways, Scheper-Hughes and Lock’s (1987) Three Bodies units of analysis present a particularly helpful framework for understanding the fluid nature of the notion of culture in addition to the cultural-derived meanings of health and illness. During our discussions about the conflict, Kavitha regularly demonstrated the suffering and visceral pain that she experienced and continues to experience through physical, embodied actions. She often rubbed the left side of her chest, breathed in sharply or laced her hands in her hair or held her head low cradling it in her hands. Additionally, CSOs often commented on how individuals would describe physical pain in their head or heart when discussing the reconstruction and reconciliation efforts, exhibiting physical manifestations of distress or mental upheaval. Somasundaram (2007: 7) explains that in his work as a psychiatrist in the North of Sri Lanka, he often observed somatic complaints ‘or more traditional idioms of distress like Perumuchu (deep sighing breathing signifying worries and emotional burdens) in the Tamil community’.

This highlights the clear benefit of the role of brokers like the clinicians I observed and interacted with. These broker-clinicians fill a significant gap in translation particularly in recognising the symbolism behind physical ailments or sickness. I observed them regularly interpreting the narratives associated with the physical manifestation of distress that were expressed, which reinforced the social, political and cultural exchange that occurs in this process of interpretation. As Koster and Van Leynseele (2018: 808) assert, brokers, like the clinicians I observed, bring ‘together different logics, representations and meanings. In joining these, they also explore and re-emphasise the (blurred) boundaries between distinct economic and political rationales and moralities’. Interpretive strategies were also required during my time with communities in Jaffna. Interpreting mental distress and the vernacular used in these communities required identifying euphemisms and language heavy with meaning.

Understanding cultural dimensions of distress and the challenges of euphemistic speech

To contextualise this notion of implied or discursive references further, my observations led to some interesting revelations regarding sexual violence or abuse. A few CSOs commented that they never explicitly discussed any female medical concerns with the women nor any violent experiences that were interpreted as gender-based (e.g. rape or domestic abuse). Rather, issues that were considered gendered were discussed using diffusive, culturally-specific speech. I too experienced this veiled language when talking to Kavitha. She told me about other women who were compelled to provide sexual favours to contractors, and in some cases, army personnel, who had been brought in to assist with the construction efforts, in order to expedite their house reconstruction. The implications of these abuses of power were discussed in ways that were heavy with nuance but also communicated with little emotion or distress. Words like ‘there was work to do’ were used to explain the transaction of sexual favours for reconstruction efforts. There wasn’t any reference to shame or pity, rather there was almost a sense of these encounters being a short-term strategy for long-term gain. Interestingly, when discussed with the broker-clinicians, it was clear that they had knowledge of these circumstances, with a number often explicitly acknowledging the situation in private. However, it was never something that was brought up as needing to be addressed as it was considered a private issue and the women who offered sexual favours to contractors were simply entering into a transaction that achieved a bigger and more significant purpose; rebuilding a home, reclaiming a sense of place and re-establishing a life. References to sexual encounters were also never included in any donor reporting that I had access to which limited the recognition of the local ways in which some women, in Kavitha’s community, experienced and navigated unequal power, privilege and vulnerability. In many ways, the broker-clinician’s role in translating and in creating donor reports also means that they convert, categorise and objectify lived realities. In other words, the paperwork they create provides a concrete objectification of the subjective experience, whereby forms of distress are only represented in ways that are acceptable and recognisable for back donors. This also relates to the key characteristic of moral ambiguity and the often problematic nature of brokerage. On the one hand, the translation and mediation that clinicians facilitate enhances and enables understanding of the social and cultural dimensions of local realities in mental health; and on the other, the omission of information relating to sexual exploitation in reporting not only erases the abuse but potentially encourages continued abuse and inhibits positive social change, ultimately enhancing inequalities.

The notion of euphemistic speech is analysed in Argenti-Pillen’s (2003) ethnographic work with Sinhala women in the South of Sri Lanka, who have experienced extreme violence during the youth political uprisings in 1988–1990. She argues that these women ‘reconstruct their communicative worlds and interrupt the cycle of violence’ through ‘traditional, culture-specific’ narrative styles (p. 104). These narratives, based on local conceptions of the untamed, gaze of yakku (plural), demonic figures or yaka-like wild spirits, use delicately euphemistic, colloquial Sinhala expressions to describe and communicate their experience of terror and violence, thereby creating a form of ‘acoustic cleansing’ and supressing fear and terror (Argenti-Pillen, 2003: 85). Argenti-Pillen’s (2003) analysis is based on examination of linguistic expressions of anxiety and distress.

This notion of acoustic cleansing was also observed in individuals, particularly women, in Kavitha’s community when narrating the things that caused the most intense sense of upheaval in order to subdue and contain their terror. Cleansing rituals provided opportunities for collaborative expressions of support (Argenti-Pillen, 2003). This was often observed in Kavitha’s village and in surrounding villages in Jaffna. The Kovil (Hindu Temples) or local church, was used as a place of regular ritual cleansing. For some, taking vows (nethi kadan) to Gods at the Kovil provided particular comfort and a source of meaning making. Kavadi (burdens) rituals were also practiced that ranged in form from carrying large pots of milk to forms of self-flagellation. As Somasundaram and Sivayokan (2013: 2) explain, traditional coping strategies in the form of devotional rituals like thuku kavadi, where an individual or individuals (mainly men) hang themselves from hooks pierced through their skin, has increased in use following the war, in the North of Sri Lanka, as a platform to ‘heal and provide meaning to suffering after trauma’.

Rituals and devotional deeds like kavadi funnel fear and turmoil into embodied acts. However, Argenti-Pillen (2003: 170) asserts that the ‘global flow of knowledge on war trauma’ and the concerted investment by the Sri Lankan Government and NGO’s to treat PTSD have imposed Western-centric values, based on universal clinical paradigms, progressively eradicating indigenous sources of local knowledge and practice, ultimately undermining community and social cohesion. She explains that formal PTSD interventions have catalysed a social transformation amongst women that has brought with it a categorisation of the ‘fearless’ woman who no longer needs or sees these spiritual rituals of cleansing as useful (Campbell, 2011; Lindholm, 2008; Watters, 2010). As Lindholm (2008) explains, these women become

‘. . .the ‘self-actualizing’ local leaders picked by the mental health administration to be taught how to administer therapy for PTSD, and they are the ones put in charge of local clinics. Thus, what is seen locally as a dangerous and impious aberration is turned into an ideal by governmental support. Meanwhile, indigenous ritual cleansing ceremonies are interpreted by government mental health professionals as inefficient and primitive modes for coping with PTSD, to be discouraged in favour of a more empowering therapy aimed at inducing autonomy and fearlessness’ (Lindholm, 2008: 10).

Further, as Argenti-Pillen (2003: 193) elaborates, ‘NGOs . . . support “fearlessness” as a viable form of sociality’ contradicting and undermining the traditional discursive use of the gaze of the wild, fear-based narratives defining moral and social boundaries. Argenti-Pillen (2003: 169) argues that this fearlessness should not be perceived as a form of strength or capacity building but rather as a form of moral and social isolation from the collective solidarity of local spiritual or ritual interventions to purge the gaze of the wild. Further, she asserts that the fearless women are likely to impress on their children these narratives of fearlessness, creating a new generation of individuals, distanced from the euphemistic and spiritual narratives of the gaze of the wild and the indigenous cleansing ceremonies of exorcism. In so doing, this socialisation in fearlessness distances these children from circumscriptive moral and social narratives, which potentially perpetuates the cycles of social violence by explicitly decontextualising and universalising enemy families, in this context, creating conditions for retaliation, destruction and eradication en masse (Argenti-Pillen, 2003: 194).

I do have strong reservations about Argenti-Pillen’s focus on and belief in the conceptual currency of tradition correlating with all things good. While I acknowledge her arguments that there is a certain balance and containment of violence, that is created through euphemistic narratives and cleansing rituals, there is, however, no discussion about the entrenched social and moral norms of village culture in confining women in fear-based narratives that moderate their active participation outside the household and village. No narrative analysis is conducted of embedded cultural propriety and practices that confines village women to remain fearful. Additionally, there is little emphasis placed on how spiritual tradition and decorum influence the perpetrator of violence and destruction and, in the case of Kavitha’s village, the lack of explicit discussion about the obvious abuses of power perpetuate and normalise these abuses. This is also asserted by de Alwis (2004: 105) in her review of Argenti-Pillen’s work when she states that, in the lionising of traditional culture, there is no recognition of

‘. . .how women can be constrained and disciplined through a system of beliefs and rituals that seeks to constitute them as perennially vulnerable to contamination. The containment of violence seems to be produced at a great cost—to women. Additionally, the perpetrator seems to be left out of this analytical equation’.

Further, in Kavitha’s village, collaborative expressions of support through activities like broker-clinician mediated psycho social programs where, on many occasions, violence and suffering were discussed, brought together individuals in the community actively looking for support for their experience of upheaval and distress. It was clear the benefit Kavitha and individuals in her community saw in receiving the support they sought, whether spiritual or related to livelihoods. Moreover, collaborative reflection on war-time experiences and narration of trauma stories had strong social significance opening up opportunities to transform communal trauma into social action and political advocacy, particularly drawing attention to the inequity of health infrastructure and services between rural and urban populations and the post conflict and structural realities of institutionalised violence (Somasundaram, 2007; Somasundaram and Sivayokan, 2013; Ramanathapillai, 2006).

This stance is augmented by Somasundaram (1998, 2007) who asserts that mental health and education programs are powerful peacebuilding and advocacy strategies. Although his work and commentary does align with Argenti-Pillen’s (2003) view of the inadequacy of diagnostic categories of mental health in understanding the social and cultural contexts of illness, he also presents a strong argument about the advocacy power of using clinical aetiologies ‘to draw attention to the plight of civilians and in the long term to create social awareness and mobilise support for affected populations’ (Somasundaram, 1998: 169). He states that children, in particular, in the North, are significantly impacted by their exposure to war. He references an epidemiological survey undertaken in the Vanni, the mainland area of the Northern province of Sri Lanka, which found that 92 percent of primary school children had been exposed to ‘potentially terrorising experiences including combat, shelling and witnessing the death of loved ones’ with approximately, 25 percent found to suffer from PTSD (Somasundaram, 2007: 7). Further Somasundaram (2007) asserts that child soldiers are the worst affected with higher numbers suffering from depression and other mental illnesses. Explicitly discussing and socialising the impact of war, through opportunities for community members to gather and share their experiences of suffering through livelihoods programs for example, is a powerful tool in presenting the inadequacy of war in addressing injustice and social oppression.

However, there is little doubt that defining the dimensions of suffering is complex, particularly in communities impacted by war. The broker-clinicians whom I worked with in Jaffna had an awareness of the need to enhance their knowledge and skills to explore the kind of meaning, that is attached to the experience of suffering and illness in the communities they worked in. In discussions they were willing to consider the applicability (or otherwise) of current clinical interpretations and perceptions of illness cross-culturally and were open to discussion that interrogated pathologised categories of mental illness. In many ways, in considering these questions of applicability and meaning making, broker-clinicians were organically engaging in critically scrutinising the clinical assumptions associated with distress and suffering that phrase the diagnostic categories of mental health like depression, PTSD and anxiety.

It is important to note that interrogating PTSD or anxiety as an illness does not question the legitimacy of trauma suffered by individuals. Rather, the broker-clinicians I observed nurtured the analysis and demonstration of the embodied effects of war, individual responses to war and the diverse forms of healing practices utilised to piece together social worlds that were fractured as a result of war and, as a consequence, actively moved the narratives away from a one-dimensional, universal model of the mind. As such, broker-clinicians were attempting to actively create a space for a greater understanding of local conceptions of ill health and approaches to mental health interventions through reflexive and holistic analysis (Campbell, 2011: 77). In so doing, they exposed the social and cultural exchange that occurs in translation, interpretation and diagnostic analysis and their ongoing work calls for further scrutiny and critique of these translocal processes.

Conclusion

There is no doubt that the applicability of mental health services will invariably vary from one space and place to another, depending on available resources and on the existence of alternative interventions. However, I have shown in this article how the act of translating, literally and figuratively, global mental health paradigms, policies and initiatives into localised, relevant and impactful interventions are plainly performed at the nexus between broker-clinicians and the individuals they work with and their communities. My analysis demonstrates how, through their situatedness, broker-clinicians translate and navigate their relationships to knowingly or otherwise, vernacularise mental health and rights-based health narratives and, in so doing, possess the power to improve efficiency and relevance of mental health interventions.

By comparing the two key characteristics of a broker, informed by Boissevain (1974) and Merry (2006), I illustrate how clinicians in the North of Sri Lanka can be defined as brokers through their work in building relationships and translating, mediating and facilitating between local, national and global mental health paradigms. In analysing their work, aspirations and impact, I present how the broker-clinician also influences social and cultural dynamics, particularly in relation to mental health and wellbeing. The opportunity for broker-clinicians to evolve is demonstrated by discussing the mental health burden in the country and the many dimensions of suffering. This analysis, nested within a discussion of the historical backdrop of mental health approaches and the current service system, considers the work of broker-clinicians and how their brokering can enhance their own knowledge, skills and networks and influence post conflict mental health strategies. With references to Kleinman’s (1977, 1988) work on illness narratives, Somasundaram’s (1998, 2007) and Somasundaram and Sivayokan’s (2013) studies in the North of Sri Lanka, Scheper-Hughes and Lock’s (1987) analysis of embodied distress and Argenti-Pillen’s (2003) work in how traditional and religious beliefs support the containment of violence, I have shown how broker-clinicians navigate the illness experience, and the layered nature of suffering, in their interactions with individuals in communities impacted by war.

The article also highlights the notion of privileging of knowledge and information. In so doing, it encourages reflection on whose knowledge and information matters most in dealing with mental distress and suffering. Distress and suffering are experienced globally however what it means and how it is demonstrated locally is unlikely to be replicated in different contexts in exactly the same way. My article underscores the importance of understanding the political, social and cultural influences on distress and suffering and encourages the integration of locally inspired ideas into everyday mental health intervention and treatment. Further, it creates the space to actively investigate the politics of diagnoses and access to mental health care in Jaffna, in Sri Lanka’s North and reinforces the need for ongoing appraisal of the work of broker-clinicians to recognise evolving dynamics in translocal mental health diagnosis and treatment.