psychosocial needs assessment of communities Psychosocial Needs...“A Psychosocial Needs Assessment...

psychosocial needs assessment of communities affected by the conflict in the districts of pidie, bireuen and aceh utara

2006

i foreword from the ministry of health of indonesia

ii foreword from syiah Kuala university

iii foreword form the embassy of canada

1 acknowledgements

2 executive summary

2 ProjectDesign

2 KeyFindings

4 Recommendations

6 introduction and background

8 research design and methodology

8 TheResearchTeam

8 StudyDesign

10 FieldResearchTeamsandInvitationstoParticipate

11 demography of respondents

11 QuestionnaireRespondents

12 KeyInformants

14 traumatic events

14 TraumaticEventsDuringtheConflict

16 GenderedTrauma

18 VariationbyDistrict

18 ForcedEvacuationsandOtherPopulationDisplacements

19 ExperiencedEventsDuringtheTsunami

19 InsecurityofDailyLivingPost-Conflict

22 depression, anxiety and traumatic stress disorders

22 MeasuresofPsychologicalDistressandNeuropsychiatricDisorders

23 AnalysesofPsychologicalSymptomsandPsychiatricDiagnoses

25 SymptomFindings

27 TheDistributionofRisk:WhatGroupsAreatHighestRisk?

32 TheEffectsofTraumaticExperiencesonPsychologicalDistress

34 HeadTrauma

38 local idioms of distress

39 DreamsandSpirits

42 community mental and psychosocial health

44 ExperiencesofCommunityLeaders

46 EffectoftheTsunami

46 ResilienceandResponse

48 TraditionalMedicineinAceh

49 CommunityOpinions:WhatShouldBeDone?

51 CommunityPerceptionsofNGOsandPublicHealthServices

52 PublicHealthProviderPerceptionsofConflict-AffectedCommunities

52 ChildrenandYouth

53 OnthePeaceProcess

55 recommendations

55 TheCommunityMentalHealthNursingProgram

55 MentalHealthOutreachTeamsforConflict-AffectedCommunities

56 FamilyOutreachPrograms

56 EvaluationandCounselingonHeadTrauma

57 IntegrationwithOtherHealthServices

57 IntegrationofPsychosocialandLivelihoodDevelopmentPrograms

57 TheImportanceofInnovationandEvaluation

57 LocalizedImplementation

table of contents

11 Table1.1 DemographicsofStudyParticipantsByGender,Residence,Age

11 Table1.2 DemographicsofStudyParticipantsByMaritalStatus,Schooling,andHousing

12 Table1.3 DemographicsofKeyInformantsByGender,Residence,Age

13 Table1.4 DemographicsofKeyInformantsByMaritalStatus,Schooling,andPositioninCommunity

14 Table2 PastTraumaEventsExperienced,byGenderandDistrict

15 Table2 (cont.)PastTraumaEvents

16 Table3.1 HeadTrauma/PotentialBrainInjuryBySexandRegion

17 Table3.2 PastRape&SexualAssault,CurrentGenderViolence,&HomeDestruction,bySexandRegion

19 Table4 PostConflictStressorsandInsecuritiesofDailyLiving

20 Table4 (cont.)PostConflictStressorsandInsecuritiesofDailyLiving

24 Table5.1 HSCL-DepressionCategories

25 Table5.2 HarvardTraumaQuestionnaireCoreCategories

25 Table6.0 GeneralEmotionalDistressandConflict

26 Table6.1 DepressionbyGenderandDistrict

26 Table6.2 TraumaSymptomsandPTSDbyGenderandDistrict

26 Table6.3 AnxietySymptoms,byGenderandDistrict

27 Table7.1 AdjustedOddsRatiosforDepressionandPTSDbyDistrict

28 Table7.2 AdjustedOddsRatiosforDepressionandPTSDbyGender

28 Table7.3 AdjustedOddsRatiosforDepressionandPTSDbyAge

29 Table8.1 Pidie:DepressionbyGenderbyAge

30 Table8.2 Pidie:PTSDbyGenderbyAge

30 Table8.3 Bireuen:DepressionbyGenderbyAge

31 Table8.4 Bireuen:PTSDbyGenderbyAge

31 Table8.5 AcehUtara:DepressionbyGenderbyAge

32 Table8.6 AcehUtara:PTSDbyGenderbyAge

32 Table9.1 MentalHealthMeasures(OddsRatios)forRespondentsExperiencingPastTraumaticEvents-Unadjusted

33 Table9.2 MentalHealthMeasures(OddsRatios)forRespondentsExperiencingPresentStressfulEvents-Unadjusted

35 Table9.4 HeadTrauma/PotentialBrainInjury:PercentofRespondentsbyGenderandAge

35 Table9.5 HeadTrauma/PotentialBrainInjury:PercentofRespondentsByGenderandAgeforBireuen

36 Table9.6 HeadTrauma/PotentialBrainInjury:PercentofRespondentsbyGenderandAgeforAcehUtara

37 Table9.7 IncreasedRiskforDepressionorPTSDforPersonsSufferingHeadTrauma(AdjustedOddsRatios)

42 Table10.1RespondentPerceptionsofMentalIllnessintheCommunityandatHome

44 Table10.2RespondentSelectionofGroupsintheirCommunitySufferingMostfromConflict-RelatedStressorTrauma

47 Table10.3HelpSeekingBehaviorDuringthePastSixMonths

51 Table10.4OpinionsaboutNGOMentalHealthServicesandImplementingPartners

53 Table10.5 AttitudesTowardthePeaceProcess

list of tables

“APsychosocialNeedsAssessmentofCommunitiesAffectedbytheConflictintheDistrictsofPidie,BireuenandAcehUtara”/September20064

foreword

ForewordfromtheMinistryofHealthofIndonesiaForewordfromSyiahKualaUniversityForewordfromtheEmbassyofCanada

“APsychosocialNeedsAssessmentofCommunitiesAffectedbytheConflictintheDistrictsofPidie,BireuenandAcehUtara”/September2006 i

foreword from the ministry of health of indonesia

TheIndonesianProvinceofNanggroeAcehDarusalam(NAD)isaregionwhichisfacingauniquesetofproblems,amongwhich

istheprotractedinternalconflict,exacerbatedbythetsunamionDecember26,2004.

These events have generated a widespread impact on the lives of the communities. One of the most crucial issues to be

addressedasidefromlegal,security,socialandeconomicproblemsisthematterofhealth,includingmentalhealth.

We are joyous that we have left the these difficult times, and it is now our obligation to restore aspects of life that would

otherwisebringadverseeffectonthepeople,includingthelingeringeffectsofsuchevents.

In regards to health issues, comprehensive steps have been formulated into various short-, medium-, and long-term

programs.

Specificallyonmentalhealthissue,whoseimpactisquitesignificant,theIndonesianMinistryofHealthhascollaboratedwith

the NAD government and national as well international NGOs.With this aim in mind, a comprehensive mental healthcare

modelhasbeendesignedandcommenced,targetingnotonlyregionsaffectedbythetsunami,butalsootherprovincesin

whichthismodelmayserveasreferenceindevelopingmentalhealth.

Therefore,weareveryhappytoseetheorganizingofthispsychosocialneedassessmentinPidie,BireunandAcehUtaraunder

acooperationbetweentheInternationalOrganizationforMigration(IOM),theDepartmentofSocialMedicinefromHarvard

MedicalSchoolandtheSyiahKualaUniversity(SKU).

Iamconvincedthattheoutcomeofthisassessmentisinlinewithandsignificantlycontributetotheprogramsthatweare

currentlydeveloping,suchasthecapacitybuildingprojectintheformoftrainingsforcommunityhealthcenterandhospital

physiciansat thedistrict level,aswellas thedevelopmentof theCommunityMentalHealthNursing (CMHN)concept. It is

hopedthatthispartnershipwillbefollowedbyotherprograms.

Toallthepartieswhohavemadethisundertakingareality,Iexpressmyhighestappreciation.

LetushopethatitwillbringgreatbenefittotheAcehneseinparticular,andtheentireIndonesianpeopleingeneral.

MayGodtheAlmightygrantHisblessinguponusall.

DR.Dr.SitiFadilahSupari,Sp.JP(K)

MinisterofHealthoftheRepublicofIndonesia

“APsychosocialNeedsAssessmentofCommunitiesAffectedbytheConflictintheDistrictsofPidie,BireuenandAcehUtara”/September2006ii

foreword from syiah Kuala university

Thisreportrepresentsthefirstempiricalandsystematicsurveyoftheexperiencesofcommunitiesthatsufferedhighconflict

priortotheAugust15,2005signingoftheMemorandumofUnderstandingbetweentheGovernmentofIndonesiaandthe

FreeAcehMovementinitiatedthepeaceprocess.Itisthefirstattempttostudytheconsequencesoftheconflict,focusingon

thePsychosocialNeedsofCommunitiesAffectedbytheConflict.Thesurveywascarriedoutbyateamofresearchersrecruited

bythePusat Pengembangan Studi Kawasan(RegionalStudiesDevelopmentCenter),UniversitasSyiahKuala,incollaboration

withSeniorResearchersfromtheDepartmentofSocialMedicine,HarvardMedicalSchool,andsupportedbytheInternational

OrganizationofMigration(IOM),Indonesia,anditsBandaAcehoffice.FieldresearchwascarriedoutinthedistrictsofPidie,

Bireuen,andAcehUtaraduringFebruary2006.

Thesurveywasspecificallydesignedtoassessandevaluatethepsychologicalandmentalhealthconditionsorproblemsof

communitieswhohavebeenverymuchaffectedbythearmedconflict.However,theunderlyinggoalofthisstudywastolearn

andunderstandasmuchaswecouldaboutsuchissuesinordertoprovideabasisforpolicyjudgments.

Onemajorfindingofthestudyisthatthesesurvivorsoftheconflictexperiencetrauma,highlevelsofdepression,andmental

healthproblems,inadditiontoinadequateresourcesoflivelihood.However,theconsequenceswerenotequallydistributed

amongthethreeDistricts.Oncertainquantitativemeasures,thedistrictofPidie,thehomeofthenumberoneleaderofGAM,

sufferedlesscomparedtotheothertwodistricts.

Individualexperiencerelatedtotheconflictvariesfromonepersontoanother.Themajorityofthecommunitiesneedsome

professionalhelpfortheirtraumaandmentalhealth;theyneedhelptocopewiththeirsociallife,andtheyneedeconomic

resources.Inotherwords,theseunfortunatepeopleneedhealingofthedeepscarsintheirheartinflictedbyaconflictnotof

theirmaking.

Therefore,thismanuscriptisnecessaryfortheGovernor,membersoftheDPRD,theMinistryofSocialWelfare,andtheMinistry

ofHealthtoreadanduseasabasisforjudgmentintheirpolicyanddecision-makingprocess.Alongthesameline,findings

ofthisreportshouldbeofconcerntolocalaswellasinternationalNGO’s,donors,theacademiccommunityinAceh,andany

individualwhofeelsconcernedaboutthismisfortune.

ProfessorBahreinT.Sugihen

SyiahKualaUniversity

“APsychosocialNeedsAssessmentofCommunitiesAffectedbytheConflictintheDistrictsofPidie,BireuenandAcehUtara”/September2006 iii

foreword from the embassy of canada

ThepastyearhasbeenamomentousoneforAceh,asthefoundationforalastingpeace,fornewfoundautonomyandfornewly

democraticinstitutionshasemerged.Thebeneficiariesofthispeaceprocess-whichisstillinprogress-aremanyandinclude

notonlyresidentsofAcehbutallIndonesiansaswellastheinternationalcommunity.

AlongsidesubstantialhumanitariananddevelopmentassistancetothepeopleofAcehfollowingthedevastatingtsunami,

Canadawasalsoquicktoacceptthechallengeofsupportingpost-conflictreconstructionandpeace-buildingwithinAceh.

ForthisreasontheGovernmentofCanada,throughtheDepartmentofForeignAffairsandInternationalTrade’sGlobalPeace

andSecurityFund,waspleasedtoworkwithotherpartnerstosupportthePsychosocialNeedsAssessmentofCommunities

AffectedBytheConflictintheDistrictsofPidie,Bireuen,andAcehUtaraproject.

Therecommendationsinthisreportamplydemonstratetheutilityofthisassessment,andtheneeditfilled,byprovidingthe

datanecessarytoenabledecisionsabouttheroleofhealthservicesinsupportingre-integration.Thereportalsodemonstrates

the importance of partnerships between governments, international agencies, academia, and community-based leaders in

peace-building.

It is therefore with great pleasure that I congratulate, on behalf of the Government of Canada, our partners whose efforts

producedthisinvaluablereport,addingtothetoolkitofallthosecontinuingtorebuildapeacefulanddemocraticAceh.

RosalindColeman

Chargéd’affairesa.i.

EmbassyofCanada

“APsychosocialNeedsAssessmentofCommunitiesAffectedbytheConflictintheDistrictsofPidie,BireuenandAcehUtara”/September2006iv

acKnowledgements

The psychosocial research team at the International Organization forMigrationinBandaAcehcouldnothavecompletedthisprojectwithoutthecontributionsofthefollowingparticipants:

“APsychosocialNeedsAssessmentofCommunitiesAffectedbytheConflictintheDistrictsofPidie,BireuenandAcehUtara”/September2006 1

1. Aboveallweacknowledgethegracioustimeandbravecandorgivenby596anonymousquestionnairerespondents,75

keyinformants,and17GAMmembersfromthroughoutPidie,Bireuen,andAcehUtaradistrictswhocontributedthedata

presentedinthisreport.

2. The Center for the Development of Regional Studies at Syiah Kuala University (SKU) managed the field research, staff

training, and data entry. Professor Bahrein Sugihen was a key consultant on study design. Ibu Rosnani organized the

training,coordinatedthefieldwork,andassistedtheHarvardteaminAceh.TheCenteralsohiredaresearchstaffcomposed

oftwelvefacultylecturersfromSKU.WeacknowledgetheteamleadershipofPakAdnanAbdullah,PakNazirBasyir,andPak

HusainiDaudforleadingthePidie,Bireuen,andAcehUtararesearchteamsrespectively,aswellasalloftheinterviewerson

theproject.WealsothankPakSofyanfromSKUforhisdataentrywork.

3. TheIndonesianMinistryofHealthsupportedIOM’spsychosocialreesarchinAceh,especiallytheProvincialHealthOffice

inBandaAceh,andtheDistrictHealthOfficesofPidie,Bireuen,AcehUtaraandLhokseumawemunicipality. Themental

hospitalinBandaAcehprovidedfivenursestojointheresearchstaff,andtheDistrictHealthOfficesofPidieandBireuen

each provided two community mental health nurses to join the research staff as well. The nurse contributions to this

researchwereoutstanding.

4. WearegratefultotheCommunityProtectionandStateUnityBoardattheGovernor’sOfficeinBandaAcehforextending

theirpermissionandlettersofintroductiontocarryoutsocialscientificandpublichealthresearchinAcehnesevillages.

5. IOM’sresearchpartnersatHarvardMedicalSchoolareresponsiblefortheoverallstudydesign,questionnairedevelopment,

databasemanagement,statisticalanalyses,andthisreport.ProfessorByronGoodandProfessorMary-JoDelVecchioGood

werethePrimaryInvestigatorsofthisproject. MatthewLakomadeliveredefficientandcreativestatisticalanalyses,and

SharonAbramowitzspenttwodenselypackedweeksinAcehassistingwithquestionnairedevelopment,stafftraining,and

researchprotocols.

6. IOM’sPostConflictProgrammeinBandaAcehisaterrificforumforplanninganddiscussingthematerialcontainedinthis

report.JesseGraymanwasoverallProjectManagerandcoordinatorofthisstudy.TheMedicalTeamhasbeenareliable

sourceofprogrammingandmaterialsupport.WethankDr.IbrahimPutehforhispsychiatricexpertiseandforhelpingus

navigatethehealthanduniversitysystemsinBandaAceh.ICRSdoctorsDr.AbdulRazakKelanaIbrahim,Dr.TeukuArief

Dian, and Dr. Noor Anita Humaira facilitated field research in Pidie, Bireuen, and Aceh Utara respectively. Su Lin Lewis

providedcrucialinsightandbackgrounddatafordesigningthesamplingmethodology.Mentalhealthisanovelfeature

inDDRprogramming,andwethankProgramDirectorMarkKnightforrecognizingitsimportanceinIOM’sPostConflict

ReintegrationProgram.Finally,Dr.NenetteMotuswrotetheoriginalproposaltocarryoutthisworkandstartedtheresearch

processwithaphonecalltoHarvardMedicalSchoolinOctober2005.Wethankherforherpatienceandconfidenceinour

work.

7. TheCanadianDepartmentofForeignAffairsandInternationalTradesupportedIOM’sPostConflictmedicalactivities in

Aceh. Wethankthemfor fundingthefield research.Financial support fordataanalysisandwritingof thisReportwas

providedby funds fromtheDepartmentofSocialMedicine,HarvardMedicalSchool,unrestricted researchaccountsof

Profs.ByronandMary-JoGood,andfundsfromanIOMconsultingagreementwiththeDepartmentofSocialMedicine,

HarvardMedicalSchool.

8. AuthorsofthisReportareByronGood,Mary-JoDelVecchioGood,JesseGrayman,andMatthewLakoma.


Between December 2005 and February 2006, a team of researchers from the InternationalOrganizationforMigration(IOM)andtheDepartmentofSocialMedicinefromHarvardMedicalSchool,carriedoutaPsychosocialNeedsAssessment(PNA)inthreehighconflictdistrictsonthenortheastcoastoftheprovinceofAceh(N.A.D.),withfinancialsupportfromtheCanadianDepartment of Foreign Affairs and International Trade and an IOM contract with HarvardMedicalSchool.

ThebasicgoaloftheassessmentwastoevaluatethepsychosocialandmentalhealthneedsincommunitieswhichhavebeendeeplyaffectedbytheyearsofconflictbetweenarmedforcesoftheRepublicofIndonesiaandtheFreeAcehMovement(G.A.M.),giventhecessationofviolencefollowingthesigningoftheMemorandumofUnderstandingofAugust15,2005.

ThisreportfocusesoncurrentpsychosocialandmentalhealthneedsinhighconflictareasofPidie,Bireuen,andAcehUtaraanddeliberatelyrefrainsfromidentifyinggroupsorindividualsinstrumentalintheviolencevisiteduponthesecommunities.

project designTheprojectwasdesignedtoprovidescientifically-derived,empiricaldatawhichcanserveasabasisfordevelopingmental

healthandpsychosocialservicestosupportthesecommunities’effortsatrecovery.Specifically,thePNAsoughttodetermine

thelevelofconflict-relatedtraumaticexperiencessufferedbymembersofthesecommunities,toassesslevelsofpsychosocial

andmentalhealthproblemsandidentifyhighrisksubgroupsinthepopulation,toidentifypatternsofresilienceandresources

drawnonbycommunitiesandtheirmembersinmanagingmentalhealthproblems,andtoassesstheurgencyforparticular

formsofmentalhealthinterventionsinareasaffectedbydecadesofviolence.

ThestudywasdesignedbyseniorresearchersfromHarvardMedicalSchool.Itincludedtwocomponents:aqualitative,key-

informantstudydesignedtoexplorehowtheconflicthasaffectedparticularcommunitiesandpartsofthepopulationandwhat

communityleadersfeelshouldbetheprioritiesforrespondingtothepsychosocialeffectsoftheconflict;andsecond,aformal

surveyofadultmembersofselectedcommunitiesdesignedtomeasurelevelsofexperienceoftraumaeventsassociatedwith

theviolence,levelsofpsychologicaldistressassociatedresultingfromtheseexperiences,andperceivedprioritiesforservices.

These were supplemented by a focus group discussion with GAM members including former combatants and amnestied

prisoners.FieldresearchersfromtheCenterforDevelopmentofRegionalStudiesattheUniversityofSyiahKualaconducted

interviewsin30randomlyselectedvillagesinconflict-affectedsubdistrictsofPidie,Bireuen,andAcehUtaraduringthefirsttwo

weeksofFebruary2006.DatawereanalyzedjointlybytheHarvardandIOMteams.

Thesampleforthequantitativesurveyconsistedof596adultrespondents,aged17orolder, randomlyselected in30rural

communities.Samplingproceduresproducedawelldistributedandrepresentativesampleofadultmenandwomeninthese

communities.Inaddition,75keyinformants,consistingofleadersintheselectedcommunities,wereinterviewed.Findings

maybegeneralizedtohighconflictcommunitiesinthedistrictsofPidie,Bireuen,andAcehUtara..

Key findings1. Thefirstandmostover-whelmingfindingofthesurveyisthatmembersofthesecommunitieshaveexperiencedremarkably

highlevelsofterribleandaccumulatedtraumaticeventsasaresultoftheviolence.Afewexamplesfromthedataillustrate

executive summary


theprofoundeffectstheconflicthashadonthecivilianpopulationsinthisarea.78%ofthetotalsamplereporthaving

livedthroughcombatexperiences.38%experiencedhavingtofleefromburningbuildingsintheircommunityand47%

havingtofleefromdanger.8%ofwomenhavehadtheirhusbandkilledintheconflict,and5%ofthetotalsamplehave

hadchildrenkilled. 41%ofthesamplereporthavinghadafamilymemberorfriendkilled,and33%reportedhavinga

familymemberorfriendhavingbeenkidnappedorhavingdisappeared.45%reportedhavingtheirpropertyconfiscated

ordestroyed,and33%experiencedextortionorrobbery.

2. Bothmenandwomenexperiencedextraordinarylevelsofviolence,butthelevelandtypeoftraumaticeventsexperienced

aspartoftheconflictvariedbygender.Menreportedsignificantlygreaterphysicalviolencethanwomen.56%ofmen

reporthavingbeenbeaten(20%ofwomen),36%reportbeingattackedbyagunorknife(14%ofwomen),25%ofmen

report being tortured (11% of women), 19% of men reported being been taken captive (5% of women), and 65% of

men(and45%ofwomen)reportedbeingforcedtowatchphysicalviolenceagainstothers. Althoughratesofreported

sexualviolencetowardwomenarelow,owinginparttostigma,womenexperiencedphysicalattacksbymalecombatant

as gendered violence. In addition, the very common experience of having their houses ransacked and destroyed was

experiencedasanespeciallypowerfulattackonthedomainofwomen.

3. Thereisverysignificantvariationbyregion. Somewhatunexpectedly,respondentsinBireuenandAcehUtarareported

farhigherratesofbothtraumaticeventsandpsychologicalsymptomsthanrespondents inPidie. 85%of respondents

inBireuenand87%inAcehUtaraexperiencedcombat,incomparisonwith66%inPidie.66%ofrespondentsinBireuen

report having had a family member or friend killed, in comparison with 40% in Aceh Utara and 21% in Pidie. 22% of

respondentsinAcehUtarareportedbeingcapturedandheldbyoneofthepartiestotheconflict,14%inBireuen,and4%

inPidie.

4. ThesetofquestionsonstressfulortraumaticeventssincethesigningoftheMOUpeaceagreementhighlightsanother

criticalfindingofthisstudy.Anextraordinarynumberofpersonsdescribedifficultiesofprovidingfortheirfamilies(85%),

difficultyfindingwork(90%),ordifficultyinrestartingtheirlivelihoodactivitiespost-conflict(71%).72%reportconcerns

aboutadequatefood,whereas59%reportconcernsabouthavingpropershelter.Thesenumericalfindingssupportthe

qualitativeinterviews,whichdescribedeepconcernsaboutbasic livelihoodissues. Thenearly30yearsofconflicthave

clearlywreakedhavoconlocaleconomies,preventingvillagersfromworkingtheirland,killingtheiranimals,destroying

tradenetworks,wreckingtheirhouses,andpreventingyoungpeoplefromenteringintothelaboreconomy.Thus,‘recovery’

willrequireboththattheterribletraumaticeventssufferedbythesecommunitiesandthebrokeneconomyanddestroyed

communityresourcesbedealtwithinatimelyfashion.

Inaddition,47%ofrespondentsreportseeingperpetratorsofcrimeandviolence(pelakukejahatan)asacontinuingstressor,

30%reportexperiencingphysicalorpsychologicalattacksorthreats(penyerangan)and21%robbery(perampokan)since

theMOU.Despitethecessationofformalconflict,continuedinsecurityremainsachallengetorecoveryofindividualsand

communities.

5. Psychologicalsymptomsinthispopulationareextraordinarilyhigh,rankingwithpost-conflictpopulationsinsettingssuchas

BosniaorAfghanistan.Thestudyusedwidelyacceptedsymptomchecklists,translatedandadaptedforAcehnesesymptom

expressions, and standard procedures for estimating persons who meet criteria for a clinical diagnosis. Internationally

accepted protocols for determining persons who suffer major depression, an anxiety disorder, or PostTraumatic Stress

Disorderindicatethat65%ofthetotalsamplerankedhighondepressionsymptoms,69%onanxietysymptoms,and34%

onPTSDsymptoms.Usingextremelyhighsymptomlevelstoidentifythemostseverecases,18%ofthesamplemetcriteria

foradiagnosisofdepressionatasevereleveland10%foradiagnosisofPTSDataseverelevel.Clearly,theneedformental

healthservicestorespondtothementalhealthconsequencesoftheconflictisverygreatinthispopulation.

Itshouldbenotedthatmanyrespondentssuffertheeffectsof“complextrauma”–manyyearsofrepeatedexperiencesof


violenceandinsecurity,notasingleepisodeoftraumaandareturntoasituationofsafetyandsecurity.“Trauma”refers

toexperiencesofbothindividualsandcommunities,andeffectivementalhealthresponseswillrequirebothindividual

clinicaltreatmentandpsychosocialinterventionsforcommunities.

6.Oddsanalysissuggestsfactorsassociatedwithgreaterlikelihoodofsufferingdepressionandtrauma-relatedillness,aswell

asparticulargroupsathighrisk.First,thereisadirectandhighlysignificantrelationshipbetweennumberoftraumatic

eventssufferedandbothdepressionandPTSD.Highernumbersofreportedexperiencesofconflict-relatedeventsincrease

thelikelihoodthatpersonswillsufferbothmildandthemostseveresymptomsofdepressionandPTSD.Second,allgroups

inBireuenandAcehUtarahavefargreateroddsofsufferingthesesymptomsthaninPidie.Womenhaveslightlygreater

odds than men, though far less than in most studies of normal populations. Third, looking closely by gender, age and

districtidentifiessomegroupswithextremelyhighratesofdepressionandPTSD.Theyoungest(17-29)andoldest(54and

above)agecohortsofmenandwomenareathighestrisk.Forexample,inBireuen,48%ofyoungmenreportveryhigh

symptomsofmajordepression;24%ofyoungmen,25%oftheoldestmen,and33%oftheoldestwomenreportveryhigh

symptomsofPTSD.

7.Ratesofheadtraumaandpotentialbraininjury,sufferedthroughbeatings,strangulation,neardrownings,andotherformsof

tortureorviolence,areextraordinarilyhighanddeserveclinicalinterventionsandfurtherresearch.Men,particularlyyoung

men,inBireuenandAcehUtarawereatthehighestrisk.Remarkably,67%ofyoungmeninAcehUtaraand68%inBireuen

reporthavingsufferedheadtrauma.Thesefindingssuggestacriticalareaforintervention.

8.Forcedandvoluntaryevacuationswerefrequenteventsintheseconflictareas.38%ofrespondentssaidthattheywereforced

tofleeburningbuildingsandnearlyhalfofthesample(47%)saidtheywereforcedtofleedangeratsometimeduring

theconflict. Thequalitativedatamorethanadequatelysupportsthesefigures. Therespondents inthissample largely

reportedlocalizedandtemporarydisplacement,usuallywithintheirowndistrict,andoftenwithinthesamesub-district.

Evacuations were frequently collective events, entire villages leaving their land together, and moving to a government

facilityineitherthesub-districtordistrictseat.Villagecommunitieswouldremaindisplacedforasshortasafewweeksor

aslongasseveralyears,returningonlywhengivenpermissionorafterthepeaceagreement.Returninggroupsfoundtheir

homesandlivelihoodassetssuchaslivestock,ricefields,gardens,plantations,andtoolseitherburntdownorcompletely

pillaged.“Wehavehadtostartfromzero,”isasimplebutaccurateexpressionconveyedrepeatedlytoeachinterviewer

whileconductingthisresearch.

9. Despite the history of trauma and the resulting high symptoms, these communities and most individuals within them

remainstrongandhighlyresilient.Theyreportdealingwiththeirtraumaticexperiencesbyprayerandconsultingreligious

specialists,bylookingforgeneralmedicalattention,andbytalkingwithfriendsorfamilymembersandbysimplytryingto

forgetwhathappened.Almostnoonehasconsultedamentalhealthconsultanttodealwiththeirproblems.Respondents

areenormouslygratefulfortheendtoviolence,andmostareworkinghardtorebuildbadlydamagedcommunitiesand

moveforwardwiththeirlives.

10. Thereremainssignificantmistrustofpublichealthfacilities,particularly inBireuenandAcehUtara,whichconstitutesa

barriertoprovidingmentalhealthcarethroughthepublichealthsystem.Forexample,only35%ofrespondentsinBireuen

and36%inAcehUtarasaidtheywouldbewillingtoacceptmentalhealthassistanceprovidedthroughgovernmentclinics,

comparedwith74%inPidie.Insomecases,primaryhealthcarecenterswereoccupiedbycombatantgroupsduringthe

conflict.Thereisalsolimitedawarenessthatsomepublichealthclinicsaredevelopingnewmentalhealthcapabilities,and

littleisknownaboutthenewcommunitymentalhealthnurses(trainedaspartoftheMinistryofHealthefforts,supported

by WHO and the Asian Development Bank). Very specific outreach activities will be required to reach many isolated

communities that suffered the most during the conflict and to link these communities with the newly trained mental

healthworkersintheprimarycaresystem.

recommendations1. Experiences with the IOM mobile medical teams, supported by grants from the Canadian government, indicate high

willingnesstousementalhealthservicesprovidedbyspecializedmobilemedicalteams.Thereisagreatopportunityto

developmentalhealthoutreachteamsatthedistrictlevel,buildingonthemobilemedicalteamapproachestablishedby


IOM.Suchteamswouldprovideimmediatementalhealthservices,family-basededucationandsupportforunderstanding

andtreatingmentalillness,aswellasbasicmedicalcare,andwouldcontributegreatlytobridgingthecurrentgapbetween

thepopulationandthenewlytrainedcommunitymentalhealthnursesinthepublicprimaryhealthcaresystem.

2. Nearlyhalf thesample reportedbeing forced tofleedangerat sometimeduring theconflict.Returnpopulationshave

particularneedsastheyrebuildtheirconflict-shatteredlivesduringthistimeofpeacebuildingandreintegrationworkin

AcehandshouldbeconsideredInternallyDisplacedPersonsandthusthecoretargetofIOMreliefservices.Itshouldbe

notedthatthesampledoesnotincluderespondentswhoarestilldisplacedduetotheconflict,soactualpercentagesof

conflictIDPsfromformerconflictareasarelikelytobehigherthanreportedhere.

3. The internationalcommunityshouldrecognizetheurgencytoprovidementalhealthservicestothecommunitiesmost

affectedbytheconflict.Developingmentalhealthservicesisnotwithoutrisk.Talkingaboutpastexperiencesofviolence

maybeseenaspoliticallythreateningbysomepartiestotheconflict,andwillrequiresupportfromhigherlevelsinthese

institutions.However,resolutionofthemanyyearsofviolencewillrequireconcertedpsychosocialandmentalhealthwork,

aswellaseconomicaid,todealwithindividualandcommunitytraumaandtosupportthebroadrangeofeffortsneeded

torebuildthesecommunities.

4. Managingmentalhealthandpsychosocialproblemsassociatedwithcomplextraumainrelatively isolatedsettingswith

limitedaccesstomentalhealthcare isextremelychallenging. Itshouldbeexplicitlyrecognizedthatthere isnosingle

therapeuticmodalitywhichiscertaintobeeffectiveandsustainable.Instead,acommitmentshouldbemadetodeveloping

innovativetherapeuticprogramsinselectedsettings,todocumentationofeachprogram,andtocarefulevaluationofthe

efficacyoftherapeuticapproaches.


introduction and bacKground

TheDecember26,20049.1earthquakeandtsunamiinAcehprovincedevastatedmanycoastalcommunitiesofWestandNorthSumatra;thehumantollaloneexceeds135,000deaths.Homes,schools,healthcentersandhospitals,mosquesandbusinesseswerewashedaway,orfloodedbythetsunamianddamagedbytheearthquake;entirecommunitiesdisappeared.Thousandsofmilitaryandpoliceforcesperished,entirebarracksandfamilyhousingcomplexeswashedaway.Bases,posts,offices,militaryequipmentandvehicleswereeithersweptawayorseriouslydestroyed. Coastal fishing, agriculture, and business economies were decimated, and soonreplaced with emergency relief and disaster services of Indonesian and international NGOs,bringingmanynon-AcheneseIndonesianciviliansaswellasforeignersintoaregionnotedforitsrestrictedaccess,amilitaryzoneofoperation,aprovinceafflictedbyviolenceandconflictbetweentheFreeAcehmovement(GAM)andtheIndonesianmilitaryandpoliceforces.

Nature’stragedyandthevastnessofthehumandevastationwroughtbythetsunamirenewedthepoliticalwillonthepartof

theGovernmentofIndonesiaandtheinternationalcommunity,inparticulartheEuropeanCommunity,toseekaresolutionto

theconflictbetweenGAM,theFreeAcehMovement,andtheRepublicofIndonesia’smilitaryandpoliceforces.1OnAugust15,

2005,aMemorandumofUnderstandingtobringaboutDemobilization,DemilitarizationandReintegration(DDR)wassigned

byGAMandtheGovernmentofIndonesia.

TheInternationalOrganizationforMigration(IOM)waschargedbytheIndonesiangovernment(GoI)toassistwiththeDDR

processaccordingtothetermssetforthinthepeaceagreement.IOM’spost-conflictexpertisecoversawiderangeofcountries

includingEastTimor,Cambodia,Afghanistan,andKosovoamongseveralothers.ActivitiesinDDRprogramsoftenfacilitated

byIOMincluderegistrationofex-combatantsandformerprisoners,transportationtohomecommunities,quickimpactpeace

dividendprojects for returncommunities, reconstructionofhealthservices in formerconflictareas,andemergencyhealth

interventions for conflict victims and ex-combatants. Specifically in Aceh, IOM has set up ten Information Counseling and

ReferralService(ICRS)officesindistricttownsthroughoutAcehtofacilitatethereintegrationneedsofamnestiedprisoners

and former GAM combatants. ICRS clients receive transitional financial reinsertion support, health care and facilitation of

healthreferrals,alongwithvocationaltrainingandotherlivelihoodsupport.ICRSstaffalsofacilitatecommunity-drivenpeace

dividendprojectsinvillageswithlargenumbersofreturningamnestiedprisonersandcombatantsand/oraseverehistoryof

conflictactivity.

As a part of its program of medical and psychosocial support for persons and communities affected by the conflict, IOM

proposedtocarryoutapsychosocialneedsassessmentinthreedistrictsinnortheastAcehheavilyaffectedbytheconflict.The

basicgoaloftheproposedneedsassessmentwastoevaluatethepsychosocialandmentalhealthneedsinconflict-affected

communities,providingempiricaldatawhichcanserveasabasisfordevelopingservicestosupportthesecommunities’efforts

atrecoveryduringtheperiodfollowingthecessationofviolence.Specifically,IOMproposedtodeterminethelevelofconflict-

relatedtraumaticexperiencessufferedbymembersofthesecommunities,toassesslevelsofpsychosocialandmentalhealth

problemsandidentifyhighrisksubgroupsinthepopulation,todeterminetheprioritiesformentalhealthandpsychosocial

servicesbymembersofthecommunities,toidentifypatternsofresilienceandresourcesdrawnonbycommunitiesandtheir

membersinmanagingmentalhealthproblems,andtoassesstheurgencyforparticularformsofmentalhealthcareinareas

1 ThelastpeacetalksheldpriortothetsunamiweremediatedbytheGeneva-basedHenryDunantCenterforHumanitarian

Dialogue.ThesetalksfailedinMay2003.


affectedbydecadesoftragicviolence.TheCanadianDepartmentofForeignAffairsandInternationalTradeagreedtosupport

the proposed Psychosocial Needs Assessment, and the study was designed and carried out between December 2005 and

February2006.

ThethreedistrictsonthenortheastcoastofAcehprovince–Pidie,Bireuen,andAcehUtara–aregeographicallycontiguous

fromwesttoeastrespectively.TheeffectofthetsunamiinthesethreedistrictswasfarlessseverethanalongAceh’swestcoast

andintheprovincialcapitalofBandaAceh.2However,takentogetherthesethreedistrictsmakeuparegionofAcehwiththe

longestandmostintensivehistoryofconflictactivitydatingbacktothelate1970s.Conflict-relatedinsecurityinthesedistricts

was frequentlyextremelyhigh, inhibitingdailyactivities fromschoolingto farmingtoseekinghealthcare tomarketingto

travelfromtowntotownandvillagetovillage.Exposuretoviolence,personalassault,humiliation,extortion,andkillingwere

commonexperiencesformanyresidentsalloverAceh,butespeciallyinthisregion.Thus,theAugust2005Memorandumof

UnderstandingbetweentheGoIandtheleadersofGAMtoresolvetheconflictwaswelcomedwithreliefandhopebymany

Acehnese.TheMOUandtheensuingperiodofpeacealsoprovideanopportunityforrebuildingcommunitiesandproviding

‘traumahealing’andmentalhealthservicesforthosewhocontinuetosuffertheeffectsofyearsofcomplextrauma.

2 ThenumbersoftsunamiIDPsinPidie,Bireuen,andAcehUtara(inclusiveofLhokseumawemunicipality)atthetimeofthe

fieldresearchwas19906(4.2%ofPidie’spopulation),10032(2.9%),and11171(1.8%)respectively.


research design and methodology

the research teamThe psychosocial needs assessment was conducted as a collaborative project by the IOM psychosocial coordinator and

technicalstaff,ateamfromtheDepartmentofSocialMedicine,HarvardMedicalSchool,andfaculty,staff,andfieldresearchers

fromtheCenterfortheDevelopmentofRegionalStudies,UniversityofSyiahKuala,BandaAceh.IOMwasthecontractorforthe

PNAproject;IOManditsstaffcoordinatedthestudyandprovidedaprojectcoordinator.TheDepartmentofSocialMedicine,

HarvardMedicalSchool,hasenteredacollaborativeagreementwithIOMtoprovidetechnicalconsultationandcollaboration

onmentalhealthandcommunityandenvironmentalhealthprojectsaimedatsupportingrecoveryfromthetsunamiandthe

conflictinAceh,andatinvestinginhumanresourcedevelopmentforhealthandmentalhealthinN.A.D.Ateamofseniorsocial

scientistswithlongexperienceinIndonesia,physicianswithinternationalhealthexperience,andsocialscienceresearchers

playedanactiveroleindesigningthepsychosocialneedsassessmentprojectandcarryingoutthequantitativeresearchdesign.

AteamfromtheUniversityofSyiahKuala(USK)wassubcontractedtocarryoutthecommunitysurveyandthekeyinformant

interviews.TheIOMcoordinatorandtheHarvardteamarejointlyresponsiblefortheoverallanalysisofthedata.

TheHarvardteamandtheIOMfieldcoordinatordevelopedthedesignoftheoverallstudyandthesurveyinDecember2005.

Members of the IOM, Harvard, and USK teams developed final forms of the questionnaires, translated and back translated

themandpretestedtheminBandaAcehinJanuary.Finalsampleuniverse,procedures,andfieldmethodsweredetermined

inconsultationwithallthreegroups.TheIOMcoordinator,aHarvardtraumaspecialistconsultant,andmembersoftheUSK

organizedatrainingseminarinJanuary,afterfinalrecruitmentoffieldinterviewersandteamleaders.Interviewswererevised

andfinalizedfollowingthetrainingworkshop,duringwhichthesurveyinstrumentwaspretested.

ThequestionnaireandkeyinformantinterviewswereconductedbytheUSKteamin30villagesselectedrandomlyfromsub-

districtsmostaffectedbytheconflict,tenvillagesfromeachofthethreedistricts,betweenFebruary2-12,2006,withtheIOM

teamprovidingsupervisionandfieldoversight.Selectionofconflict-affectedkecamatanutilizedaconflictstressassessment

previouslyconductedbytheWorldBank,supplementedwithanecdotalreportsfromsub-districtgovernmentofficials,local

NGOs,localGAMleaders,andtheICRSstaffworkinginthearea.SeniormembersoftheHarvardteamjoinedforthesecond

weekoffieldresearch,asdidUSKfaculty,meetingwithGAMleadersinformallyandwithaGAMfocusgroup,arrangedbyIOM

staff,aswellasholdinginformaldiscussionswithgatheringsofvillagewomenandmen.

Aftercompletionoftheresearch,datafromthesurveyinstrumentswereenteredbytheUSKteam,usingSPSS,andtransferred

toHarvardforcleaning,developmentofvariables,initialdescriptiveanalyses,andmorecomplexstatisticalanalyses(usingSAS).

AllquantitativedataanalysishasbeenconductedbytheHarvardresearchteam,aspartof theHarvard-IOMcollaboration.

Analysesaredesignedinparticulartoidentifylevelsoftraumaticexperiences,psychologicaldistressandpsychiatricdisorders,

riskfactorsassociatedwiththesedisorders,andprioritiesinthecommunityformentalhealthandpsychosocialinterventions.

Open-ended,qualitativeresponsesontheinterviewformswerealsoenteredintothedatabase,sortedbydistrictandgender,

codedforemergentthemes,andusedformoreculturallysensitiveanalyses.Theteamleaderswereresponsibleforthekey

informantinterviews.Theywroteextensivenotesabouteachinterview,aswellassummaryanalyses.Theseweretranscribed

foranalysisusingbothstandardethnographictechniquesaswellasusingqualitativedataanalysistools(Atlas-TI).

study designThestudysetforthninegoals:

1. TounderstandhowspecificcommunitiesinAcehhavebeenaffectedbytheconflict.

2. Tounderstandthenatureoftraumasufferedbythegeneralpopulationandbyspecificsocialgroups.

3. Tounderstandthesocialandpsychologicalproblemsthathaveresultedfromtheconflict.

4. Toobserveanddocumentthewaycommunitymembersspeakabouttheconflictandthecurrentdemilitarizationand

reintegrationprocess,

5. Toidentifythemostimportantpsychosocialandmentalhealthproblemsinthethreedistrictschosenasaffectedbythe

conflictandinsomecasesbythetsunami.


6. To determine the priorities of community members and leaders concerning which psychosocial and mental health

problemsareregardedasrequiringimmediateresponse.

7. Todeterminewhatgroupsareatspecialriskformentalhealthandstressortraumaexperiences,andtoassesstheneedfor

theprovisionofcommunitybasedmentalhealthservices.

8. Toidentifyandcomparelevelsofmentalhealthproblemsofstressortraumaexperiences,depressionandPTSD,ofparticular

atriskpopulations.

9. To identify resources in the community that may be useful for collaboration in developing particular psychosocial

interventions.

Thestudydesignincludestwocomponents:keyinformantinterviewsandaformalsurveyofrandomlyselectedadultsaged

17yearsandolder.

The key informant qualitative interviews were designed to explore the historical context of the conflict, how it affected

communities over time, and whether certain segments of the population were more vulnerable than other segments.

Community leaderswereaskedtodiscussprioritiesforpsychosocialandmentalhealthservicesfortheircommunities,and

theirviewsofthebestwaystorespondtotheeffectsoftheconflict.

The formal survey interview was designed to measure past experience of traumatic events associated with the conflict, to

assess experiences of current stressor events, and to identify levels of current psychological distress associated with these

experiences.Thesurveycombinedopen-endedquestionsdesignedforAcehnesepopulationsthathadexperienceddecades

ofconflictandatsunami,andwidelyusedvalidatedscalesallowingforcomparabilitywithpreviousstudiesofpsychosocial

needsofconflictandpostconflictpopulations.

Theinterviewbeganwithbasicdemographicquestionsfollowedbyopenquestions.Respondentswereaskediftheywere

affectedby the tsunami,whether theconflictaffected their lifeandthatof their family,andwhetheranyone in the family,

includingtherespondent,wasavictimoftheconflict.Theseopenquestionswerefollowedbyquantitativemeasuresdrawn

fromthevalidatedHarvardTraumaEventsscales,adaptedspecificallytorepresenttypicalformsoftraumaexperiencedinthe

communitiesbeingsurveyed. These includedayes/nochecklistoftraumaticeventsexperiencedduringtheconflictanda

yes/nochecklistofexperiencesofcurrentstressesandtraumaticeventsinthepost-conflictperiod.Levelsofemotionaland

psychologicaldistresswereassessedwithageneralselfassessmentquestion.Theseelementaryquestionswerefollowedby

a25itemversionoftheHopkinsSymptomChecklistforDepressionandAnxiety,ascaleusedwidelyindisasterandtrauma

community assessments of emotional distress.The 42 item HarvardTrauma Questionnaire (HTQ) is a broad measure that

includesa16itemcoreusedtoassessPostTraumaticStressDisorder(PTSD).Inaddition,itemsdesignedtocapturepopular

discoursesaboutdisturbingexperiencespost-tsunamiandpost-conflictwere integrated into thequantitativemeasures to

elicitexperiencesofnightmares,ghosts,spirits,andhearingvoicesofpeoplewhohaddied.

AfouritemmeasurewasincludedfromtheHarvardTraumaQuestionnairetoassesspresenceandseverityofeventsthatmight

haveproducedheadtraumaorbraininjury,includingbeatingstothehead,suffocationorstrangulation,neardrowning,and

otherphysicalinjuries.

Thesurveyconcludedwithclosedandopenquestionsregardingtherespondent’sperceptionsofwhatcommunitymental

healthservicesaremostneeded,theiropinionsaboutwhichgroupssufferedmosttraumaduetotheconflictorareatthe

greatestmentalhealthrisk,assessmentsofwhoprovidescareandtowhomcommunitymemberscanturntoovercomebad

experiences that remain fromtheconflict,attitudesabout thepublichealthcareservices,andcommentsandsuggestions

aboutthepost-conflictpeaceprocessandcommunityrebuilding.

Thesurveywasdesignedtofacilitatecomparabilitywithotherstudiesofconflict-affectedpopulationswiththeintentionof

drawinglessonsconcerningusefulmentalhealthinterventionsfrompreviouscases.Asignificantpartofthesurveywasalso


devotedtoopenquestionsallowingforthespecificityofAcehneseexperiencestodeterminetheinterpretationandmeaning

ofcomparativeanalysesandlessons.

Overall, thekey informant interviewsandthesurveywerefocusedonmentalandpsychosocialhealthproblemsrelatedto

previousconflictexperience.Asaninstrumentforhealthresearch,thequestionsdonotaskaboutgroupsorindividualswho

may have been responsible for committing violence against Acehnese communities. Rather, this research connects past

traumaticexperiencewithcurrenthealthneeds. Assuch, the resultsof thisstudydonotmeet thespecificcriteriausually

requiredinhumanrightsinvestigations.Rather,theresultsofthisstudyareusefulforinformingthedevelopmentofmental

andpsychosocialhealthservicesinconflictaffectedcommunitiesinPidie,Bireuen,andAcehUtara.

field research teams and invitations to participatePermissiontocarryoutsocialscientificandpublichealthresearchinAcehnesevillagesforthisprojectwassecuredfromthe

CommunityProtectionandStateUnityBoardattheGovernor’sOfficeinBandaAceh.MembersoftheUniversityofSyiahKuala

socialscienceandeducationfacultywerethefieldteamleadersforinterviewersforPidie,Bireuen,andAcehUtara.Atotalof18

surveyinterviewersincludedmentalhealthnursesandeducationfacultymembers.AllwereAcehnese,allbutfourweremen.

Thefourwomen,threenursesandoneeducationfacultylecturer,weresurveyinterviewers.Teamleadersheldinitialmeetings

withsubdistrictleadersandvillageheads,compiledalistofhouseholds,randomlychosethehouseholds,andassignedeach

interviewerthreetofourhouseholdspervillage.Eachinterviewergreetedthepersonwhotheyfirstmetwiththestatement:

“Hello,mynameis….IamworkingwithSyiahKualaUniversitytolearnaboutissuesoftraumaandmentalhealthrelatedto

theconflict.WearegatheringinformationonAcehneseadults’feelingsandexperiencessincetheMOUwassigned.Weare

conductingasurveyamongadultsresidinginthiscommunitywhoareaged17andover.Iwouldliketoinvitesomeoneinthis

housetoparticipateinthesurvey.MayIcontinue?”

The interviewer proceeded to compile a list of the household members aged 17 and over, listed the names, and using a

randomizednumberingsystem,invitedthedesignatedpersontoparticipatewiththecomment:

“Wepickedyoubecauseweassignedeachmemberofyourhouseholdanumberandyouanumberandthenwerandomly

selected your number. Once we make the selection of an adult in the household, no other adult in the household can be

selected.Thatwaywemakesureweareselectingrespondentsaccordingtoreliableresearchmethods.”

Oncethepersonagreedtotheinvitation,adescriptionoftheprojectwasreadtogetherwiththeperson,coveringprocedures,

risksandbenefits,questionsorconcerns,confidentiality,andvoluntaryparticipationusingAcehnesewhenpreferred.Theform

wasthensignedanddatedbytheintervieweronlyandacopywasprovidedtotheintervieweeincludingalistoforganizations

helpful in dealing with psychosocial problems. Each questionnaire was assigned a numerical code leaving no personal

identifiersinordertoensuretheanonymityofallrespondents.Researchersfollowedstandardconsentprotocolsthatwere

approvedbytheHarvardUniversityFacultyofArtsandSciences’InternalReviewBoard.

Teamleaders’interviewswithkeyinformantswerelessformal.Consentwasobtained,andteamleadersheldconversations,

usually in the meunasah – the community center used primarily by the men of the community but also by women when

receivingoutsideresearchteams.Teamleadersconducted75keyinformantinterviews,67withmenandeightwithwomen.

Amongthese75informantswerevillageheads,religiousleaders,GAMmembers,womenandyouthleaders,retiredIndonesian

militaryofficers,andvillageelders.Fieldnotesoneachinterviewwereprepareddailybytheteamleaders.Topicscoveredlocal

conflicthistory,localunderstandingsofmentalillness,storiesofmentalillnessintheircommunityrelatedtotheconflict,local

resourcesandprioritiesformanagingmentalillness,andopinionsaboutthepeaceprocess.

In addition to those conducted by the team leaders, additional key informant interviews were conducted by the Harvard

andUSKteams,theIOMcoordinatorandIOMtechnicalassistants.TheIOMcoordinatorintervieweddoctors,nurses,and/or

midwivesfromthenearestpublichealthclinicswhereresearchteamswerevisitingandalsotraditionalhealers.Harvardand

USKteamsheldgroupdiscussionsinseveralcommunities,particularlyamongwomen,andtogetherwiththeIOMcoordinator

convenedafocusgroupdiscussionwithaheterogeneousgroupofmenfromGAMincludingcommanders,ex-combatants,

amnestiedprisoners,andcivilianmembers.


demography of respondents

Questionnaire respondentsTheteam interviewed596adultsaged17yearsorolderaspartof thePNAsurvey. Respondentswerewelldistributedby

age,sex,maritalstatusandschooling,validatingthevalueoftherandomchoiceofhouseholdmembers.Fewrefusedtobe

interviewed.

Table1.2DemographicsofStudyParticipantsByMaritalStatus,Schooling,andHousing

Table1.1DemographicsofStudyParticipantsByGender,Residence,Age

Gender

Male

Female

District

Pidie

Bireuen

AcehUtara

Age

17-29

30-40

41-53

54-82

%TotalSample(N=596)

53

47

40

30

30

25

31

24

20

MarriageStatus

Nevermarried

Currentlymarried

Divorcedorseparated

Widowed

Schooling

Noschooling

Primaryschool

Middleschool

Secondaryschool

Vocationalschool

Universityeducation

Housing

Liveinownhome

Livewithfriendorrelative

Liveinabandoned/destroyedhome

Rentinghousing

Liveinbarracksortent

%Male

(N=315)

%Female

(N=281)

20

77

2

2

6

48

23

20

2

2

84

8

4

2

2

12

70

3

16

11

48

21

13

5

2

87

3

2

5

3

%TotalSample

(N=596)

16

74

2

9

9

48

22

17

3

2

85

6

3

3

2


Tables1.1and1.2illustratethedemographiccharacteristicsofrespondents.Themajorityaremarried,haveatleastaprimary

schooleducation,andowntheirownhomesinwhichtheylive.Thecommunitiesstudiedwereonlyslightlydestroyedbythe

tsunami,thusonlytwopercentofrespondentslivedinabarrackscreatedforthosewholosthomesduetothetsunami.Slightly

overhalfofrespondentsaremale(53%).Thedistributionbyageandgenderareindicativeofthesuccessofthemethodof

randomnumberhouseholdselection,with25%beinginthe17-29agegroup,31%from30-40,24%from41-53,and20%from

54-82years.Fortypercentofthesample(n=237)isfromcommunitiesinthePidiedistrict;thirtypercenteachfromBireuen

(n=179)andAcehUtara(n=180).Thethreeresearchteamsspentseventotendaysinthefieldcollectingdata.

The quantitative analyses in the following sections are presented by two significant independent variables: gender and

district.Districtvariationiscriticaltounderstandingtheregionalvariabilityoftraumaconflictevents.RespondentsfromPidie

communities consistently report experiencing lower levels of conflict events, personal trauma, and psychological distress;

whereas respondents in Bireuen and Aceh Utara report much higher experiences with conflict, trauma and psychological

distress,althoughthe typesof trauma differ tosomedegree. This variationbydistrict is consistentacrossmostmeasures,

butdifferencesare lowerwhencurrent lifesecurity issuesareassessed. Thedifferencesbydistrictaresurprisinggiventhe

prevailingimpressionbymostobserversoftheconflictthatthenortheasterndistrictsofAcehrepresentonecontinuousregion

withacommonhistoryandexperienceduringtheconflictcomparedtootherregionsofAcehsuchasthecentralhighlands

orthesouthwestcoastaldistricts. Investigationintootherfactorssuchaslocal level leadershipinGAMandTNIduringthe

conflictaswellaslocaleconomiesmayhelpunderstandthesedifferences.Analysesbygenderarepresentedbecausethedata

indicatequitesignificantdifferencesinexperiencesofviolenceandtraumaticeventsonthepartofmenandwomen,aswell

astraditionalfindingsofdifferencesinratesofdepressionbygender.Insomecases,analysesarepresentedintermsofageas

well,notonlybecauseagepredictsriskforsomeformsofmentalillnessbutbecauseageandgendertogetherwereassociated

withparticularexperiencesoftraumaticeventsaspartoftheconflict.

Key informantsTables1.3and1.4showtheprofileofkeyinformantsthatwereinterviewedbytheresearchteamleadersineachdistrict.Team

leaderstypicallyinterviewedtwoorthreecommunityleadersineachvillagetheyvisited.Theagedistributionisrepresentative,

consideringthatleadersdonottypicallyassumetheirpositionuntilatleasttheirthirties.Thegenderbreakdownofkeyinformants

is an unfortunate shortcoming reflecting the challenges of male interviewers finding women for private conversations in

ruralIslamicsocieties.Teamleaderstypicallyinterviewedvillageheadswherevertheywent,especiallybecauseprotocolfor

outsidersuponarrivalinruralcommunitiesdemandscheckinginwiththevillageheadanyway.Aftermeetingwiththevillage

head,teamleadersaskedtomeetwithotherformalandinformal leaders inthevillagewhowerebestabletorecountthe

experiencesofthecommunityduringtheconflictandtalkaboutissuessurroundingmentalandpsychosocialhealth.Village

elders,religiousleaders,andvillagesecretarieswerethemostcommonlyinterviewedmembersinthesecommunitiesafterthe

villagehead,thoughwomen’sgroupleadersandGAMmembersarefairlyrepresentedaswell.

Table1.3DemographicsofKeyInformantsByGender,Residence,Age

Gender

Male

Female

District

Pidie

Bireuen

AcehUtara

Age

17-29

30-40

41-53

54-82

%TotalSampel(N=75)

89

11

43

32

25

7

27

31

35


Table1.4DemographicsofKeyInformantsByMaritalStatus,Schooling,andPositioninCommunity

MarriageStatus

Nevermarried

Currentlymarried

Divorcedorseparated

Widowed

Schooling

Noschooling

Primaryschool

Middleschool

Secondaryschool

Oneyeardiploma

Universityeducation

PositioninCommunity

Villagehead

Religiousleaders

Villagesecretary

GAMmembers

Villageelders

Womenleaders

Youthleaders

Othercommunityleaders

Indonesianarmyofficer(retired)

%Male

(N=67)

%Female

(N=8)

6

92.5

0

1.5

0

26

26

36

9

3

12.5

62.5

0

25

0

12.5

37.5

12.5

25

12.5

%TotalSample

(N=75)

7

89

0

4

0

24

27

34

11

4

32

13

12

7

16

7

3

9

1


traumatic events

traumatic events during the conflictThefirstandmostoverwhelmingfindingofthesurveyisthatmembersofthethreedistrictsexperiencedremarkablyhigh

levelsoftraumaticevents.Afewexamplesillustratetheprofoundeffectstheconflicthashadonthecivilianpopulationsinthis

area.78%ofthetotalsamplereporthavinglivedthroughcombatexperiences.38%experiencedhavingtofleefromburning

buildingsintheircommunity,and47%havingtofleefromdanger.Eightpercentofwomenhavehadtheirhusbandkilledin

theconflict,andfivepercentofallrespondentshavehadchildrenkilledintheconflict.41%ofthesamplehavehadafamily

memberorfriendkilled,and33%reportedhavingafamilymemberorfriendhavingbeenkidnappedorhavingdisappeared.

45%reportedhavingtheirpropertyconfiscatedordestroyed,and33%experiencedextortionorrobbery.Manyrespondents

werehumiliated,theirhumanitystripped.17%ofrespondentswerepubliclyhumiliated,eightpercentwereforcedtohumiliate

anotherperson,sevenpercentwereforcedtobetrayfamilyorfriends,sixpercenttoharmandinjurefamilymembers.People

wereforcedtofight(22%)ortofeed(27%)combatants,andforcedtosearchformembersoftheircommunityintheforest

(35%).Theseexperiencesofhumiliationweremorecommonlyexperiencedbymenthanwomen,exceptforbeingforcedto

givefoodorshelter.Pidiedistrictstoodoutastheregionleastlikelytohaveexperiencedthesepractices.

Table2inthefourpagesbelowillustratesthedifferencesindegreeofmagnitudeofpasttraumaticexperiencesrelatedtothe

conflictbygenderandbyregion:

Table2PastTraumaEventsExperienced,byGenderandDistrict

Experiencedcombat(bombing,firefights)

Forcedtofleeburningbuildings

Forcedtofleedanger

Forvedtohide

Beatingtothebody

Attackedbyknifeorgun

Tortured

Seriousphysicalinjuryfromcombat

Witnessedphysicalpunishment

Humiliatedorshamedinpublic

Rape

Forcedtorapeafamilymember

Othersexualassault

Spousekilled

Spousedisappeared,kidnapped

Childkilled

Childdisappeared,kidnapped

Familymemberorfriendkilled

Familymemberorfrienddisappeared

Kidnapped

Captured,heldbyTNI/POLRIorGAM

%Male

(N=315)

83

43

52

20

56

36

25

19

61

22

1

1

3

2

2

5

2

49

36

8

19

%TotalSample

(N=596)

%Female

(N=281)

73

33

42

12

20

14

11

6

45

11

1

0

4

8

3

5

4

31

30

2

5

%Pidie

(N=237)

66

30

42

4

20

14

7

6

37

4

0

0

0

3

1

4

1

21

12

1

4

%Bireuen

(N=237)

85

59

61

25

49

32

25

17

68

26

1

0

5

3

5

4

1

66

52

5

14

%AcehUtara

(N=237)

87

28

40

24

53

35

25

17

62

25

2

1

6

8

3

9

7

40

42

12

22

78

38

47

16

39

26

18

13

54

17

1

0.2

3

5

3

5

3

41

33

5

12


Thesestatisticsprovideclearevidenceofthemagnitudeofsufferingandterrorexperiencedinthesecommunities,butthe

narrativesfoundinboththeopenresponsequestionsonthesurveyandthekeyinformantinterviewshaveemotionaland

testimonialqualitiesthatnumberscannotmeasure.Thequalitativedataofthestudyarefirstandforemostfilledwithstories

aboutmenandwomenbeingbrutallyinterrogated,intimidated,andthreatenedforinformationtheycouldnotprovideand

thenseverelybeaten(orworse)fornothavinganswers.Somevividadditionalexamplesincludesuffocationwithplasticbags,

publicdisplaysofsexualhumiliation,drownings inseptictanksandsewagecanals,andbeingforcedto injureorhumiliate

friendsand lovedones justtonamea few. Womendescribedbeingforcedtowatchwiththeirchildrenastheirhusbands

andsonsweremutilatedandkilled.Storiesofbeingforcedtoprovidelabororofbeingforcedtoserveashumanshieldsare

common.Inaddition,manycommunitiesreportedhavingschoolsandpublicbuildingsburnedordestroyed,ofhavingbeen

extortedformoneybyboththeguerillaandthegovernmentsecurityforces,leavingthembereftofcommunityresources.And

allcommunityofficialswereinvariablyrequiredtoprovideinformationaboutandtakeresponsibilityfortheactionsoftheir

villagepopulationstobothsidesduringtheconflict,creatingahopelesssenseofentrapmentandareluctancetolead.(See

“ExperiencesofCommunityLeaders”below)

Senttoprison

Forcedseparationfromfamily

Forcedisolation

Confiscation,destructionofproperty

Extortion,robbery

Forcedlabour

Forcedtogivefood,sheltertoTNIorGAM

ForcedtofightagainstTNIorGAM

PunishedfornotfightingagainstTNIorGAM

Forcedtosearchforcorpses

NotallowedtoprovideMuslimburial

Forcedtoinjurefamilymember

Forcedtoinjurenon-familymember

Forcedtodestroysomeone’sproperty

Forcedtobetray/endangerfamilymember

Forcedtobetray/

endangernon-familymember

Someoneforcedtobetray/endangeryou

Forcedtohumiliateanotherperson

Forcedtosearchforfamilymemberinforest

Lackofshelterbecauseofconflict

Lackoffood,waterbecauseofconflict

Sick,lackofaccesstohealthcare

4

11

10

49

36

44

29

28

17

15

7

10

11

6

10

10

11

11

46

22

86

64

2

7

4

40

28

11

25

16

5

8

4

2

2

1

3

4

3

5

24

25

77

55

1

1

1

25

16

21

13

11

1

5

1

2

1

1

1

1

2

2

18

14

71

33

3

14

12

57

44

40

41

28

14

16

13

14

15

7

17

17

16

16

55

34

96

82

5

15

11

59

44

29

33

33

23

17

4

3

6

2

4

4

5

8

39

26

83

73

3

9

7

45

33

29

27

22

11

12

5

6

7

3

7

7

7

8

35

24

82

60


gendered traumaphysical abuse against men, including head injuries“Ada orang yang dipukul sampai hilang ingatan” – orang dituakan di Bireuen

“Peoplewerebeatenuntiltheylosttheirmemory”–villageelderinBireuen

Someformsoftraumaareclearlygenderrelated.Althoughphysicalviolencehasbeenwidelyexperiencedbybothmenand

womenofallages,menreportgreaterphysicalviolencetotheirbodiesthandowomen. 56%ofmenreporthavingbeen

beaten(20%ofwomen),36%reportbeingattackedbyagunorknife(14%ofwomen),25%ofmenreportbeingtortured(11%

ofwomen),19%reportedbeingbeentakencaptivebysoldiers(5%ofwomen),and65%ofmen(and45%ofwomen)reported

beingforcedtowatchphysicalviolenceagainstothers.Variationbyregionisconsistentacrossthesemeasures.

Onespecificsetofquestions,drawnfromtheHarvardTraumaQuestionnaireandpresentedinTable3.1belowindicatesjust

howcommonlymenhavesufferedthekindofheadtraumathatproducesbraininjuryoranoxia(injuryfromlackofoxygen).

36%ofmenreportedbeingbeatenonthehead,19%havingsufferedstrangulationorsuffocation,7%neardrowning,8%other

formsofheadtrauma.Whenbrokendownbygenderandage,ourdatashow,forexample,that48%ofyoungmenbetween

ages17and29werebeatenonthehead.

Table3.1HeadTrauma/PotentialBrainInjuryBySexandRegion

Beatenonthehead

Suffocationorstrangulation

Neardrowning

Otherheadtrauma

%Male

(N=315)

36

19

7

9

%TotalSample

(N=596)

%Female

(N=281)

7

7

0.4

2

%Pidie

(N=228)

8

7

2

0.5

%Bireuen

(N=180)

29

18

6

9

%AcehUtara

(N=179)

35

17

5

10

22

13

4

6

124questionnairerespondents(103menand21women)providedqualitativedescriptionsofthetypesofheadinjuriesthey

sustained,thecontextofthephysicaltraumaevent,andthenoticeablechangesinbehaviorandphysicalhealththatfollowed

theseinjuries.Althoughsomeheadinjuriesoccurredwhilerespondentswerebeingdetainedandquestioned,mostoccurred

inordinaryplacesinthecommunity—athome,infarmfieldsandgardens,atthevillagecafé,andmostespeciallywhengoing

toandfromthemarket.Reasonsgivenforgettingbeatenweremostoftenbecausevillagerswereaccusedoflyingor“giving

thewronganswer”whenunder interrogation. Mostrespondentsreportgettingbeatenontheheadwiththeback-endof

firearmsorheavypiecesofwood,butheadinjuriesalsoincludedgettingsteppedon,electrocuted,heldunderwaterinwellsor

septictanks,draggedthroughthestreets,coveredinplastic,andhitintheeyesorears.Manyrespondentsshowedinterviewers

theirphysicalscars(berbekas),includingneckandboneinjuries,andalsoreportedmemoryloss(hilang ingatan),confusion,

difficultyinthinking,shortnessofbreath,andlastingpainsandheadaches.Asignificantminorityoftherespondentstoldtheir

interviewersthatthesesymptomslastedonlyafewweeksandthenresolvedontheirown.Thesedatasuggestthatclinical

neuropsychiatric screenings may be needed to determine levels of neurocognitive effects of the specific forms of organic

traumasufferedbythispopulation.

OneclinicalcasefromtheIOMDDRworksuggeststheimportanceofthesefindings.InearlyDecember2005IOMmedical

staffinvestigatedthecaseofanamnestiedprisoner,anICRSclientwhowasrecentlythrownbackinjailbecause—hisfamily

claimed—hewascrazy.Othersclaimedhewasacriminal,caughtred-handedthievingfromtheneighborsinhisvillagewhere

hehadrecentlyreturned.Afterseveralvisitstothelocaljailandtheclient’shomecommunity,thestorydevelopedintoan

altogethermorecomplexnarrative.Atthejail,theyoungmanwasnotpsychotic,buthisexpressionwasdazedandhisbody

wasunkemptwithnoticeablepanufungusonhisskin;hehaddifficultymakingeyecontactwiththeexaminingpsychiatrist.

Headmittedhestoleamotorbikeandwasarrested for it. In thevillage,his familyandneighborssaid thateversincehis

amnesty from prison, he has exhibited odd behavior that disrupted the community. He would take things and put them

somewhereelse;small things likecoconutsandchickens,andbigthings likecowsandmotorbikes. Henevermademuch

secretaboutit,andhewasusuallycaughteverytime.Whensomeonecametodeliverthenewsthathismotherhadpassed


awayinanotherdistrictofAceh,heclimbedacoconuttree.Whenscoldedforclimbinginsteadofmakingimmediateplansto

travel,heaskedthemessengerifhewasalsogoingtopayforhisbusticket.Atnight,hewouldtakeoffhisshirt,slingitover

hisshoulder,wearthebackpackthatwasgiventohimuponhisamnestyfromprison,andgowalkingthroughthevillage,

backandforth,usuallybehindpeople’shouses,withoutanydestination.Thecommunityacknowledgedthathehadchanged

significantlywhilehewasinprison.Beforehisarresthewasaquietbutfunctioningmemberofhisvillagecommunity.Now,

hisneighborssaid,hewassufferingfromstresssustainedinprisonwherehewasbeatenseverelyonatleastoneoccasionthat

resultedinmajorswellingofhishead.Thevillagerstriedtounderstandandtoleratehisstrangeandexasperatingbehavior,

butwhenonevillagerdiscoveredhis“stolen”motorbikeparkedbehindanotherneighbor’shouse,communitypatiencewas

spentandthevillageheadhadhimarrested.

Inalatersectioninthisreport(Tables9.4–9.7),wedescribeinmoredetailwhowasatparticularriskforheadinjuriesofthekind

thatmayleadtolongertermmentalhealthconsequences,andhowheadtraumaisrelatedtobothdepressionandPTSD.

sexual violenceSexualassaultsandrapearementionedrarelybywomenandmeninthesurveyasnotedinTable3.2.Thismaywellbedue

toshameandstigmaandtothefactthatmostwomenrespondentswereinterviewedbymales.Ontheotherhand,village

womeninconversationswiththewomenteammembersfromHarvardandUSKtoldabouthowtheywereinterrogatedby

havingsnakesthrustintotheirfaces,andabouthowaggressivetacticsofclosebodycontactandloomingthreatwereused

toaspartofinterrogationbycombatantgroups.Althoughmenreportthemostseverephysicalaggression,womendidnot

escape.Onefifthoffemalerespondentsreportedbeingbeatentothebody,14%ofbeingattackedwithaknifeorgun,eleven

percentofbeingtortured,andsixpercentofsufferingseriousinjuryfromcombat,sevenpercentsufferedbeatingstoheadand

sevenpercentstrangulation.Onlyonepercentreportedrapeandfourpercentothersexualassault.Thepostconflictperiod

appearsaggressiveandviolentaswell.24%ofwomenreportedexperiencing“attack”(penyerangan,men36%);fourpercentof

womenandmenreportedviolencetowardwomen;sevenpercentofwomenandmenreportedviolencetowardchildren.

Table3.2PastRape&SexualAssault,CurrentGenderViolence,&HomeDestruction,bySexandRegion

Conflicterarelatedrape

Conflicterasexualassaultandforced

familyrape

Currentexperiencesofattack

Curentviolencetowardwomen

Currentviolencetowardchildren

Currenterareturnedfofindhome

destroyed

Conflicteradestruction/confiscationof

property*(notjusthomes)

%Male

(N=315)

1

4

36

4

7

24

49

%TotalSample

(N=596)

%Female

(N=281)

1

0

24

4

7

17

40

%Pidie

(N=228)

0

0

24

2

4

9

25

%Bireuen

(N=180)

1

5

28

8

9

22

57

%AcehUtara

(N=179)

2

7

42

5

9

36

59

1

3.2

30

4

7

21

45

Inahighconflictvillagewherethechaosofcombathadwreckedhavoc,thewomenvociferouslycomplainedoftheassaults

notontheirbodiesbutontheirhouses.Youngandoldrecountedhowonedaytwoyearsearliertheywereforcedtoleave

theirhomesandsenttoadistrictoffice.Upontheirreturn,theyfoundtheirhomesdestroyed,thetinroofsshotfullofholes,

theirhouseholditemsandpersonalbelongingsdecimatedanddestroyedorstolen–“theyleftnotoneplateunbroken,not

evenoneplate,”explodedonewomaninherearly40sassherecountedwithirritationtheeventwhichhadtraumatizedmany

womeninthevillage.Anotherwomanof65,whohadatonetimesufficientfundstogoontheHajjtoMecca,exclaimed“we

wereforcedtoleavewithonlytheclothesonourback;whenwereturnedthatwasallwehadleft,justtheclothesonourback.

Everythinginourhouseswasgoneordestroyed.”Anotherrecountedhowagroupofsoldiersmovedintoherhousetotake

shelterandpunishedthewomen.“Forthreenightstheyfearedtheyheardghosts”–“theyshotupmyhousewiththeirrifles

destroyingit,theyshotholesintheroof,itnowleaksandisinpieces,fallingdown;theyshotoutthewalls,theceilingcrashed


in.”“Theydestroyedallmythings,mydishesandthings.Nothingwasleftuntouched.”Theseyoungmenwereshootingupthe

midnightghosts,certaintheyheardthestealthofcombatantsinthesurroundingforest.

InafocusgroupdiscussionwithmaleGAMleadersandrankandfilemembers,themennotedthattheirfamilies,wivesand

children, were traumatized by the conflict. Women were interrogated and aggressed, their things stolen, or money taken.

WomenarebyandlargetheownersofthefamilyhousesintheseregionsofAceh,andtheymanagemuchoftheagricultural

workandmarket.Itmaywellbethatthedestructionofhouseswasmuchlikeasullyingrape,the“rape”ofthewomen’shouses,

asnotedabove,whichbroughtintenseragethatwasnotsilencednorstigmatized,butarageandirritationaboutinjustice.

variation by districtEachoftheabovetablesillustratesanunexpectedbutconsistentvariationbydistrict.Althoughratesofciviliantraumaarehigh

inallthreedistrictsstudied,itisdistributedunequally.ClearlyBireuenandAcehUtaracommunitieshavesignificantlyhigher

levelsofphysicalviolenceagainstcivilians,burnedbuildings,andbroadformsofterroragainstvillagepopulations.Asnoted

inTable2,fewerrespondentsinPidievillagesreportedhavingafamilymemberorfriendkilledintheconflict,comparedwith

65%inBireuenand42%inAcehUtara.22%reportedbeingphysicallybeateninPidie,47%inBireuen,and55%inAcehUtara.

Itisclearlypossiblewiththesedatatoidentifydistrictswiththeveryhighestlevelsofexperiencesoftraumaassociatedwith

theconflictaswellasvariationsinassociatedintensityofpsychiatricsymptomsand“caseness”andtoask:“Whatisnecessary

forthesespecificregionstobringaboutrepair?”

Theconsistentvariationbydistrictwasanunexpectedandsurprisingresultofthisdata.AsnotedintheBackgroundsection

above,thesethreegeographicallycontiguousdistrictsareperceivedasacorridorofcommonconflicthistory,especiallywhen

comparedagainstotherhighconflictareasofAcehwithremarkablydifferenthistoricalandpopulationdynamicssuchasthe

centralhighlandsorthesouthwest.GAM’soriginalleadershipandmembershipcomefromthisdenselypopulatedandfertile

regionoftheprovince,datingbacktothelate1970swhenthefirstGAMrebelactivitiesbegan.Thereislittlereasontosuspect

thatPidiewouldhavesuchlowerratesoftraumaticexperienceandpsychologicaldistressespeciallywhenconsideringthe

manysub-districtsofPidiethatwerewell-knowntheatersofconflict(includingTirosub-district,whereHasanDiTiro,leader

oftheGAMmovement,wasborn). Pidiealsohastheinfamous bukit janda (widow’shill)andrumoh geudong,ahousethat

wasconvertedintoadetentionfacility.AlloftheseplacesfigureheavilyinthecollectiveAcehnesememoryofconflictevents,

contributingtotheoverallcuriosityofthissystematicregionalvariationinthedata.

Subsequentconsultationswithknowledgeable researchersandscholarsof theconflict inAcehmayyieldamore indepth

understandingofthesourcesofvariationbetweendistricts. Butratherthanspeculateuponthesourceofthesevariations,

afundamentalconclusionfromthisresearchisthatsystematicneedsassessmentssuchasthisonearecriticalforidentifying

appropriatedevelopmentandprioritizationofmentalhealthservicesinAceh.

forced evacuations and other population displacements38%ofrespondentssaidthattheywereforcedtofleeburningbuildingsandnearlyhalfofthesample(47%)saidtheywere

forcedtofleedangerat sometimeduringtheconflict. Thequalitativedatamore thanadequatelysupports thesefigures.

Theconflict inAcehcausedavarietyofpopulationdisplacements,andthis isanareaofparticular relevanceto IOM’score

mandatetomeettheneedsofpopulationsbefore,during,andaftertheirdisplacement.Transmigrantpopulationsfromother

partsofIndonesialivinginAcehpriortothemostrecentyearsofconflictevacuatedbacktotheirhomeisland;manyother

transmigrantstookrefugeintheneighboringdistrictofNorthSumatra.ManyAcehnesefledtootherpartsofIndonesiatosave

theirownlives,andlargenumbersofAcehnesealsocrossedinternationalborderstogotoMalaysia,EuropeandtheUnited

States.

Therespondentsinthissamplelargelyreportedlocalizedandtemporarydisplacement,usuallywithintheirowndistrict,and

oftenwithinthesamesub-district.Atypicalnarrativeofinternaldisplacementduringtheconflictinthesethreedistrictsof

Acehbeginswiththearrivalofsecurityforces(fromeitherside)inavillageandeitherwarningcommunitiesofimpendingwar

operationswithimplicitinstructiontoleaveoramoreforcefulordertoleave.Villagersweretoldthatsecurityforceswouldnot

beheldresponsibleforthesafetyofanyoneinthevillagewhochoosestostay.Evacuationswerefrequentlycollectiveevents,

entirevillagesleavingtheirlandtogetherandmovingtoagovernmentfacilityineitherthesub-districtordistrictseat.Village


communitieswouldremaindisplacedforasshortasafewweeks,returningonlywhengivenpermission,butonlytofindthat

homesandlivelihoodassetssuchaslivestock,ricefields,gardens,plantations,andtoolswereeitherburntdownorcompletely

pillaged.“Wehavehadtostartfromzero,”isasimplebutaccurateexpressionconveyedrepeatedlytoeachinterviewerwhile

conductingthisresearch.

Many IDP communities chose to stay away from their home villages after their evacuation until the end of the conflict,

sometimeslivinginbarracksfor18monthsorlonger.ManyIDPcommunitieshavedecidedtoreturnhomesincethesigningof

thepeaceagreement,but“startingfromzero”stillconveysasenseofvulnerability.Returnpopulationshaveparticularneedsas

theyrebuildtheirconflict-shatteredlivesduringthistransitionaltimeofpeacebuildingandreintegrationworkinAceh.

experienced events during the tsunamiGenerally speaking, the tsunami had decreasing impact as one travels eastward along the coast from Banda Aceh toward

Medan.ThereforeitisnotsurprisingthatinmovingeastwardfromPidie,toBireuen,andthenfinallytoAcehUtara,respondents

describelessofaneffectofthetsunamiintheirownlives.101respondentsfromPidiegaveanswerstotheopen-endedquestion

thatasksthemtodescribewhathappenedtothemduringthetsunami,59respondentsfromBireuen,and43respondents

fromAcehUtara.Mostoftheserespondentslamentedthelossoflovedones,especiallythosewholivedinBandaAceh;others

describedtheirphysical injuriesandmaterial loss includinghouseholdsandsourceof livelihood(suchasshrimpfisheries).

Othersdescribedcommonsymptomsoftraumaintrudingupontheirlivesaftersurvivingthedisaster:

• “Sad,andfrequentlylostinthoughteversince.”

• “IfeelrestlessandlosemyappetitewheneverIthinkaboutwhathappened.”

• “IthoughtitwasJudgementDay(kiamat)”

• “Dizzywithfear,unsettledthoughts.”

• “Don’taskmeanymoreaboutit,Iwillfaint.”

• “Stillcannotsleepatnight.”

• “Ifeelpanicandfearthinkingitwillhappenagain.”

insecurity of daily living post-conflictResponsestocurrentstressfulortraumaticeventshighlighttheinsecurityofdailylivingthatmanyexperience.Table4analyzes

theseresponsesbygenderanddistrict.Anextraordinarynumberofpersonsdescribedifficultiesofprovidingfortheirfamilies

(85%),difficultyfindingwork(90%),ordifficultyinrestartingtheirlivelihoodactivitiespost-conflict(71%).72%reportconcerns

aboutadequatefood,whereas59%reportconcernsabouthavingpropershelter.Differentpatternsareevidentforthethree

regionswithfewerrespondentsfromPidiedistrictidentifyingdifficulties.However,eveninthisregionofwealthandsubstance,

twothirdsofrespondentsexperiencedbeinghungryandlackingfood,and82percentcomplainedofhavingdifficultyfinding

work.Thesenumericalfindingssupportthequalitativeinterviews,whichdescribedeepconcernsaboutbasiclivelihoodissues

acrossallthreedistricts,evenintheso-calledlowerconflictareas.

Table4PostConflictStressorsandInsecuritiesofDailyLiving

Lackofproperplacetolive

Lackofwater,sanitationfacilities

Hungryorlackoffood

Difficultyprovidingforyourfamily

Difficultyfindingwork

Difficultystartingalivelihood

Returnedtofindhomedestroyed

Learnedofdeathoffamilymember,friend

Notknowingwhathappenedtofamily/

friend

%Male

(N=315)

63

79

75

86

92

72

24

48

16

%TotalSample

(N=596)

%Female

(N=281)

54

71

69

85

86

70

17

43

13

%Pidie

(N=237)

40

61

66

78

82

56

9

42

10

%Bireuen

(N=180)

80

92

86

96

97

95

22

50

20

%AcehUtara

(N=179)

62

78

67

84

92

67

36

45

15

59

75

72

85

90

71

21

45

14


Table4PostConflictStressorsandInsecuritiesofDailyLiving(continue)

%Male

(N=315)

%TotalSample

(N=596)

%Female

(N=281)

%Pidie

(N=237)

%Bireuen

(N=180)

%AcehUtara

(N=179)

Seeingperpetrators

Rejectionbyfamily,community

Fearoflivingwithfamily,community

Experiencedattack

Experiencedrobbery

Changeinreligiousvalues

Changeincommunityvalues

Violencetowardwomen

Violencetowardchildren

49

4

21

36

22

12

20

4

7

46

1

13

24

20

11

21

4

7

38

3

20

24

11

3

7

2

4

54

3

23

28

23

13

33

8

9

54

2

9

42

32

21

25

5

9

47

3

18

30

21

11

20

4

7

economic insecurity Theneartwodecadesofconflicthaveclearlywreakedhavoconlocaleconomies,preventingvillagersfromgoingtothefields

andworkingtheirland,killingtheiranimals,destroyingtradenetworks,andpreventingyoungpeoplefromenteringthelabor

economy. WomeninPidiedistrictspeakingaboutapeacebringingamorehopefulfuture,explicitlystatedthatwhatthey

trulyneededweresmallcashgrantsofUS$40toUS$100dollarstorestarttheirhomebusinessesthathadcrumbledunder

theconflictandunderextortion.Theyneededmoneytopurchasenewimplementsforproducingemping,anutcrackersnack

food,forthecashsnackurbanmarket,orsewingmachinesforstitchingandembroideringthewhitecottonheadscarves(jilbab)

usedbyalmostallprimaryandmiddleschoolgirls,therebygivingthemtheopportunitytosecureamarketshareofavastand

growingconsumeritemusedbyallgirlstudents.Sittinginthecompanyofamaleintruder,“anextorter,”tellingustheseneeds,

theyuncomfortablyeyedtheiryoungkinsman,wishinghetoowouldbegrantedacashsumtoleaveforrantau–aperiodoflife

whenyoungadultsleavetheirvillagesoforigintoseekbetteropportunitieselsewhereinthearchipelago–tofulfillhisdesire

tosearchforhisfortuneinMedanasafruitseller,farfromhisgrandmother,aunts,nieces,sisters,andevenhiswife,fromwhom

hehastakenwhateverhecouldextract.Thewomeneyedhimuneasilyastheyspokewithus,buttheydidnotdesistfrom

pressingtheirowncase,astheyeasedawayfromtheyoungman’sside,dismissinghisblusterandselfimportantbehavior.

Even in low conflict villages, where children were frequently kept home from school on days when gunshots were heard,

women not only lost motorbikes and cows and sewing machines to the extortion from men of both sides, but they were

pressedintoaccompanyingsoldiersbacktocamp,toprotectsoldiersfearfulofwalkinginthedark,becomingshields,even

astheyprovidedsuccorandsecretspacesfortheirrebelkin,theirhusbands,theirsons,andtheirnotsoclosekin.Theytold

thesestoriesofbeingcaughtinapredominantlymalegamewithacertainamusementandamazementtoothatitwasforthe

momentover,nowthatthepeaceprocesswasunderway.Theydidnothesitatetoexplaindirectly,albeitwithacertainpleasant

earnestness,thatthemostimportantroutetorecoveryincludessomefashionofmonetarysupporttothemwhichwillindeed

haveamentalhealthbenefit. ‘Recovery’ inconditionssuchastheseandworsewillclearlyrequireboththatthetraumatic

eventssufferedbythesecommunitiesandthebrokeneconomyanddestroyedcommunityresourcesbedealtwithinadirect

andtimelyfashion.Thismaybehelpedby“themoneypill”–whichoftensuppliesthegreatestofassistancetoresilientalbeit

abusedandaggressedindividuals.

safetyNearlyhalfthesample(47%)reported“seeingperpetrators,”whichisunderstoodtomeanthatrespondentscontinuetosee

thosewhocommittedactsofcrimeorviolenceintheircommunitiesduringtheconflict,evenafterthesigningofthepeace

agreement.54%ofrespondentsinbothAcehUtaraandBireuenstillseethesepeoplecomparedwith38%ofrespondentsin

Pidie.Whothesepersonsmightbewasnotasked,sothesefigureshaveambiguousinterpretations.Thesenumbersmayrefer

tothereturnGAMcombatantsortheymayalsorefertotheroutinemonitoringactivitiesofso-called“organic”government

securityforces,whichdenotesnativeAcehnesepolicemenandsoldiersasopposedtotheimportedforcesfromotherparts


ofIndonesia,mostofwhomhaveleftAcehsincethesigningofthepeaceagreement. 30%ofthesample(36%ofallmen)

reportexperiencingattacks(penyerangan)and21%reportrobbery.ThesefiguresarebothhigherforAcehUtaraalone.Both

continuingviolence in thecommunityandseeing formerperpetratorscontributes toacontinuingsenseof insecurityand

uneaseinthesevillages,eveninthistimeofpeace.

changes in religious and community valuesItisfairtosaythatthequestionsthataskedaboutchangesinreligiousandcommunityvalueswereambiguousandtheresults

raisemorequestionsthananswersabouttheirinterpretation.Oneisstruckbytheincreasingbeliefthatthereisachangein

religiousvaluesmovingeastwardfromPidie(3%),toBireuen(13%),andthenAcehUtara(21%),butwhatdoesthatmean?The

peaceagreementaffordsrespondentstheopportunitytovisitthevillagemeunasahormosquefortheirdailyprayers,even

beforesunriseandaftersundown,amostwelcomeandpositivechangeinreligiousvalues.Ontheotherhand,thepassageof

IslamicsharialawinAcehbeforethetsunamiandthenitshighlyvisibleimplementationandenforcementstartinginJuly2005

maybeseenasarestrictiveornegativechangeinreligiousvaluesthatinhibitswomen’smobilityandcomfortincarryingout

typicaldailychoresaroundthevillage.Thesequestionsrequirefurtherinvestigationbeforemakinganyconclusions.Thesame

canbesaidaboutthequestionaboutchangesincommunityvalues.20%ofrespondentsfeelthattherehasbeenachange,

butitremainsunclearwhatkindofchange.Someofthequalitativedataprovidessomeinsight(seeCommunityMentaland

PsychosocialHealth),butlargelyyieldsmorequestionsforfollow-upinvestigation.


depression, anxiety and traumatic stress disorders

One of the key purposes of this psychosocial needs assessment was to assess levelsof psychological disturbances, emotional distress, and diagnosable mental health andneuropsychiatric problems in highly affected rural communities following the cessation ofarmed conflict. As the previous sections have shown, members of these communities havesufferedextraordinaryviolenceandextremelyhighratesoftraumatizingevents.Inthissection,wereportonfindingsofthisstudyconcerninglevelsofpsychologicaldistress.

Ourresearchusedtwogeneralmethodstoassesslevelsofpsychologicaldistressandneedsformentalhealthandpsychosocialservices:qualitative,open-endedquestions,askingpeopleto report on the most important emotional, behavioral and psychological problems facingthemselvesandmembersoftheircommunities;andstandardpsychologicalmeasuresdesignedtomeasurelevelsofpsychologicalsymptomsamongarandomlyselectedgroupofmembersofthecommunitiesstudied.

measures of psychological distress and neuropsychiatric disordersMeasurementofpsychologicaldistressbeganwithaverygeneralself-assessment:“Inthepastyear,haveyoueverhaddifficulties

withyourmoodorthewayyoufeel(forexample,feltdepressedoroftensad,anxious,fearful,ornotbeingabletocontrolyour

anger)?”“Ifyes,howseriouswasthis?”(measuredbya1-4scale,from‘notserious’to‘extremelyserious’).“Ifyes,inyouropinion

werethesecausedbystressortraumaconnectedtotheconflict?”

Thisgeneralquestionwasfollowedbyaskingrespondentstoreportonpsychologicalsymptomsorproblemstheyexperienced

inthepastweek,usinga25itemversionoftheHopkinsSymptomChecklist(HSCL)forDepressionandAnxiety.15symptoms

associatedwithdepressionand10symptomsassociatedwithanxietywereasked,andrespondentswereaskedtodescribe

whethertheyhaveexperiencedtheseduringthepastweek‘notatall,’‘alittle,’‘sometimes,’and‘often.’Thisscaleisincorporated

intotheHarvardTraumaQuestionnaireandhasbeenusedwidelyindisasterandtraumacommunityassessmentsofemotional

distress(refs).

Inaddition,weaskedrespondentstotellus(usingthesameformat)whethertheyhadexperiencedsymptomsorproblems

whichare listedaspartof the42 itemHarvardTraumaQuestionnaire (HTQ),developedbyMollicaandhis teamforuse in

conflictareas.TheHTQisabroadmeasureofsymptomsassociatedwithtrauma,whichincludesa16itemcoreusedtoassess

PostTraumaticStressDisorder(PTSD).

CarewastakentoincorporatecommonwaysofexpressingpsychologicaldistressinIndonesia,andspecificallyinAceh,into

thesequestions. ItemsontheHSCLandHTQweretranslatedusingcommon Indonesianterms–suchas bingung (feeling

confused),melamun(day-dreamingor‘spacingout’)andpusing(acombinationoffeelingdizzyandhavingaheadache).In

addition, items designed to capture popular discourses about disturbing experiences post-tsunami and post-conflict were

integratedintothequantitativemeasurestoelicitexperiencesofnightmares,ghosts,spirits,andhearingvoicesofpeoplewho

haddied.

AfouritemmeasurewasincludedfromtheHarvardTraumaQuestionnairetoassesspresenceandseverityofeventsthatmight

haveproducedheadtraumaorbraininjury,includingbeatingstothehead,suffocationorstrangulation,neardrowning,and

otherphysicalinjuries.


analyses of psychological symptoms and psychiatric diagnosesPsychologicaldistresscanbeconceptualizedintwoways: asa‘continuousvariable,’ i.e.,asa levelofdistressorsymptoms,

suchasdepressionoranxiety,rangingcontinuouslyfromverylowlevelstoveryhighlevels;andasa‘dichotomousvariable,’

i.e.,asbeingeitherhighorlow,asbeinga‘case’ornot(forexample,ofdepressionoranxiety,oracaserequiringtreatment),or

assomeonemeetingcriteriaforaclinicaldiagnosis(forexample,ofmajordepressivedisorder,panicdisorder,orPTSD)ornot

meetingcriteriafordiagnosis.

Psychologicalsymptomchecklistsaredesignedprimarilytobeusedascontinuousvariablesinclinicalworkorresearch–to

answersuchquestionsas‘isthispatientfeelingbetterthanheorshedidonemonthago?’,or‘arepsychologicalsymptoms

especiallyhighinsomeriskgroups,’or‘arelevelsofpsychologicaldistresshighlycorrelatedwithlevelsofstressornumbers

of traumatic events experienced?’ On the other hand, questions such as‘what percentage of persons in this village suffer

depressionorrequirementalhealthservices?’requiremakingdichotomousratings,determiningwhethersomeoneisorisnot

a‘case’ofdepressionordoesordoesnotmeetdiagnosticcriteriaforPTSD.

Inmentalhealthsurveys,therearetwomethodsusedfortransforminga‘continuousvariable’ intoa‘dichotomousvariable’.

First,onecanmakeadeterminationthatanyrespondentwhoreportssymptomsaboveaparticularlevelwillbejudgedtobe

a‘case’–forexample,someonewhoisadequatelydepressedastoneedmentalhealthtreatment.Theleveltheanalystsetsfor

the‘cut-offpoint,’alongwiththelevelofsymptomsinthecommunity,willdeterminewhatnumberofpersonsareconsidered

tobea‘case’.

Second,onecanuseadiagnosticalgorithm,basedoncurrentpsychiatricdiagnosticpractices.Ifarespondentindicatesthathe

orshehasexperiencedaparticularcombinationofsymptomsthatserveascriteriaforaparticulardiagnosis(“majordepressive

disorder”or“post-traumaticstressdisorder,”forexample),thatpersonmayberatedas‘meetingcriteria’forthatdisorder.

Inwhatfollows,wereportourfindingsinfourways.First,wefollowthestandardprocedurerecommendedbyMollicaetal

(2004)touseascut-offsameanof1.75ondepressionitemsontheHSCL15itemdepressionscale,and2.50onthe42trauma

symptomsontheHTQ,toidentifyapersonassufferingdepressionorapost-traumaticdisorder.3Usingthismethodallowsus

tocomparefindingsfortheAcehsamplewithsimilarsamplesfromhighconflictareassuchasBosniaorCambodia.Second,

forsomeanalyses,weusedmoreconservativeorstringentcut-offs,3.0ondepressionitemsontheHSCLand3.0onthetrauma

symptomsontheHTQ. Raisingthecut-off levels identifiesasmallergroupof individualswhoarecurrentlysufferingmore

severesymptoms,andallowsustoaskwhatgroupsofpersonsorwhatformsoftraumaticexperienceplaceanindividuala

particularlyhighriskforsufferingmajorpsychiatricdistress.

Third,wefollowedthealgorithmdevisedbyMollicaetal(2004)todeterminewhetherindividualssufferparticularconstellations

ofsymptomsassociatedwithdepressiveillnessorPTSD,accordingtotheAmericanPsychiatricAssociation’sDiagnosticand

StatisticalManual4thedition(DSM-IV).Becausethisalgorithmisbasedonsymptomsfromasymptomchecklistratherthana

psychologicalinterviewdesignedexplicitlytodetermineaclinicaldiagnosis,theseratingscanbeconsideredapproximations

only.Theydo,however,indicatelevelsofdepressionandtrauma-relatedsufferinginthesecommunities.

Atotalof14depressionitemsfromtheHSCLwereincludedwithinthedepressionalgorithm(seeTable5.1).Individualswere

consideredtobesufferingaparticularsymptomiftheyratedthemselves3or4onaparticularitem.Inordertobeclassified

3 Mollica, Richard F., Laura S. MadDonald, Michael Massagli, and Derrick M. Silove. 2004. Measuring Trauma, Measuring

Torture.InstructionsandGuidanceontheUtilizationoftheHarvardPrograminRefugeeTraumasVersionsofTheHopkins

SymptomChecklist-25(HSCL-25)&TheHarvardTraumaQuestionnaire(HTQ).Cambridge,MA:HarvardPrograminRefugee

Trauma.


4 Mollicaetal.“DisabilityAssociatedwithPsychiatricComorbidityandHealthStatusinBosnianRefugeesLivinginCroatia”

inJournaloftheAmericanMedicalAssociation(JAMA).Volume282(5),04August1999,pp433-439.5 Mollica et al. “Dose-effect Relationships of Trauma to Symptoms of Depression and Post-Traumatic Stress Disorder

Among Cambodian Survivors of Mass Violence” in The British Journal of Psychiatry. Volume 173(12), December 1998,

pp482-488.6 Sabinetal.“FactorsAssociatedwithPoorMentalHealthAmongGuatemalanRefugeesLivinginMexico20YearsAfterCivil

Conflict”inJournaloftheAmericanMedicalAssociation(JAMA).Volume290(5),06August2003,pp635-642.

assymptomatic fordepression,asubject initiallyneededapositive responseonanyof thedepressedmoodordecreased

interest/pleasureitems.Additionally,apositivescoreon4outofthe6DSM-IVCriterionAsymptomswererequiredforpositive

classification.Atotalof3outofthe6DSM-IVCriterionAsymptomswererequiredwhenpositiveresponsesforbothdepressed

moodanddecreasedinterest/pleasurewerepresent.456

Amoreconservativealgorithmwasalsoexamined.Inthiscase,questionswerechecklistpositiveifratingswere4only.Allother

stepsintheprimarydepressionalgorithmremainedthesame.

Table5.1HSCL-DepressionCategories

Depressedmood

• Cryingeasily

•Feelinghopelessaboutthefuture

•Feelingblue

•Feelinglonely

Diminishedinterest/pleasure

•Feelingnointerestinthings

•Lossofsexualinterestorpleasure

DSM-IVcriterionasymptoms

•Poorappetite

•Difficultyfallingasleeporstayingasleep

•Feelinglowinenergyand/orfeelingeverythingisaneffort

•Blamingyourselfforthings

•Worryingtoomuchaboutthingsand/orfeelingorworthlessness

•Thoughtsofendingyourlife

Eachquestionwasratedas“Notatall”,“Alittle”,“Quiteabit”,or“Extremelyoften”,1-4respectively.

Atotalof16HarvardTraumaQuestionnaire(HTQ)itemswereincludedwithinthePTSDalgorithm.Individualswereconsidered

tobesufferingaparticularsymptomiftheyratedthemselves3or4onaparticularitem.Inordertobeclassifiedassymptomatic

forPTSD(or‘meetingdiagnosticcriteriaforPTSD’),asubjectneededapositiveresponseon1ormorere-experiencingsymptoms,

3ormoreavoidanceandnumbingsymptoms,and2ormorearousalsymptoms.(Seetable5.2)Subjectexposuretoatraumatic

event(criterionA)hasbeenassumedforallrespondents.

Onceagain,amoreconservativealgorithmwasalsoexamined.Inthiscase,questionswerechecklistpositiveifratingswere4

only.AllotherstepsintheprimaryPTSDalgorithmremainedthesame.


Table5.2HarvardTraumaQuestionnaireCoreCategories

Re-experiencingSymptoms(DSM-IVcriterionB)

• Recurrentthoughtsormemoriesofthemosthurtfulorterrifyingevents

•Feelingasthoughtheeventishappeningagain

•Recurrentnightmares

•Suddenemotionalorphysicalreactionwhenremindedofthemsothurtfulortraumaticevents

AvoidanceandNumbingSymptoms(DSM-IVcriterionC)

•Feelingdetachedorwithdrawnfrompeople

•Unabletofeelemotions

•Avoidingdoingthingsorgoingplacesthatremindyouofthetraumaticorhurtfulevents

• Inabilitytorememberpartsofthemosttraumaticorhurtfulevents

•Lessinterestindailyactivities

•Feelingasifyoudon’thaveafuture

•Avoidingthoughtsorfeelingsassociatedwiththetraumaticorhurtfulevents

ArousalSymptoms(DSM-IVcriterionD)

•Feelingjumpy,easilystartled

•Difficultyconcentrating

•Troublesleeping

•Feelingonguard

•Feelingirritableorhavingoutburstsofanger

Eachquestionwasratedas“Notatall”,“Alittle”,“Quiteabit”,or“Extremelyoften”,1-4respectively.

symptom findingsTables6.0,6.1,and6.2providefindingsconcerningself-perceivedlevelsofgeneralemotionaldistress,symptomsanddiagnoses

ofdepression,andsymptomsanddiagnosesofPTSD,bothbygenderandbydistrict.Overall,thefindingssuggestextremely

highlevelsofpsychologicaldistressinthispopulation.

Table6.0reportsfindingsfromthreegeneralquestionsdesignedtoassessrespondents’globalsenseofemotionaldistress.

Inansweringthesequestions,76%ofmenand85%ofwomenindicatedthattheysufferdifficultieswiththeirmoodortheir

feelings,suchasfeelingdepressed,sad,anxious,fearful,orunabletocontroltheiranger,andratedthelevelofseriousnessas

3.0and2.9respectivelyonaverage.95%ofbothmenandwomenindicatedthattheiremotionaldifficultiesarecausedbythe

conflict.

Table6.0GeneralEmotionalDistressandConflict

%Male

(N=315)

%TotalSample

(N=596)

%Female

(N=281)

%Pidie

(N=237)

%Bireuen

(N=180)

%AcehUtara

(N=179)

Experiencegeneralemotionaldistress?

Causedbytheconflict?

Seriousness(1-4scalemean(SD))

76

95

3.0

(0.9)

85

95

2.9

(0.9)

62

90

2.6

(0.8)

91

98

3.1

(0.9)

94

98

3.0

(0.8)

80

95

2.9

(0.9)

Note:8noresponses


Table6.1DepressionbyGenderandDistrict

%Male

(N=315)

%TotalSample

(N=596)

%Female

(N=281)

%Pidie

(N=237)

%Bireuen

(N=180)

%AcehUtara

(N=179)

MeandepressionSxscore>1.75=

“symptomatic”

DSMDepressionDiagnosis

*InitialDSMAlgorithmSx=3or4

MeandepressionSxscore>3=

“symptomatic”


**RevisedDSMAlgorithm,Sx=4

64

54

16

18

67

57

18

19

44

38

6

6

81

72

26

31

78

62

23

22

65

55

17

18

Psychologicalsymptomsorpsychiatric

diagnosesforinformants

Table6.2TraumaSymptomsandPTSDbyGenderandDistrict

%Male

(N=315)

%TotalSample

(N=596)

%Female

(N=281)

%Pidie

(N=237)

%Bireuen

(N=180)

%AcehUtara

(N=179)

MeanPTSDSxscore>2.5=

“symptomatic”

PTSDDiagnosis

InitialDSMAlgorithmSx=3or4

MeanPTSDSxscore>3=

“symptomatic”

PTSDDiagnosis

RevisedDSMAlgorithm,Sx=4

33

37

17

11

35

35

16

10

12

14

3

1

51

52

26

16

45

51

25

17

34

36

16

10

Psychologicalsymptomsor

DSM-IVPsychiatricdiagnoses

Note: Significantdifferenceingender:“Meananxietyscore(>1.75)”

Significantdifferenceindistrict:“Meananxietyscore(>1.75)”and“Meananxietyscore(>3)”

Table6.3AnxietySymptoms,byGenderandDistrict

%Male

(N=315)

%TotalSample

(N=596)

%Female

(N=281)

%Pidie

(N=237)

%Bireuen

(N=180)

%AcehUtara

(N=179)

Meananxietyscore(>1.75)

Meananxietyscore(>3)

64

30

75

36

54

23

79

39

79

39

69

33

Anxietysymptomsexperienced

byinformants

Table6.1ismorecomplex.First,usingthecutoffscoreof1.75asthemeanscoreonHSCLdepressionitems,asrecommended

byMollicaandhiscolleagues,65%ofthetotalpopulation–64%ofmenand67%ofwomen–maybeconsidereddepressed.

UsingadiagnosticalgorithmasrecommendedbyMollicaandcolleagues,55%ofthetotalpopulation–54%ofmenand57%

ofwomen–meritsadiagnosisofmajordepression.Levelsofdepressionvarybydistrict,closelymatchingfindingsoflevelof

traumaticeventsinthethreedistrictsstudied.38%ofrespondentsinPidiemeetcriteriaforadiagnosisofmajordepression,

usingtherecommendedalgorithm,62%ofrespondentsinAcehUtara,and72%ofrespondentsinBireuenmeetcriteriafor

majordepression.


Table6.1alsoprovidesfindingsforthepercentageofpersonswithhighlevelsofdepressivesymptoms(ameanof3.0orhigher)

andthosewhomeetmoreconservativecriteriaforadiagnosisofmajordepressivedisorder(countingasymptomasmeeting

criteriaonlyiftherespondentanswered4,indicatingthattheyhaveoftenexperiencedthatsymptomduringthepastweek).

17%and18%ofthetotalpopulationrespectivelysufferthesehigherlevelsofsymptomsormoresevereformsofdepression.

Again,menandwomenarenearlyequal,andratesarehighestinBireuen,lowestinPidie.

Table6.2providescomparablefindings forsymptomsof traumaandfordiagnosesofPTSD. Usingthecutoffmeanscores

andthealgorithmsrecommendedbyMollicaandhiscolleagues,andusedinstudiesinmanyotherconflictsettings,ratesof

personssufferingtraumasymptomsoradiagnosisofPTSDareestimatedat34%and36%ofthetotalpopulation.Usingthe

initialalgorithmcriteria,16%ofthetotalpopulationmeetPTSD;utilizingthemorestringentcriteriaoftherevisedalgorithm,

10%ofthetotalpopulationsuffersPTSD.

Table 6.3 provides findings for symptoms of anxiety and anxiety disorders. These include symptoms such as feelings of

acuteanxietyorpanicaswellaschronicfeelingsofworry,insecurity,andfear.Thesesymptomsareparticularlyhighinthese

communities.69%ofallrespondentsreportsymptomsatastandardcutofflevel,and33%reportanxietysymptomsatavery

highlevel(mean3.0orgreater).Womenareonlyslightmorelikelytosufferanxietythanmen,butlevelsinBireuenandAceh

Utaraareremarkablyhigh,reflectingpatternsofviolenceandtraumainthesecommunities.

Thecomplexityofthesetablesshouldnotobscurethefindings:thispopulationhasextraordinarilyhighlevelsofdepression

and trauma-related symptoms, ranking with traumatized populations in high conflict areas such as Bosnia or Cambodia

or Afghanistan. Members of these communities are highly resilient, but they have experienced years of violence that has

producedhighlevelsofdepressionandcomplextrauma.Community-basedservicesaimedbothat‘clinical’disordersandat

helpingmembersofthesecommunitiesrebuildtheirlivesshouldbeanurgentpriority.

the distribution of risK: what groups are at highest risK?VariationinsymptomlevelsandseverityforbothdepressionandPTSDisclearlyassociatedwithdistrict,whereasassociations

withgenderandagearemuchlesspowerfulandfarlessclearpredictorsofwhoisatriskforpsychologicaldisorders.These

relationshipsareanalyzedutilizingadjustedoddsratiosfordepressionandPTSDasmeasuredbytheinitialcriteriaandstringent

criteriaalgorithmspreviouslydiscussed.Thisisastatisticalmodelthatallowsonetodeterminehowmuchtheriskforanillness

likedepressionisincreasedforwomenratherthanmen,forpersonsinparticularagegroups,orforthosewhohavesuffered

particularpatternsoftraumaticviolence.

* District:0=Pidie(reference)andadjustedforgenderandage † Statisticallysignificantlydifferentatp<0.0001

Table7.1AdjustedOddsRatiosforDepressionandPTSDbyDistrict

Pidie





PTSDDiagnosis


PTSDDiagnosis


1.00

1.00

1.00

1.00

4.96

(3.19-7.72)†

9.63

(4.93-18.82)†

7.10

(4.36-11.57)†

26.87

(6.23-115.88)†

2.63

(1.74-3.96)†

5.59

(2.84-11.03)†

6.65

(4.11-10.78)†

28.18

(6.56-120.98)†


DSM-IVpsychiatricdiagnoses Bireuen AcehUtara

*District

or(95%CI)


*Gender:0=female(reference)andadjustedfordistrictandage † Statisticallysignificantlydifferentatp<0.05

Table7.2AdjustedOddsRatiosforDepressionandPTSDbyGender





PTSDDiagnosis


PTSDDiagnosis



DSM-IVpsychiatricdiagnoses

0.68

(0.47-0.97)†

0.69

(0.43-1.09)

0.90

(0.62-1.32)

0.76

(0.43-1.34)

*Gender

or(95%CI)

* Age:0=17-29(reference)andadjustedforgenderanddistrict † Statisticallysignificantlydifferentatp<0.05

Table7.3AdjustedOddsRatiosforDepressionandPTSDbyAge

17-29 30-40 41-53 54-82





PTSDDiagnosis


PTSDDiagnosis


1.00

1.00

1.00

1.00

0.93

(0.59-1.48)

0.42

(0.23-0.78)†

0.78

(0.48-1.26)

0.43

(0.20-0.91)†

1.19

(0.71-2.02)

1.36

(0.71-2.57)

0.91

(0.51-1.60)

1.29

(0.59-2.79)



*Age

or(95%CI)

1.78

(1.07-2.96)†

0.81

(0.44-1.49)

0.83

(0.49-1.41)

0.56

(0.26-1.23)

Tables 7.1-7.3 indicate the explanatory power of district, gender and age in the scores of respondents on depression and

PTSDsymptoms;eachoddsratioanalysisadjustsforvariationintroducedbydistrict,ageorgender.InTable7.1,respondents

from Bireuen and Aceh Utara are far more likely to score positive on all depression and PTSD algorithms as compared to

respondentsinPidiedistrict.Thesedifferencesarehighlysignificantacrossthealgorithms,withrespondentsfromBireuen5

to10timesmorelikelytomeetdepressioncriteriaand7to27timesmorelikelytomeetPTSDcriteriathanPidierespondents.

RespondentsfromAcehUtaraare3-6timesmorelikelytomeetdepressioncriteriaand6to28timesmorelikelytomeetPTSD

criteriaascomparedtorespondentsfromPidie.


Table7.2 indicatesthatgender isafar less importantcontributorthandistricttovariationinmeetingcriteria.Forexample,

whencontrollingfordistrictandage,menaresignificantlylesslikelytomeetcriteriathanarewomenfordepressiononthe

initialdepressionalgorithmby.68. Significanceatthe.05levelisnotmetbytheotherscoresonthedepressionandPTSD

algorithms,althoughtheoddsratiosindicatemenasbeingslightlylesslikelythanwomentosuffersymptomsofdepression

andPTSD.Thisfindinginandofitselfisimportant.Womentypicallysufferhigherratesofdepressionanddepressivesymptoms

thanmeninpopulationstudies.Here,menandwomenbothsufferhighlevelsofdepression,withmenonlyslightlylessatrisk

thanwomen,reflectingthelevelsofviolencemenhaveexperiencedintheseAcehnesecommunities.

Table7.3presentstherelationshipbetweenageanddepressionandPTSDalgorithmscores,adjustedfortheeffectsofgender

anddistrict.Itisacomplexpicture.Comparingdepressionscoresofolderagegroupstotheyoung,respondentsinthe41-53

agegrouparesignificantlymorelikelytosuffersymptomsofdepressionthanareyoungerpeopleby1.78times).However,

individualsinthe30to40agegroup,aresignificantlymorelikelytoscoreloweronbothdepression(.42)andPTSDscores(.43)

utilizingthemoststringentcriteriaalgorithm.

Thedescriptivedataunderlyingtheoddsratiosanalysesarenoted inTable8.1-8.6,examiningthedistributionbydistrict,

genderandageofindividualswhoscoresmeetcriteriaontheinitialandmorestringentdepressionalgorithmsandonthe

initialandmorestringentPTSDalgorithms.Againtheimportanceofwhereonelivesasanexplanationforscoringhighfor

depressionandanxietyisexceedinglyimportant.Genderexplainslittleofthevariation,andthescoresofmenandwomen

acrossthetotalsamplearehighlysimilar.Variationsbyagearemorecomplexandmayreflectbothlifecycleexperiencesas

wellasconflict-relatedandpost-conflictstressexperiences,withmanyyoungermenandwomenaged17-29fromBireuenand

AcehUtarascoringhighonalgorithmsfordepressionandPTSD,withthemiddleagedappearingmoreresilient,andtheold

scoringhigheragainonthesemeasures.Thesefigurestellamostcomplexstory.However,Pidiedistrictwhererespondents

reportedlesstraumaalsohadveryfewrespondentsregardlessofagemeetingthemorestringentcriteriaforthedepression

andPTSDalgorithms.Thedifferenceismoststrikinginthesedescriptivetables.

* Age:0=17-29(reference)andadjustedforgenderanddistrict † Statisticallysignificantlydifferentatp<0.05

Table8.1Pidie:DepressionbyGenderbyAge

Age

17-29

(n=15)









47

0

42

5

15

0

43

10

26

3

52

12



PIDIESAMPLE

%

(N=236)

Male(N=106)

35

4

52

7

Age

30-40

(n=26)

Age

41-53

(n=26)

Age

54-82

(n=39)

Age

17-29

(n=38)

Female(N=130)

Age

30-40

(n=40)

Age

41-53

(n=27)

Age

54-82

(n=25)


Table8.2Pidie:PTSDbyGenderbyAge

5

3

12

0

Age

17-29

(n=15)

PTSDDiagnosis


PTSDDiagnosis


PTSDDiagnosis


PTSDDiagnosis


13

0

21

3

4

0

23

0



PIDIESAMPLE

%

(N=236)

Male(N=106)

12

0

15

0

Age

30-40

(n=26)

Age

41-53

(n=26)

Age

54-82

(n=39)

Age

17-29

(n=38)

Female(N=130)

Age

30-40

(n=40)

Age

41-53

(n=27)

Age

54-82

(n=25)

Table8.3Bireuen:DepressionbyGenderbyAge

79

42

67

67

Age

17-29

(n=25)









68

48

72

36

75

16

68

14



BIREUENSAMPLE

%

(N=177)

Male(N=114)

67

33

80

30

Age

30-40

(n=44)

Age

41-53

(n=21)

Age

54-82

(n=24)

Age

17-29

(n=25)

Female(N=63)

Age

30-40

(n=22)

Age

41-53

(n=10)

Age

54-82

(n=6)


Table8.5AcehUtara:DepressionbyGenderbyAge

44

28

88

38

Age

17-29

(n=19)









58

21

44

30

56

16

50

14



ACEHUTARASAMPLE

%

(N=176)

Male(N=90)

75

14

85

30

Age

30-40

(n=25)

Age

41-53

(n=28)

Age

54-82

(n=18)

Age

17-29

(n=23)

Female(N=86)

Age

30-40

(n=28)

Age

41-53

(n=27)

Age

54-82

(n=8)

Table8.4Bireuen:PTSDbyGenderbyAge

67

25

50

33

Age

17-29

(n=25)

PTSDDiagnosis


PTSDDiagnosis


PTSDDiagnosis


PTSDDiagnosis


56

24

56

20

48

5

50

18



BIREUENSAMPLE

%

(N=177)

Male(N=114)

48

10

30

20

Age

30-40

(n=44)

Age

41-53

(n=21)

Age

54-82

(n=24)

Age

17-29

(n=25)

Female(N=63)

Age

30-40

(n=22)

Age

41-53

(n=10)

Age

54-82

(n=6)


Table8.6AcehUtara:PTSDbyGenderbyAge

50

22

63

25

Age

17-29

(n=19)

PTSDDiagnosis


PTSDDiagnosis


PTSDDiagnosis


PTSDDiagnosis


58

21

44

22

48

12

43

14



ACEHUTARASAMPLE

%

(N=176)

Male(N=90)

54

14

56

15

Age

30-40

(n=25)

Age

41-53

(n=28)

Age

54-82

(n=18)

Age

17-29

(n=23)

Female(N=86)

Age

30-40

(n=28)

Age

41-53

(n=27)

Age

54-82

(n=8)

the effects of traumatic experiences on psychological distressAlthoughitisreasonabletoassumethatexperiencinghighlevelsofviolenceorparticulartraumaticeventsplacescommunity

membersathigherriskforpsychologicalproblems,itisimportanttoexaminethisquestionempirically.Oddsratiosbynumber

oftraumaticeventsarevividrepresentationsoftherelationshipbetweenpasttraumaticexperiencesandcurrentsymptom

scoresondepressionandPTSDalgorithms;similarly,higherlevelsofcurrentstressfuleventsaresignificantlyincreasetheodds

ofmeetingthesymptomaticcriteriaonallthefouralgorithms.TheserelationshipsarepicturedinTables9.1and9.2andthe

accompanyinggraphs.

Table9.1MentalHealthMeasures(OddsRatios)forRespondentsExperiencingPastTraumaticEvents-Unadjusted

PTSD

Symptoms-Revised

Algorithm

OR

(95%CI)

No.of

traumatic

events

Depression

Symptoms-Initial

Algorithm

OR

(95%CI)

PTSD

Symptoms-Initial

Algorithm

OR

(95%CI)

0-3

4-7

8-10

>11

1.00

3.04

(1.84-5.02)*

6.25

(3.64-10.75)*

11.42

(6.80-19.16)*

Depression

Symptoms-Revised

Algorithm

OR

(95%CI)

1.00

1.83

(0.66-5.10)

5.83

(2.30-14.81)*

12.75

(5.34-30.44)*

1.00

6.91

(3.12-15.32)*

11.57

(5.19-25.80)*

28.19

(13.03-61.02)*

1.00

2.94

(0.30-28.54)

22.26

(2.91-170.39)*

41.10

(5.59-302.41)*

EmotionalDistressExperiencedbyInformants

* Statisticallysignificantlydifferentatp<0.0001top<0.05 Note:“0-3Events”=referencegroup


Table9.2MentalHealthMeasures(OddsRatios)forRespondentsExperiencingPresentStressfulEvents-Unadjusted

PTSD

Symptoms-Revised

Algorithm

OR

(95%CI)

No.of

traumatic

events

Depression

Symptoms-Initial

Algorithm

OR

(95%CI)

PTSD

Symptoms-Initial

Algorithm

OR

(95%CI)

0-3

4-7

8-10

>11

1.00

5.40

(2.90-10.03)*

14.55

(7.50-28.25)*

21.42

(9.59-47.85)*

Depression

Symptoms-Revised

Algorithm

OR

(95%CI)

1.00

6.96

(1.64-29.53)*

14.16

(3.34-60.04)*

25.92

(5.91-113.59)*

1.00

4.87

(2.04-11.67)*

14.00

(5.80-33.78)*

40.77

(15.33-108.45)*

1.00

6.13

(0.80-46.75)

11.66

(1.54-88.34)*

41.41

(5.44-315.26)*


* Statisticallysignificantlydifferentatp<0.0001top<0.05 Note:“0-3Events”=referencegroup

OddsRatios-MentalHealthAlgorithmsbyNumberofPastTraumaticEvents

8-10events4-7events0-3events >or=11events

45.00

40.00

35.00

30.00

25.00

20.00

15.00

10.00

5.00

0.00 1.003.04*

6.25*

11.42*

1.00 1.835.83*

12.75*

1.00

6.91*

11.57*

28.19*

1.002.94

22.26*

41.10*

Od

ds

Rat

ios

MentalHealthAlgorithms

Depression-Initial Depression-Revised PTSD-Initial PTSD-Revised


Thereisapowerfulrelationshipbetweenthenumberoftraumaticeventsarespondentreportedandtheirlevelofpsychological

distress–bothdepressionandtrauma-relatedsymptoms.Tables9.1and9.2demonstratethisquitedramatically. Table9.1

reportsoddsratiosforrespondentswhoexperiencedvariouslevelsofpasttraumaticevents.Individualswhoexperienced4to

7eventsarethreetimesmorelikelytomeetcriteriafordepressionontheinitialalgorithm,andalmosttwiceaslikelytomeet

criteriaonthemorestringentalgorithm,incomparisontothosewhoexperienced0to3traumaticevents.Theyarealmost

seventimesmorelikelytomeetcriteriaforPTSDontheinitialalgorithmandalmost3timesonthemorestringentalgorithm.

Individualswhohadexperienced8to10pasttraumaticeventsare6moretimeslikelytomeetcriteriafordepressionand11to

22timesmorelikelytomeetcriteriaforbothPTSDalgorithms.Whenindividualsexperience11ormorepasttraumaticevents

theirlikelihoodofscoringhighonallfourcriteriaalgorithmsfordepressionandPTSDbecomeexceedinglyhigh–over11for

depressionandbetween28and41forPTSD,asnotedinthetableandchart.Significantdifferencesareparticularlypowerful

whenpeoplehaveexperienced8ormoretraumaticevents.

Table9.2reportsoddsratiosforlevelsofpsychologicaldistressforrespondentsexperiencingpresentstressfulevents.Again,

individualswhoexperience4-7currentstressfuleventsare5to7timesmorelikelytomeetcriteriafordepressionand5to

6timesmorelikelytomeetcriteriaforPTSDthanthosewhoexperience0to3events.Individualswhoexperienced8to10

currentstressfuleventsareover14timesmorelikelytomeetcriteriafordepressiononbothalgorithms,and11to14times

morelikelytomeetPTSDcriteria.Individualswhoexperience11ormorecurrentstressfuleventsare20to26timesmorelikely

tomeetcriteriafordepressiononbothalgorithms,andover40timesmorelikelytomeetcriteriaforPTSDonbothalgorithms.

Theseoddsratiosinallbutoneinstancearesignificantwhencomparingindividualsinthethreeeventcategories(4-7,8-10,>

11,respectively)toindividualswhoexperience0-3stressfulevents.

head traumaAsdescribedabove,astartlinglyhighnumberofpersonshavesufferedheadtraumaandstrangulationorneardrowning,both

ofwhichmayproducelastingbraininjuriesthatcanaffectcognitivefunctioning,emotionallability,andbehavior.(SeeTable3.1,

referredtoabove.)Althoughasignificantnumberofwomensufferedheadtrauma,mensufferedextremelyhighrates.36%of

allmeninthesurveyreportedbeingbeatenonthehead,19%beingsuffocatedorstrangled,andanother7%experiencednear

drowningand9%otherformsofheadtrauma.Breakingthesefindingsdownbygenderandageclarifieswhowasatspecial

risk(seeTable9.4).

OddsRatios-MentalHealthAlgorithmsbyNumberofCurrentStressfulEvents

>or=11events8-10events4-7events0-3events

Od

ds

Rat

ios

MentalHealthAlgorithms

45.00

40.00

35.00

30.00

25.00

20.00

15.00

10.00

5.00

0.00Depression-Initial Depression-Revised PTSD-Initial PTSD-Revised

1.00

5.40*

14.55*

21.42*

1.00

6.96*

14.16*

25.92*

1.004.87*

14.00*

40.77*

1.00

6.13

11.66*

41.41*


Table9.4HeadTrauma/PotentialBrainInjury:PercentofRespondentsbyGenderandAge

33

23

14

10

7

5

0

5

0

3

AGE17-29

%(N=53-58)

*AnyTypeofHeadTrauma

SpecificType

Beatenonthehead


Neardrowning

Otherheadtrauma


SpecificType

Beatenonthehead


Neardrowning

Otherheadtrauma

52

48

18

13

17

17

10

7

1

3

40

39

20

5

6

15

10

9

0

2

TypesofHeadTrauma/

PotentialBrainInjury

Male(N=280-304)

40

35

24

4

9

5

2

3

0

0

AGE30-40

%(N=84-92)

AGE41-53

%(N=70-75)

AGE54-82

%(N=72-79)

AGE17-29

%(N=81-84)

Female(N=258-272)

AGE30-40

%(N=82-88)

AGE41-53

%(N=62-70)

AGE54-82

%(N=33-37)

Thesefindingsareparticularlystartlingwhenexaminingpercentagesofpersonsinvolvedbydistrict,aswellasageandgender.

Tables9.5and9.6showjusthowmanyyoungmeninBireuenandAcehUtarasufferedvarioustypesofheadtraumaaspartof

theconflictsituation.Allmenwereathighrisk,butyoungmenwereatparticularlyhighriskforvariousformsofheadtrauma

inthesetwodistricts.

Table9.5HeadTrauma/PotentialBrainInjury:PercentofRespondentsByGenderandAgeforBireuen

44

32

14

12

21

0

0

0

0

0

AGE17-29

%(N=23-25)


SpecificType

Beatenonthehead


Neardrowning

Otherheadtrauma


SpecificType

Beatenonthehead


Neardrowning

Otherheadtrauma

68

60

29

17

17

28

12

17

0

4

40

37

16

7

5

23

14

18

0

5

HeadTrauma/


Male(N=100-112)

43

29

26

5

10

0

0

0

0

0

AGE30-40

%(N=41-43)

AGE41-53

%(N=19-21)

AGE54-82

%(N=17-23)

AGE17-29

%(N=23-25)

Female(N=59-61)

AGE30-40

%(N=20-22)

AGE41-53

%(N=9)

AGE54-82

%(N=5)

BIREUEN


Table9.6HeadTrauma/PotentialBrainInjury:PercentofRespondentsbyGenderandAgeforAcehUtara

33

28

17

18

6

0

0

0

0

0

AGE17-29

%(N=17-18)


SpecificType

Beatenonthehead


Neardrowning

Otherheadtrauma


SpecificType

Beatenonthehead


Neardrowning

Otherheadtrauma

67

67

11

12

29

29

19

11

5

5

61

57

35

5

16

27

24

13

0

4

HeadTrauma/


Male(N=80-87)

61

61

33

4

15

7

4

4

0

0

AGE30-40

%(N=19-23)

AGE41-53

%(N=26-28)

AGE54-82

%(N=17-18)

AGE17-29

%(N=19-21)

Female(N=75-81)

AGE30-40

%(N=22-26)

AGE41-53

%(N=26-27)

AGE54-82

%(N=7)

ACEHUTARA

* Fromthefourdifferenttypesofheadinjury,ifarespondentanswersyestooneormoreofthosefourquestions,thenthe

answerisyesforthenewvariable(“Anytypeofheadtrauma”),whichwillthentellushowmanyrespondentsexperienced

physicalheadtraumaofanykindatall”

Note: Chisquareanalysis:

Significantdifference(p<0.001)forgenderanddistrict

Non-significantdifferenceinage

Note: Severity(lossofconsciousnessandduration)wereexamined,88%didnotbecomeunconscious.Onlytwopercenttold

interviewersaboutdurationofunconsciousstate.

Headtraumamaycausespecificanddirecteffectsonemotions,cognitiveabilities(memory,learningability),andbehavior,as

theclinicalcasedescribedaboveillustrates.ThisformoftraumaalsoplacespersonsatincreasedriskfordepressionandPTSD.

Table9.7illustratesthis.Itshouldbereadtoindicatethatsufferingbeatingtothehead,suffocationorneardrowning,orother

typesofheadinjuriesmakesit2.2to2.6timesaslikelythattherespondentwillsufferaclinicaldepressionorPTSD.


Table9.7IncreasedRiskforDepressionorPTSDforPersonsSufferingHeadTrauma(AdjustedOddsRatios)

PTSD

Symptoms-

Revised

Algorithm

OR

(95%CI)

Head

trauma

Depression

Symptoms-

Initial

Algorithm

OR

(95%CI)

PTSD

Symptoms-

Initial

Algorithm

OR

(95%CI)

AnyTypeof

HeadTrauma

Beatenon

thehead

Suffocation

or

strangulation

Near

drowning

Otherhead

trauma

2.21

(1.40-3.47)‡

3.23

(1.92-5.42)†

2.55

(1.40-4.62)**

2.13

(0.78-5.82)

2.36

(0.92-6.07)

Depression

Symptoms-

Revised

Algorithm

OR

(95%CI)

2.59

(1.54-4.36)‡

3.07

(1.74-5.42)†

1.70

(0.92-3.14)

2.94

(1.12-7.71)*

1.49

(0.64-3.46)

2.33

(1.49-3.62)‡

3.14

(1.92-5.15)†

2.69

(1.54-4.68)‡

2.13

(0.82-5.50)

2.30

(1.00-5.30)*

2.43

(1.29-4.59)**

2.75

(1.40-5.40)**

2.34

(1.15-4.75)*

1.88

(0.60-5.84)

2.04

(0.82-5.09)


Anxiety

Symptoms-

Mean

(>3.00)

OR

(95%CI)

Anxiety

Symptoms-

Mean

(>1.75)

OR

(95%CI)

2.75

(1.63-4.65)‡

3.15

(1.74-5.70)‡

2.40

(1.21-4.75)*

1.56

(0.54-4.53)

2.06

(0.69-6.17)

2.95

(1.89-4.58)†

3.52

(2.17-5.72)†

2.08

(1.24-3.50)**

1.92

(0.78-4.69)

1.97

(0.92-4.26)

Adjustedforgender,age,anddistrict

† Statisticallysignificantlydifferentatp<0.0001

‡ Statisticallysignificantlydifferentatp<0.001

**Statisticallysignificantlydifferentatp<0.01

* Statisticallysignificantlydifferentatp<0.05

Todate,verylittlementalhealthworkhasfocusedonheadinjury.Becauseheadtraumamayaffectlong-termbehaviorwhich

canbemistakenforcriminalbehavior,andcanalsoaffectattention,learning,andothercognitivefunctions,specificattention

needstobedirectedatthisproblem.Inparticular,researchneedstoaddresswhatpercentageofpersonshavelastingeffects

ofheadtrauma–forthepopulationingeneral,aswellasforformercombatantsandformerprisoners.Thesefindingsalsohave

directclinicalrelevance.Communitymentalhealthnurses,generalpractitioners,andpsychiatristsneedadvancedtrainingto

assessandrespondtoproblemsassociatedwithheadinjuryaspartofroutineclinicalworkandaspartofadvancedreferral

services.Thisneedsassessmentprovidesevidencethataspecializedprogramfocusedonheadtraumashouldbeundertaken

withsupportoftheinternationalcommunity.


local idioms of distress

The symptom checklists used above are useful for comparative purposes with populationsaroundtheworldinpost-conflictandotherdisastersettings.Neverthelessthesearesymptomcategoriesdefinedlargelybypsychiatriststrainedinadistinctlybiomedicaltradition.Itispossiblethat some commonly understood symptoms in psychiatric practice have little meaning forpopulationsnotschooledwiththesecategoriesofmentalillness.Somesymptomsconsideredpathologicalinonesettingmightactuallybeanadaptivesurvivalstrategyinsettingsofhighdangerandconflict.Inanysettingofpsychosocialresearchitisimportanttounderstandlocalcategoriesofillnessbeforepathologiesinacommunitycanbedescribed.

Beforethedepression,anxiety,andtraumasymptomschecklistswerereadtothequestionnairerespondents,theywereasked

thefollowingquestion: “TheconflicthasbroughtuniquepressuresupontheAcehnesepeopleduringthepastnumberof

years.Havethesepressureshadaneffectonyourfeelings,energy,oryourhealthinyourdailylife?Canyouexplainwhatthis

effecthasbeen?”Theresponsestothisquestionareinterestingbecauserespondentsdescribeforinterviewershowtheythink

ofmentalillnessintheirownwordsbeforetheyhearthesymptomsthatareinthestandardizedchecklists.Theiranswersyield

alistoflocalidiomsofdistress,anessentialfirststepinanycross-culturalmentalhealthresearchorintervention.

ThefirstthingonelearnswhentalkingtoAcehneseaboutmentalhealthisthattheEnglishwords“stress”and“trauma”have

beenthoroughlyabsorbedintolocalidiomsformentalillness,notleastbecauseofthethirtyyearsofconflictandmorerecently

theearthquakeandtsunaminaturaldisasters.Onekeyinformanttoldhisinterviewer:“beforetheconflict,noonearoundhere

knewthewordtrauma.”LikeinEnglish,thesetwowordshavegainedsuchabroadcurrencyinthelocallanguagethatitishard

toknowexactlywhatsomeonemeanswhentheysaystresortrauma.Nevertheless,deeperinvestigationyieldssomebroad

generalizations.Manypeopleusestresandtraumainterchangeably,bothdenotingdeeppsychologicaldistressbroughton

byexternaleventssuchaswar,adeathinthefamily,oranaturaldisaster.Theirmeaningsoverlap,butjudgingfromtheuseof

thesewordsduringkeyinformantinterviews,traumacanbeatemporaryconditionfromwhichonecanrecover.Incontrast,the

wordstress—unlikeinEnglishwherestressmightsuggestsomethingaslightastheeffectsofabaddayattheoffice—denotes

amoreserious,long-termconditionthatmayrequirepsychiatriccareatahospital.Onemightbesufferingfromtraumabut

stillbepresentandatleastappearingfunctionalinthecommunity,whereaswhensomeonehasstres,heorsheisnoticably

debilitatedfromperformingnormalsocialroles.Hencethewordtraumatendstoappearmoreoftenininterviewtranscripts

(e.g.“everyoneinthisvillageisstilltraumafromtheconflict”).

Beyondthesetwobroadlocalcategoriesofmentaldistress,theanswerstothequestionquotedaboveyieldadistinctlistof

commonsymptomsthatdescribelocalunderstandingsoftraumaandalsocorrespondtoasubsetofthesymptomchecklists,

butwithsome localspecificity tiedtothem. Additionally,manyAcehnesereferdirectly tosomatizationofmentaldistress,

whichistosaynotjustthatthepsychologicaldistressbroughtonbytheconflictfrequentlymanifestsasphysicalillness,but

alsothatAcehneseunderstandsomeoftheirphysicalailmentsarecausedbypsychologicaldistress.Mostpeoplementioned

“fear”(takut)asacommonsymptomoftrauma,butrarelywasfearmentionedasageneralcondition.Usually,respondents

tiedtheirfeartosomethingspecificlike“Iamafraidofcrowds,”“IgetscaredwheneverIseemilitaryuniforms/hearamotor

vehicle/hearanoise thatsounds likegunfire.” “Pressure” (tekanan,or tertekan) ismentionedrepeatedlybut thismightbe

therespondentquotingandaffirmingthelanguageoftheoriginalquestionbacktotheinterviewer.Thefollowingisalistof

symptoms,physicalandpsychological,thatwerefrequentlymentionedtodescribeAcehneseunderstandingsofpsychological

distress:

• Lossofspirit(kehilangan semangat)

• Uneasy,restless

• Unabletosleepatnight


• Frequentheadaches

• Daydreaming

• Rememberingwhathappened

• Shakinguncontrollably

• Heartproblems(manyvarieties)

• Heartache

• Racingheartbeat

• “Itfeelsasifmyhearthasfallen”

• Weakheart

• Heartattack(uponhearingbadnews)

• Exhaustedfornoreason

• Frequentsadness/frequenttears

• Hardtothink,slowtothink,forgetfulnessorthinkingtoomuch

• Helplessness

• Suspiciousnessofothers/hardtosocialize/self-isolation

• Unabletowork

• Otherphysicalailments

• Bodyhurts

• Weakness

dreams and spiritsTalesofthesupernaturalanddreamworldssupplementsomeofthemoreformalindicatorsofpsychosocialandmentalhealthin

Acehnesecommunitiesdiscussedabove.Localattitudestowardtheseexperiencescanalsochallengeconventionalpsychiatric

understandingsofvisualandauralhallucinationsaspathologicalandrequiringtreatment.Basedonseveralanecdotalstories

heardaboutAcehnesepeoplebeingvisitedbythespiritsoflovedoneswhodiedordisappearedinthetsunamidisaster,the

investigatorsincludedthreeclosedandtwoopenquestionsaboutdreamsandspiritsandexaminedtheopenresponsesto

explorepossibleconnections withconflictexperiences. Thefirstopenended questionasked“Canyou tellmeaboutyour

experiencewithghosts,spiritsorseeingsomeonewhohasdied?”andthesecondopenendedquestionwasaboutnightmares:

“Canyoutellmeaboutanynightmaresthatyoufrequentlyhavesincetheconflict?”Mostresponsesreferreddirectlytoconflict

experiences,butafewrelatedtothetsunamiaswell.Ingeneral,theresponsestothesetwoquestionsareremarkablysimilar

tooneanothersuggestingthatthewakefulworldofspiritsinAcehisnotclearlydistinguishedfromtheworldofdreams.More

than150respondentsgaveanswerstoeachquestion.InPidieandAcehUtarawomenansweredthisquestionmorefrequently

thanmen,withthereversebeingtrueinBireuen.Compilingtheanswersgiventothesetwoquestionsyieldsareliablesetof

preoccupyingthemessummarizedbelowwithbriefillustrativeexamples:

seeing the deceasedByfar themostcommonresponsewasseeingordreamingaboutthespiritsof thedeceased,mostusually relatives. Most

respondentstookthetimetoexplainwhetherthespiritspeaks;manyarefrustratinglysilent:

• “Theghostsaidnothing.Hejustlookedatme.”Or“Hejustsmiledatme.”

• “Iseetheghostforafleetingglimpseonly.”

• “Theghostjustwalksaroundthevillage.”

• “Theghostsitsaroundthehousewherethepersonusedtospendhis/hertime.”

• “Inmydreamthevisitorsaidnothing.”

• “Isawmyhusbandinmydreambuthedidn’ttellmewherehewas.”

• “Idreamedthatadeadconflictvictimwasstandinginfrontofmyhouse.”


Manyreturningspiritsconveyspecificmessages:

• ThankingtheirsurvivingrelativesformovingthecorpseandensuringaproperIslamicburial

• Asking(orthanking)theirsurvivingrelativestotakecareofthedeadperson’sdependents

• Givingadvicetoprayoften,benicetorelatives,donotsin

• “Idreamedaboutadeadconflictvictimwhotoldmeeverythingthathappenedtohim.”

dreams about violent eventsLivingthroughtheconflictandlosinglovedonesarehauntingexperiencesthatreappearasterrifyingghostlyencountersand

nightmares.Someresponsesthatreflecttheseexperiencesinclude:

• Seeingghosts/corpseswithphysicalinjuries,deformities,andwounds

• Dreamsthatrepeatconflicteventsthathappenedinreallife

• “IdreamedthatIbroughtthebonesofdeadpeoplehomefromtheforest.”

• “IdreamedthatIsawthedumpingofdeadbodiesintheriver.”

• “Inmydream,Isawsomeonegetshot.”

dreams and visits after recent violent eventsSeveralrespondentscorrelatedtheirvisitswithspiritsanddreamsabouttheconflictwiththetimingofactualconflictevents,

noting that thesevividexperienceswereonly temporary. Somevillagerseven recalledmemorabledreams thatpredicted

conflicteventswhichcametopassshortlythereafter:

• “Yes,Ihadnightmaresabouttheconflict,butnotsincetheMOU”

• “Ialwayshadnightmaresrightafteraconflicteventinmyvillage.”

• “Ihavenightmareswheneverthesecuritysituationisbad.”

• “Ihadadreamabouttheconflictthatactuallycametruethenextday.”

• “Isawthespiritsofpeoplerightaftertheywerekilled.”

dreams about violence afflicting oneselfArangeofresponsestothequestionaboutnightmaresrecountdreamsthatechomanyoftheactualtraumaticeventsreported

inTable2:

• “Ihavedreamsofbeingraped.”

• “InmydreamIwasbeaten.”or“Iwasattacked.”

• “IhadadreamthatIwaschokedbyajin(mischievousspirit)”

• “InmydreamIwaschased/draggedaround/strippednaked/tortured.”

• “Iworry/imaginethatwhathappenedinmydreamwillreallyhappentomeorsomeoneinmyfamily.”

• “IdreamedthatIwasshot,butdidnotdie.”

• “IdreamedthatIwasbeingchasedbyacrazyperson.”

• “InmydreamIwasskinnedandburned.”

• “IdreamedthatIwastrappedingunfire.”

tsunami dreamsAfewvillagesinthesamplewerecoastalcommunitiesthatlivedthroughthetsunamidisaster.Butregardlessofgeography,

nearlyeveryoneinAcehlostsomeoneclosetothemonDecember26th,2004.Eventhoughthesecondquestionmentionedthe

conflictinparticularasasourceofnightmares,stillsomerespondentsthoughtitwasimportanttosharetheirdreamsabout

theirlossesinthenaturaldisasterinstead:

• “Mynightmaresareaboutthetsunami,nottheconflict.”

• “InmydreamIwasvisitedbymychildwhodiedinthetsunamiinBandaAceh.”

• “Idreamedthatabigwinddestroyedmyhouse.”

• “Iheardcryingnoisesinthenight-time,whenthewindblowsorwhenitrains.”

• “IoftendreamaboutabigfloodandIdon’tknowwheretofindshelterorhowtosavemychild.”


pleasant visits with the deceasedThe question about dreams specifically uses the word“nightmare” (mimpi buruk), but when talking about dreams or spirit

visitations from loved ones, a large number of respondents corrected the interviewer and emphasized that it was not a

nightmare,butratherquitetheopposite:“Idreamaboutmyhusbandanditispleasingandbeautiful,notanightmare.”Their

commentssuggestpleasure,comfort,wonder,andyearningformorevisitswiththespouses,childrenandfriendstheymiss.

Whenrespondentstold interviewersthattheirdeceasedbrotherorsistervisitedthemtosaythankyouforaproperburial

andtoaskthemtotakecareofsurvivingorphanedchildren,onemightthinkthroughthesevisitstherapeuticallyratherthan

pathologically,aprocessthatperhapshelpsbringclosuretotraumaticloss:

• “Isawtheghostanditwasasifthepersonneverdied…itwassoreal…lookedjustlikehedidbeforehedied.”

• “Idreamaboutmyfriend,hecomestovisitme.Hewasshotinthe1990s.”

• “Ioftendreamaboutmyhusbandwhoalwaysasksmefirstaboutourchildren…itfeelssoreal.”

• “Imethiminmydreamandfeltinspiredbecausehewasdoingwell.”

• “Itfeltlikemysoncamehome,andweweretalkingwitheachother.”

manifestations of personal guiltOtherdreamsandvisitationsleaverespondentswithuncertaintyordiscomfort,notbecauseofterrorbutperhapsbecauseof

unresolvedfeelingsofguiltaboutdebtsunsettled,sinsunforgiven,ordeedsthatmayhavedirectlyorindirectlyaffectedthe

lossoflifeduringtheconflict:

• “Theghostblamedmefornothelpinginhistimeofneed.”

• “Theghosthadamessagethatdeathispainful,sodonotsin.”

• “Theghostaskedmetopaymydebtstohim.”

• “InmydreamIheardthevoiceofsomeonecryingforhelp.”

• “Inmydreamtheghostblamedmeforwhathappened.”

• “IdreamedthatIcouldnothelpmyfriend.”

religious themesIslamic imageryand instruction aresignificantly featured in thesupernaturalanddreamworldsofAcehnesecommunities

livinginformerconflictareas.Ithasalreadybeendescribedabovehowonespiritthankedhisfriendforprovidinghisbody

withaproperIslamicburial.Anotherrespondentrecountedaspiritaskinghimtoproperlywraphisbodyinakafanshroud,

oneoftheproceduresinaproperIslamicburial.Othersrecountbeingvisitedbydeceasedreligiousleadersoftheircommunity

whoremindthemtoprayregularly. Anothertoldofaspiritrecitingthesyahadat, theMuslimconfessionoffaith. Tsunami

and earthquake dreams, filled with floods and the earth ripping open, remind Acehnese of kiamat, the Islamic concept of

JudgementDayattheendoftheworld.


community mental and psychosocial health

Afteransweringanumberofquestionsabouttraumaandmentalhealth,respondentswereaskedabroadseriesofquestions

aboutmentalhealthproblemsintheirowncommunitiesandlocalresourcesavailabletoaddressthem.Thissectionofthe

questionnairebeganbyaskingwhetherrespondentsfeltthattherearementalhealthproblemsintheircommunityrelatedto

thetsunamiand/ortheconflict,andifthoseproblemsareaffectingtherespondentsortherespondents’families.Theresults

arepresentedinTable10.1below:

Table10.1RespondentPerceptionsofMentalIllnessintheCommunityandatHome

Doyouthinkthereareany

mentalhealthproblemsin

yourcommunityrelatedto

thetsunamiandand/orthe

conflict?(%Yes)

Thoserespondingyes:

Doyoufeelthattheseproblems

haveaffectedyouandyour

family?(%Yes)

Numberofpeoplewho

gavedescriptiveresponses

aboutmentalhealthproblems

withinthefamily:

Male

(n=315)

Total

(n=596)

Female

(n=281)

Pidie

(n=237)

Bireuen

(n=180)

Aceh

Utara

(n=179)

69

Male

(n=218)

54

n=123

59

Pidie

(n=140)

29

n=43

80

Bireuen

(n=144)

67

n=96

61

Aceh

Utara

(n=109)

70

n=77

66

Total

(n=393)

55

n=216

62

Female

(n=175)

55

n=93

66%ofallrespondentsthinktherearementalhealthproblemsintheircommunitiesrelatedtothetsunami,theconflict,orboth.

Thedifferencebetweenmenandwomen isnotstatistically significant,however thedifferencesbetweenall threedistricts

are significantly different from each other. 55% of those who answered yes to the first question then reported that these

problemsaffecteithertherespondentortheresopndent’sfamily,withsignificantvariationbetweendistricts: 29%inPidie,

67%inBireuen,and70%inAcehUtara.

Justoveronethirdofthetotalsamplegavedescriptionsofthepsychosocialproblemsaffectingthemselvesandtheirfamilies.

Whatisinterestingabouttheresponsestothisquestionistheoverwhelmingnumberofanswersthatdescriberespondents

feelingsprojectedoutwardtowardotherswhohavebeenaffectedbytheconflictorthetsunami.Theplightofothervictimsis

mentionedagainandagainassomethingthataffectstherespondentandtherespondent’sfamily.Respondentsaremovedto

sadness,pity,fear,helplessness,andcharityuponfacingtheconflictexperiencesofothers,andtheycitethis—quitecorrectly—

as psychosocial problems of their own. Starting with concerned feelings for others, the description of problems listed by

respondentscanbegroupedintothefollowingadditionalthemes:psychologicaldistress,dailyhardships,changesinsocial

relationships,andmemoriesofwhathappened:


concerned feelings for others

• Sadnessforconflictvictims

• Pityforconflictvictims

• Feelingresponsibleforothers’suffering

• Hardtothinkaboutorseeotherconflictvictims

• Givingadvicetoothers

• Afraidorbotheredbyotherswithmentalillness

• Afraidtobeaconflictvictims:“whenIseeothers,Ican’tthinkaboutwhatifthathappenedtome”

• Helplessnessorinabilitytohelpothers

psychological distress

• Stillfearfulorcautious(was-was)

• Shock

• Forgetfulness

• Physicalweakness

• Fearofleavingthehouse,fearofgoingtowork

• Frequentlysurprised

• Difficultthoughts

• Feelingsickwithheadaches

• Lossofspirit

• Constantlyrememberingwhathappened

• Passingout/fainting(pingsan)

• Afraidtotalkwithotherpeople

• Afraidofmennearby

• Nottrustinganyone

• Hatefulfeelings

• Difficultysleeping

• Cannotlookattheocean(tsunamispecific)

• Cannotlookatmilitaryorothersecurityforceuniforms

• Fearofcrowds

daily hardships

• Caringforconflictvictimsinthefamily

• Difficultyearningaliving/worseemployment

• Notenoughmoney

• Physicalhealthproblems/needmedicalassistance

• Stoppedschooling

• Extortion

• Responsibilityforsupportingfamilyalone

• Livingwithphysicalhandicap

• Landdestroyed/landunfitforconstructionorfarming

• Unfithousing/Housingburneddown

• Nojustice

changes in social relationships

• FamilymemberjoinedGAM

• Leadershiprolesmoredifficult

• Singleparenthomes


• Lossoftrustedfriendsorfamilymembers

• Supporting/providinghousingforconflictortsunamivictims

• Rumorsofchildkidnapping

• Fearofbecominga“meaninglessperson”

• Mistrustwithinthecommunity

• Unhappymarriage

• Morebeggarscomingtothedoor

memories of what happened

• Kidnappinginthefamily

• Torture

• Beatings

• Gunfire/shotingunfire

• Hunteddownbysecurityforces

Respondentswerethenaskedtotelluswhichgroupsintheircommunitysufferedthemostfrom“stressortraumarelatedto

theconflict.”Respondentswerefreetochooseasmanygroupstheywanted,withoutrank,fromthefollowinggroups:women,

men,children,youth,formerpoliticalprisoners,formerGAM-TNAcombatants,theelderly,conflictwidowsandwidowers,and

“other.”TheresultsarepresentedinTable10.2below:

Table10.2RespondentSelectionofGroupsintheirCommunitySufferingMostfromConflict-RelatedStressorTrauma

Male

(n=315)

Total

(n=596)

Female

(n=281)

Pidie

(n=237)

Bireuen

(n=180)

Aceh

Utara

(n=179)

Women

Men

Children

Youth

Formerpoliticalprisoners

FormerGAM-TNAcombatants

Elderly

Conflictwidows/widowers

Other

70

84

37

76

24

32

43

37

4

44

70

3

57

0

2

10

4

12

87

94

56

95

43

61

66

66

1

69

81

45

65

20

22

48

35

3

65

81

32

71

19

26

38

32

6

59

77

26

66

13

18

33

26

9

Whichofthefollowing

groupsinyourcommunity

sufferthemostbecauseof

stressortraumarelatedto

theconflict?(%Yes)

Since respondentswere free tochooseasmanygroups fromthe listas theywanted,eachrow in the table represents the

percentofpeoplewhosaid“yes”tothatcategory,butnotattheexpenseofothers.Thepercentagesineachcolumntherefore

donotsumto100%.

experiences of community leadersThekeyinformantinterviewstellusalotabouttheuniquepressuresfacedbyvillageheads,teachers,religiousfigures,and

othercommunityleadersinconflict-affectedareasofPidie,Bireuen,andAcehUtaradistricts.Fromapsychosocialperspective

thetwomostoverwhelmingthemestoemergeabouttheexperienceofcommunityleadersduringtheconflictarefeelingsof

entrapment,andasaconsequenceofthat,areluctancetolead.


entrapment (TerjepiT)The Indonesian word terjepit is perhaps more accurately translated as“squeezed” or“pressed,” as if by tweezers or clamps.

Thiskindoflanguageoccursrepeatedlywhenkeyinformantsdiscusstheirroleandexperienceduringtheconflict.Security

forcesonbothsidesoftheconflictheldvillageleadersresponsiblefortheactionsandsympathiesoftheircommunity.Inthe

Acehneselanguage,onereligiousleader inBireuendescribeditas“keuchik lageu boh sunti,”villageleadersarepressedlike

tamarindfruitunderastone.Otherssaidvillageheadswere“pressuredfromrightandleft,”or“fromupanddown.”Leaders

felttheycouldneverpleaseeveryoneandalwaysfoundthemselvesintrouble(“serba salah”).AnotherreligiousfigureinPidie

explainedthathewasabletokeepbothsidesatadistancebysimplygivingmonetarycontributionswhenGAMcameasking

foritandthenagainwhenIndonesianforcescametocheckin.Butnotallleadersavoidedamoreviolentsqueeze;villageheads

werefrequentlytorturedforinformationaboutmembersoftheircommunity,otherswerekilledinfrontoftheirfamilies,who

inonenarrativefromPidiewerethensaidtoisolatethemselvesandsufferedgreatpsychologicalstress.

reluctance to leadKey informants again and again used the expression“nafsi-nafsi” (which generally means“personal” or“individualistic”) to

describe the effect of the conflict on people in their communities, which is to say that people were so busy ensuring the

safetyoftheirownlivesandthelivesoftheirfamiliesthattheywereunabletolookoutfortheneedsofthecommunity.At

worst,nafsi-nafsiimpliesselfishindividualismwithoutregardforothers,butinreadingthekeyinformantinterviewtranscripts

onegetstheimpressionthatnafsi-nafsiwasanunfortunatebutunderstandablynecessaryconsequenceifordinarypeoplein

thesevillageswantedtosavetheirownlivesduringtheconflict.Nafsi-nafsihaditsmostpublicexpressionwithareluctance

ofvillagerstoassumepositionsofleadership.Inasettingofdangerouspressuresfromrightandleft,upanddown,itisnot

surprisingthatmanyvillagesfounditdifficulttonominateleadersduringtheconflict.One26yearoldvillageheadexplained

thatallhispredecessorslastedonlyafewmonths,unabletohandlethedifficultpressuresofleadership,untiltheresponsibility

eventuallyfelluponhim.VillageheadsinAceharealmostinvariablymen,andconflictareashadadistinctshortageofthem

eitherbecausethemenwerefighting,hadrunawaytosavetheirlives,orhaddied.OneregioninPidieisstillknownasbukit

janda (widow’shill). Youngermensuddenlyfoundthemselves inpositionsof leadershipusuallyreservedforvillageelders,

butsuchpositionsareevenmoredangerousfortheyoungermen,asthequestionnairedataaboveshowsthatyoungmen

inparticularwerethemostlikelygroupinthecommunitytohaveviolencecommittedagainstthem.A34yearoldvillage

headtoldhis interviewer: “Asayouthinthecommunity[duringtheconflict], IwassuspectedofgivingprotectiontoGAM

members.”Sincethepeaceagreement,youngermenhavebeenreturninghomeandtheirexperiencesbeyondAcehconvince

thecommunitytonominatethemintopositionsofleadership.One32yearoldkeyinformantwasnominatedforvillagehead

shortlyafterhereturnedfromMalaysiafollowingthetsunami.

one village leader, two nations (“Sidroe Geuchik, dua NaNGGroe” )Thestoryofavisitbythepsychosocial researchteamtoavillage inPidieneatly illustratestheaforementionedchallenges

facedbycommunityleadersinAcehduringtheconflictandtheirrelevancetomentalhealth.Afterspendingahalfhourin

thevillagehead’shomechoosingarandomsampleofhousesforthequestionnaireinterviewers,theteamleaderwentonto

conductthreekeyinformantinterviewsandtheIOMcoordinatorwenttothevillagecaféforinformaldiscussionswithvillage

residents. Theteamleaderfirst interviewedthevillagesecretary,whoexplainedthat“theothervillagersherearereluctant

tobecomevillageleadersbecausetheymustfaceenormousoutsidepressuresthatdeeplyoppressandaffecttheirmental

health.”Althoughhisofficialroleinthecommunitywasvillagesecretary,heexplainedthathehandlesmuchoftheworkofthe

villageheadsuchasinfrastructuredevelopmentandyouthactivitiesbecausethevillagehead“hasafewhealthproblems.”The

teamleader’snextinterviewwaswitha33yearoldformerGAMcombatantwhotoldhimthat“thepersonwhosufferedmost

hereduringtheconflictwasthevillageheadbecausehewassidroeguechik,duanaggroe,”asinglevillageleadermanaging

theaffairsof twonations, twogovernments,eachofwhichmadeclaimsuponhim. Meanwhile, the IOMcoordinator,after

explainingtovillagersatthecaféthathisresearchteamwascollectinginformationaboutmentalhealthrelatedtotheconflict,

listenedtolocalresidents’storiesabouttheir“crazy”villagehead.“Everynowandthenhedisappearsforacoupleofdaysat

atime,”and“everyoneknowsthatwheneverheleaveslikethatheishavingprivateepisodesofprayeroutinthewilderness,

butnooneunderstandswhatheissaying.”“Hisfamilyisusedtoit,”andsowaseveryoneelseinthecommunity,itseemed,as

theytoldthestoryabouthimwithoutfanfare,malice,orfear.Throughouttheday,theresearchstaffallsawthevillagehead

walkingaroundthevillage,backandforth,astheyconductedtheirinterviewsindifferenthouseholds,andhepassedbythe

caféseveraltimesaswell.


ThePidie team leader’s thirdkey informant interviewthatdaywaswith thevillageheadhimself,whowas frankabouthis

experiencewithmentalillness.Astheysattogetherinthevillagemeunasahfor80minutes,theteamleadernotedthatthe

villageheadwaspresentingwithmanyofthesymptomshedescribed,suchasrestlesnessandaninabilitytositstill.Healways

feels compelled to move, perhaps explaining his erratic walkabout through the village while the research team was there.

Hewasquiteawarethathebehavedasapersonwithmentaldisturbance,anddescribedhisperiodicepisodesofhermitage

whenhebehavesmoststrangely.Despitehisillness,thecommunitynominatedhimtobethevillagehead,hesaid,because

nobodyelsewaswillingtofaceuptobothsidesduringtheconflict.Hewasnotafraidtoassumetheposition,heexplained,

becausehehasdeepreligiousknowledge. Thecommunitysaysheis“pugo na’hu,”crazybecausehewouldmemorizeand

reciteesotericspeechconfigurationsinArabic.Additionally,heknewsomephrasesinJavaneselanguageandthiswasuseful

inhisneogtiationswithIndonesiansecurityforceswhoconsideredhimafriendforhiseffort.Afewtimeshewasaccusedof

assistingGAM,andhisvillagewasunderconstantsurveillanceduringtheconflict,buthewasalwaysabletoescapeaviolent

fatewhenhespokeinJavanese.Avisittohiscommunityforonlyonedaymakesitdifficulttoassesscausesandeffects,but

whiletheconflictmaycertainlyhaveexacerbatedthevillagehead’smentalhealthcondition(asreportedbyothers),perhaps

thisisasingularexampleinallofAcehwhenmentalillnessmayhavehadaprotectiveeffectonthevillagehead’slifeandsocial

statusduringtheconflictyears.Thisexampleshowshowacommunityandanindividualwereabletostrategicallyposition

mentalillnessintoanunusuallyprotectivecapacity.

effect of the tsunamiWhenaskedwhethertheythoughttherewereanymentalhealthproblemsrelatedtothetsunami,respondentsreportedin

numbersconsistentwiththedecreasingtsunamieffectindistrictsfromwesttoeast(56fromPidie,46fromBireuen,and20

fromAcehUtara).Havingjustbeenadministeredseveralsymptomschecklists,respondentsansweredthisquestionwithlists

of thosesymptomsthat they feltmostclosely resembledwhat theyobserved in theirowncommunities,alongwithsome

descriptionsofhowthosesymptomspresent.Thefollowingwerethemostfrequentlymentionedsymptomsrelatedtothe

tsunami:

• Lossofhope,spirit,and/orenergytolive

• Laziness

• Reluctancetosocialize,lonely

• Fearoftheoceanandbeaches

• Fear,trembling,panicand/orflightaftereveryearthquake

• Cryingalone

• Toomanythoughts/thinkingtoomuch

• Cannotbeartothinkaboutit

• Difficultyprovidingforfamily

• Facingproblemsatwork

Somerespondentsnotedthatmostpeoplewiththesesymptomsresolvedontheirownseveralweeksormonthsafterthe

tsunami,andonetsunamisurvivorevensaid“No,becausepeoplecametovisitandcomfortme,”suggestingnotonlythatthe

worsttraumasustainedduringthetsunamihaspassedandcommunitiesaremovingon,butthatsocialsupportmechanisms

are in place to address it. Several key informant interviews from tsunami villages in our sample mentioned that tsunami

aidhasamelioratedconflict-relatedstressandtrauma:“Withthetsunamiassistance,thecommunitybegantorelaxseveral

monthslater,asiftheburdenofconflictcouldbeforgotten…thepost-tsunamiassistanceputourcommunityatease.”More

politically-mindedobserversofthesituationrecognizedthekeyrolethetsunamiplayedinbringinganendtotheconflictand

alsobringingtheirrelativeshome:“Afterthetsunamiandtheimprovedsecuritysituation,alongwithmanyforeignerscoming

toworkinAceh,mysondecidedtocomehomeagain.”Meanwhile,severalquestionnairerespondentsfromvillagesfarfrom

thetsunami-affectedcoastlinesarecognizantofmassiveaidbeingdeliveredelsewhere,apartfromtheirownconflict-affected

communities,inspiteofclaimsofassistanceforconflictvictimsinthepeaceagreement.

resilience and responseInterviewers asked all respondents“In the past 6 months, have you done any of the following things to overcome bad

experiencesrelatedtotheconflict?”ThelistofpossibleresponsesisshownintheleftcolumnofTable10.3.Respondentswere


Table10.3HelpSeekingBehaviorDuringthePastSixMonths

• Talkaboutitwithfriend

orfamily

•Visitatraditionalhealer/

taketraditionalmedicines

•Lookformedicalhelp

•Consultamentalhealth

specialist

•Consultareligiousspecialist

•Prayer

•Sports/Exercise

•Trytoforgetaboutthe

experience

•Movesomewhereelse

•Donothing

•Other

•No“badexperience”

(Notapplicable)

Male

(n=315)

Total

(n=596)

Female

(n=281)

Pidie

(n=237)

Bireuen

(n=180)

Aceh

Utara

(n=179)

36

2

19

1

23

71

4

17

1

6

2

23

18

0

3

0

8

47

0

5

4

0

1

53

56

7

34

3

34

92

3

17

2

5

1

6

37

2

12

1

11

81

4

29

2

15

4

4

35

3

15

1

17

71

2

16

3

6

2

24

34

3

11

2

11

70

1

15

5

6

2

26

Inthepastsixmonths,

haveyoudoneanyof

thefollowingthingsto

overcomebadexperiences

relatedtotheconflict?

(%Yes)

freetochooseasmanyoftheseitemsastheywanted;eachrowinthetablerepresentsthepercentofpeoplewhosaid“yes”to

thatcategory,butnotattheexpenseofothers.Thepercentagesineachcolumnthereforedonotsumto100%.

Menaremorelikelytolookformedicalhelp(19%versus11%)andconsultareligiousspecialist(23%versus11%).Womenand

menbothseeksuccorinprayer(71%)andmoreindividualsfromBireuen(92%)andAcehUtara(81%)thanPidie(47%)feelthe

needtodoso.35%ofpeople,womenandmenequally,andmorefromBireuen(56%)andAcehUtara(37%)thanPidie(18%),

talkedaboutmentalhealthissueswithfriendsorfamily.Only1%ofrespondentssoughthelpfromamentalhealthspecialist,

reflectinga lackofboththeavailabilityofcommunitybasedmentalhealthservices inAcehandalsotheability topay for

specializedmedicalcare.

Respondentswerealsoaskedanopenquestionaboutwhohelpstakecareofconflictvictimsthatsufferfrommentalillness

intheircommunity. Almosthalfofthesample(280respondents,47%)tookthetimetogiveanswers. Thevastmajorityof

responsessay“familiesdoitthemselves”andoftenemphasizethat“thereisnootherhelpforconflictvictimswithmentalillness

exceptforfamiliesthemselves.”AsignificantminorityofrespondentsmentionedwellknowncomponentsoftheIndonesian

publichealthcaresystemsuchasvillagemidwives,puskesmas (sub-district levelprimaryhealthclinics)doctorsandnurses,

districthospitals,andalso thementalhospital inBandaAceh,but thisquestionwasalsoanunanticipatedopportunity for

respondents to express their dissatisfaction with disparities in health care in Aceh. Common responses along these lines

includedversionsofthefollowing:

• “Onlyforthosewhocanpay”

• “Notaroundhere”or“thereisnohelpherebecauseoftheconflict”

• “ThereisnoNGOassistancehere”

• “Thereisnogovernmentassistancehere”


• “Noone”

• “Ihavetotakecareofmysickrelativeallbymyself”

• Expressionsofhopelessness,givingup,orgivingintofate(“pasrah”)

• ExpressionsofangertowardAcehneseelites

It isworthnotingthat inonevillagethatwasaffectedbythetsunamianNGOhadopenedupatraumaclinic fortsunami

survivorsinthecommunity.Severalrespondentsfromthisonevillagementionedthisclinicspecificallyasaresourceintheir

community,againsuggestingthatmorethan18monthsafterthedisasterthereisnowdisproportionateservicecoveragein

tsunamiareaswhencomparedwiththerestofAceh.

Whenaskedaboutresourcesinthecommunityforaddressingconflict-relatedmentalillness,keyinformantsgaveanswersthat

wereentirelyconsistentwithwhatquestionnairerespondentssaid,butwithmoredetailthatsuggestsreligioussupportisthe

nextresortfollowingfamily-basedcare.Alsoapparentfromkeyinformantsisthenafsi-nafsielementdescribedabove,i.e.the

conflictforcedindividualsandfamiliestoprioritizetheirownneedsovertheneedsoftheircommunity.

• “Therearenoinstitutionsnorevenonepersonwhocaresaboutmentalillnessinthecommunity,italldependsonfamilies

themselves”

• “Noattentiongetspaidtowardthosewithstresortraumabecausenooneisablenordoesanyonehavetheopportunity

becausepeoplearehardlyabletotakecareoftheirownselves.”

• “Thecommunityisunableanddoesnotcareaboutthefateofthosewithmentalillness;iftheygethealthyagain,theyget

healthyontheirown.”

• “Hisfriendsadvisedhimtoparticipateinprayeractivities(pengajian)andinthiswayhisconditionstabilizedovertimeand

latelyhehaslookedhealthyagain.”

• “Communityassistancecomesonlyfromthefamiliesofthesickandfrom zakat(religiouscharity).”

• “Thosewhohavementalillnessareonlytreatedbytheirfamiliesandbyattendingprayergroups(pengajian)”

traditional medicine in acehAnimportantbiastoconsiderwhenreadingTable10.3 is thatmanyofthepsychosocial researchstaffwerementalhealth

nurses, which may have an effect on how respondents answered this question. The remainder of the research staff were

lecturersfromSyiahKualaUniversityinBandaAceh,whichistosaythattheywerehighlyeducatedurbanelites.Qualitative

ethnographicresearchsuggeststhattheuseoftraditionalhealersinAcehisfarmorewidespreadthanthetableabovesuggests,

butquestionnairerespondentswerelikelyreluctanttomentionitinfrontofmedicalprofessionalsandurbanelitesbecause

bothgroupsareperceivedbyruralcommunitiesasmodernrationalcitizenswholookdownon“backward”villageways.Only

twokeyinformantinterviewsmadespecificmentionoftraditionalmedicineasanoptionfortreatingmental illness. Akey

informantinAcehUtaramentionedthatfamiliesusuallytreatthementallyillontheirownbutthattheycandrinkwaterboiled

withthenestofredantsasamedicinaltreatment.AnotherinformantfromPidietoldhisinterviewerthatpatientswithmental

illnessareusuallybroughttothetraditionalhealerinaneighboringvillage.

HealersinAcehareusuallyreferredtoaseithertabibordukun,andthereisregionalvariationastowhichtermispreferable.

There is no formal organization, training or codification of practice for healers in Aceh. Each one works independently of

others,butknowsabouttheothersandtheirspecialtiesinordertomakereferrals.Healersareneithercompetitivewithone

anothernorwiththepuskesmassystem,fortheyacknowledgethateveryhealerhastheirspecialtyandthatmanymedical

conditionsaremoreappropriatelyaddressedatthepuskesmas(suchasopenwounds,vomiting,anddiarrhea).Theylearntheir

skillseitherasanapprenticetoapredecessor,ortheirskillispasseddownthroughafamilylineage.Mostpracticeinvolves

detailedknowledgeforthecollection,preparation,andapplicationoflocalplantsandfoodproductsintoacompressordrink.

AllthehealersinterviewedbytheIOMcoordinatorhadaspecialabilitytobringanIslamicelementtobearonthetreatments

theyprepareandgivetotheirpatients.TheAcehneselanguageverbngerajahcomesclosesttothemeaningsassociatedwith

Englishwordssuchas“mantra,”“offering,”or“blessing.”Ngerajahusuallyinvolvestherecitationofakoranicverseuponeither

thepreparationoradministeringofahealer’smedicine.NohealerinAcehwoulddareclaimtohaveahealinghand,ratherthey

havetheabilitytocallforthandchannelthehealinghandofGod.Healersaddressbothphysicalandspiritualillnesses,ranging

frombone-settingandpersistentgastritistospiritpossessionandthecastingoutofblackmagicspellsthatcauseillness.The


healerinterviewedbytheIOMcoordinatorinBireuenhadanywherefromthreetotwentypatientsaday.Somepatientscome

fromdistantpartsofAcehandbeyondbasedonwordofmouth.Patientsstayinthehomeofahealerforanaverageoffive

days,butsometimesaslongasthreemonths,receivingconstantattentionwhiletheyarethere.Patientsrarelypaywithmoney,

butwithgoodsinkind,anditrarelymatchesthevalueofthefeespaidtodoctorsinmedicalclinics.

ManypeopleinAcehuseclinicalandtraditionalservicesside-by-sideforthetreatmentofoneillness.Itisnotuncommonto

visitthelocalhealerfirstbecauseitiseasierthantravelingtotheclinic.Patientsmightalsovisittheirlocalhealereitheron

theirwaytotheclinicoronthewayhome,becausehisorhertreatmentcouldnotpossiblyhurtandhastheaddedbenefitof

addressingthespiritualsideofillnesslackinginthepillstheygetfromthepharmacist.VillagersinAcehhaveveryclearideas

aboutwhichillnessesrequiregoingonlytotheclinic,whichillnessescanuseboth,andwhichonesrequiregoingonlytothe

healer.Ayoungwomanwhorecentlygraduatedfromhighschoolmentionedthatfromherlessonsatschoolsheknowshow

medicineworksbiologically,howthescientificmethoddemonstratestheefficacyofmodernmedicine,butshenevertheless

feltthatthehealerofferedacomfortandfamiliaritythatgoesalongwaytowardamorepositiveoutcomethanavisittothe

clinic.Shewentontosaythatavisittothecliniconlyreinforcedhersenseofillness,remindingherthatsheissick,andforthe

shorttermmakesherfeelworse.Whenpillsdonotwork,herfrustrationincreasesbecausesheworriesaboutsideeffects.She

cannotexplainwhy,anditsurpriseshereverytimegivenwhatshehaslearnedinschool,butthehealerhasgreatersuccess

withherhealthneedsthanthepuskesmas.

ThereareatleastthreefeaturesoftraditionalhealingpracticesinAcehthatmaycontributetoperceptionsofitsefficacy.Firstis

thetimespentbyhealerswithpatients,lastinganywherefromoneeveningtoseveralmonths.Puskesmaspatientsfrequently

complainthattheattendingdoctorornursespendsonlyfiveortenminuteswiththem,andsometimesdonotevenperform

aphysicalexamination.Secondistheproximitytohome.Mostpatientscanfindahealerintheirowncommunityandthe

familiaritybetweenhealerandpatientensuresmorecarefulattentionandcomfort.Thirdisthereligiousandspiritualelement.

ClinicalsettingsaredistinctlydivorcedfromIslamicpractice,whereasthehealinghandofGod,administeredthroughhome

remediespreparedundertherecitationofkoranicverse,removesthekindofuncertaintythatusuallyaccompaniesthegeneric

andfrequentlymisunderstoodpillshandedoutatclinics.

Three members of the IOM psychosocial research team interviewed a well-known traditional healer for mental illness in

Bireuen. He distinguished conflict victims from the black magic cases he treats, and told us that most of the patients he

seescouldrightfullybecategorizedasconflictvictims,suspectingthattheirsymptomscamefromexcessivebeatingstothe

body.Hehimselfsustainedbeatingstohisheadfromthebackendofafirearmduringasweepingoperationinhisvillage.

At that timehewastoldtoclosehishousetopatients,anorderheobeyedfor20daysbeforere-opening. Conflictvictim

patientscanbedistinguishedfromotherkindsofpatientsheseesbecausetheyareusuallyabletostillreciteIslamicprayers

withoutdisturbancewhilehisblackmagicpatientstendtoresistprayer.HeclaimedtohavetreatedbothGAMandKOSTRAD

(Indonesianspecialforces)soldiersduringtheconflict.Thenumberofhispatientshasincreasedsincethesigningofthepeace

agreementbecauseordinarycivilianshavemore libertytotravel. Hehastwoapprenticestohelphimandanewbuilding

nexttohishousewascurrentlyunderconstructiontohouseadditionalpatients,particularlypsychoticpatientswhomightbe

violenttoothers.

community opinions: what should be done?After questionnaire respondents and key informants were asked to describe some of the common mental health and

psychosocialproblemsintheircommunitiesrelatedtotheconflict,theywereaskedaboutwhattheythinkshouldbedoneto

helpthepeoplewhohavetheseproblems.Keyinformantswereaskedthesamequestion.Justaswiththequestionwhich

asked respondents about who usually cares for people with mental health problems in the community, respondents took

an unanticipated opportunity to vent their frustrations and anger against the government and against the two opposing

forces during the conflict. A second major thematic response to this question, especially from the key informants, was an

unambiguousdemandforpost-conflictmaterialassistance.Mostpeopleinthesecommunities,notunliketsunamisurvivors

alongtheAcehcoast,recognizethetherapeuticvalueofrebuildingtheirdestroyedinfrastructureandlivelihoods,gettingback

towork,andmovingon.Otherthemesthatemergedfromthisquestionwereparticularsuggestionsformedicalassistance,

religioussupport,andimprovedsocialengagementinthecommunityforthementallyill.Finally,somerespondentsexpressed

hopelessnessorsurrendertofate,whileothersexpressedungeneralizablepersonalrequests(e.g.“Findmyhusband!”)


expressions of frustration / anger, demands for justice

• “Moreattentionshouldbepaidtoconflictvictimsandtheircommunities.”

• “Icouldnotgotothepuskesmas/government.”

• “Ihavenoideabecausewehaveneverhadanyhelpforanythingbefore.”

• “Nomoremurdersinthiscommunity!”

• “Executetheperpetratorsofthesecrimes”

• “Thegovernmentmustaddressthecrimesandviolationscommittedduringtheconflict.”

• “Bothsidesoftheconflictneedmoreselfcontrol/needtoreturntotheirsenses.”

• “Endtheconflictforgood.”Or“Maintainthepeace.”

• “IamprayingforNGOassistancehere.”

• “Weneedmoreinformationaboutwhat’sgoingonwiththepeaceprocess.”

material assistance

• Socioeconomicassistance

• Housingassistance

• Micro-creditprograms

• Vocationalassistance

• “Fixtheroads!”andotherinfrastructureimprovements

• Landrehabilitationandotheragriculturereconstruction

• “Tractors”andothercapitalinputs

medical assistance

• “Weneedeasieraccesstomedicalservices.”

• “Weneedhealthoutreachintoourcommunity”or“Doctorsshouldbecomingtoourvillage.”

• “BuildamentalhospitalcloserthanBandaAceh.”

• “Financialaidformedicalcare.”

• “Givepatientsbettertreatmentintheclinicsandhospitals.”

• “Weneedmoremedicine.”“Weneedregular/consistentmedication.”“Weneedcorrectmedicines.”Andalso“Weneedfree

medicine.”

• “Weneedtherapy/counseling.”

• “Weshouldbevisitingtraditionalhealers”

• “Mentalhealthpatientsshouldreceivetreatmentimmediatelybeforetheirconditionsworsen.”

• “Gotothetraumacenter”(specifictoonetsunami-affectedvillageonlythathadatraumacenter)

• “Weneedmorehelperclinics”(i.e.satellitepuskesmas,aka“puskesmaspembantu”or“pustu”)

• Transportationassistanceformedicalservices

• “TreatmentforthementallyillrequirestheroleofanNGOthatwillmoreactivelysocializeandtakeaction.Don’tjustwait

forpatientstocomeformedication.”

religious support

• Prayergroupsforthementallyill(pengajian)

• Individualprayer

• Putone’sfateinGod’shands(“tawakkal kepada Allah”)

• “Treatmentforthementallyillshouldbeaccompaniedbythesupportofreligiousleadersinthecommunity.”

improved social engagement

• “Donotleavethesickalone.”Accompanimentforthementallyill.

• “Givethementallyillspirit/hopetolive.”

• Frequentgatheringswithfriendsandneighbors

• Joininginwithdailyactivities

• Sharingexperienceswithoneanother.Talkingwithcloserelativesandfriends.

• Createaspecialinstitute(lembaga)forthepeople’saspirations

• Spendmoretimeatthevillagecafé

• “Theyneedsupportanddirection.”


helplessness

• “Wearejusthelplessvillagers.”

• “Theycannothelpthemselves.”

• “Assistingthementallyillshouldbethetaskofexperts.Wecannotfoolaroundwiththesoulsofothers.”

community perceptions of ngos and public health servicesSeveralofthecommentsabovementionoutreachandaninterestinhavingnon-governmentalorganization(NGO)support

fordevelopingcommunity-basedmentalhealthservices. Thequestionnaireincludedtwoquestionsaboutinterest inNGO

services,designedalsotomeasurepreferenceinlocalimplementingpartners,i.e.theIndonesiangovernmentorGAM,which

nowoperatesinAcehasacivilsocietyorganization.TheresultsarepresentedinTable10.4below:

Table10.4OpinionsaboutNGOMentalHealthServicesandImplementingPartners

Male

(n=315)

Total

(n=596)

Female

(n=281)

Pidie

(n=237)

Bireuen

(n=180)

Aceh

Utara

(n=179)

IfanoutsideNGOofferedyou

oramemberofyourfamily

mentalhealthassistance,

administeredthroughGAM,

wouldyouacceptit?

(%Yes)

IfanoutsideNGOofferedyou

oramemberofyourfamily

mentalhealthassistance,

administeredbythe

Indonesiangovernment,would

youacceptit?(%Yes)

68

51

64

74

65

35

50

36

60

51

51

52

Overall,conflict-affectedcommunitiesslightlypreferNGOservicesadministeredincollaborationwithGAMovertheIndonesian

government,butthisdifferenceappearslargelydrivenbytheresponsesgivenbymen.WomenequallyacceptNGOservices

administeredbytheIndonesiangovernmentorGAMwith52%and51%approvalraterespectively,butwhatstandsoutisthe

differencebetweenmale(68%)andfemale(51%)supportforGAMservices,perhapsreflectingmen’sperceptionsofhowthey

weretreatedbyIndonesiansecurityforcesduringtheconflict.Ineitherscenario,amajorityofrespondentssupportthedelivery

ofmentalhealthservicesintheircommunities.Thisopinionismoreunanimouslyexpressedinthekeyinformantinterviews;

communityleadersalmostinvariablyandveryenthusiasticallysupported“anykind”ofNGOassistanceintheirvillages.

Table10.4aboveisastartingpointfordiscussionsaboutcommunityperceptionsaboutexistingpublichealthservices.Only

35%and36%ofrespondentsfromBireuenandAcehUtararespectivelywouldavailthemselvesofNGOservicesiftheywere

administeredbythegovernment. Mostpeople,whenaskingforNGOassistance,ask fordirectassistance,not throughthe

government, which is perceived as“project minded,” where the word“project” (proyek) has come to mean an opportunity

for bureaucrats to play with budgets for personal gain. Key informant interviews conducted by the IOM Coordinator, and

HarvardandSyiahKualaresearchteamsrevealedastrongmistrustofpuskesmasclinicsandothergovernmenthealthservices.

Puskesmasclinicsduringtheconflictwereattimessitesforsecurityforcesoneithersidetocollect informationabout local

populations,placingdoctorsandnursesinthesamedifficultpositionsdescribedbycommunityleaders. Somesub-district

levelmilitarypostswerebuiltrightnexttoclinics,ensuringthatpeoplewouldnotusethemeveniftheylivednearby.Inmost

formerconflictcommunities,healthservicessimplywerenotavailablebecausetheseareaswerecutoffand isolated from


them. Recall that themostcommonanswertowhotreatsmentalhealthproblems in respondents’communitieswerethe

familiesofthesickthemselves.Oneofthekeyinformantquotesfromabovebearsrepeatinghere:“Therearenoinstitutions

norevenonepersonwhocaresaboutmentalillnessinthecommunity,italldependsonfamiliesthemselves.”

Poverty,ofcourse,isanotherbarriertoaccessinghealthservices,evenfrominexpensivegovernmentclinicsoncetransportation

costsfromremotevillagesarefactoredin. Indonesianscangetfreemedicalservicethroughthenationalhealth insurance

program but only with proper referral letters that verify poverty status from village heads, sub-district offices, and even

districtofficesifsecondaryreferralisrequiredatthedistricthospitals.Uponprocuringtheseletters,theinsuranceneedsto

beacquiredfromtheinsuranceoffice,thenpatientsmustreturntotheprimaryclinicnearestone’shomevillageforproper

movement throughthe referralnetwork. Theentireprocess, including transportation,probablycostsasmuch ifnotmore

thanasimplefee-for-servicevisittotheclinic,andforallthatcostandeffort,mostpatientswouldpreferusingtheirmoneyfor

privateclinics.

public health provider perceptions of conflict-affected communitiesWhileresearchteamsconductedtheirinterviewsinrandomlyselectedvillages,theIOMCoordinatorwouldusuallyvisitthe

nearestpuskesmastomeetwithlocalhealthpersonnel.Likevillageleaders,healthstaffareresponsibleandheldaccountable

forcertainneedsoftheirsurroundingcommunities,andsoinevitablyfoundthemselvesinextremelydifficultpositionscaught

betweenbothsidesduringtheconflict.Ontheonehand,puskesmasstaff,asgovernmentemployees,areexpectedtodeliver

reportsandotherinformationabouttheircommunitiestoanynumberofgovernmentagencies,sometimesunderduress.On

theotherhand,GAMwasknownforregularlyextortinghealthpersonnelonsalarypayday,andoccasionallykidnappingdoctors

andnurses totreat injuredmen in the forestsandotherhideouts. Likeschool teachers,manyhealthstaffunderstandably

stoppedreportingtowork,effectivelyshuttingdownhealthservicesthroughoutmost“blackareas”ofAceh.Itisnotsurprising

thenthattheIOMCoordinatorfoundapronouncedlackofknowledgeaboutconflictissuesandconflictareasamongpuskesmas

staffs—thelesstheyknew,thelesstheywouldbeheldaccountabletoeitherside.Mostpuskesmashavere-openedsincethe

peaceagreement,andsomedestroyedsatellitehealthclinicsareslatedforreconstructionwithinthenextfewyears,buthealth

staffstilldonotconductoutreachintoformerconflictareas,andlikemanyurbanAcehneseremainapprehensiveaboutthe

securityconditionsthere.

children and youthThequestionnairedesignedbythepsychosocialresearchteamdoesnotsystematicallyaddresstheexperiencesofchildrenand

youthbecauseastudyofchildren’sissuesrequiresparticularethicalandmethodologicalconsiderations.Butitisworthnoting

inTable2abovethat7%ofallrespondents(9%inbothBireuenandAcehUtara)reportviolenceagainstchildrenasaproblem

inthepost-conflictlandscape.Table10.2showsthat32%ofallrespondents(56%and45%ofresidentsinBireuenandAceh

Utararespectively)citechildrenasagroupthatsufferedmostduringtheconflict.71%ofallrespondents(95%ofresidentsin

Bireuen)citeyouth,echoingtheindividuallyreportedindicatorsthatshowyoungmentypicallysufferedthegreatestamount

ofphysicalviolence.Nearlyallkeyinformantinterviewsaffirmthiscommunityperceptionaboutyoungmen.Onecommunity

leadertoldhisinterviewerthatheencouragedyoungmentoleaveAcehuntiltheconflictwasover.

Anumberofkeyinformantsmentionedtheburdensplaceduponchildrenduringandaftertheconflict.A28yearoldyouth

leaderinPidie,forexample,reportedthatconflictactivityinhisvillagedatesbacktowhenhewasstillinelementaryschool,

recalling on several occasions finding dead bodies placed in the village meunasah. Most key informants took the time to

mentionthateducationforchildrenwasentirelydisruptedduringtheconflictyears;motherswiselykeepingtheirchildren

homefromschoolwhenevergunfirewasheardinthevicinity. Dozensifnothundredsofvillageschoolswereburntdown

alloverAcehduringtheconflict,andteachersfromthetownsstoppedtravelingtothedangerousareaswheretheytaught.

Religiouseducation(pengajian),usuallyheldintheevening,wasalsodisruptedduetonightlycurfews.TodayleadersinAceh

arewonderingwhythechildrenofAcehscoresolowonnationalstandardizedtestsandfailtopassgraduateexams.

Youngchildreninremotevillagesarestillfrightenedwhentheyhearvehiclesenterthecommunity.Allthreepsychosocialfield

researchteamswitnessedchildrenfleeingwhentheirvehiclesapproached.Duringtheconflict,theonlyvehiclesevertogoin

andoutofthesecommunitiesweresecurityforces.Whatremainstroublingisthatthesefearsarenotjusthangoverreactions

fromtheconflict.FirsttheBireuenteam,andthentheAcehUtarateamweresurprisedtohearkeyinformantsmentionrumors


thatchildkidnappersindarkvehicleswerestrikingtheircommunities.Atacaféwhereelementaryschoolstudentsstoppedto

watchcartoonsontheirwayhomefromschool,theyoungwomanwhoservedcoffeeandsnacksaskedtoseetheresearchers’

IDcardsandlettersofpermissiontoconductpsychosocialresearchinthevillage.“Theyseemlikenicepeoplejustlikeyou,”

shetoldtheresearcherssuspiciously,“butthentheytakeourchildren.”Perhapsnotunrelated,onequestionnairerespondent

mentionedtwicetherecentappearanceofvillagepeddlers inhiscommunityandothernearbyvillageswhodonotspeak

Acehnese.Tobesure,theseareallunprovenrumors,buttheirveracityisbesidethepoint.Rumorsaregoodindicatorsofsocial

uncertaintyandrevealenduringconcernsaboutthreatstothecommunityfromoutsiders.

on the peace processSimultaneousopinionsofbothpraiseanddoubtweresharedwithallinterviewerswhenaskedaboutthepeaceprocess.The

firstthingworthmentioningisthatcommunitiesdefineorfeel“peace”asanopportunitytowork,travel,andsocializeagain.

Forexample,beatingstothebodyduringtheconflictweremostoftenexperiencedinordinarysettingsofthevillage,especially

onjourneystoandfromthemarketfortrade.NowAcehnesevillagerscanbringtheirgoodsdowntomarketwithoutfearof

extortionalongtheway,andcanbringbackhouseholdsupplieswithoutbeingaccusedofprovidingsoldiersfromeitherside

withlogisticalsupport.Keyinformantsoftendescribethisas“freedom”andeven“independence”(kemerdekaan),atermloaded

withnationalistfervorforIndonesiansandacrucialdemandthatwasdroppedfromGAM’splatformuponsigningofthepeace

agreementinHelsinki.Otherdailyactivitiesthatdefineasenseofpeaceforrespondentsaretheabilitytotravelintheevening,

tosocializeingroupsinpublicsettings(especiallyvillagecafés),andtoreturntofarmlandsandforestgardensforagricultural

livelihoods.

Table10.5belowsummarizesrespondentanswerstoquestionsrelatedtothepeaceprocessinAceh.Noonegave“disagree”or

“stronglydisagree”answerstoaquestionwhichaskedrespondents’opinionsaboutthepeaceprocesssincethesigningofthe

treatyinHelsinkionAugust15th2005,andavastmajority(78%)saidthey“stronglyagree”withtheprocess.

Table10.5AttitudesTowardthePeaceProcess

Male

(n=315)

Total

(n=596)

Female

(n=281)

Pidie

(n=237)

Bireuen

(n=180)

Aceh

Utara

(n=179)

Whatisyouropinionaboutthepeaceprocesssincethe

signingoftheMOU?(%Yes)

Stronglyagree

Agree

Hastherebeenapeusijeukorotherceremonyheld

inyourvillageforformerpoliticalprisonersorformer

GAMcombatantsthathavereturnedtothecommunity

sincethesigningoftheMOU?(%Yes)

Ifso,Haveyouattendedorparticipatedinthese

events?(%Yes)

Never

Rarely

Often

Always

Don’tKnow/Refuse

85

15

35

42

18

18

15

6

70

30

29

74

6

13

6

1

94

6

39

28

25

16

18

13

73

27

17

31

19

24

7

19

78

22

28

52

14

16

10

8

70

30

21

63

10

13

4

11


Apeusijeuk isanAcehneseceremonyusuallyheldafterturbulentevents;theterm(fromsijeuk, thesameastheIndonesian

sejuk,meaning“cool”)literallysuggestsa“coolingoff,”ametaphordenotingthecalmingofemotions.Peusijeukcanbeeither

collectivevillageeventsorprivateeventsheldinindvidualhomes.Sincethepeaceagreement,villagesandfamiliesallover

Acehhavebeenorganizingpeusijeukeventstowelcomehomeamnestiedprisonersandformercombatants,andcanbeused

asonemeasureofpost-conflictreintegration.ItishardtointerpretthestatisticsaboutpeusijeukinTable10.5becauselittleis

knownabouthowthisceremonialpracticevariesbetweendistrictsorevenbetweenvillages,butingeneralnearlyonethird

ofall respondentsacknowledged peusijeuk in thecommunitiesafter thepeaceagreement. Many respondentsnoted that

theydidnotknowaboutordidnotattendpeusijeukintheirowncommunitiesbecausetheysuggesteditwouldbeafamily

affairratherthanacommunalone.Acloserlookattheparticipationinpeusijeukactivitiesbygenderandregionsuggeststhat

peusijeukareacknowledgedbymenmorethanwomenandperhapsaremoreprevalentinBireuenandAcehUtaraoverPidie.

Table10.5showsthatrespondentsoverwhelminglysupportthepeaceprocessingeneral.Neverthelesshavinglivedthrough

the failure of peace agreements in the past, several concerns were expresssed. Both questionnaire respondents and key

informantswereaskedabouttheiropinionofthecurrentpeaceprocess,problemsandchallengeswiththeimplementation,

andsuggestionsformovingforward.Severalconsistentthemesemergedthatraisedoubtsandconcernsamongtheresidents

offormerconflictareas:

• “WhenAMMleaves,weareworriedthattheconflictwill resumeagain.” Manyrespondentsexpressedconcernsnot just

aboutwhat willhappenwhen AMM leaves, but theentirecommunityof foreignerswhohave arrived in Aceh since the

tsunami. (e.g.“Whentheforeigners leave, therewillbeproblems.”)Theverypresenceofpeople fromallovertheworld

working inAcehsinceJanuary2005hasplayedan importantrole,albeit indirect, inachievingandmaintainingpeace in

Aceh.

• Severalrespondentsandkeyinformantsnotedanincreaseincrimeinrecentmonths.

• Unequaldistributionofassistance for Acehnese. Therewere twomajor stand-outexamples thatvillagers cited tomark

unfair aid assistance in Aceh. The first example was the disproportionate aid delivered to tsunami areas while heavily

damagedconflictareasremainneglected.Thesecondexamplewastheunequaldistributionofvillagefuelsubsidiesfrom

thegovernment. Villageheadswereheldaccountable forgiving thegovernment’scashassistance toclose friendsand

familyinsteadofthepoorestpeoplewhoneededitthemost.Onerespondentsaidforthrightly:“Thereisacrisisoftrustin

ourvillageleaders.”

• ManyrespondentswereconcernedthatGAMandtheIndonesiangovernmentmightnotsticktotheagreeduponterms

oftheMoU.Examplescitedwerethedelayinthedraftingofaregionalautonomylaw,theabsenceofassistanceforcivilian

conflictvictims,afailuretoadequatelysocializethepeaceprocessthroughoutAceh,andtheloomingquestionaboutlocal

elections.Manyrespondentsregisteredtheirhopethatbothsideswillremainethicalandfaithfultotheletterofthepeace

agreement.

• Finally,forsometherestillremainsnon-specificfearsthatlingerbecauseofmemoriesaboutfailedpeaceeffortsinthepast,

orperhapsalsoanunshakeableuneasesustainedduringtheconflict:

• “Iamworriedthatthereareelementsinsocietythatarestillinterestedinmaintainingthedestructionandconflict.”

• Untilnowmanypeopleinthecommunityarestillafraidtoworkintheirfields,gardents,andforests.

• “Afterthepeace,wearestillworried,stillunsure.”


The following are recommendations based on the data presented above, the experience ofconductingfield-basedpsychosocialresearch,anddiscussionswithcolleaguesatdistricthealthoffices,puskesmas(primaryhealthcarecenters),andthementalhospitalinBandaAceh.

the community mental health nursing programShortlyafterthetsunami,theWorldHealthOrganization,incollaborationwiththeProvincialHealthOfficeinBandaAcehand

theUniversityofIndonesia’snursingprograminJakarta,developedanovelcurriculumtotrainpuskesmasnursesincommunity

mentalhealthnursing(CMHN).Theprogramalsoincludedrefreshercoursesonbasicpsychiatryandprescribingprotocolsfor

generalphysiciansfromthesamepuskesmas.Fundingwasdirectedfirsttowardtsunami-affectedsub-districtsalongAceh’s

entire coastline. Nurses were taught how to treat some of the major acute psychiatric disorders in a curriculum that also

emphasized basic nursing care for the mentally ill and family education. Their job as CMHN includes active outreach into

communitiesforcaseidentification,familyeducation,treatment,andreferralforcomplexcasesbeyondtheirskill. Selected

nurseswereprovidedinitiallywiththefoundationalcourse,thefirstofthree. Theintermediatecoursehassofaronlybeen

implementedinafewsub-districtsofBireuen;itincludesabroadcommunityeducationalcomponent,trainingCMHNnurses

toconductmoreintensiveoutreachwithentirevillages,focusedonearlydetection,andbasiccounselingskills.Ifthebasic,

theintermediate,andeventuallytheadvancedCMHNtrainingprogramissuccessful,itwouldserveasamodelforcommunity-

basedmentalhealthservicesthroughoutAcehandallofIndonesia.Continuedsupportforthisprogramcurrentlycomesfrom

theAsianDevelopmentBank.

TheCMHNprogramisanidealinfrastructurewithwhichtocollaboratewiththeIndonesianMinistryofHealthinJakartaand

theProvincialandDistrictHealthOfficesinAcehincreatingcommunity-basedmentalhealthservicesforformerconflictareas.

Todate,theCMHNprogramisstillininitialphasesandhasnotbeenextendedtointeriordistricts,andthebudgetfornurse

transportationisrarelyenoughfortraveltothemoreremotevillagesthatsufferedthegreatesteffectsoftheconflict.However,

theCMHNprogram’semphasesoncommunityoutreachandeducationarepreciselythekindsofactivitiesthatwillberequired

toreintegrateconflictareasintothehealthcaresystemandtobridgelongstandinggapsintrustandunderstandingbetween

conflictvictimsandhealthpersonnel.Anyfutureinterventionforconflict-affectedcommunitiesshouldcollaboratewithCMHN

nursesandtheircoordinatorsatthenearestDistrictHealthOffice.

mental health outreach teams for conflict-affected communitiesThePsychosocialNeedsAssessmentdescribedherehasidentifiedanurgentneedforimmediatementalhealthandpsychosocial

servicestocommunitiesmostaffectedbytheconflict.Thesecommunitiesareoftenremoteandlargelybeyondthereachof

current health services, and both impoverishment (associated with the conflict) and mistrust of formal government-based

healthservicesconstitutebarrierstoprovidingcare.Yetmembersofthesecommunitiessufferextremelyhighratesofboth

physical injury and mental health problems resulting from violence and forced evacuation of their communities. Specific

outreachservicesarethusurgentlyneededtoprovideimmediatecareandtobuildbridgesbetweenthesecommunitiesand

thenewlydevelopingcommunitymentalhealthservices.

Werecommendthatdistrict-levelmentalhealthoutreachteams,basedonthemodelof IOM’s ICRSmobilemedical teams,

beestablishedtoprovide immediatemedicalandpsychosocialservicestovillages inthesubdistrictsmostaffectedbythe

conflict,andtohelpbridgethegapoftrustbetweenconflict-affectedpopulationsandthenewlydevelopingmentalhealth

servicesbeingestablished in theprimaryhealthcaresystem. These teamsshouldprovideclinicalandcommunitymental

healthservices,includingcommunity-basedtraumasupportactivities,aswellasgeneralmedicalcareaimedatmeetingthe

mosturgentneeds inthesecommunities. Theyshouldbedesignedneitherasa‘parallel’servicesystemnoraspermanent

services,butastransitionalservicestomeet immediateneedsofconflict-affectedcommunitiesandtoreestablish linkages

recommendations


betweenthesecommunitiesandpublichealthservices.Fromtheoutset,CMHN’sshouldbeincludedontheoutreachteams

tofacilitatethedevelopmentofsuchlinkages.

IOMhasbeenassistingthe Indonesiangovernmentwithpostconflict reintegrationactivitiessincethefirstprisonerswere

givenamnestyjustdaysafterthepeaceagreementwassignedinAugust2005.SincetheopeningoftenICRS(Information,

CounselingandReferralService)officesthroughoutAceh,IOMhasbeencollaboratingwithlocaldistrictauthoritiesonavariety

ofreintegrationissues,includingmedicalandpsychosocialhealth.ICRSstaffhavebeenconductingextensiveoutreachinto

formerconflictareas,andassuchIOMisideallypositionedtoinitiatecommunity-basedtraumasupportprogramsinthemost

seriouslyaffectedconflictareasofAceh.

An IOM mobile medical team’s visit to the mountain interior village of “Cot Pinang” (a pseudonym) demonstrated how

community-basedpsychosocialoutreachmightworkandwhatitcouldlooklike.AnAcehnesepsychiatrist,thedistrict-based

ICRSgeneralphysician,andanurse,alongwithmembersfromthepsychosocialresearchteamfromHarvard,IOM,andSyiah

KualaUniversity, traveledtoCotPinangvillage toholdamentalhealthclinic in themeunasah. ICRSstaff informedvillage

leaders in advance so that those who most needed treatment would be able to plan ahead to attend. Dozens of people

gatheredinthemeunasah,andonebyone,peoplesatwiththepsychiatrist,describedtheirsymptoms,andtoldtheirstoriesof

conflict-relatedtrauma.Basicevaluationswereconducted,somemedicaltreatmentsinitiated,andmanyreferralsweremade

topuskesmasclinicsforfollow-upcare.Approximately50patientswereseenoverthecourseofalongafternoon.Thevisitby

theMobileMedicalTeambecameakindofcommunityritual,withmembersofthecommunitytestifyingtotheirexperiences

duringtheconflictwiththemedicalteamaswellastheresearchteam.Thiseventprovideddataconcerningtheurgentneed

formentalhealthservicesinvillageslikeCotPinang.ItalsosuggestedthatmembersofaffectedcommunitieslikeCotPinang

recognizethe importanceofstress, trauma,andmental illness, that theydesireandarewillingtoengage inmentalhealth

evaluationsandclinicalinterventions,andthatmobileserviceshavethecapabilitytoprovideaccesstocareforpersonsmost

deeplyaffectedbytheconflict.Datafromthestudyreportedherealsosuggestthatserviceslimitedtoevaluationandreferral

willbeineffective,andthatsuchteamsneedtoinitiateclinicalcareandtreatment,providetransitionalfollow-upcare,andover

timebuildlinkagestothepuskesmas.

ThevisittoCotPinangsuggeststhatIOMshouldpursuethemobileoutreachmodel,giventheICRSoffices’prioroutreachinto

someofthemostdamagedcommunitiesinAceh.Outreachteamsaspartofatransitionalprogramofhealthservicesshould

certainly includeCMHNnurses fromnearbypuskesmas. Integrationofthesetwoprogramsfromtheverybeginningcould

facilitatere-entryofhealthpersonnelintolongisolatedregionsofAcehandinitiatecaseloadsforfollow-upbytheseCMHN

nursesatthenearestclinic.IOMisinanexcellentpositiontohelpbridgethegapoftrustbetweenconflict-affectedpopulations

andthehealthservicesthatestrangedthemforsolongandshouldexplorethepossibilityofinitiatingsuchaprogram.

family outreach programsThedatareportedinthissurvey,aswellasnearlyallmentalhealthresearchinIndonesia,showthatfamiliesconstitutethemost

importantlocalresourceforprovidingcaretothosewithmentalillness.Mostpersonswithseverementalillnesslivewiththeir

families.Personssufferingdepressionandsymptomsoftraumaticexperiencedependontheirfamiliesasaprimarysourceof

supportandcare.Communitymentalhealthoutreachshouldthusbefamilyoriented,helpingprovidefamilieswithskillsfor

supportingorcaringforthosesufferingmentalhealthproblemsinamoreeffectiveway.Werecommendthatprogramsof

familysupportandeducationbedevelopedaspartoftheinitiationofmentalhealthoutreachteams.

evaluation and counseling on head traumaOneofthemostdramaticfindingsofthisresearchsuggeststhattheincidenceofphysicalheadinjuryduringtheconflictyears

was incrediblyhigh,particularlyamongyoungmen. Werecommendthataprogramof training,clinical interventions,and

researchshouldbeinitiated,focusingonevaluationoforganicheadtraumaanditsneuropsychiatriceffects.Astartingpoint

forthiskindofworkmightbeginwiththeICRSdoctorswhohavealreadyestablishedrelationshipswiththedirectbeneficiaries

ofIOM’sPostConflictProgrammeaswellasthesurroundingcommunities.Thesedoctorscanbetrainedtoincorporatesome

simple neuropsychiatric evaluation methods into their routine work with amnestied prisoners, former combatants, and

ordinaryconflictvictims. Focusonheadtraumashouldalsobebuilt intotheworkofthementalhealthoutreachteamsas

wellas theCMHNprogram.Wheretreatment ispossible,physiciansorcommunitymentalhealthnursesshouldbetrained


to initiatetreatment. Wheretreatment isunlikelytobeeffective, familiesandaffected individualsshouldbecounseledon

theeffectsofheadinjuryandwaystoaccommodateresultingdisabilities.Acounselingtoolshouldbedevelopedtoteach

thosewithheadinjuriesandtheirfamilieshowtounderstandeffectsofsuchinjuriesandhowtolivewithanylong-lasting

outcomes.Difficultcasesshouldbereferredformoreadvancedneurologicalandnueropsychiatricevaluationandtreatment.

This will require training of specialist psychiatrists and neurologists to evaluate complicated cases and provide advanced

care.Inaddition,neuropsychiatrictestingshouldbemadeapartofforensicevaluationsofformerprisoners,combatants,or

communitymembersaffectedbyviolencewhoarechargedwithroutinecrimes.

integration with other health servicesMental health outreach can and should be integrated with other medical outreach services in Aceh. People living in the

villagesmostdamagedbyconflictactivityaresufferingfromallkindsoflingeringmaladiessustainedduringcombatortorture

–gunshotorknifewounds,paralysis, lost limbs,eyeandear injuries,aswellasheadinjuries. Atotal lackofhealthservices

duringtheconflictmeansthatchildrenhavenothadtheirimmunizations,mothershavenothadadequatepreandpostnatal

care,andeasilytreatedinfectiousdiseasessuchastuberculosisandmalariahavenotbeenattended.Whilefocusingonmental

healthcare,themobilemedicalservicesrecommendedshouldalsobedesignedtomeeturgentmedicalneedsandbeginto

reinstitutepublichealthservicesaswell.

integration of psychosocial and livelihood development programsFindingsofthePsychosocialNeedsAssessmentmakeitclearthatmentalhealthproblemsgohandinhandwitheconomic

problemsassociatedwiththeconflict. This isparticularlycritical incommunitieswhichsufferedforcedevacuationof their

villagesorsystematicdestructionofbasicinfrastructure.Thisstudyprovidespowerfulevidencefortheneedformentalhealth

services. On the other hand, our research suggests that the mental health programs and economic and infrastructure aid

programs should go hand in hand. Mental health programs are unlikely to be successful in the absence of investment in

rebuildinglocaleconomies.Ontheotherhand,mentalhealthinterventionsandlivelihoodprogramsmayinteractsynergistically,

withmentalhealthprogramsprovidingamultipliereffectonthebenefitsoflivelihoodprograms.

the importance of innovation and evaluationManagingmentalhealthandpsychosocialproblemsassociatedwithcomplextraumainrelativelyisolatedsettingswithlimited

accesstomentalhealthcareisextremelychallenging. Itshouldbeexplicitlyrecognizedthatthereisnosingletherapeutic

modalitywhichiscertaintobeeffectiveandsustainable.Instead,acommitmentshouldbemadetodevelopinginnovative

therapeutic programs in selected settings, to documentation of each program, and to careful evaluation of the efficacy of

therapeuticapproaches.Evidencefromothersettingssuggeststhatgrouptherapyapproachestothetreatmentofdepression,

Cognitive-Behavioral Therapies incorporating local relaxation approaches (including Islamic meditation practices), dance

therapiesdrawingonlocalculturalforms,familysupportgroupsthatincludepsychoeducationalcomponents,school-based

programsforchildrenandadolescents,aswellasstandardpharmaceuticalapproachesarepotentiallyvaluableapproachesfor

theAcehnesesetting.Butunlessprogramsaimedatprovidinginnovativesolutionstotrauma-relatedmentalhealthproblems

aresystematicallyevaluated,itwillbedifficulttoassesstheefficacyofparticularapproaches.Werecommendthattheneedfor

innovativeservicedevelopmentbeexplicitlyrecognized,andthatexploratoryserviceapproachesbesystematicallydeveloped

andevaluated.

localized implementationInnovativeapproachestodevelopingtherapeuticprogramsinformerconflictareasofAcehrequireadditionalresearchatthe

locallevel.Arandomsampleassumesarandomdistributionofviolence,buttheregionaldifferencesbetweenPidieonthe

onehandandBireuenandAcehUtaraontheothersuggestthatconflictviolenceinAcehwashardlyrandom.Theresultsof

thisassessmentaremerelythefirststeptowarddevelopingtargetedservicesforspecificcommunities,recognizingthatevery

regioninAcehexperiencedtheconflictdifferentlyduetovariablepopulationdynamics,economicresources,andgeographies.

DifferentconflicthistoriesacrossAceharelikelytoproducedifferentpsychosocialandmentalhealthneeds.Everyinnovative

therapeuticinterventiondevelopedforlocalimplementationshouldattendtothesedifferences.


for further information:

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jl. mh. thamrin Kav.9

jakarta 10350

indonesia

ph. +6221 3983 8529

fax. +6221 3983 8528

email. [email protected]

www.iom.or.id

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