1. Introduction
The local organization Social Services of Cambodia, founded by Khmer-American social workers in 1996, aims to help vulnerable Cambodian individuals, families and communities to gain or regain the ability to be participating and contributing members of their communities.[1] At present, the organization is funded by JICA to, among other activities, provide social and mental health services to individuals and families in Kampong Speu and in Phnom Penh.
At present, the social and mental health services are provided to all persons and families requesting for help, regardless of the nature of their problems. There are some landmine survivors among the clients of SSC (+- 125). However, at present landmine survivors are not being approached as a separate group, though they may have specific needs for social and mental health services. So far, not much is known yet about their needs in terms of social and mental health services.
JICA/SSC requested the Center for Advanced Study (CAS) to conduct a short study of one month in order to determine the nature and extent of mental health needs of people who have survived landmine accidents and to determine resources available to provide services.
The Terms of reference emphasized that the following questions be covered:
-What is the degree of need and desire for mental health services in the target group?
-What kind of mental health problems do the members of the target group typically experience?
-What is the estimated percentage of the target group that suffers from mental health problems?
-What are the current services available?
-What plans have been made for future provision of such services, by government, by NGO's?
1.1 Research design and
methodology
The research methodology for this study was designed by JICA, with input from SSC, and consisted of structured interviews, a self-report of difficulties, and two psychological tests (the Hopkins Symptomatic Test and the Harvard Trauma test) among 100 landmine survivors in/around Phnom Penh and in a village in Kampong Speu. In addition, organizations providing services to handicapped people/landmine survivors, and other organizations that are involved in policy making or coordinating activities, were interviewed (see appendix for a list of organizations interviewed).
The structured interviews focused on the life history of the interviewee (childhood, life before the accident, memories of the accident, feelings right after the accident, relationships with family and friends, difficulties experienced, etc.). After the structured interview, the interviewee was asked to report the most important difficulties encountered nowadays, in an order ranking from most to least important. Upon completion of the self-report of difficulties, two psychological tests were administered: the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire.
Interviewees were selected randomly (those who were available at a particular time) on a cluster sampling basis. The clusters consisted of three rehabilitation centers (VI, AARJ, and JSC), a village in Kampong Speu where SSC is providing services, and areas with a concentration of handicapped beggars in the streets of Phnom Penh (Wat Ounalom, Khlang Rom Ser, along the Chaktomuck river, in front of the Royal Palace, Wat Phnom, squatter areas near the Tonly Bassac River, Chroy Chang Va , Olympic market, Pochen Tong, and Borei Keila stadium. A total of 35 landmine survivors were interviewed in the streets of Phnom Penh, 20 landmine survivors were interviewed at VI, 20 at JSC, 17 at AARJ, and 8 landmine survivors were interviewed at the village in Kampong Speu.
The interviews were conducted by four teams, each consisting of one experienced socio-cultural researcher, and one psychologist researcher. The researchers presented themselves as members of an independent non-governental organization devoted to research. We explained the aims of the research to our informants as an effort to obtain their experiences, knowledge and views to provide input to the process of establishing and improving mental health services in Cambodia. Every informant was assured of anonymity and the interviews were tape-recorded only with the expressed consent of the interviewee. The tapes served as a back-up for the researchers, and were not transcribed and translated.
Prior to interviewing, the interviewees were informed that the interview might cause great emotional as well as psychological distress and painful memories. The interviewees were informed about emotional and psychological support services at SSC, TPO and CMHDP, and were provided with an official note stating that they had participated in a research project and might need counseling after interviewing.
The research was managed by a Cambodian-American medical anthropologist, Pollie Bith, Ph.D. Candidate. The teams consisted of Un Mononita, BA. and Lay Sokhanak, BA., Heng Kim Van, MA., and Ngan Sreyrath, BA., Nguon Sokunthea, BA., and Khat Saret, BA., and Chan Kanha, BA., and Chey Sam Oeun, BA . The researchers have extensive experience in in-depth interviewing and administering psychological tests in various communities in Cambodia. The data were processed, analyzed and written up by Pollie Bith and Judith Zweers, MA.
1.2 Research limitations
The study was conducted in March, with duration of one month. Given the time constraints, it was not possible to provide an in-depth analysis of the mental health situation of land mine survivors. This study should rather be seen as a preliminary assessment: an in-depth analysis would require more time and other, more qualitative methodologies.
Most interviews were conducted in and around Phnom Penh. We therefore do not claim that this study is representative for the situation of landmine survivors in Cambodia. This study was conducted mainly in the urban setting, whereas the majority of landmine survivors live in the rural areas. The situation in a city is entirely different from that in the countryside. Moreover, most of our interviewees in and around Phnom Penh were former soldiers, receiving a small government pension, whereas there are more civilian landmine survivors in the countryside.
It is important to note that this study mainly presents a picture from the point of view of the landmine survivors themselves. In order to provide a complete picture, especially when discussing issues such as discrimination and relating to society, it is especially important to bear in mind the one-sided view that is presented in this report. This report shows perceptions of one particular group, which may not always entirely reflect reality.
2. Landmine accidents and disability in Cambodia
Cambodia is one of the countries with the highest rate of accidents due to landmines. The laying of landmines began already towards the end of the 60s, during the Vietnam war, and continued throughout the 70s. The use of landmines increased considerably with the invasion of Vietnam in 1979, when landmines were used both by the Cambodian government and the Khmer Rouge, and its use continued until the late nineties. As a consequence, Cambodia is also one of the countries with the highest rates of casualties due to landmine accidents, although the number of casualties per year is decreasing since 1997. In 1996, 3,046 landmine accidents were reported (a monthly number of casualties between 518 and 133); in 1997 this figure dropped to 1,698 (monthly between 237 and 84), and stayed constant throughout 1998. In 1999 it dropped again to 1,012, with a monthly number of casualties ranging from 157 to 43.[2]
Figure 1: Number of
casualties due to landmines from 1996-1999
Source:
Cambodia Mine Incident Database Project: Monthly Mine Incidence Report,
December 1999 and February 2000
By far most accidents take place in Battambang and Banteay Meanchey provinces, which are among the most heavily mined areas in Cambodia. Although exact figures about the number of casualties per province are not available, those two provinces together probably accounted for approximately half of all landmine casualties in 1999.[3]
Figure 2: Percentage
of casualties per province in 1999
Source:
Cambodia Mine Incident Database Project: Monthly Mine Incidence Report,
December 1999
In the past, during the civil war in Cambodia, most mine incidents happened during warfare, with most casualties being among the military. After the civil war, this trend has changed visibly. Nowadays most landmine casualties are among civilians: in 1999 this was 91% of all reported casualties. [4]
Landmines are designed to maim the victim, causing complicated wounds, which often - but not necessarily - lead to amputation of one or more limbs. 23% of the casualties reported in 1999 died; 31% had to get a limb amputated, and 46% got injured without amputation needed. It is important to stress that land mine survivors are not necessarily amputees: they may well have other physical problems.
After the war, the government as well as international organizations have tried to respond to this situation through various rehabilitation programs, emphasizing physical therapy, prosthetics, orthotics and other devices, as well as skills training for casualties of landmine accidents. Meanwhile, a large number of national and international organizations is working in the field of physical rehabilitation of disabled people in general: whereas the organizations initially focused on war veterans, most are now open to the disabled in general, whatever the cause of the disability. More than 50% of Handicap International's clients nowadays for example, are people who got disabled due to other causes than mine accidents, the most important cause being diseases such as polio (27%), followed by accidents (10%), use of weapons, congenital causes, and disability due to delivery problems.[5]
Physical dysfunction is however only one part of the handicap. The WHO published an Internal Classification of Impairment, Disability and Handicap, which classifies handicaps according to the disabling consequences. It makes a distinction between impairment, disability and handicap. Impairment refers to the physical dysfunction; disability refers to the disabling consequences of the impairment (i.e. a restriction on the activities of a person), and handicap refers to the changed role of the person in society due to the disability, i.e. the physical independence, the mobility, occupation, social integration, self-sufficiency, etc.[6] In a poor society like Cambodia, a disability is more likely to result in a more serious handicap than in a Western society: most disabled are poor and marginalized people, for whom the consequences of the physical impairment are "exacerbated by an inability to earn a decent livelihood (thus worsening the cycle of poverty), displacement due to conflicts, and ostrasization from their society. As such, their impairment quickly becomes a disability and in many cases a handicap."[7]
Dr. Sar Sothearith in his thesis on handicapped soldiers and mental health (1998), emphasizes the consequences of disability in Cambodia in terms of the relationship between disabled people and society, indicating that the loss of a limb is often followed by other "losses", such as decreased job-finding ability, decreased social interaction, lower self-esteem, and increased dependence.[8] Also Somasundaram and Kea see a change in social interaction after a person becomes disabled. In their study on the psychosocial effects of landmines in Cambodia, they refer to studies from other heavily mined countries where changes were found in the relationship with family, a loss of productivity and ability to support the family, increased dependency on the spouse, divorce or desertion, inability to marry, an inability to educate and feed the children, etc. Also other relationships had changed, and feelings of embarrassment in public, of shame, depression, bad temper, uselessness and depression were reported.[9]
Somasundaram and Kea also refer to mental problems of landmine survivors: "it is not only the physical outer body that is damaged by the land mine explosion, but the inner self also suffers considerably".[10] In their study among 90 landmine survivors in and around Phnom Penh, they found considerable numbers of landmine survivors with post-traumatic stress disorder, anxiety, depression and somatization. Although in Cambodia at large the need for psychosocial help for trauma victims is increasingly being recognized, this is not yet the case for landmine survivors: Somasundaram and kea even discern a tendency towards denial of psychosocial needs among some of the rehabilitation programs. They call for a holistic approach of care for land mine survivors, in which all aspects, both physically and mentally are being addressed.
Sothearith in 1998 interviewed 10 handicapped soldiers at a military hospital in Phnom Penh, and also found a high level of depression and symptoms of post-traumatic stress disorder among them: symptoms of anxiety, recurrent dreams about traumatic events, flashbacks, and avoidant behavior in order to avoid stimuli that can be associated with the traumatic event.[11] In the last two decades several questionnaires have been developed to assess the level of anxiety, depression and post traumatic stress disorder among Cambodians. The symptoms checklists make use of a Cambodian idiom for symptoms. Although minor mental disorders such as depression, anxiety and post-traumatic stress disorder were first named in the West, they are often accepted to be natural and prevalent in all cultures. Departing from the assumption that there is such a universal response, psychological tests can be developed that capture the culture specific responses to stressful events and translate those into Western concepts of mental health disorders, such as anxiety, depression and post-traumatic stress disorder.
However, the question remains how to interpret the outcome of such tests, because the meaning of depression may be different for people from a Western or a Cambodian culture. Or, as Summerfield puts it: "for one person, recurrent violent nightmares might be an irrelevance, revealed only by direct questioning; to another, they may indicate a need to visit a health clinic; to a third they might represent a helpful message from his/her ancestors."[12] Although we recognize this as a valid, and very important point, we do not intend to further explore this issue in this report.
This study is based on the assumption that there are universal human responses to stressful events, and that those responses can, to a certain extent, be measured.
3. Demographics
In total 100 land mine survivors were interviewed for this study: 56 informants were interviewed at different rehabilitation centers in and around Phnom Penh, 35 informants were interviewed in the streets of Phnom Penh (mainly beggars), and 8 informants were interviewed at a village in Kampong Speu, where SSC is providing services.
Only 8 informants were women. This more or less reflects the national trend: according to the Cambodia Mine Incident Database Project 6% of the landmine casualties nation wide (deaths, injured and amputees) are women. Although the database also shows a percentage of 28% children, there were no children in our sample. Almost half of our respondents (46%) was aged between 26 and 35 years. 34% was aged between 36 and 45, 11% was between 16 and 25, 8% was between 46 and 55, and only one respondent was older than 55 years.
Figure 3: Age groups of landmine survivors interviewed
Most informants (47%) had had no, or almost no education (0 to 2 years). 31% had attended school for 3 to 5 years (Primary school level: able to read and write), 18% had attended school for 6 to 8 years (lower secondary school), and only 4% 9 to 12 years (higher secondary school).
Figure 4: Number of
years of school attendance
Most informants were married and were having children (72%), 23% was single or divorced. Most people from this group stated that they did not have enough money in order to marry a woman and support a family. The disability in itself was not perceived as the main problem: most informants stated that they would be able to find a wife if only they would have enough money. Some informants told us that they got married and had children after the accident had taken place. Most live separate from their parents and siblings: only three informants were either living with one or two parents, or with an older brother or sister. The informants came from different provinces: Battambang, Kampong Cham, Kandal, Prey Veng, Svay Rieng, Kampong Thom and Takeo. Most recounted a happy childhood, with a normal/good relationship with both parents and siblings. In only three cases more than three siblings had died during the Pol Pot regime.
The large majority (79%) used to be soldier before the accident happened. 10% was farmer. In case people from the countryside would have been interviewed, we probably would have seen more civilians in our sample. At present most people who get injured by a landmine are civilians in the rural areas.
Figure 5: Job before
the landmine accident
68 of the 100 informants told us the year of the accident. Of those, the majority (41%) stepped on a mine between 1986 and 1990. 25% got wounded before 1986. 21% stepped on a mine during the last five years, and for 13% of our informants this happened six to ten years ago.
Figure 6: Year of
landmine accident (only 68 respondents)
Most of the interviewees stepped on a mine while being at war. 32% was doing farm work or related activities, 5% was clearing the forest during K-5 mission, and 3% was involved in other activities when stepping on a mine (traveling, stone breaking, etc).
Figure 7: activity
involved in at the time of the accident
4. Memories and feelings, coping mechanisms, and
society
During the structured interviewing we asked our informants to tell us about their memories of the accident, dreams they have either of the accident or of the situation afterwards, and whether certain events ever trigger flashbacks. We also asked them about their feelings when thinking of the accident, and their feelings about their present situation.
4.1 Memories of the accident
Most informants remembered the accident in detail, and have memories that are emotional and painful. The memories are often still very real, despite the fact that the accident in most cases took place many years ago. A few informants were very young when they got disabled, but were still able to describe the situation that preceded the accident. Most informants remember exactly what activities they were involved in, and who were with them. They remember the explosion, and them calling for help. Most lost consciousness soon afterwards. Below are some accounts of landmine survivors described during interviewing.
I remember the accident very well. I paved
the way for other Cambodians to put up the camp during the K5 Mission in Kom
Kieng and Thmorda zones. I was injured in 1984. I got out of a truck and soon
afterwards, I stepped on a mine. It was 10 AM on the 6th of January.
I fell unconscious. [man, code 010, Tonle Bassac, p.2]
I worked in Kampong Speu Province as a rock breaking worker. In the morning at 7.30 I climbed a mountain, cut a hole in the rock, and placed a mine into it. I left, but the mine didn't explode, so I climbed back to re-prepare the mine. But as I climbed back, the mine suddenly exploded. Debris hit my head and my arm. [man, code 045, VI, p. 2]
I remember the accident. I went to carry water from a well nearby my neighbor's house. I carried water twice that day. The second time I carried water, it was then that I stepped on a mine. I lost my consciousness after I called people to help me. [woman, code 057, JS, p. 2]
Some even remembered dreams they had the nights before the accident, telling them that something bad was going to happen:
Before I stepped on a mine, I had a dream that my parents gave me rice with a spoon. I had the same dream for three days. I was worried about my dream, so I talked about it to my commander. He told me that my parents made an offering for me. After that I went with a soldier to hunt animals and I followed him to a lake. He went ahead. I stepped on a mine after I walked back from the lake. [man, code 015, Wat Phnom, p.2]
4.2 Flashbacks and dreams
Flashbacks and nightmares seem to be common among landmine survivors: 79% of our respondents reported recurrent bad dreams, and 83% were regularly having flashbacks of the accident. They described their dreams and flashbacks as something natural, and did not appear to be too concerned about them. However, they do fear events that remind them of the accident. Explosions, firework, guns, loud noises, car accidents, screaming and blood are some of the events that trigger flashbacks. These occurrences remind them directly of the accident, being again at the site of the accident and going through the same experience all over again. Some reported getting nervous when they hear people screaming, wanting to hide away from everyone.
I don’t want to hear screaming or explosions, because it reminds me of the accident. It is too real for me to deal with again. I try not to think about it when it happens. [man, code 082, JSC, p. 3]
I have a flashback when I hear a loud sound of explosion. I feel fearful. I have never dealt with these feelings. [man, code 044, VI, p.4]
I am afraid of explosion, blood and accidents because these things remind me of the accident I had. It frightens me and makes me have strange feelings inside my heart. [woman, code 057, JSC, p.4]
Most nightmares of the landmine survivors that were interviewed were about the accident or about their lost limbs. Some did not perceive their dreams as a major problem, but nevertheless want to understand the meaning of their dreams.
I dreamed that I have all four limbs back again. I could walk like everyone else. I jumped up and down the bed. But when I woke up, I realized that I only have one limb. I was disappointed and desperate. [man, code 016, Wat Phnom, p.3]
I dreamed that my father begged for one leg and the government begged for the other. I have difficulty interpreting my dreams. t is difficult for me to talk to people about my dreams because I am afraid that people will look down on me. [man, code 064, JSC, p.3]
I have many dreams about fighting. I don’t know how to deal with my bad dreams. I just keep all my bad dreams in my mind. [man, code 016, Wat Phnom, p.3]
65,8% of the landmine survivors who reported dreams and flashback, share their dreams with family and friends. 34,2% keeps these occurrences entirely to themselves: they seem afraid of mockery.
No, I did not seek help. I am afraid that they will blame me if I tell other people about my feelings.[man, code 070, JSC, p.5]
4.3 Feelings after the accident
Almost all survivors of landmine accidents remembered how they felt right after the accident, or when they regained consciousness. They showed deep regret about the accident and most felt that they had lost hope completely. They realized that they would not have the kind of future they were looking forward to as a 'whole' person. Many expressed the feeling that they lost everything because they lost a limb. Several informants explain that they get angry more easily, and that they don't know how to deal with those angry feelings.
I was happy before the accident. Now, after the accident, I feel great sadness, and I feel nervous when I think about it. [man, code 082, JSC, p.4]
Before the accident, I had light in my life, but now I feel sad. I cannot do whatever I want. I cannot climb coconut trees, carry water, or dig a well. [man, code 049, VI, p.5]
I feel bad. I had a lot of hope before the accident, but I have less hope now. My feelings are different now. I get angry more easily. I am fed up with my feelings and I don't know how to get help. [man, code 029, Rem Bur, p.5]
Some expressed the wish to ending their lives because they feel hopeless about their future. Others were angry with the government because they were drafted into the army. Many believe that it was their destiny to be disabled, because they sinned in previous life and are paying for it now.
Many informants explained that they wanted to commit suicide right after the accident: this was 56% of our interviewees. Hopelessness is the main reason for wanting to kill oneself. 29% actually made at least one attempt to commit suicide.
I
thought my life and future were finished. [man, code 022, Pochen Tong, p. 5]
I wanted to kill myself after my leg was amputated. I would have killed myself if I had a grenade or gun with me at the time. I wanted to use a gun to shoot myself, but my bodyguards took the gun away from me [man, code 010, Tonle Bassac, p. 3]
I wanted to kill myself. I tried to take pills. I took medicine to kill myself, but my mother took me to the hospital [woman, code 036, AARJ, p.5]
Most recovered quickly from this initial reaction, being glad that they did not commit suicide. They want to live to see their families and children, to make something out of their life despite their disability. There is often a sense of obligation towards their family and children.
I felt sad and I didn't want to live anymore. But then I saw many people who are disabled like me, and then I did not want to kill myself anymore.[man, code 019, Wat Phnom, p.4]
If I had killed myself after the accident, it would have been wrong. I would not be able to see my wife and see my children grow up. Now my second wife has passed away; my first wife died during the Pol Pot regime. I now live with my child. [man, code 029, Rem Bur, p. 6]
I feel that killing is not a good way, because I have a wife and a child to support. Who is going to educate my child if I die? [man, code 088, Wat Than, p.5]
Three informants were still thinking of committing suicide, despite the help they get from family, friend and organizations.
I considered killing myself soon after I was injured. I took a grenade from another soldier, but he stopped me. Now, I want to kill myself again, because I have many complications with my disability. I once climbed a tree with a rope around my neck. But people kept calling me to come down the tree. I don't want to live with no freedom and happiness. [man, code 002, Tonle Bassac, p.5]
4.4 Coping strategies
Many landmine survivors told that they can count on emotional support from their family and friends. Some figured out a way to deal with their emotional problems, whether it be talking to friends, neighbors or family members, or finding alternatives to momentarily ease the pain. Most land mine survivors expressed being tired of thinking about their disabilities. Some coped with their emotional problems by drinking. Some explained that they turned to television or karaoke as a form of coping mechanism, and others reported talking to friends and neighbors when they were feeling sad, although they would usually talk about other things than their disability.
When I feel pain in my heart, I quickly overcome it by doing something fun or cheerful. This is a way to educate my heart. [man, code 046, VI, p. 8]
I was causing trouble in the [rehabilitation] center. I drank wine and was bothering the others. That's why they kicked me out. [man, code 004, Tonle Bassac, p. 11]
I talk to my friends when I am sad. I talk about social problems and politics at the coffee table in a restaurant near here. Then I forget my painful feelings for a while. [man, code 029, Rem Bur, p.5]
The support of family and children is very important to landmine survivors. Family and friends can encourage positive thinking and provide reasons for them to continue living. A man pointed out that when he is angry about his condition, his wife and children would comfort him and that makes him feel less angry with himself.
When I am angry, my hands tremble and my feelings are broken. My wife and children help me to deal with my feelings. I was always thinking of bitter memories. But my feelings are different now. I reduced 50 to 60% of my negative feelings. I also calm myself down by watching television and talk to a neighbor. [man, code 010, Tonle Bassac, p.4]
Those who have support from a rehabilitation center seem to have a more positive understanding of their own situation. They seem better able to cope with their feelings. They appear to be more active: not only do they receive training from an NGO, they also seek help from siblings, neighbors, friends or parents, or start a small business in their village. Support is an important part in the recuperation and rehabilitation process of disabled people. Those who have support, tend to think in a more positive way and are more active in terms of learning new skills and taking up new opportunities.
My friends often do me a favor. My neighbors helped to build my house. The government gives me a salary on a monthly basis and an NGO provides me with skills training at the center. I am happy that people help me, as I am a disabled person who needs a lot of help. [man, code 044, VI, p. 8]
My friends give me money. Maryknoll comforts me and tells me to forget about my sad feelings. My neighbor is very nice to me and he gives me money. [man, code 049, Wat Phnom, p.8]
My family helps me cooking rice. An NGO gave me an artificial leg and provides me with skills training and gives me food. I am happy, but the government does not give me anything for my disability. [woman, code 036, AARJ, p.6]
Not everyone was able to find ways to cope with their feelings. A few interviewees reported continuous suicidal feelings: they expressed waiting for the day that they will die.
4.5 Landmine survivors and society
Most landmine survivors felt a change in attitude from society towards them after the accident happened. Many survivors reported acts of discrimination, varying from looking down on landmine survivors, to calling bad names, perceiving them as beggars, and underestimating the activities a disabled person is able to undertake.
When I was in the village, people hated me for being disabled. I was unhappy and fed up with my body. They liked me when I was not disabled. They changed their feelings toward me when I lost a limb. [woman, code 057, JS, p.7]
People in the village have pity on me. But I don't understand the hearts of some people. (...) when I stop a remorque, the driver doesn';t want to take me. [man, code 065, JSC, p. 7,8]
A young man in my village looks down on me because I am a disabled man. I didn't do anything to him, but he still uses bad words. He called me a "person without a leg". I am very angry that they call bad names due to my disability. [man, code 002, Tonle Bassac, p.9]
I was considered a beggar because I am disabled. When I went to a restaurant to have dinner with friends, they thought I came to beg for money from the customers. I told them that I have money and that I have come with my friends. [man, code 029, Rem Bur, p.8]
I have a job now, but clients don't want to give me important work to do because they said that I am disabled. I only get small tasks from clients. [man, code 018, Pochen Tong, p.10]
Others were noticing discriminative behavior, but were accepting it as normal, as something natural. They would get angry with themselves, rather then with the people discriminating against them. One informant however, indicated not to care about discriminative behavior.
Some people look down on me because I am disabled. Others don't pay attention to me, but I am not angry with them. I am fed up with myself for being disabled. [man, code 020, Toul Sleng, p. 8]
I don't have feelings for people who discriminate against me. It is up to them to think what they want and I don't think anymore about this. [man, code 015, Wat Phnom, p.7]
However, there were also informants who did not see a change in behavior of society towards them.
The relationship between my friends and me didn't change. They even have more pity on me. I am happy because they don't neglect me because of my disability. [man, code 032, VI, p.4]
Many
people make friends with me. I am happy and have hope in my life. I think there
is no discrimination against me from the community. I can talk to people and
laugh with them. They treat me nicely. [man, code 096, Kampong Speu, p.7]
A few interviewees also indicated that a change within themselves had taken place after the accident happened, which makes it more difficult for society to relate to them. Several landmine survivors reported an increase in alcohol abuse, others explained that they get angry with people more easily:
I cannot cope with these problems (my disability). I just wait for death to come. But sometimes it makes me calm down a little when I yell at a person. But people think I am crazy when I scream at them. [man, code 049, VI, p.7]
Many informants indicated withdrawing themselves from society. They are shy and feel ashamed. Most reported avoiding celebrations and festivals.
Especially when I am going to a religious ceremony, it is difficult for me. I take off my artificial leg to sit down and respect the monks. But it has a bad smell, and I feel ashamed. That's why I avoid religious ceremonies. (...) I ask my neighbor or wife to go. [ man, code 049, VI, p. 7,8]
When people enjoy the New Year Holidays, I stay at home or in the center, and I sometimes drink wine. [man, code 065, JSC, p. 8]
5. Reported difficulties and services needed
All informants were asked to express the most important difficulties they face in daily life, and rank them in an order from most to least important.
We were able to group most answers under the following five categories: poor living conditions, physical handicaps, emotional problems, health problems, and problems with relating to society. 'Poor living conditions' includes 'being poor', not having enough money, or inability to support the family, lack of job, etc. Physical handicaps refer to all problems directly related to the physical handicap due to the landmine accident, such as: problems with walking, traveling, taking a bath, going to the toilet, dressing, sleeping, eating, doing housework, etc. In the emotional problems we included all psycho-social and emotional problems the informants described, such as being upset, being sad, worried, concerned, unhappy, 'having unhappy feelings', etc. The category 'relation with society' includes difficulties making friends, hostile behavior towards society, inability to communicate, feelings of shame, and discrimination. Health problems included all health complications, e.g. recurrent headaches, infections, pain, illness, etc.
The first pie below displays the problems that were ranked first. 66% of all informants mentioned poor living conditions in general as the most important problem. Physical handicaps were ranked second (19%). 12% mentioned emotional problems as the most important difficulties encountered.
Figure 8: First ranking difficulty
Quite understandably, informants from the streets of Phnom Penh ranked poor living conditions higher and more often than the informants interviewed at rehabilitation centers and in Kampong Speu. Their problems are in general more basic, as they are often homeless.
A closer look at the problems that were ranked second, reconfirms the importance of poor living conditions as first, physical handicaps as second, closely followed by emotional and health problems (see figure 9).
The problems ranked third, fourth and fifth show the same pattern. Other difficulties that were mentioned less often and with a much lower ranking were: lack of capital and tools, lack of land, lack of skills and knowledge, and worries about the future of the children.
Figure 9: second
ranking difficulty
Not all informants mentioned all five difficulties. Some mentioned only one, others two or three, others four or five. Poor living conditions as a difficulty was mentioned by almost all interviewees, as well as problems directly related to the physical handicaps. About 46% of all interviewees mentioned emotional problems, and 31% mentioned health problems. The most obvious difference in answers between groups of interviewees, was a difference in percentage of interviewees mentioning difficulties with relating to society between on one hand people interviewed at rehabilitation centers (25%) and on the other people interviewed in the streets of Phnom Penh (57%). Feelings of shame and discrimination and problems with relating to friends and neighbors were more often mentioned among the last group.
The findings of the self-report of difficulties are supported by the difficulties that were mentioned by informants during the structured interviewing. Being the sole provider and disabled, they have a hard time sustaining their families. Some are concerned about their children's future, especially their children's education. Those who have to support a family stress not having the capacity to secure their children's future through proper schooling, so the children will not be able to take care of their parents in the future. Some described their disability in the form of physical difficulties (physical movement, e.g. eating, going to the toilet, sleeping, etc) while others stressed problems such as discrimination, poor relationship with people, worrying too much, a 'painful heart', etc. Lack of food and shelter seemed to be one of the most important difficulties faced.
Most informants expressed the need for socio-economic assistance, e.g. skills building, credit to start a small business, a house, land, etc. They view those support services as an important part of their rehabilitation process. Although they express the need for mental health services as well, they rather view this as a long-term process, something to think about when the socio-economic problems are solved. Acceptance, tolerance and mental nurturing are considered as an important part of the healing and coping process. But for now, they suggested services that will help them in becoming self-sufficient as the first priority.
I want money or a loan from an organization to buy repair tools, so I can repair bicycles and motorbikes. I don't know how to do this and I want to ask an organization to train me how to do this. [man, code 019, Wat Phnom, p.4]
I want organizations to help the disabled persons to get training and help them find jobs. So they can earn money to support their living. I want the government to give loans to the disabled people so that they can open a small business. [woman, code 057, JSC, p. 8]
6. Psychological tests
Although there seems to be a similar pattern with regard to post-traumatic stress disorder across cultures, each culture has its own specific symptoms for mental health problems such as anxiety and depression. The Hopkins Checklist-25 was developed to facilitate the evaluation and treatment of Southeast Asian refugee patients in America, and measures the level of anxiety and depression. A Cambodian version was developed, using the particular Cambodian idiom for describing certain symptoms. The test consists of a list of symptoms with a scale allowing for four responses: 'not at all', 'a little', 'quite a bit', and 'extremely'. A number of points is then assigned to each answer, and through a simple calculation one finds a number ranging from 0 to 4. Scores above 1.75 are considered symptomatic for anxiety, depression or both, meaning that the person is suffering consiberable emotional distress.
The Harvard Trauma Questionnaire was developed to obtain information about trauma events experienced by Indo-Chinese refugee patients and the level of Posttraumatic stress disorder (PTSD), with the same scale of responses as in the Hopkins Checklist. The results of the second part of the test show a number between 0 and 4. Results equal to or above 2.5 are considered symptomatic for PTSD.
6.1 Hopkins Test: anxiety and
depression
The Hopkins test measures the level of anxiety and depression. The test results among the 100 landmine survivors interviewed suggest that depression is more prevalent than anxiety among this group. Whereas 46% of the interviewees were tested symptomatic for anxiety, this is 66% for depression. Figures 10 and 12 give an average for anxiety of 1.86, and an average for depression of 2.07, both well above 1.75.
Figure 10: Hopkins
anxiety score
Scores of 1.75 and above indicate that the person is symptomatic for anxiety. This means that among our group of 100 landmine survivors 46% can be considered symptomatic for anxiety (see figure 11).
Figure 11: Percentage
symptomatic for anxiety
Figures 12 and 13 show the distribution of scores for depression among the 100 respondents, and a percentage of 66 that can be considered as symptomatic for depression.
Figure 12: Hopkins
depression scores (percentages)
Figure 13: Percentage
symptomatic for depression
Figure 14:
Symptomatic for anxiety and depression in % (Hopkins total score 1.75 or above)
6.2 Harvard Test: Post-Traumatic
Stress Disorder (PTSD)
The scores on the Harvard Trauma test are substantially lower than those on the Hopkins checklist. Harvard does not measure the level of anxiety and depression, but focuses on traumatic events and the prevalence of post-traumatic stress disorder. Although most informants witnessed and experienced many traumatic events in their lives (on average almost 8 traumatic events experienced), most of them did not develop post-traumatic stress disorder. Only 17% of all informants interviewed were found symptomatic for PTSD (see figure 16).
Figure 15: Number of
traumatic events experienced (in percentages)
Figure 16: Harvard
total scores (symptomatic for PTSD: in percentages)
6.3 Discussion of test scores:
some correlations
There seems to be no correlation between the year the accident took place (i.e. the number of years that have passed since the accident) and either the level of anxiety, depression or PTSD: depression, anxiety and PTSD are as prevalent among landmine survivors who got wounded 15 years ago, as they are among those who stepped on a mine one year ago. This suggests that among landmine survivors interviewed 'mental wounds' do not heal significantly over time.
However, there seems to be a difference between on the one hand landmine survivors interviewed at rehabilitation centers and in the village in Kampong Speu, and on the other hand those who were interviewed in the streets of Phnom Penh, although the low number of landmine survivors interviewed for this study, do not really allow for such comparisons. PTSD seems to be more prevalent among the interviewees from the streets of Phnom Penh (29%) than among the landmine survivors interviewed at rehabilitation centers and Kampong Speu (11%). Symptomatic depression and anxiety were also more prevalent among the land mine survivors interviewed in the streets of Phnom Penh.
Figure 20: Percentage
of interviewees symptomatic for Depression/Anxiety and PTSD
Overall, we can conclude that depression is more common among landmine survivors in and around Phnom Penh than are anxiety and PTSD. The data show some difference between on one hand landmine survivors living in the streets of Phnom Penh, and on the other landmine survivors who either receive help from a rehabilitation center or those who live in a community (village in Kampong Speu). The immediate assumption would be that the informants from the streets of Phnom Penh are suffering more from mental health problems than the others, although generalizations of that kind are difficult to make, viewing the small number of people interviewed for this study.
7. Service providers
There are 51 national and international
organizations working in the field of disability in Cambodia. Services provided
include vocational training, community-based programs, prostheses, physical
therapy, assistive devices, orthotics, programs for visually impaired,
handicrafts, and education programs and children programs 9. The government has set up a council of
management to run the National Center for Disabled Persons (NCDP), which
consists of MoSALVY, Cambodia Disabled Peoples Organization (CDPO), Maryknoll,
Cambodia Trust, American Red Cross, Veterans International (VI), Khemara, Rehab
Craft, Wat Than National Rehabilitation Center, World Vision International
(WVI) and other organizations.
A national task force, the Disability Action
Council, functions as a coordinating body for organizations working with disabled
people in general. It provides a regular forum for dialogue and exchange of
information and ideas among local and international organizations and the
government. The aim is to ensure that disabled people can get all the
assistance needed, despite the limited resources available in Cambodia.
Below is a brief description of 12 organizations
about their existing programs and availability of services specifically for
landmine survivors and/or for disabled persons in general.
7.1 The Government and Coordinating
Bodies
In
the past, three ministries (Ministry of Health, Ministry of Social Action,
Labour and Veteran Affairs, and Ministry of Education, Youth and Sports), were
assigned to work on issues related to disabled people. However, with the
reorganization of the government, MoSALVY has been mandated to work with all
vulnerable groups in Cambodia, including disabled persons. Since 1994, a number
of local and international organizations have provided technical assistance to
the ministry. This resulted in the strategic plan entitled Future Directions 1995 and 1996~200010. The
strategic planning focuses on human resource development, aid management
and coordination, networking and policy-oriented research. A task force was set
up by MoSALVY to collaborate with local and international organizations working
with disabled persons to implement a national rehabilitation plan with strong
linkages between the national, provincial, district, commune and village
levels.
The
DAC (Disability Action Council) was set up by the Ministry of Social Affairs,
Labor and Veterans Affair, and is the coordinating body for other
subcommittees, including the Sub-committee of Community Work with Disabled
People and Children with Disabilities, the Rehab-sectoral Sub-committee concerned
with vocational rehabilitation and other sub-sectoral meetings related to
disability issues11.
DAC is working
with the government to develop a policy framework for a national five-year plan
of action. The DAC consists of MoSALVY, MoH and MOE, international and local
organizations.
In an
attempt to include also mental health aspects of disability, a program for
mental health was added to the National Plan for Physiotherapy Implementation
and National Plan for Prosthetics and Orthotics Services in 1995. 12 However, little is mentioned about the
availability of mental health services for disabled people. It appears that
government and NGOs working in the field of disability place more emphasis on
physical therapy than on mental health support. At present, the government and
the coordinating committee for disabled people are drafting a new five-year
plan.
7.2 Organizations providing
services to Iandmine survivors
Organizations
(potentially) working with landmine survivors, are World Vision International (WVI),
Cambodia Trust (CT), Veterans International (VI), Cambodian Disabled People’s
Organization (CDPO) and Action for Disability and Development (ADD). None of
these organizations have a specific mental health program for survivors of
landmine accidents. Some organizations reported having clients who got disabled
as a result of a landmine accident, but none of the organizations keep records
of the percentage of landmine survivors among their clients.
7.1.1
World Vision International
World
Vision International is a non-profit Christian humanitarian organization,
dedicated to working with poor and oppressed people, to promote human
transformation and justice. WVI does not have a mental health program
specifically for disabled people, but it provides mine education and physical
rehabilitation, mainly for children. WVI has two counseling centers, mainly set
up for people living with HIV/AIDS. Most clients who seek counseling are AIDS
patients. WVI would provide mental health services to disabled people if they were
to seek help in the WVI counseling centers.
7.1.2
Cambodia Trust
Cambodia
Trust Rehabilitation Project is located in Calmette Hospital and provides
humanitarian assistance to disabled people in Cambodia. It has developed a
long-term Khmer staffed Prosthetic/Orthotic service. At present, is has three
rehabilitation clinics in Kampong Som, Kampong Chnang, and Phnom Penh, that
focus on prosthetic services and physical therapy. In addition to a school for
Prosthetics and Orthotics, they have outreach services for children with
artificial limbs, to ensure that there are no problems with the devices.
Cambodia Trust recently developed a new re-integration program to help disabled
persons with employment and education. Cambodia Trust serves about 1000 clients
per year. Although it does not provide any mental health services and has no
referral system, the organization is planning to start some activities in this
field in the near future.
7.1.3
Handicap International
Handicap
International is working toward the development of a holistic approach of
services for disabled people by focusing on four specific programs. The
services of HI are not limited to people with a particular type of disability:
the organization provides services to all disabled persons in the target areas.
The four programs include an Orthopedic Program, a Physical Treatment Program,
a Program for Economic and Social Rehabilitation, and a Capacity Building
Program of People with Disability in the Community. The Economic and Social
Rehabilitation Program focuses on the provision of therapeutic and economic
support by setting up income generating activities, giving access to grants,
vocational training and job placement. HI provides counseling to their clients,
with the aim to stimulate self-autonomy and create a positive image of oneself
as a productive person. HI also refers people to appropriate services that are
available in the province: the organization seems well aware of the existence
of organizations providing mental health services. Another activity is
awareness raising in the communities and society at large.
7.1.4
Veteran International
Veteran
International works with disabled people, but does not make a distinction
between disabilities due to landmine accidents and disabilities due to other
causes. It was set up in 1991 to assist war victims, but later on decided to
focus on disabled people in general. The organization provides prosthetics,
orthotics, physical physiotherapy, wheel chairs, and follow-up services. It
serves around 1000 clients annually; the percentage of landmine survivors among
them is unknown. VI established three centers, one in Phnom Penh, one in Prey
Veng, and a small one in Preah Vihear. The first two centers are basically
physical rehabilitation centers, whereas the one in Preah Vihear focuses on
income generation for female landmine survivors. VI does not have mental health
services for disabled clients. The organization refers children who need mental
help to the Ta Khma hospital. VI is not aware of any organization specialized
in providing mental health services.
7.1.5
Cambodian Disabled People's Organization
CDPO is a local NGO, a social movement and membership organization working for and run by disabled people. It is an advocate group that puts together a voice for the disabled people in Cambodia. CDPO has 260 full members, and is represented in 18 provinces, serving in total around 1000 disabled people. They recently established sections in Kampot, Bantey Meanchey, and Svay Rieng. The organization acts as the lead agency for collaboration with the Australian Embassy, Australian Red Cross, Australian Volunteers International (OSB), Action on Disability and Development (