Trauma Healing Initiative: Cambodia

Building a culturally appropriate healing network Carol White The Center for Victims of Torture Oct. 31, 2007

Project charge

To address the high levels of trauma in Cambodia Poverty Domestic violence Community violence and exploitation Depression, alcohol abuse, PTSD

What model to choose?

• Direct services with a training component?

• Training community mental health workers?

• Professional education?

• Support a torture treatment/human rights organization?

Project Context

Problems

• Currently one of the poorest countries • 80% of population engaged in rural subsistence farming • Trauma is a public health problem.

– Older generation – New levels of violence • Rampant government corruption, land-grabbing and use of violence and intimidation

Project Context

Assets

• At peace for over 15 years • Active civil society and many NGOs • Rapid economic growth • Strong family systems • A budding mental health infrastructure

A culture of impunity

• No legitimate war crimes trials have been held since Pol Pot times • No truth and reconciliation process • Former Khmer Rouge and KR victims live side by side; many local officials are former khmer Rouge • After 30 years a tribunal has now been authorized, to last 3 years and prosecute up to 6 top leaders, starting in 2007 Exhumed skulls from the “killing fields”

The model we chose

Trauma Healing Initiative Strategy

1. Training of trainers 2. Community outreach & education strategies 3. Training the Network 4. Network model development

Steps in the planning phase

Our first challenge: Setting the stage

• Is it feasible? • How can we position the project to get the broadest support? • Who should lead the effort in Cambodia?

Feasibility assessment

• Met with 20 organizations • 30 key informants • Explained project concept

Mapping networks of support and healing for communities affected by torture War crimes documentation Media for public education Local health NGOs & village health workers Schools War crimes tribunal Spiritual healers Public clinics & hospitals Traditional healers

Trauma survivor, family & communities

Training institutions Human rights environment Community leaders & community support International health NGOs Ministry of health Human Rights NGOs

Get National Program for Mental Health congruence & blessing • Dr. Ka Sunbaunet, Director • 20-year mental health plan • Interest in participating • Congruent with plan

Assess relevance to upcoming Khmer Rouge trials (ECCC) • Royal Government of Cambodia task force • Helen Jarvis, special advisor

Choose implementing partner • TPO Cambodia – MOU/subgrant – scope of work – Hire coordinator And the partner chooses us.

Bring potential core group agency leaders together for the “call”

Our next challenge: Engaging partners in the project

• Engage individual clinicians • Get buy-in from agencies • Build knowledge & trust in CVT and among individuals

Engagement tactics

• International training events • Start regular meetings to share cases and decide training topics • Help review project plan • Social time

A core group of clinicians begins to meet monthly from 9 organizations • Trafficking victims • Human rights/torture clients • Extreme domestic violence/rape clients • Government psychiatry • University psychology department • Children’s mental health • Community mental health/training/trauma treatment • Khmer Rouge anti-impunity and documentation • Cambodian returnees from the U.S.

Progress in the implementing phase

The next challenge: How to train the Core Group of Clinicians

Expert trauma training consultant living in-country for one year • In-depth training in psychotherapy(150 hours to date) • Case consultation and observation • Agency consults as requested • Pilot curricula for future manualization

The next challenge: How to sustain and deepen the learning ?

• Create treatment and training manuals • Continue expatriate consultancy as long as possible • Incent organizational experimentation & service enhancement • Encourage collaboration among partner agencies

Examples of collaboration among partners

• Department of psychology • National Program for Mental Health • NGO requests for assistance • 5 requests for service enhancement subgrants

By the end of four years, THI hopes to have:

• Trauma treatment and training manuals • Piloted public education strategies • A core group of multi-disciplinary Cambodian clinicians who can train others • Piloted innovations in ongoing clinical supervision and training • A trauma clinic functioning in Phnom Penh that cares for torture survivors and serves as a training site

By the end of four years, THI plans to have:

• A functioning network of agencies and individuals in one urban and one rural area. • Ongoing relationships between clinical providers serving torture/trauma survivors and human rights organizations • A means of tracking and evaluating the level of impact the network is having on reaching and serving the target population.

Overall challenges with this model of capacity-building

• Low control vs. buy-in and low cost • Potential for high impact & sustainability—but • High risk for failure • How can technology help in low resource/tech savvy environment?

• Is there a “tipping point” when local agents continue to collaborate and train on trauma treatment ?

Opportunities: a brighter future for Cambodia !

Summary

International Services International Capacity Building Trauma Healing Initiative

Context Scope Control Culturally appropriate Cost Evaluation Local buy-in Sustainability The model chosen must fit the country context: culture, resources, potential for local control & broader impact Training & direct services: Local scale Training & OD: One indigenous institution with torture/human rights focus Training only: Potential for reaching many agencies & governmt health structure Low Low-medium High Direct long term supervision makes adaptation of western therapy models to indigenous culture easier High High control & direct services makes evaluation easier Run by local professionals Professional core group is consulted, but lack of direct services makes

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ing this difficult Low Self report & consultant monitoring Low Classroom evaluation & some work observation Indigenous staff of CVT Hard, because of cost & INGO model One institution Medium: Need to find other funders Implementing partner, partner agencies, core group of clinicians High potential: Depends on buy-in & appropriateness of training