More than three decades after an estimated two million Cambodians died in a genocide perpetrated by the Khmer Rouge, post-traumatic stress disorder and other forms of emotional trauma continue to prey on the peace of mind of survivors and their descendants, say mental health experts who are advocating culturally adaptive trauma treatment.
“There are differences in human responses to trauma, and it is important to address the idioms of distress and cultural narratives in the response,” said Sandra Mattar, an associate professor of trauma at St. Mary's College of California.
Siem Reap Province in northwestern Cambodia borders an area that was once a Khmer Rouge stronghold. Before the genocide, which took place between 1975 and 1979, it was also the site of overspill bombing from the war in neighbouring Vietnam. Almost half of the province’s population suffer from post-traumatic stress disorder (PTSD), according to a recent study published in the International Journal of Psychiatry.
PTSD began to be mentioned in the mid-1970s and was recognized by the American Psychiatric Association (APA) in 1980, with the criteria revised in 2013. Exposure to a traumatic event can trigger PTSD, which is characterized by persistent re-experiencing of that event, avoidance and emotional numbing, persistent hyperarousal including a high level of anxiety, and hypervigilance, among other symptoms.
These general criteria have been widely adopted internationally, causing experts to call for “adaptive” treatments in different contexts. While Cambodian psychiatrists say the fusion of psychotherapy and Buddhist ways of dealing with grief have helped address the emotional trauma of some people, widespread poverty and limited mental healthcare have stalled mental health progress and contributed to transgenerational trauma, in which trauma is passed from one generation to the next.
“Trauma [that is not dealt with] can transfer from the first generation to the second. It is in the way they raise their children, [their] aggressiveness [and] inappropriate reactions,” said Muny Sothara, a psychologist with the Cambodian Transcultural Psychosocial Organization (TPO), an NGO providing mental health treatment, based in the capital, Phnom Penh.
“We should not assume that treatments developed for PTSD in the West are helpful or useful in non-Western contexts,” said Mattar, who wrote a report on training traumatologists in culturally adaptive methods in 2010. Trauma therapy based solely on talking and medication runs the risk of “eclipsing the mechanisms that [the] culture has around resilience and coping,” she said.
In North America, PTSD treatment often consists of cognitive behavioural therapy and/or medication, but these treatments do not address the role of the deceased, who many Cambodians believe are responsible for their mental health ailments, according to TPO.
Many Cambodians diagnosed with PTSD believe their frequent sleep disturbances occur because the spirits of their deceased loved ones are not at rest. “They have sleep difficulties, and pain, mostly pain in the heart, feeling numb in the heart,” said Sothara, who said patients interpret pain, insomnia and nightmares as signs of the unsettled afterlife of their dead relatives.
Cambodia is a mainly Buddhist country and it is widely believed that the monks are able to communicate with the deceased. TPO has incorporated Buddhist ceremonies, in which families testify about the deaths of their loved ones before monks in a pagoda, into conventional psychotherapeutic treatments such as counselling and, if necessary, medication.
“The ceremony provides the opportunity for them [survivors] to connect with dead relatives, to show the dead that they are fighting for them, they are doing something for them,” said Sothara, who noted that Buddhist ceremonies alone are insufficient to treat some cases of trauma, which is where conventional treatments, including psychotherapy, can help.
“The most important issue is that they [survivors] - and only they - are the ones to make the decision [about] if and when and to who[m] they want to tell their experience,” said Beini Ye, a lawyer with the Cambodian Defenders Project (CDP), an NGO representing survivors before an ongoing tribunal in which Khmer Rouge officials stand accused of war crimes. “For some, the decision to not disclose anything is the path to psychological healing.”
Poverty makes it worse
The consequences of PTSD are aggravated by poverty, which may be a stronger predictor of the severity of the disorder than the trauma event itself, suggested a 2010 study by US psychiatrists Devon Hinton and Roberto Lewis-Fernandez.
“If you add factors such as the impact of poverty, social and political instability, and poor access to resources, you have a recipe for non-stop cycles of victimization and violence, with no room for trust development or healing opportunities,” said Mattar.
An estimated 20 to 25 percent of women and young girls in Cambodia are victims of domestic violence, according to the Cambodian Human Rights and Development Association, as noted in a 2012 report by the New York-based Leitner Centre for International Law and Justice.
Ye said most people's psychological wounds have been untreated for decades, compounding the severity of their current distress.
Almost 46 percent of Cambodians live in “multidimensional” poverty - a UN measurement that considers multiple deprivations in health, education and living standards - according to the UN Development Programme in 2013.
In 2012, the government spent US$300,000 on mental healthcare, which amounted to $0.02 per person, far short of the $0.20 other low-income countries spent per capita in 2011, the most recent year analyzed by the World Health Organization.
The Leitner Centre for International Law and Justice noted, “The devastation of the Khmer Rouge regime is not solely responsible for the continued presence and impact of many determinants of poor mental health in Cambodia.”