Paths to Recovery:
Coordinated and Comprehensive Care for Landmine Survivors


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By conducting interviews with survivors of landmine incidents, Landmine Survivors Network (LSN) has been able to learn a lot about rehabilitative needs from the perspective of the patients. This article describes how physical health, psychological well-being and socio-economic reintegration are all important components of a complete recovery for landmine victims.


by Beth Sperber Richie, Ph.D., Angela Ferguson, Ph.D., Zahabia Adamaly, Dalia El-Khoury, Maria Gomez, Ph.D., Trauma Research Team, Landmine Survivors Network

Introduction

Healing from a landmine explosion is a painful and arduous process. Recovery from limb loss requires patience, tenacity, hope and help from friends, family and community. Getting a working prosthesis and learning to walk again is often transforming. But artificial limbs alone do not put food on the table or ensure psychological health and social integration. Certainly, mine victims worldwide need access to better medical care and mobility equipment, but LSN research indicates that physical rehabilitation alone is not sufficient for full recovery, and the need to develop psychological and social support cannot be ignored. Recovery is a multifaceted and dynamic process, and the field of victim assistance must therefore be interdisciplinary.

Some of the stages of recovery from landmine injury are obvious. There must be immediate and competent medical care; there must be appropriate mobility equipment and adequate rehabilitation. But some of the crucial factors that enable complete recovery are not so obvious. Psychological factors, like the survivor’s own resilience and the impact of social support, also play a key role in determining how landmine survivors recover from trauma.

Survivor Interviews

Over the past two years, LSN has gathered information and conducted in-depth interviews with landmine survivors in six mine-affected countries to examine the social and psychological factors that facilitate recovery from landmine injury. Our fieldwork and analysis have identified the following central aspects of recovery: physical health, psychological well-being, and social and economic integration. Survivors’ stories from El Salvador to Ethiopia reveal that these recovery factors interact with each other in dynamic ways. Each needs to be addressed in an interdisciplinary fashion when working with a survivor on the road to recovery.

LSN social workers interviewed 59 amputees, family members and service providers in six countries: 11 in Bosnia, five in El Salvador, 10 in Eritrea, nine in Ethiopia, nine in Jordan and 14 in Mozambique. Interviews included 33 survivors of traumatic limb loss, of whom 30 had been injured from mine/UXO explosions. The amputees ranged in age, gender, socio-economic status, urban-rural location, time since injury and extent of rehabilitation. Other interviewees included immediate family members and experienced service providers, including prosthetists, physical therapists, psychiatrists and physicians. This broad set of participants captured individual, family and community perspectives.

“I got a new prosthesis and I got rid of my crutches. I am ready to live a new life. I can go to the hospital by myself.... I can walk five to seven kilometers.... It is an amazing feeling when someone who has lost a leg—who was not even sure that he would still live, who did not see any light in the tunnel—gets a prosthesis and starts a life as a person and starts thinking about the future.”—A landmine survivor

LSN chose a qualitative research approach, including open-ended, in-depth interview techniques to allow survivors to describe their own experiences in their own words.

Trauma and its Manifestations in Different Socio-Economic and Political Contexts

The psychological and emotional impact of the physical trauma of a mine injury and limb loss can be devastating. Survivors describe initial reactions ranging from horror to numbness to rage, with a number of amputees describing suicidal feelings. One participant said, “I thought about taking my life; I had intentions to kill myself because I said to myself: ‘Well, now without an arm, what am I going to do?’” Interviewees across all the countries express similar strong emotions. Yet our data also reveal that the occurrence of a landmine accident in the individual’s life may be one more trauma in a series of chronic stressors with which they have to cope, like hunger and displacement. As a result, the notion of a single traumatic event followed by a particular set of psychological responses, highlighted in much of the current literature on trauma recovery (which primarily focuses on levels of Post-Traumatic Stress Disorder) is an inaccurate reflection of the post-limb loss experiences of many landmine survivors.

The Interaction of Recovery Factors

Physical Health
Survivors often describe a fundamental relationship between their physical health and psychological well-being. An individual’s self-perception is greatly influenced by his physical health and appearance after a landmine injury. Landmine explosions occur suddenly and without warning. In an instant, a survivor’s body is forever changed and scarred. A survivor not only loses a limb or eyesight, he/she often loses his/her place in society. Self-perception and the perception of others also change. Stated one survivor: “Initially, I developed a psychological complex when I would think of myself without a limb.”

Survivors who face the challenge of learning to walk again—often with mobility equipment that inflicts pain—express uncertainty, helplessness and hopelessness. In countries where prostheses are available, there appears to be a connection between the quality of the equipment and the survivor’s overall sense of physical health: “[when] everything was going well and things actually worked, I came alive. That gave me some strength.”

The impact of survivors’ physical functioning on their social and economic integration is evident. Without physical health, survivors are unable to farm or care for their children, and the physical limitations of their disability often preclude a return to their previous occupation. They are suddenly disconnected from their family roles as providers or caretakers, which has an impact on survivors’ psychological well-being. Survivors’ physical health also has an impact on how they perceive their interaction with their communities and families (social integration), and their ability to become productive members of society (economic integration). Access to mobility equipment is often the deciding factor in whether or not survivors are able to get the follow-up health care and rehabilitation services they require, as well as whether or not they can find or return to work.

Psychological Well-Being
Many survivors describe their need to feel some hope in order to continue to deal with ongoing physical adjustments and mobility challenges. One service provider described the issue this way: “Even if we receive a patient who is 100 percent rehabilitated, but his psychological condition is not good, we will face difficulties with him.... Being not ready psychologically is a tiring process.”

Some survivors had to develop new coping strategies and ways of thinking to help them adjust to their new roles in society, in their family and in their work. For many survivors, religious or spiritual beliefs contribute to finding meaning in the aftermath of the injury, which contributes to their acceptance of the injury and their recovery. Survivors cite their own determination, perseverance and positive thinking as important for their recovery. “I can’t get rid of what happened to me, so I stopped thinking and worrying about what had happened to me and I then started thinking about going back to work.” Another survivor stated, “I knew that I had to forget a lot of things, what I had been, my past, when I was in good condition and healthy. I had to forget a lot of things in order to move on with the situation that I was facing.” Many survivors describe having to give themselves encouragement and hope when it was not available from their family, community or hospital staff.

Personality characteristics of psychological well-being, like self-reliance, independence, and feeling normal and capable make it more likely that survivors will be proactive about integration. Said one survivor, “Things are different when a person goes out into the world and hears his opinions in conversation, when others will see his work, not reject it, and be able to say that he’s not so disabled that he can’t help....” Likewise, the presence of the above characteristics also made it more likely that survivors would be able to deal with the inevitable barriers to such integration. The same survivor said, “…I’ve felt rejected when some people say you’re disabled, or look at you, but you meet their gazes—that’s right, I’m an invalid.” Both the individual as well as those in his/her immediate societal environment influence his/her self-concept and psychological well-being.

Social Integration
Societal barriers play a significant and rather insidious role in preventing a survivor from feeling valued, both as a member of his/her family and community and as an active contributing member of society. Across all country studies, perceptions of normalcy prove to be an important indicator of a survivor’s level of social and economic integration. A yardstick of “normalcy” was evident in the vast majority of interviews and reflected the survivor’s success at negotiating and managing his/her re-integration into society, often mediated (and usually in a positive way) through the immediate family, a spouse or the community.

Many survivors describe the impact of their family and community on their recovery. Family and social support from other amputees and community members is key to improving survivors’ psychological well-being. Social support also contributes to survivors feeling that they will recover from their injuries and live “healthy, normal” lives. Almost all of the interviewed survivors discussed their desire to live as “normal” individuals in their family, community and society. When the family was unavailable, the survivors looked for social support from peers, others in the hospital with them, or the professionals treating them. The encouragement that survivors received from these human interactions often gave them the hope that they would indeed be accepted and valued and that they were in fact “normal.” One survivor said, “Maybe because it was the closest support to a family. Then that helped me seeing my other companions (other amputees) and that gave me more courage. That is, they didn’t tell me to have courage or anything like that, but yes, when we talked I liked it and I copied something good from each one of them.”

Interaction with other survivors—peer support—is key to empowering survivors to persevere, believe in their capabilities and get into a frame of mind whereby they feel able to take charge of their bodies and their lives. The bonds built between survivors who are also soldiers are especially strong and supportive. Survivors in more than one country talk of feeling less pain because they went through the painful post-amputation period together. One survivor attributes ongoing visits from other amputees as the first step in drawing himself out of a “severe mental crisis” that lasted years. Another survivor talks of the unparalleled sense of comfort that she feels when she interacts with other disabled people like herself. Others are motivated by the negative experiences of other amputees: “We talked and I heard stories that were so sad, even worse than my own story. Then I said, ‘God, why wouldn’t I try to get up, to walk, to try to do something with my hands? My hands are healthy, my brain is healthy.’...”

The simple reality of seeing recovered survivors in a society where they are otherwise considered “not normal” has a highly motivating impact: “[A survivor] visited me and told me that this was not the end of the world: ‘You are not the only one who has installed a limb. I have an artificial limb and I am doing fine.’ His words gave me the hope to try to live again.”

Cultural norms, values and beliefs influence perceptions of normalcy and can create potential barriers to the individual survivor. To the extent that a particular country’s cultural norms, values and beliefs impede social integration for the survivor, there is a greater chance that survivors in that country may feel isolated and rejected. In the more extreme cases where survivors are harshly ostracized by their communities or seen as a burden on their families, their self-worth suffers accordingly: one survivor uses words like “goat” and “dog” to describe his feelings; another refers to himself as a “doll” and describes feeling like a child.

Societal attitudes toward the survivor’s landmine injuries make a big difference in their psychological well-being. War veteran status generally mitigates discriminatory attitudes toward persons with disability. Survivors who are injured in a war effort often possess higher levels of self-esteem and benefit from greater societal acceptance. Some survivors describe their injury as endowing them with the respected status of would-be martyrs, since the injury demonstrates to the community the survivor’s willingness to fight and die in a popular struggle. As a result, these survivors view the injury in a more positive manner, and the physical injury has a more positive than negative impact on their standing in the community. Social integration allows survivors to feel included and embraced, giving way to positive self-perception.

The discrimination and rejection that other survivors describe has a direct impact on their ability to be reintegrated socially and economically and therefore impacts their psychological well-being as well. One survivor describes his girlfriend’s father as discouraging their relationship because of his amputation. Others describe being passed over for job opportunities. A service provider stated, “Unfortunately, the atmosphere around them and the society are not suitable for people suffering from this condition.” The service providers in each country echo this concern.

Economic Integration
The ability to be productive and provide for one’s own and one’s family’s basic needs is a central and core issue for many of the survivors interviewed. “You bring a big life when you earn your own living. It also gives you some moral encouragement.” Without the ability to meet basic needs, survivors describe feeling depressed, angry and hurt. The inability to find or pay for accessible transportation limits most survivors’ opportunities to get adequate health care and better-fitting prostheses and/or to find work. For many survivors, the family’s basic needs prevail over the “extras” for the amputee such as medical care, well-functioning mobility equipment or vocational training. The desire to work goes beyond simply having an income. Talk of employment reflects deeper psychological needs, to resume breadwinner roles and status in the family, to feel “capable,” to demonstrate they are not a burden, to “participate” in society, to know they are “normal.” Survivors who receive some re-training and have hope that they might find work describe the positive impact on their psychological state: “Thank God I got a diploma; now I feel capable and ready to work like a normal person.”

Conclusion and Recommendations

Recovery from a landmine injury involves more than the provision of basic healthcare and work opportunities. Many types of humanitarian intervention attempt to provide physically traumatized individuals with ways to re-establish physical function. This is an important goal of recovery. However, LSN research finds that recovery depends on a dynamic relationship among several factors, including physical health, psychological well-being and socio-economic integration (the opportunity to be a productive member of society). Full recovery cannot happen without access to basic economic needs such as food and shelter, comprehensive and coordinated professional care, and affirming social relationships with the family and community.

Service providers who address one aspect of the recovery process need to remain mindful of other essential ingredients for recovery. No single program can cover every aspect of recovery, but all programs should promote access to the range of assistance needed for survivors to heal, recover and reclaim their lives. Systematic coordination among service providers with different competencies—medical, rehabilitative, psychological, social and economic—is crucial.

Service providers involved in psychosocial support programs can:

  • Work collaboratively with other service providers in the field of victim assistance.
  • Ensure that the population they serve has access to the requisite level of medical care and physical rehabilitation, and that opportunities to promote socio-economic integration also exist.
  • Expand their work and technical assistance to include training on psychological issues for service providers in other disciplines. All service providers can learn from psychosocial service providers how to incorporate psychological support into their programs, rather than viewing that function as external.
  • Incorporate the principles and practice of peer support in the delivery of their services. Having survivors closely involved is key to a meaningful integration of the psychosocial aspect to victim assistance in general.

Service providers involved in programs that provide assistance in physical function (such as medical care, physical therapy, prosthetics) can:

  • Provide timely information about the psychological responses to limb loss and physical injury.
  • Encourage survivors to utilize their usual means of social support and to develop contacts with other amputees who can provide peer support.
  • Ensure that the population they serve has access to appropriate psychological services and opportunities for economic integration, such as vocational training.

Finally, every program can strive to provide a discrimination-free and physically accessible environment.

Conclusion

Ideal recovery from trauma involves physical health, psychological well-being and socio-economic integration being met at the individual, family, community, and societal levels. While every program may not be able to meet all of those goals, every person working with landmine survivors can incorporate the knowledge of the multi-faceted recovery process in their work, making comprehensive and coordinated care a reality.

One service provider (who is also an amputee) described the process following a landmine injury: “…[H]is life will change completely. From that moment, he has to start a new life, face a new life. …[H]e has to undergo rehabilitation treatmentand I mean in all the areas: psychological, technical, educational, physical rehabilitationin order to cope with his new life and be able to be reincorporated into the productive and social life of the country. It does not mean that he is going to do the same things he did before, but according to his disability, he can be prepared and [can] succeed.”

Contact Information

Trauma Research Team
Landmine Survivors Network
1420 K St., NW
Suite 650
Washington, DC 20005
Tel: 202-464-0007
Fax: 202-464-0011
E-mail: dalia@landminesurvivors.org
Website: www.landminesurvivors.org

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