VOT Report: October 2004 through March 2005

The Victims of Torture Project:

Helping the Victims of the Khmer Rouge

Semester Report: October 2004 through March 2005

Reports and Evaluation. We have recently written the annual report for the project’s first year and posted it on DC-Cam’s homepage. We are also planning for the completion of all project reports and the editing of three TPO-Cambodia progress reports submitted to DC-Cam. These will be posted on our homepage as well.

At the end of this two-year project, we will ask overseas experts to evaluate the results of the project’s overall activities (both for DC-Cam and TPO-Cambodia). This evaluation will probably take the form of a research paper of about 200 pages in length.

Counseling and Treatment. TPO-Cambodia has offered counseling services since 1997 and has helped more than 1,250 people to date. Prior to delivering counseling and treatment services to the VOT project’s clients, TPO-Cambodia assesses each proposed client’s mental health status, level of functioning, and level of distress. Medical treatment is provided only to those with serious mental health disorders, while individual and group counseling is provided to those referred by DC-Cam and wish to receive these services.

This semester, DC-Cam project staff accompanied TPO-Cambodia staff on 9 trips to the field to deliver counseling and treatment in Kandal, Takeo and Kampot provinces. TPO-Cambodia provided 5 sessions of group and individual counseling and treatment in Kandal and Takeo (12 sessions are anticipated over the life of the project) and 2 of individual counseling and treatment in Kampot (6 are anticipated in total).

Table 1. First Semester, Year Two Results: Summary of Activities

1.2     Staff Training and Conferences

             1.2.1     TPO Local Training and Conferences

In February, our staff attended two local conferences organized by TPO-Cambodia. On February 9, one staff member attended a one-day conference on the “Efficacy and Cost-Effectiveness of Mental Health Care in Cambodia,” which was held at the Himawari Hotel and sponsored by the Inter-Church Cooperation Agency. On February 16, two VOT project representatives from DC-Cam attended a conference at the Juliana Hotel on “Empowering the Community through Mental Health and Psychosocial Rehabilitation – the Achievements of TPO-Cambodia in Kampong Thom Province,” which was sponsored by the Japanese International Cooperation Agency. We anticipate that TPO-Cambodia will organize additional conferences and training events for our staff members this year.

            1.2.2     Overseas Training and Conference

Two of our project staff members – Dr. Sotheara Chhim of TPO-Cambodia and Mr. Sophearith Choung of DC-Cam – will attend a five-day conference on “Psychiatry in a Changing World” at the Sydney, Australia Convention and Exhibition Centre from May 22-26. The two men will present a joint paper on the project’s activities.

In addition, we anticipate that one VOT staff member will also attend training on health and human rights at Boston University, USA, from June 20-23.

1.3     Field Interviews

In the beginning of 2005 we developed a questionnaire on survivors’ views on justice and reconciliation. We categorized our questions in five parts: Khmer Rouge leaders, the tribunal, reconciliation, revenge, trauma healing, and preserving the history of Democratic Kampuchea. We developed this questionnaire to improve the quality of our interviews and to collect as much information on justice and reconciliation as possible.

During this semester, VOT project staff members conducted 19 field trips to Kandal, Takeo and Kampot provinces. Seven of the trips were made for DC-Cam field interviews and 12 for field observations and to assist TPO-Cambodia staff during counseling and treatment.

            1.3.1     DC-Cam Interviews

During this semester, we completed 7 field trips (2 trips to Kandal, 2 to Takeo and 3 to Kampot provinces) over 34 days. As a result, we interviewed 86 people, of which 29 were identified as PTSD victims. Of these, 26 were women.

Table 2. Interviews and PTSD Victims

October 2004. Table 3 shows the results of our trip to Kandal province from October 24-28, 2004.

Table 3. October Interviews and PTSD Victims

November 2004. Table 4 shows the results of our trip to Takeo province from November 19-23, 2004.

Table 4. November Interviews and PTSD Victims

December 2004. Table 5 shows the results of our two trips to Kampot province from December 14-18 and 25-29, 2004.

Table 5. December Interviews and PTSD Victims

January 2005. Our trip results to Takeo province from January 24-28, 2005 are summarized in Table 6.

Table 6. January Interviews and PTSD Victims

February 2005. Table 7 summarizes the results of our February 2-5, 2005 trip to Kandal province.

Table 7. February Interviews and PTSD Victims

March 2005. Our March 14-18, 2005 trip to Kampot province is summarized in Table 8.

Table 8. March Interviews and PTSD Victims

            1.3.2     TPO-Cambodia Interviews

DC-Cam project staff accompanied TPO-Cambodia to the field in three provinces. We spent two days per month in each province.

November 2004. Prior to TPO-Cambodia’s provision of counseling and treatment, we accompanied their staff members to the field in Kandal and Takeo provinces on November11-12. This trip was held to familiarize our staff with various locations, to inform local authorities, and to meet members of our target group.  

On November 11, 2004 4 TPO-Cambodia therapists interviewed 8 victims (7 women and 1 man) in Tram Kak district of Takeo province. On November 12, the therapists interviewed 14 victims (12 women and 2 men) in Kandal Stung district of Kandal province. This two-day trip was taken to assess mental health status, levels of functioning and distress among our clients.

December 2004. On December 8-9, we conducted two-day field trips with five TPO-Cambodia staff members to Kandal and Takeo provinces for the purpose of assessing mental health status, levels of functioning and distress. With DC-Cam staff acting as observers, TPO-Cambodia staff members interviewed 8 victims (7 women and 1 man) in Takeo province on December 8, 14 victims (12 women and 2 men) in Kandal province on December 9.

On December 30, we accompanied TPO-Cambodia staff on trips to Kandal and Takeo provinces. TPO-Cambodia interviewed 3 people in Tram Kok district of Takeo province and 7 people in Kandal Stung district of Kandal province.

January 2005. On January 5-6, we conducted a two-day field trip with TPO-Cambodia staff members to Kandal and Takeo provinces. On January 5, TPO-Cambodia interviewed 4 victims for assessment; subsequently, 1 victim in Kandal was provided medication. For the purposes of later group counseling, TPO-Cambodia introduced its staff and described their activities in dealing with mental health problems. Those interviewed expressed reluctance to take part in group counseling because of their harvest season activities.

As the result, we decided to form two groups for counseling in Kandal; one with 6 victims and the other with 7. At the end of the session, the people attendance expressed their interest. On January 6, before counseling began in Takeo province, TPO-Cambodia interviewed 1 victim for assessment and provided medication to 3 others. One group was slated for counseling in Takeo; it consisted of 12 victims (2 men and 10 women). Most of them had used metal health services from the Outpatient Psychiatric Department at the provincial hospital.  

From January 12-13, our staffs took a two-day trip with to Kampot province to introduce DC-Cam and TPO-Cambodia, and to assessment potential clients. We divided into two groups to and took TPO-Cambodia staff to meet 6 victims DC-Cam had identified as suffering from PTSD. However, we were only able to meet two victims (the others were working away from home); both were interviewed by TPO-Cambodia. After assessment, medication was provided to both.

Last, from January 20-21, we visited Kandal and Takeo provinces to administer individual counseling and treatment. On January 20, TPO-Cambodia staff first let people speak about their past experiences and present feelings. After interviewing 2 victims, TPO-Cambodia suggested that one join group therapy. We also took a TPO-Cambodia doctor to meet 4 victims who had already been interviewed for assessment. The doctor provided medication to 5 people. TPO had given one of them medicine before, but he became sick and stopped using it. TPO decided not to give this victim more medicine until he improved. In Kandal, we divided 25 PTSD victims into three groups: one with 10 women, one with 6 women, and one with 2 men and 7 women. On January 21, TPO-Cambodia staff interviewed one victim for assessment and recommended that she join group therapy. 

February 2005. From February 3-4, we went to Kandal and Takeo provinces with TPO-Cambodia to educate people about trauma and to modify catastrophic cognition (the second of the 12 planned sessions). With DC-Cam staff acting as observers, TPO-Cambodia interviewed 3 victims for assessment and 3 for individual counseling and treatment on February 3. They also provided medicine to 10 victims in Kandal province and helped 2 people with mental health problems (a husband of our client and one of their neighbors). On February 4, TPO interviewed 4 victims for assessment and provided medication to 10 people in Takeo province. 

From February 10-11, we DC-Cam and TPO-Cambodia visited Kampot province for the first session of individual counseling. Our staff split up into two groups in order to meet 5 PTSD victims who DC-Cam had identified, all of whom were interviewed by TPO-Cambodia staff. Some medication was also provided after the interviews and counseling.

Last, from February 16-17, our staffs traveled to Kandal and Takeo provinces for the third of 12 sessions of group and individual counseling and treatment sessions. This aim of this trip was to introduce muscle relaxation and visualization to those being counseled.

March 2005. On March 3-4, we accompanied TPO-Cambodia to Kandal and Takeo provinces. These trips were undertaken to introduce distressed individuals to muscle relaxation techniques. On March 3, TPO-Cambodia staff members provided individual counseling to 4 victims and medication to 3 people in Kandal. We also held three group counseling sessions in Kandal. One victim who was traumatized during Democratic Kampuchea and had earlier refused to talk to our team was given medication by a doctor from TPO-Cambodia. On March 4, TPO-Cambodia held 2 group counseling sessions and 3 individual counseling sessions in Takeo province.

On a March 10-11 trip to Kampot province, we introduced our team, and assessed several potential clients’ mental health status and levels of functioning and distress. Our staffs divided into two groups to meet 6 PTSD victims DC-Cam had identified. Four of our potential clients were farming away from home; as a result, TPO was able to interview 2 people, to whom it also provided medication.

Last, on March 17-18, we traveled to Kandal and Takeo provinces to teach people about the process of remembering trauma. TPO held 4 counseling sessions for individuals and 2 for groups in Kandal on March 17, and 2 group and 3 individual sessions in Takeo on March 18. We were accompanied by three journalists (one from the French-language newspaper Cambodge Soir and two from Associated Press) on this trip. They observed and interviewed four people in Kandal province who we had identified as PTSD victims.

1.4     Documentation

This semester, we transcribed 3800 pages encompassing 211 audio cassettes from 108 interviews, which included 22 of the 34 interviews we conducted between January and March. For filing, we registered 67 trauma questionnaires, 304 photos, 163 recorded cassettes, and 211 transcriptions. Moreover, we made 119 data entries and listed 86 interviewees (victims with and without PTSD). All of data entries will be posted on our website. In 2005, our volunteers will translate the interviews into English for research purposes.

            1.4.1     Transcription 

We transcribed 24 interviews (978 pages) from Kandal province this semester, 53 (1902 pages) from Takeo, and 31 (920 pages) from Kandal province. Tables 9 and 10 show the transcription results for the first semester; they are organized by province and month.

Table 9. First Semester Results: Cassettes and Transcriptions by Province

Table 10. First Semester Results: Cassettes and Transcriptions by Month      

            1.4.2     Filing

This semester we filed and registered 72 trauma questionnaires, 304 photos, 163 recorded cassettes, and transcriptions from 211 cassettes. This included 22 of the 34 interviews we conducted between January and March 2005. Moreover, we made 119 data entries and listed 86 interviewees. All of the data entries will be posted on our website. In 2005, our volunteers will translate the interviews into English for research purposes.

Table 11. First Semester Results: Filing Activities

            1.4.3     Data Entry and VOT Library

Transcription has been time consuming due to the large number of cassettes recorded. We thus had little time to enter data before transcribing the interviews. During the first year, we entered 25 records into our project library/database using Microsoft Access. However, we encountered a number of difficulties, such as the inability to print out discrete data, and decided it was necessary to first determine what kinds of information would be useful to enter. After much discussion in September, we agreed to create a manual for the VOT project’s data entries.

Table 12. Composition of the VOT Database/Library

Based on the requirements for this manual, we made 119 data entries into the VOT project’s library/database this semester. They covered 30 interviews in Kandal, 52 in Takeo, and 37 in Kampot. After all the transcriptions are complete, we will post all our data entries on DC-Cam's homepage.

Table 13. First Semester Results: Data Entries and PTSD Victims

1.5     Reports and Evaluation

            1.5.1     Reports

Initially, we anticipated writing 8 quarterly and 2 annual reports for the project. Unfortunately, we failed to prepare them because our staff members were tied up with interview transcription. We thus modified our plan and will now prepare two semester reports and a final report. We recently wrote the annual report for the project’s first year and posted it on DC-Cam’s homepage.

DC-Cam Reports. We are working to complete all of the project’s semester reports and have edited and posted three of TPO-Cambodia’s progress reports. In addition, we have completed the project’s first annual report and posted it on our homepage.

TPO Reports. TPO-Cambodia staff members have submitted 3 of the 5 required progress reports to date.

            1.5.2     Evaluation 

After receiving training from TPO-Cambodia, DC-Cam’s VOT staff have been able to identify traumatized individuals more accurately and easily. We are also formulating ideas to help our interviewees cope with their emotional reactions over the course of our work. In addition, we have become more sensitive to trauma issues during our interviews, making us better able to find ways of supporting and helping people we encounter with PTSD.

Observers from TPO-Cambodia have found that our VOT project staff members have become very sensitive to the issues related to traumatic events, including their causes and emotional responses from the people we interview. Also, when interviewees appeared distressed, we taught them breathing and relaxation exercises.

At the end of this two-year project, we will have overseas experts evaluate the project’s overall activities. The evaluation will probably take the form of a long (about 200 pages) research paper.

1.6     TPO-Cambodia Trauma Counseling and Treatment

Before providing counseling and treatment, TPO-Cambodia interviews potential clients in order to assess their mental health status, level of functioning, and level of distress using such standardized questionnaires such Short Form-12 (SF12), Mental Health Inventory-5 (MHI-5), General Health Questionnaires (GHQ), and WHO-Disability Assessment Schedule 12 (WHO-DAS-12).

Counseling and treatment began in January 2005 and will continue through September 2005. This semester, TPO-Cambodia conducted 6 group and individual sessions in Kandal and Takeo provinces, and 3 individual sessions in Kampot province. These sessions aimed to educate people about trauma, help them reflect on their traumatic experiences and reaction to trauma, teach them breathing exercises and Buddhist concepts (mindfulness) to deal with physical and emotional symptoms, teach them progressive muscle relaxation, give them supportive psychotherapy, and desensitize and rehabilitate PTSD victims. Of the 64 potential PTSD victims identified by DC-Cam, 60 have been interviewed and all 64 received group or individual counseling. The 29 determined to have PTSD were provided psychiatric treatment; some were also given multi-vitamins (in cases where a person’s mental health status is very unstable, they are given psychiatric medications).

DC-Cam assisted TPO-Cambodia by taking notes on the group therapy sessions. Usually, after each session we asked questions about issues encountered. TPO-Cambodia’s answers have enabled us to learn about therapeutic techniques.

2. Achievements, Challenges AND Impacts

2.1     Achievements

The people treated by TPO-Cambodia have reported that they feel their symptoms have decreased, and they are experiencing a greater level of confidence and improvements in their daily functioning. The majority of our interviewees have been disturbed by problems related to earlier traumatic events. The most common problems identified were PTSD, panic disorders, generalized anxiety disorder and depression. Their symptoms included headaches, shortness of breath/chest tension, cold limbs, exhaustion, poor sleep, disturbing dreams, irritation, poor concentration, and jumpiness. Most were easily angered and avoided situations that remind them of past traumatic events. This interfered with their daily functioning (e.g., ability to work, social relationships). Most of the victims now understand that their difficulties are related to what they have experienced, especially during the Khmer Rouge regime.

2.2     Challenges

At the project’s onset, we planned to interview 388 people in 194 days. In the first year, our goal was to interview 238 people in 119 days. Unfortunately, we could spend only 101 days in the field and interviewed only 144 people owing to the initial reluctance on the part of Koh Sla villagers and former Khmer Rouge cadres to cooperate with the project. A few people were also occupied by farm or other work and thus hesitated to participate in the project. In addition, funding for the project was not released until January 2004, which delayed the interviews. Forty-nine of those interviewed were identified as victims of PTSD and were referred to TPO-Cambodia.

In the second year, we planned to interview 150 people in 75 days. However, in order to come closer to our original goal, we added 18 more days of field trips to the second-year plan. Thus, we will be in the field for 93 days and anticipate that we can interview 186 people in the second year of the project. This will bring the number of people interviewed by the project to 330.

Our revised proposal to USAID (July 10, 2003) stated that DC-Cam would refer 10 to 15 PTSD victims to TPO-Cambodia each year. This semester, TPO-Cambodia and DC-Cam discussed how the project could provide counseling and treatment to as many victims as possible. We agreed that TPO would counsel and treat 49 PTSD victims, which DC-Cam had identified in the first year of the project. This semester, we referred 9 more victims, bringing the total to 58. TPO-Cambodia agreed to treat them, but was experiencing difficulties with this number because some of the people slated for treatment live in remote areas. We solved this problem by agreeing to exclude those living too far away, identifying more PTSD victims who lived near other victims, and focusing on group therapy. Individual therapy is only provided to a few people who live in remote areas and are unable to join group therapy.

As a result of these actions, DC-Cam has now referred 64 victims to TPO-Cambodia for counselling and treatment. No others will be referred because TPO-Cambodia’s human resources are already at their limit and it does not have the capacity to treat more victims. However, DC-Cam will continue to identify and interview PTSD victims next semester in the hopes that TPO-Cambodia will hire additional staff or find volunteers who are able to treat them.

Group or individual therapy is a concept adapted from the West and is new to many Cambodians. Thus, it may be difficult for them to accept. It took TPO-Cambodia staff members a long time to build trust among the participants. Some participants live far away from others, which also makes it difficult for them to attend group therapy. In addition, long distances and poor road conditions also make it difficult for TPO-Cambodia staff members to see participants often (round trips to project sites range from 3 to 6 hours).

Despite these challenges, the group therapy has been well received and improvements in symptoms have already been seen. As symptoms have improved, the villagers have learned to trust both the therapy and therapist. This has led to further disclosure of past traumatic experiences.

2.3     Impacts

Client Trust. As the project progresses, we have seen trust build between former Khmer Rouge soldiers/cadres and VOT project staff members. One reason for this has been our distribution of DC-Cam's monthly magazine in the project area and our broadcasts of stories on the Khmer Rouge regime on Kampot provincial radio. In addition, we have provided books and magazines to the UNESCO office and mobile libraries, which were recently established in Trapaing Plang and Ta Ken sub-districts where many Khmer Rouge defectors live.
 

Demand for Project Services. Most of the PTSD victims we identified have acknowledged their problems and that they need help from TPO-Cambodia. This is especially true of the victims we identified in Lay Bo sub-district of Takeo province and in Prek Rokar sub-district of Kandal province. Some of them have already begun to ask us when TPO-Cambodia is coming to support them. They also asked if we had any anti-depressant medication. Their hope is that the sooner TPO-Cambodia comes, the more their mental health will improve and the higher the odds are that they can begin to resume normal lives.
 

Value of Interviews. We have learned that interviews allow victims to talk about the painful events they experienced during the Pol Pot regime. Therefore, interviews help the victims attain some measure of relief.
 

Liaison with Other Organizations. On November 30, two staff from the Center for Victims of Torture (CVT) – Carol White (manager of the Minnesota Training and National Capacity Building Projects) and David R. Johnson (co-medical director of psychiatry) – arrived in Phnom Penh. They were introduced to DC-Cam’s VOT project by Danuta Lockett of USAID/ Washington. CVT also receives VOT funding and works on international capacity building at torture rehabilitation centers worldwide.  They are starting a new project in Cambodia to strengthen mental health services for trauma/torture survivors. Ms. White and Dr. Johnson asked several questions regarding our project and were especially interested in our field interviews. They also asked about the interview process, difficulties during interviews, our views on the Khmer Rouge tribunal, and our understanding of the torture-related mental health needs of the people we work with in rural areas.

Members of an Affinity Group of documentation centers worldwide met in Phnom Penh in March. They asked several questions about our project, and collected our questionnaires for study and consultation.

Client Responses. One of our patients from Kandal expressed her happiness as a result of our treatment and after joining in an Affinity Group luncheon with other former prisoners and guards at S-21 in March.

Most of our clients have told us that they have been feeling 50% better as a result of our counseling and treatment. Our team members have also observed that victims are more confident in talking to journalists than when we first met with them.
 

Neighbors of the people we treat increasingly come to us for help when they learn about the project. At least ten people requested project assistance this semester.

Media Coverage. Several representatives of the media wrote articles on the VOT project and accompanied us on field trips this semester.
 

Team Leader: Sophearith Chuong, truthsophearith@dccam.org