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FOCUS June 2001 Volume 24

Psychosocial Trauma and Rehabilitation Work in East Timor

Abilio Belo

The 25-year Indonesian military occupation of East Timor is characterized by repeated allegations of human rights atrocities, few of which were ever investigated or prosecuted by the Indonesian authorities. Following the August 1999 referendum, pro-Indonesia militias, supported in part by the Indonesian military, embarked on a wide scale and largely indiscriminate program of organized violence and destruction of infrastructure, which required a major international peace-keeping and relief operation.

An inherent part of the response to such humanitarian crises must include assessment of the prevalence of torture and extreme trauma, and attention to the rehabilitation needs of victims. If people do not have the opportunity to process the mental consequences of their traumatic experiences, and to obtain an integrated, balanced perception of their history, social reconstruction becomes extremely difficult if not impossible. Although spontaneous recovery is acknowledged, previous studies of treated and untreated patients with post-traumatic stress disorder (PTSD) show a doubling of the average time needed to achieve significant remission of symptoms for those who did not receive treatment. Treatment is a critical process that must be incorporated early in the emergency phase of a post-conflict situation.

The International Rehabilitation Council for Torture Victims (IRCT), an independent international health professional organization based in Copenhagen (Denmark), carried out a national psychosocial needs assessment in East Timor in June and July 2000 last year. The aim was to assess the extent of "torture and trauma and the health impact" it had on the population. The study results provided the basis for the proposed National Psychosocial Rehabilitation Program.

One thousand thirty three households in thirteen districts of East Timor, an estimated 750,000 individuals, were interviewed. One respondent, considered to be a reliable informant, was selected from each household.

A community trauma mapping activity was carried out, with the aim of generating a picture of each district's health system, and of identifying and establishing potential partners and support systems. The questionnaire was designed to ascertain trauma and torture history, PTSD symptomatology, self-perception of health, potential for recovery, and help-seeking behavior.

Respondents had a median age of 35. 5 years and 873 (85%) individuals aged 14 to 59 years. 998 (97%) respondents said they experienced at least one traumatic event. The five most common events are direct exposure to combat situation (785 [76%]), lack of shelter (658 [64%]), and ill health with no access to medical care (623 [60%]).

351 (34%) were classified as having PTSD, based on a cut-off score of 2. 5 or greater in the Harvard trauma questionnaire symptoms checklist. Death of the father or mother is a common occurrence, reported by 320 (31%) and 248 (24%) respondents respectively, and 142 (14%) lost their spouse during the conflict period. For women, the death of a loved one was often compounded by the dilemma of taking over the sole responsibility for the family.

To get an indirect measure of the effect of trauma on children, respondents were asked if they have children who were either injured or from whom they had been separated. 227 (22%) said yes, and a further 125 (12%) said that they have children who died as a result of political violence. In several provinces, there were reports of children having been raped by the militia.

Torture appears to have been widespread. 400 (39%) respondents said that they were tortured, but a larger number, 587 (57%), said they experienced at least one of the six forms of torture included in the study instrument. Psychological torture (411 [40%]), physical beating or mauling (336 [33%]), and beating the head with or without a helmet (267 [26%]) are the most common forms reported. Other forms of torture include submersion in water (126 [12%]), electric shock (124 [12%]), crushing of hands (102 [10%]), and rape or sexual abuse (54 [5%]). Many respondents were threatened at gunpoint, especially during interrogation by the Indonesian military 227 (22%), and witnessed the murder of a family member or friend. 207 (20%) respondents believed that they would never recover from their experiences, and a further 424 (41%) believed they would only recover with some help.

The problem of under-reporting of torture in population surveys is clearly seen in this study. Asking directly whether the interviewee had been exposed to torture yielded 39% affirmative, whereas the summation over only six specific forms of torture raised the estimate to 57%. This discrepancy may be explained by the reluctance of many victims to raise the subject at all unless directly asked. Future studies to assess the prevalence of torture should use instruments that specifically address particular experiences of torture.

The study also found that the East Timorese look primarily to family members, the church, and the local community for assistance, although they are willing to approach a doctor or community nurse for problems that they perceive as being health-related. Psychosocial and rehabilitation programs are therefore likely to be most effective if they are family and community oriented.

With this in mind, the IRCT is working closely with other organizations to educate primary-school teachers in basic concepts of trauma and psychosocial recovery in children, and to provide support to children and their families. The aim is to carry out the program nationwide during the next 12 months. Giving priority to the treatment of children acknowledges that they are the population group in which the impact of conflict and disaster is greatest. Children can recover rapidly if they receive prompt treatment. By assessing traumatic events and their health sequelae, epidemiological studies can play a crucial role in the collective response to humanitarian crises.

There is a great need to set up a Psychosocial Trauma and Rehabilitation Center in East Timor because it will enable the East Timorese to cope with their traumatic experiences after the long war. It will also facilitate the Timorese's understanding of their own feelings and emotional reactions in a changing, violent world. The program itself is expected to figure out how Timorese can address their critical life experiences through discussion, cooperative group learning, art, journal writing, and role playing.

On the other hand, such a center can provide a sense of order, a feeling of safety by being ready to help the Timorese not become so vulnerable to falling apart when the actual traumatic events occur. By talking about stressful, traumatic events, the Timorese are given an opportunity to explore new ways to deal with these situations. Hopefully, whatever organization is present in East Timor that is very much involved in psychosocial programs, it will help the Timorese with new ways to express themselves and deal with their feelings and reactions to trauma in ways that are appropriate. It will also enable them to solve their own problems in their own way. The existing programs now in East Timor are able to provide a support system that contributes to the recovery of the Timorese from their traumas. The most influential institutions that are now helping a lot in terms of this program are Christian Children's Fund-Australia, IRCT, UP-CIDS Philippines, and Medical Action Group (Philippines).

Reference

Modvig, J. , Pagaduan-Lopez, J. , Rodenburg, J. , Salud, C. M. D. , Cabigon, R . V. , Panelo, C. I. A. "Health and Human Rights: Torture and Trauma in Post-conflict East Timor. " Lancet, volume 356, number 9243. (Copenhagen: International Rehabilitation Council for Torture, 2000)

Abilio Belo is an East Timorese and a MA Candidate currently finishing his thesis for masteral degree course on psychology at the Ateneo de Manila University (Philippines).

For further information please contact him at: oiliba@hotmail. com


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