Subject: SMH: Country On A Couch

Country On A Couch Paola Totaro

06/24/2000 Sydney Morning Herald Page 30

A pioneering treatment service for victims of trauma torture was opened by Xanana Gusmao in Dili last week. Paola Totaro reports on the crack team of Australian counsellors hand-picked to train locals.

IT IS a still, starry night in East Timor and up on the hill above the gut-wrenching devastation of Dili, candles flicker softly in the shell of an old hall. The generator has shuddered to a halt and cloaked only in heat and moonlight, the sagging pillars, crooked verandas and cracked walls of the Lahane nursing school lose their squalor, hinting at an architectural grace now long gone.

A toddler, excited by the flurry of visitors huddled around pools of candlelight, squeals as his mum carries platters of fragrant spiced rice and noodles to the trestle tables inside. Two tiny piglets, fat, gleaming and roasted especially for the occasion, take pride of place.

There are 30 or so men and women gathered, a varied lot, many young, some old, many East Timorese, a few Portuguese, many more Australian. Chatting above the cicada din, they are here to take on an overwhelming, imponderable challenge.

While the United Nations Transitional Administration in East Timor (UNTAET), the World Bank and myriad aid agencies struggle to rebuild the infrastructure of this shattered nation, the group have gathered to find ways to help the East Timorese people reconstruct something far less tangible the psychological health of the thousands of men, women and children who have lost literally everything.

As you drive through the streets of Dili, the extent of destruction is beyond words. Nothing combustible remains standing. Walls fight gravity, unsupported by wooden beams or roofs. Architraves and doorways are all burnt. Not a home, a shop, a public building escaped the onslaught of the militias and their fires. In the middle of town, only the cathedral and marble-clad Indonesian government building occupied by the military during the uproar and now home to UNTAET remain unscathed, brutal testimony to the selective nature of the destruction. Dust clouds rise as trucks and mopeds weave through town, settling like a shroud on everything.

And yet, along every road and laneway, beside burnt-out homes and in front of what were once shops, row after row of tiny, newly built shacks are emerging from the rubble. Built of soot-coated corrugated iron, freshly hewn logs and rusty metal scavenged from demolition sites, the shacks, all tiny, nascent businesses, are symbols of the return to life and the great resilience of the citizens of Dili. In some shacks, pyramids of green and orange tangerines are displayed meticulously on wooden benches while others show off great mounds of freshly picked greens or bananas.

On the main road outside a slightly bigger hut, two young men suck avidly on plastic tubing, transferring fuel from a giant round barrel into numerous ancient-looking drums: witness the rebirth of a service station. Along another road beside the sea, an old man wields a machete with heart-thumping precision, hacking fresh coconuts to yield soft flesh and cool juice to heat-ravaged soldiers and passing aid workers at $1 a pop.

For Professor Derrick Silove, director of the University of NSW's psychiatry research and teaching unit and one of the people gathered in the nurses' hall up on the hill, these are all hallmarks of what his profession calls the phenomenon of ``adaptation'' the seemingly inexplicable ability of most humans to survive and recover from even the most atrocious and unspeakable horrors.

It is this skill, he tells the group, that they must harness: ``We are not here to treat people but to assist recovery. There is, of course, a lot of emotion, a lot of hurt, grief, pain but that is normal, not abnormal.

``Research shows us that even though everyone may have been exposed [to great trauma], only a small percentage become sick or psychologically disabled [or will need] intensive assistance but the rest given the right recovery environment, they will recover.''

The South African-born and trained Silove is one of the world's foremost experts in the treatment of torture and trauma. He is also a major player in the global debate on how best to provide psychological treatment for societies that have suffered humanitarian emergencies and are in the early reconstruction phase.

Disagreement in the field is ferocious and polarised: one school of thought argues that entire populations exposed to war are traumatised, in need of wide-scale therapeutic help for survival, while the other school argues that it is a Western response to turn everything into a sickness and that normative responses to human rights abuses should not be ``medicalised''.

Silove stands in the middle, pleading for a unified response. In a paper published in the April edition of The Lancet, he writes: ``It seems important to identify separate, if overlapping, sub-populations with distinctive needs: those with disabling psychiatric illnesses; those with severe psychological reactions to trauma; and the majority who are able to adapt once peace and order are restored.

``The risk of excessive dissent among mental health experts in the field is that the casualties of mass conflict may become the unintended victims of our neglect.''

Research overseas, primarily in Bosnia and the former Yugoslavia, shows that in ballpark figures, between 1 and 2 per cent of the population who have suffered war trauma will develop serious mental illness or psychosis and require acute intervention. A further 5 to 15 per cent the middle ground is probably most realistic will develop extreme responses, most commonly classified as post-traumatic stress disorder (PTSD). This group may suffer varied symptoms, from long-term debilitating depression to disrupted sleep patterns. Some may exhibit symptoms immediately; others will manifest months or even years later. The remaining 80 to 90 per cent will simply get better naturally the psychiatrists call it ``natural remission'' relying on a mixture of measures to recover, from community or family-based supports to traditional healing methods to religion or spiritual rituals or simply back to a sense of identity and routine through things such as employment.

Silove's approach suggests that with limited resources you cannot counsel an entire population the most important first steps are to identify and address the five fundamental environmental and psychological issues which are known to be conducive to assisting natural recovery.

These include addressing widespread community insecurity (usually the role of multiple agencies, including military), loss (both physical and personal), justice (anger at gross injustice must be acknowledged as a fundamental human experience), restoring a sense of identity (to communities) and a sense of meaning (in individuals). Communities need to be made safe, rebuilt physically and be shown that loss, anger, pain and grief reactions are normal, and encouraged to re-embrace cultural tools such as religion and family to ease and lessen ongoing pain.

``This is not an easy road. South Africa has followed truth and reconciliation, East Timor , hopefully, will find its own, unique way,'' Silove says.

He and his team have now joined forces with a specialist counselling team, Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS), the Australian Union of Social Workers and several hand-picked specialists from other State health departments to form the Psychosocial Recovery and Development in East Timor (PRADET). This is the first formal attempt to train East Timorese health professionals in trauma and torture counselling and to help them create a framework to address these issues and provide a mental health service.

The NSW Minister for Health, Craig Knowles, who made a low-key visit this week to hand over $50,000 to seed-fund the project, admitted that he, too, like so many who had visited Dili, felt fundamentally overwhelmed.

``The impact of what we have seen is very powerful, indescribable ... to come here after 12 hours' flying and be confronted with the most disjointed, the most overwhelming scenes of devastation ... I am confronted and overwhelmed by the enormous value of what you do,'' he told the PRADET team.

STARTTS, he told the Herald later, had earned itself a reputation worldwide in the field, treating refugees from 50 nations, most recently the Kosovars brought to NSW under Operation Safe Haven.

It seemed a natural progression then that this specialist work, much of it with East Timorese who sought asylum in Australia, be extended to provide specialist training for East Timorese doctors and health professionals. The idea finally crystallised after discussions with the Nobel laureate Jose Ramos Horta in Sydney last year.

Already, four East Timorese health workers have undergone initial training in Sydney and are back home working. Another four NSW STARTT staff who arrived this week will undertake rotating postings in Dili to continue to train locals and provide support.

Knowles observed: ``Being here, I'm reminded of a story in Solzhenitsyn's A Day in the Life of Ivan Denisovich when a power station destroyed by war had to be rebuilt in great adversity.

``Snow had to be melted to mix cement, the cold was subzero. One builder worked fast, spreading cement thinly but achieving quickly. Another wanted to work slowly and meticulously. In the end they worked together and built a wall.

``But the wall fell because amidst all the discussion no-one had checked that the foundations were secure. They were not and there was no-one trained to fix them, and so the power station never worked.''

Solzhenitsyn's message, it seems, remains pertinent halfway across the world in the tropical heat of Dili: ``You must invest in the people who will stay behind, those who will be there long after the builders have gone ... because this cannot be about just bricks and mortar.

``It is people, in the end, who regenerate their own.''

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