How (Not) to Start an Orphanage

by Tara Winkler

  Baz is an upbeat, larger-than-life boy from Perth. His first self-appointed task was to review all our medical processes and medical files and review all the treatment plans for the kids with chronic illnesses. He made a special trip up to Battambang to conduct the assessment.

  By going through the files, he discovered that the results from Nimol’s viral load test for hepatitis B were a cause for great concern and the medication we’d been provided seemed to be having no real effect. Makara’s viral load wasn’t great, either. But before I had a chance to start wringing my hands over this revelation, Baz had delivered calm, matter-of-fact reassurance that all would be well. Both boys just needed to be put on an antiretroviral regime and monitored regularly. Fortunately, the other kids with hepatitis B were doing well, but he also put them on to the schedule for regular, ongoing monitoring.

  It was such a huge relief to finally have someone on board who was so very experienced and capable, not just in the field of medicine, but also on the ground in Cambodia. Baz has endless empathy for Cambodian people and is always willing to help, without ever wanting anything in return.

  He helped us put new policies and protocols in place and establish a triage system. He then set up a simple yet comprehensive home pharmacy at CCT with good-quality, registered drugs. He provided training for the staff and me, and made a second copy of all the medical files. That meant that no matter where he was, he could always look things up and offer recommendations and advice, and ensure the treatment being provided by local doctors was following best practice. For me it was as if not just a breath, but a tornado of fresh air had blown through CCT.

  The best part of Baz’s visit was when he sat down with Sinet’s sister, our gentle, sweet Sineit.

  Sineit understood all too well what it meant to have HIV. She had seen both her parents die in terrible pain from AIDS. She was often sick and knew that, like her parents, her days were numbered. She had come to accept that she’d never have a husband or child, but she couldn’t stop dreaming of being a wife and mother herself one day. She devoured romance novels and spent all her spare time helping to ‘mother’ the youngest kids at CCT and had developed a particularly close bond with Sovanni.

  Sineit, Baz and I sat around the pink stone table in the CCT courtyard. I translated as Baz said: ‘Sineit, I have some very good news for you. There are new HIV treatment regimes available at the Hope Clinic in Phnom Penh. I’ve organised for you to be treated there.’

  I translated this, and Sineit smiled politely and said, ‘Thank you,’ in her soft, sweet voice.

  ‘If you follow the doctor’s instructions and do your best to take good care of your health, then you can expect to live a long life. A normal life, with good health and almost no effects of HIV.’ Baz grinned.

  The tears began welling up in my eyes—and hers—as I translated.

  ‘And one day, when you have a partner, we can help you have a baby. And we can make sure that both your partner and the baby remain HIV negative.’

  Sineit burst into real tears now—tears of surprise and joy. That set me off too; even Baz was weeping by now.

  All the tough times I’d been through since moving to Cambodia suddenly melted away. It had all been worth it.

  Sometimes, doctors ask me if I have a medical background, because in those early days of CCT I became something of a walking encyclopaedia of tropical medicine. But I was just trying to ensure the kids were getting adequate healthcare, and that required a very steep learning curve. It had been stressful and utterly terrifying at times. Having Baz on board changed everything. After two years of feeling like I was battling through it alone, I finally had a dedicated medical professional on my side.

  These days CCT has a local team of Cambodian medical professionals running our medical outreach program. Baz is still on our medical advisory board, helping the team to access quality healthcare. It is a still a very challenging task.

  I was still on a high from Baz and Charlie’s visits when an ABC producer named Ben Cheshire got in touch. He said they’d made up their mind—they would like to feature me on the Australian Story program.

  A wave of anxiety crashed over me. I knew I couldn’t say ‘no’ to an opportunity like this to reach new supporters, but just the thought of being on TV made my heart start racing. For the first time in a while, a familiar feeling seemed to come over and tap me on the shoulder . . . ‘Hey, maybe you should skip dinner tonight.’

  Having new funds in place—and knowing more were coming—meant we could take the risk of investing in some much-needed support. Our most pressing need was to have a consultant in child psychology come and do a full assessment of our practices, and advise us on how we could best support the kids going forward.

  Essentially, all the kids were doing quite well in their day-to-day lives. They were happy and playful and came home from school each day with stories of success. They were also starting to get pretty good grades. Most of the kids amazed me with their resilience, and seemed really well-adjusted. But others did show worrying signs of inner turmoil.

  Many of the kids wolfed down their meals in a desperate hurry, as if terrified the food would be taken from them. Some of the younger kids would playfully bite and smack me and the other staff in an attempt to get attention. There were some instances where kids wouldn’t think to mention that they were sick or in pain.

  Rithy was still hoarding things. Under his mattress, there always seemed to be a stockpile of seemingly useless junk. He was also painfully shy, often finding it very hard even to make eye contact.

  Makara had improved a lot since our trip to Phnom Penh. He was still telling the kids not to fight, and would declare piously that children shouldn’t play with toy guns, because guns were bad and hurt people. He was going out of his way to be the ‘good boy’ he knew we wanted him to be. But from time to time that temper would still surface and give everyone an awful shock.

  Some of the kids—like Akara, the little girl we’d met at the lawyer’s office—were still extremely aloof and withdrawn. Akara could barely speak above a whisper and would never join in with group activities. Whenever we left the CCT grounds for an excursion, she would get panicky and have to run to the toilet over and over again. I could set my watch by her little voice crying, ‘Tara! Chu ju ait!’

  She also fidgeted an awful lot, and was unable to sit still for very long. She’d constantly stand up, adjust her pants and sit back down, only to repeat the action a couple of minutes later.

  One day, the school called Savenh to inform us that Akara had collapsed in the playground and was completely unresponsive. Another kid had been pushing her on a swing and didn’t stop when she asked her to. Akara had just fallen off the swing into unconsciousness.

  Savenh and I rushed her to hospital and called Baz en route. I was terrified that she had concussion. But the doctor confirmed that there was no head injury. He said it was just a panic attack.

  Just a panic attack! I thought to myself. What sort of panic attack makes a child fall unconscious?! I worried about her constantly.

  My dream of finding a child psychologist in Cambodia had long died, so I looked for options elsewhere. I’d been very impressed with the therapist I’d seen about my eating disorder when I was in Australia a few years earlier. Her name was Anna, and she was now doing further studies at Lancaster University, specialising in work with traumatised young refugees and asylum seekers. She had a keen interest in eastern and cross-cultural psychology.

  She agreed to fly over and undertake the assessment as part of her studies.

  I was excited about Anna’s upcoming visit. I was also amazed and humbled that someone who knew the gory details of my eating disorder—something I still felt so deeply ashamed about—would think me worthy enough to know and help, outside the walls of a therapist’s office.

  It was lovely to see such a familiar and comforting face when Anna arrived in Battambang. The night she arrived, we went to dinner at the White Rose to discuss her plans
for the workshops with the staff.

  ‘I’d like to base some of the initial sessions on attachment theory,’ Anna told me in her soft Mancunian lilt. ‘We’ll draw on the staff ’s expertise to ensure these workshops are culturally relevant, of course, but I do think this is our best starting point.’

  She reached into her backpack, pulled out a couple of books and pressed them into my hands. They were titled Nurturing Attachments: Supporting children who are fostered or adopted by Kim S. Golding and Why Love Matters: How affection shapes a baby’s brain by Sue Gerhardt.

  I scanned the backs of the books while she explained. ‘Attachment theory is one of the major ideas underpinning modern-day developmental psychology. It explains how the relationships we form in childhood with our primary carers have a direct impact on the way our brain develops. We’re all born with a need to form long-lasting, affectionate attachments. If a child has at least one secure, ongoing relationship with a stable adult—someone who loves them and makes them feel safe—they’re likely to grow up into well-adjusted adults. The adult doesn’t need to be at the child’s beck and call—that can cause problems too—but they do need to be there for them and attentive most of the time.’

  Anna then went on to explain that kids can fail to form secure attachments as a result of neglect, abuse, abrupt separation from parents or a high turnover of caregivers.

  I thought guiltily about how we’d been doing things at CCT—firing staff, hiring new staff, the shift work of the current house parents, all the coming and going I had done . . . It had been obvious that there was something unhealthy about how the kids attached to the adults in their lives and now I was beginning to understand why.

  I started bombarding Anna with more questions, but she gestured for me to keep eating my dinner. ‘Don’t worry,’ she said. ‘We’ll go through all of this in the workshops. If you like, you and I can do separate sessions, just the two of us. We’ll be able to move through all the material a lot quicker that way, and then you’ll be able to help explain it to the staff.’

  I went home that evening and read for hours, devouring the words on those pages as if I was reading a thriller, bouncing from one epiphany to the next. I was desperate to know more, to understand more.

  Human beings and their problems are, of course, far too complicated to cover in a few textbooks. We should never swallow any one theory or study whole—it’s good to question, to be sceptical—that’s how science works. But the books did give me a completely new way of thinking about where some of the kids’ issues might have been coming from.

  And attachment theory—at least for now—is a widely respected way of understanding and treating the problems that manifest in childhood development. At the time, the case studies in Kim S. Golding’s book about how attachment disorders manifested in children who had been separated from their parents rang eerily true to me. Several of them did sound like the kind of experiences some of our kids were having.

  Marcus finds it very difficult to stay still or concentrate on anything for very long. He can become excited or angry very easily and then becomes very difficult to manage . . . Sometimes Marcus feels very sad. He cannot cope with feeling sad; when he was little, feeling sad did not lead to comfort. Marcus has learnt that he can stop the feelings of sadness by being angry.

  This case study was about a little boy who had developed a ‘disorganised-controlling attachment relationship’, which happens when primary caregivers are frightened, or frightening to the child. This seemed to correspond with what Makara went through as a child.

  Then there was the case study of a little girl with an ‘avoidant’ attachment pattern.

  Catherine behaves [towards her foster parents] as if she does not expect them to be available and responsive. She makes few demands on them, plays on her own, and if upset makes little fuss . . . A few months after she came to live with them [her foster father] took Catherine to the dentist. He was amazed to be told she had a nasty abscess at the back of her mouth; she had given no sign of discomfort.

  This did sound rather like Sovanni, the baby we’d picked up from her grandmother. She never cried—she’d just go off and soothe herself if she was upset. This kind of fierce independence is unusual in Cambodia, which is a very baby-oriented culture as a rule, but this little girl had suffered terrible neglect before she came to us.

  The next case study was of a child with an ambivalent-resistant attachment pattern. In this case, the caregiver is sometimes responsive, but is usually insensitive, unresponsive and unavailable.

  Zoe learned to demand attention, expecting inconsistency and unpredictability . . . [She] works so hard at getting attention that she knows she is a nuisance. When her parents or teachers get frustrated with her this just confirms that she is naughty and that she won’t get attention when she needs it . . . It is as if they think ‘I don’t know if you will be there when I need you so I am going to make sure that you are there for me all the time.’

  One of our little girls, Jendar, fitted that description. I used to call her ‘cheeky monkey’. She’d smack your bum if you paid attention to someone else and not to her. She’d shower you in hugs and kisses and sing little songs that went: ‘I love you, I love you!’ It just seemed like cute, cheeky behaviour, so it was upsetting to think that there might have been something dysfunctional behind it all.

  The next case study was about a little boy with a ‘non-attachment’ style. This happens to kids who are subject to severe neglect.

  Luke expects little of parents but looks for attention indiscriminately from the range of people he meets during the day . . . At six, Luke is still not properly toilet trained. He will wet or soil his bed but appears not to notice . . . Luke eats voraciously, whatever is put in front of him. He also tries to secrete food in his bedroom, hiding it in unlikely places . . . Luke’s impulsivity can lead to situations that are very alarming . . . [Luke’s foster parent] fears that Luke would go with anyone that held out a hand at the right time.

  Oh dear—I’d met so many children in orphanages that could have fit that description since I’d arrived in Cambodia . . .

  Of course, it’s unwise to go around diagnosing and pathologising children when you don’t have formal training, but it was helpful to understand the kinds of issues that the kids might be facing, now and in later life, if they weren’t brought up with secure attachments.

  I couldn’t wait to see if Anna could help us put all this knowledge into practice.

  The workshops went painfully slowly at first, because some of the concepts were so hard to translate into Khmer. We hired a translator to facilitate the meetings, and Jedtha and I helped out where we could.

  Anna began with the key ideas behind attachment theory and the different ways attachment disorders manifested. Then we talked through some specific cases of the kids at CCT who the staff were most worried about.

  I was still keeping the staff at arm’s length, so it was a bit of a revelation to me to see how enthusiastic they all were about helping the kids. They seemed to really love having the chance to talk through some of the challenges they were facing, and to get Anna’s expert opinion on ways they could work through those problems. After finding it all such a revelation myself, it was wonderful to see the lights go on in everyone’s eyes.

  Given how cold I’d been feeling towards Savenh, our social worker, it was good for me to see that she was genuinely inspired. She was one of the first to go: ‘Ah! I just thought Jendar was naughty! But actually, she’s trying to get attention because she’s worried she’ll be abandoned again!’

  Jedtha was right about Savenh, it seemed. She truly was very enthusiastic about understanding the kids.

  I remember seeing the moment our new house father Samnang’s brain exploded. He was sitting on the floor, holding his chin while Anna talked, his face intense. He suddenly put a hand up and yelled: ‘Wait, hold on, oh my god, I’ve just got to stop for a minute. This is so deep.’

  We all laughed, because
it was so true.

  Anna explained to us that a lot of the behaviours we were seeing in the kids were unconscious ‘safety behaviours’ which were likely to have originated from earlier traumatic experiences, like being abruptly separated from family, or like the neglect and sexual abuse that happened at SKO. The only way to really help them grow out of these behaviours was to ensure that these kids could establish a secure attachment to a parental figure.

  ‘Kids who have secure attachments feel safe and know they can trust and rely on their caregivers,’ Anna explained. ‘Having a loving and stable primary carer lets children form a secure attachment and grow up to be happy and well-adjusted, and able to form healthy relationships of their own. They’ll be more independent and have a lower chance of developing anxiety and depression and other mental illnesses. But the problem is, forming secure attachments is hard for children to do when they’re living in an institution. More than sixty years of research has shown that growing up in institutions creates attachment disorders, which can lead to mental health issues and all sorts of other problems later in life.’

  ‘An institution?’ I queried nervously. This was the first time I’d heard that word used to describe CCT. ‘CCT’s an institution?’

  ‘Well . . .’ Anna paused. ‘It’s very clear that you and your team are trying your best to provide a happy environment for the kids, but, yes—there’s no getting around the fact that CCT is providing a form of institutional care. Having twenty-plus kids in one home, sleeping in dorms, house parents on rotating shifts . . .’ Her voice trailed off, probably in response to the devastated look on my face.