Mental Health in Cambodia: The Role of Alternative Treatment Methodologies

MENTAL HEALTH IN CAMBODIA
The Role of Alternative Treatment Methodologies
April 2013
Text, Photography and Design by
Francesca Bini
Figure 1: Wild lotus flower
Preface
This report is the result of a personal project developed during a 3-month internship at the Transcultural Psychosocial Organization (TPO), the leading mental health NGO in Cambodia. The internship was part of a 4-month servicelearning program in Phnom Penh, undertaken by the author between January 7, 2013 and April 21, 2013, resulting from the collaboration between SUNY Albany University, Global Service Corps, and Paasastra University of Cambodia. The author of this report has personally conducted research and interviews in the field with mental health workers, human rights advocates and NGO workers, survivors of the KR and civil parties of the ECCC, academic experts, and Buddhist monks. The views expressed herein remain those of the author and are not reflective of the official position of TPO.
I would like to express my deepest appreciation to all those who provided me the possibility to complete this report. Special thanks go to my supervisor, Dr. Susan Hagadorn, for her support and advice on this project. I would also like to thank the staff of TPO's KRT team and TPO Director Dr. Chhim Sotheara for their invaluable support. Finally I would like to thank Aaron Pace for his support, encouragement and proofreading of this manuscript.
Mental Health in Cambodia: The Role of Alternative Treatment Methodologies
Contents
Introduction ....................................................................................................................................... 4 PART 1: Mental Health in Cambodia Determinants of Poor Mental Health in Cambodia ................................................................... 7 The Legacy of the Khmer Rouge .................................................................................................. 7 Other Determinants .................................................................................................................... 8 Prevalence of Mental Disorders in Cambodia & the Socio-Political Climate ........................... 10 General Prevalence .................................................................................................................... 10 Prolonged Grief Disorder and Trans-generational Transmission ................................................ 11 The Socio-Political Climate ....................................................................................................... 12 The Cambodian Mental Health Sector ..................................................................................... 14 The Public Mental Health Care System ..................................................................................... 14 The Traditional Sector .............................................................................................................. 15 Traditional Beliefs and Cultural Syndromes ............................................................................... 16 PART 2: The Role of Alternative Therapies The Importance of Utilizing Alternative Treatment Approaches ............................................ 20 Desirable Characteristics of Potential Therapeutic Approaches ............................................... 21 Practical Limitations ................................................................................................................. 21 Drugs Vs Therapy ..................................................................................................................... 22 Tradition and Spirituality .......................................................................................................... 22 Buddhist Psychotherapy ............................................................................................................. 24 Buddhism in Cambodia ............................................................................................................. 28 Testimonial Therapy & Victim-Former KR Dialogue Project ................................................ 31 Testimonial Therapy ................................................................................................................. 31
Victim-Former KR Dialogue Project ............................................................................................. 34 Self-Help Groups and Art Therapy ......................................................................................... 36 Group Therapy (Self-Help Groups) ............................................................................................ 36 Art Therapy .............................................................................................................................. 38 Other Techniques: Forum Theater and EMDR ...................................................................... 41 Forum Theater .......................................................................................................................... 41 Eye Movement Desensitization and Reprocessing (EMDR) ....................................................... 43 Conclusion ....................................................................................................................................... 45 Endnotes .......................................................................................................................................... 46
Introduction
Mental health is a critical public health issue with deep human rights implications. Despite its significant impact on societies throughout the world, mental health problems are often ignored, misdiagnosed and misunderstood. 123456 At the individual level, as might be expected, poor mental health severely hinders the physical and social well being of the afflicted persons, as well as their day-to-day functionality. The effects of these complications reverberate through multiple levels of society, with profound effects on the well being of family and caregivers, the overall health of the population as well as the economic productivity of the community as a whole. Furthermore, mental health problems have been demonstrated to be significantly correlated to other disruptive pathological behaviors, such as domestic violence and substance abuse.7 Nevertheless, the cultural beliefs and stigma historically associated with mental issues have often redirected the attention of the international community towards communicable and more immediately life-threatening diseases (such as HIV/AIDS and malaria), marginalizing the relevance of mental health as a public health issue and its major role in the overall disease burden. The impact of mental health problems is particularly troublesome in the context of developing countries, where the treatment gap (the percentage of individuals who need mental health care but do not receive treatment) can be
450 million people currently suffer from mental health disorders worldwide.1
Mental health has been shown to increase risk of heart disease, diabetes, HIV/AIDS and tuberculosis.2 Mental problems are responsible for a percentage of the global disease burden, higher than the one of cancer or heart disease.3 By 2030, depression will be the single largest contributor to the burden of disease worldwide.4
$7 of lost productivity are avoided for every dollar invested in mental health.5 Mental health problems cost developed nations between 3% and 4% of their GNP (gross national product).6
as high as 90% of the population.8 Despite the widespread mental health needs of populations living in low-income countries, the mental health services provided in this settings are largely unavailable, inaccessible, and of too poor quality to be effectively utilized.9 Lack of education about mental health and superstitious traditional beliefs, further decreases the utilization of the services.10 People with mental disabilities are therefore largely abandoned to their communities where they frequently face stigma, abuse and marginalization.11
The following report will begin by analyzing the current situation of mental health in Cambodia. In line with the aforementioned problems related to mental health services in impoverished countries, Cambodia suffers from a significant gap between the overwhelming needs of the population and the alarming dearth of treatment. Part one will begin by analyzing the determinants and prevalence of mental health disorder in Cambodia. It will then explore the problems faced in the treatment of such afflictions, namely lack monetary resources, lack of infrastructures and of trained professionals, as well as over reli-
ance on medications. The role of cultural and spiritual beliefs, as well as a general lack of education in relation to mental health, will also be considered in regard to stigmatization and potential treatments. Finally, part two will examine the role of alternative methods of treatment in Cambodia, as the most effective methods of bypassing such problematics. Some of these methodologies will include brief psycho-legal approaches, community education through drama, self-expression and catharsis through art therapy and wilderness immersion as well as the application of principles of Buddhist thought within the psychotherapeutic method.
Figure 2: Ta Prohm temple
PART 1
Mental Health in Cambodia
1.1
Determinants of Poor Mental Health in Cambodia

The etiology of psychological disorders is widely believed to involve a complex interplay of genetic and environmental agents. Cambodia is home to an alarming number of environmental risk factors for poor mental health, namely the countrys traumatic history and current socio-political condition, general poverty, high rates of violence against women and the dreadful human rights situation. The following section will analyze the different determinants more in depth. Democratic Kampuchea, the twisted name of the KR state, had to face ubiquitous physical displacement and the systematic separation of family members, sexual violence and forced marriages, torture and killing of friends and relatives, and the constant threat of death, which needless to say, only increased their traumatic burden.14 Additionally, to fulfill their plan for a classless agrarian utopia, the KR leaders imposed radical transformations onto the fabric of Cambodia social life, actively challenging the way people made sense of their own existence, their relationships to others, and their spiritual dimension.15 In order to restart the civilization, to return to year zero as Pol Pot liked to say, the KR made its mission to intentionally obliterate any social, cultural and religious icon with particular symbolic relevance. Similarly to the totalitarian regimes in Nazi Germany and Soviet Union, the KR plan was to subsequently rebuild the population according to the party doctrine, by replacing new values, organizations and ethical norms for the ones taken away.16 Finally, after the fall of the regime in 1979, additional decades of armed conflict and civil war between various factions seeking control of the nation, resulted in further traumatizing experiences. Many studies have shown the strong correlation between exposure to violence and a high incidence (and comorbidity) of mental disorders in post-conflict settings.17 Among the Cambodian population, certain kinds of mental disorders have been demonstrated to be directly correlated to the trauma endured during the Pol Pot period,18 while others show more indirect characteristics which could
Traumatic History Poor Mental Health Violence Against Women
Poverty
Human Rights Violations
The Legacy of the Khmer Rouge

Modern Cambodian history has seen some of the worst horrors of the 20th century. After becoming entangled in the international conflict in Indochina, after being more heavily bombed in 1970 than Japan had been during the entirety of WWII, and after undergoing decades of civil war, Cambodia experienced an auto-genocide of massive proportions at the hands of the Khmer Rouge regime.12 From 1975 to 1979, during what the survivors refer to as the regime of 3 years, 8 months and 20 days, it is estimated that at least 25% of Cambodian civilian population at that time (1.7 million people) perished as the result of mass killings, starvation, forced labor and disease.13 Those who managed to survive the regime of
be traced back to the forced labor, torture and exposure to murder of the KR time. Many Cambodians seem to be afflicted by the cultural syndrome of Baskbat (broken courage), which in addition to physical and psychological symptoms overlapping with Post Traumatic Stress Disorders, presents an associated sense of hopelessness, helplessness, lack of confidence, mistrust and fear. Dr. Sotheara Chimm describes how symptoms of the broken courage cluster, such as planting the kapok tree (pretending to be mute) or pretending to be ignorant, are central responses presented by many Cambodians who lived under the Khmer Rouge. Owing to the fear of being persecuted by the KR guards, many people hid their identities across four years and longer to survive. Similarly, the regimes systematical erosion of trust between individuals appears to justify the prevalence of the mistrust and fear symptoms clusters.19 Moreover, studies on Cambodian refugees in the United States have shown a high correlation between the content of anxious catastrophic cognitions and hallucinations, with images, thoughts and memories directly associated with the KR time. For instance, a strikingly high number of Cambodians suffer from Sore Neck Panic (30% of a sample of psychiatric outpatients). As the researcher describes it, Khmer worry that musculo-skeletal tension in that area indicates imminent neck-vessel bursting. This catastrophic cognition exacerbates anxiety levels, which in turn worsen the neck discomfort. The traditional concepts of bodily wind and blood thickening appear in this instance to be intertwined with the evocation of trauma memories of Pol Pot events (e.g. malarial attacks, witnessing killing by clubbing the back of the neck, and slave labor, during which neck strain commonly occurred).20 60% of the men and women who suffered from PSTD comorbidity, have been shown to also experience frequent episodes of sleep paraly-
sis (49% of patients had at least one episode of SP in the previous twelve months). During this phenomenon, experienced before or after sleeping, and which could last up to 30 minutes, the victim is often able to open their eyes and be aware of their surrounding, while however experiencing a complete inability to move. Furthermore during this stage, common symptoms are hypnagogic hallucinations and a sense of chest pressure (hence the traditional name for this event of ghost pushes you down). Researchers have found that both of these circumstances, while often mediated by other supernatural beliefs, are often interpreted by survivors as related to the regime: hallucinations often present themselves as ghosts of KR victims, while chest tightness seems to resurfaces memories of common torture methods (near drowning experiences or having a plastic bag placed over their head, were both common KR torture or execution techniques). Again, the Khmer sensitivity to these particular symptoms increases their anxious response, which worsens the panic feeling experienced during and after the sleep paralysis episodes.21
Other Determinants
Post-conflict societies are known to display consistently high rates of mental disorders.22 However, trauma is not the only factor influencing the mental health levels of a population. A recent report by the Leitner Center for International Law and Justice, highlights the importance of considering additional, often overlooked, determinants of poor mental health in Cambodia: While the trauma of the Khmer Rouge understandably represents the most notorious facet of the Cambodian mental health landscape, many interviewees cautioned against ascribing too great a share of Cambodias current mental health problems to the now-defunct regime.23 Pointing out that the current life
conditions of mentally disabled Cambodians are not conductive to psychological recovery, the study emphasizes the significance of other more contemporary social factors, such as widespread poverty, high rates of violence against women, and the countrys precarious human rights situation. The World Health Organization has documented the significant relationship between indicators of poverty and mental disability in developing countries.24 A number of daily stressors appear to be linked with poverty. Low income, lack of food/poor nutrition,25 high rates of substance abuse and lack of access to education, can participate in the stemming or worsening of mental conditions, in the individual as well as in the family/caregivers. People with mental disabilities are less likely to be able to maintain a job and work productively, which by generating less income, lowers the chances of potential well-being and affordability of treatment.26 More broadly, mental health can have a significant impact on the economic development as a whole, by stunning the countrys growth with early mortality, lost productivity, and costs of care on communities.2728
Over forty percent of the Cambodian population lives on less than US$1.25 a day.28
mestic violence and that 74% of women knew someone who had been victim of domestic abuse.30 The Chbab Srey, the traditional moral code of behavior for women, teaches young girls that they are expected to remain silent even when they are abused, and law enforcement officials do not seem to be interested in putting and end to the abuse or to hold perpetrators accountable.3132
The Chbab Srey, is used to educate young Cambodian women about what is morally expected of them during their married life. The code has been heavily criticized by human rights organizations in that it is believed to promote gender inequality and abuse.32
Figure 2: Bas relief of a dancing Apsarah on the walls of Angkor Wat
Worldwide, the detrimental effects of G ender-Based Violence on mental health are well documented.29 The Leitner report identified domestic violence as one of the principal factors driving women to seek out mental health services in Cambodia. Traditional gender roles dictates that women should stay inside the house, thus earning little or nothing, taking care of the children and finances while devoting their obedience to their often abusive husbands. In a field study in 2003, researchers found one in four Cambodian women experienced severe do-
Cambodias poor human rights record has been extensively documented by local and international NGO as well as in submissions before the UNs treaty-monitoring bodies. Major areas of concern which have been shown to relate to mental health problems, include lack of freedom of expression, government corruption, violations of land rights and forced evictions, the use of extrajudicial detention facilities and the ubiquitous abuse of physical force at the hand of the police.33
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1.2
Prevalence of Mental Disorders in Cambodia & the Socio-Political Climate General Prevalence
Percentage of the Population Suering from Mental Disorders
70 60 50 40 30 20 10 0
The standardized questionnaires, used all over the world to support the clinician's diagnosis of mental health problems, need to be both culturally appropriate and only used as a complementary tool.
Anxiety Depression PTSD
Worldwide Prevalence
Studies on the Ground
Studies on Cambodian Refugees in the US
The Cambodian mental health system, however, relies too heavily on such Western-derived models, which might help to explain the lower rates of diagnosed mental disorders in Cambodia compared to the Cambodian refugee population in the US.37
As would be anticipated from the concomitance of singular levels of trauma and high prevalence of secondary environmental risk factors, it may come as no surprise that many Cambodians suffer from a high rate of diverse mental disorders. A large community survey of Cambodian refugees in Long Beach, CA, found that more than a half of the populations currently suffers from PSTD and major depression (62% and 51% respectively), with a comorbidity rate of 42%.34 Among Cambodian refugees treated at a psychiatric clinic in the Boston area, one study found that 56% had PTSD,35 and another, a 60% rate of panic disorder.36 While in-country studies have been scarce and afflicted by the poor cross-cultural nature of PTSD diagnostic tools,37 a recent populationbased study has found probable PTSD rates ranging from 14.2% among Khmer Rouge survivors (over 18 years old).38 By comparison, the worldwide prevalence of PTSD is estimated at less than 0. 4%.39 Anxiety and depression also

score well above average. In the Cambodian Mental Health Survey 2012 by the Royal University of Phnom Penh,40 findings show an average of 27.4% for probable anxiety (compared to 15% worldwide)41 and 16.7% for probable depressive disorders (compared to 2% - 7% in community samples worldwide).42 Comorbidity of multiple mental disorders is also extremely common. A 2004 survey of 1,320 Cambodian living in the Kampong Cham province has reported a prevalence of 29.2% for respondents suffering from both depression and anxiety and a 7.3% rate of triple co-morbidity (PSTD, depression and anxiety). 43 With regards to social functioning 22.3% were classified as having significantly impaired physical activities due to health problems. According to the RUPP survey, suicide rates are also alarmingly high, with an average of 42.35 per 100,000 people in 2011,44 compared to a worldwide average of around 16.45

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Prolonged Grief Disorder and Transgenerational Transmission

The high incidence of KR-related mental disorders is particularly surprising considering the average age of the population and the 30 years that have passed since the traumatic events. Although more than a half of Cambodians are younger than 30 years old,46 a recent survey shows that 7.9 % of those aged between 18 and 35 (too young to have experienced the Khmer Rouge time directly) have probable PTSD.47 Indeed mental health professionals believe that trauma in Cambodia is transmitted from one generation to the next, on account of the Khmer Rouge periods impact on the parenting styles, similarly to the effects on children of WWII Holocaust survivors or of domestically abusive parents.48 Therefore not only millions of Cambodians suffer from the damaging effects of post-traumatic symptoms, which severely affect their well-being and their ability to function normally in society, but their trauma can trickle down through the generations. Furthermore, more than thirty years following the fall of the Khmer Rouge, many Cambodians still suffer from psychological symptoms and diseases directly resulting from the trauma they experienced decades earlier. In an article published in the Journal of Affective Disorders, researchers highlighted how Cambodians grieving for loved ones killed during the Khmer Rouge era are at risk of developing what is called Prolonged Grief Disorder, namely a pathological inability to recover, accept and ultimately let go.49 PTSD has also been demonstrated to be easily re-triggered by new events. It is believed that new stresses, especially those which may remind of the past trauma, can reactivate the
entire syndrome even after a period of quiescence.50 This persistence of KR-related mental disorders might be understood by reflecting further on the Cambodian socio-political landscape.
Figure 3: Child in a village of the Kampong Cham province
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The Socio-Political Climate

Unlike survivors of other genocides, such as Holocaust survivors, Khmers never experienced a sense of justice and closure as they are forced to be governed and live in close proximity to former KR cadres. The governing CPP (Cambodia Peoples Party) and its leader, the Prime Minister Hun Sen, share similar pasts as mid-level Khmer Rouge cadres with some measure of authority.51 In this light it is easy to understand the governments adamant opposition to anything that might get too close to expose their complicated ties to the former regime. Even the ECCC (Extraordinary Chambers in the Courts of Cambodia), established to try a handful of leading members of the KR, has been often reported to suffer from corruption and political obstruction.52 This climate of political oppression and lack of freedom of expression is not new to the CPP. Hun Sens autocratic government has been known to employ extreme violence, bribery and extortion to silence the media, community leaders, union representatives and more or less anyone else who attempted to discuss topics not appreciated by the government.53
Figure 5: Traditional village abode
Additionally, following the Vietnamese invasion and the fall of the KR regime, former KR cadres returned to their formerly quiet village lives. These unpunished victimizers resumed their daily lives, side by side with the family of people they abused and killed. In a project aimed at promoting dialogue between victims and perpetrators, the researchers point out that in these villages despite the decades that have passed, tensions still exist from a lack of communication that continues to foster anger, hatred and misunderstanding.54 In conclusion, because of the oppressive sociopolitical climate, augmented by the local Buddhist concept of silence and forgetting as the proper response to trauma55 and by the stigma associated with mental health problems,56 Khmer Rouge survivors are often deprived of the therapeutic effects of disclosure.57 By excluding this emotional outlet, the survivors build up unhealthy desires for revenge, which have been shown to be detrimental for a persons psychological well-being when such feelings remain prominent over time.58
Figure 4 : Large cell at Tuol Sleng prison (S-21)
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CAMBODIAN LEADERS WITH KHMER ROUGE TIES
Hun Sen - Prime Minister

In 1975, Hun Sen headed a battalion that oversaw a brutal crackdown against the Cham, a Muslim minority group in Cambodia that opposed the Khmer Rouge.
Keat Chhon - Finance Minister and Deputy Prime Minister

Keat Chhon, worked in the Khmer Rouges foreign ministryunder Ieng Saryand occasionally acted as an interpreter for Pol Pot.
Heng Samrin - Chairman of the National Assembly

Heng Samrin was the commander of the Fourth Division of the so-called Eastern Zone, which is suspected of committing war crimes during incursions into Vietnam in 1977.
Chea Sim - President of the Senate

Chea Sim was the party secretary of Sector 20, also in the Eastern Zone, where vast purges are known to have occurred.
Hor Nam Hong - Foreign Minister

He was sent to Boeung Trabek, a reeducation camp in Phnom Penh but he was spared reportedly thanks to the intervention of Ieng Saryand is said to have then helped run the camp and collaborated in the killing of many prisoners. (Wikileaks)
The information about the CPP members' pasts as KR cadres with some measure of authority, come from the following article: Giry, S (2012, July 23). Necessary Scapegoats? The Making of the Khmer Rouge Tribunal. 51 The above images come from Google and may be subject to copyright. All rights belong to their respective owners.
The information about the CPP members' pasts as KR cadres with some measure of authority, come from the following article: Giry, S (2012, July 23). Necessary Scapegoats? The Making of the Khmer Rouge Tribunal. The images come from Google. All rights belong to their respective owners.
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1.3
The Cambodian Mental Health Sector The Public Mental Health Care System
Although the psychological needs of the population appear evident, the country suffers from a critical dearth of treatment.59 Despite being legally bound to take immediate steps towards the realization of the right to physical and mental health under its pledge to the International Covenant on Economics, Social and Cultural Rights (ICESCR),60 the Cambodian government, as well as the international community, has continued to marginalize mental health regardless of its significance. In October 2012, the U.S. Ambassador in Cambodia, William E. Todd, published an online article in response to the question How
does the U.S. government support or invest in Cambodias mental healthcare?. The ambassador The treatment gap is especially problematic in developing countries where there is the highest need for mental health care and the lowest access to it. The poorer the country, the smaller the percentage of their overall health budget invested in mental health.59
mentions a vague and mysterious plan to be launched in the future, which would supposedly involve teams of trained specialists to work with Cambodians to address the mental health consequences of conflict. The ambassador then continues by redirecting the readers attention towards the great things the U.S. Government has done in the fight against diseases such as HIV, malaria and tuberculosis.61 Furthermore, the international donors who contribute to the countrys health budget have shown little to no interest in funding the mental health sector.62 At the domestic level, the Leitner report estimates that only 0.02% (with a minimum acceptable level of 1%) of the entire Cambodian health budget goes to mental health. It is clear therefore that even taking into account its limited resources, Cambodia is falling short of its right to health obligations.63
This lack of physical, human and monetary resources drastically limits Cambodians ability to receive proper mental health care. More than 80% of Cambodians live in rural areas64 and the rural demographic is the one that faces the majority of risk factors for poor mental health, discussed in the determinants section of this report. With the few mental health facilities concentrated in major urban centers, patients must often travel long distances to receive treatment, which typically involves additional transportation costs as well as the problems related to an inconsistent pharmacological treatment. The only two inpatient units, both of which are located in Phnom Penh and which amount to fourteen psychiatric beds for the entire country, offer patients a maximum stay of two weeks, with the additional need of being accompanied by friends or family who are responsible for looking after the patient.65 Although mental health services are also available on an outpatient basis in a limited number of urban health facilities, patients who would need continuous treatment rarely return.66 These problems are compounded by a lack of trained mental health care professionals. As of 2010, Cambodia had approximately thirty-five trained psychiatrists and forty-five trained psychiatric nurses for a population of close to
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fifteen million.67 Only a small percentage of primary care physicians have taken basic courses in mental health and are able to provide some degree of treatment.68 The discipline of mental health is quite new to Cambodia. After the KR obliterated the timid origins of a mental health sector, Cambodia had to wait until the 1990s for international and nongovernmental organizations to reintroduce formal mental healthcare practices in the country.69 Additionally, the low salary70 and the cultural stigma associated with being considered a mad doctor71 do not help with promoting the profession. As a result of their limited numbers, Cambodias mental health workers are often overwhelmed by patients. At the Khmer-Soviet Friendship Hospital it would not be unusual for a doctor to have to care for 30 to 40 patients per day and the frequent burnouts among mental health professionals negatively impacts the quality of their service.72 Deprived of resources and trained personnel, Cambodias mental health system favors a purely bio-medical approach as the main method of addressing the diverse needs of patients. The overwhelming reliance on medication is especially problematic where medications shortages are frequent, which can be seriously detrimental to the mental health of patients who may require continuous treatment.73 When they are available, they are often older generations of pharmaceuticals, which typically have greater side effects and lower efficacy, if they are not counterfeit altogether.74 There are also a number of NGOs from whom Cambodians may seek help, which are working directly or in partnership with the mental health sector facilities. Unfortunately, however, there is little coordination among them
which results in a disorganized and strictly project-oriented patchwork of services.75 In addition to the poor quality of the treatment and the inaccessibility of the infrastructures, the stigma associated with mental illness constitute a significant barrier to care.76 In an attempt to distance themselves from the labels that mark them for social exclusion,77 patients often go without any form of treatment, opting instead, when cases are more severe, to consult the traditional sector and alternative healers.78
The Traditional Sector

Stigma and traditional beliefs play an important role in the self-treatment of the individuals as well as the community care of the mentally ill. Especially in the rural areas, Cambodians often interpret mental disorders through the prism of their spiritual beliefs. As a result, many turn to Buddhist monks and traditional healers (Kru Khmer) who offer an array of alternative remedies.79 Coining, for instance, consists in dermabrasion technique in which the edge of a coin is rubbed from the center of the patients body toward his/her limbs. The purpose of the procedure is to draw out of the body an excess of wind, believed to be one of the main contributors to the sufferers symptoms (See Traditional Beliefs and Cultural Syndromes).80 Another popular method of decreasing wind from the body is cupping, which employs the suction of heated glass jars on the skin.81 Furthermore, the traditional key actors might prescribe herbal remedies or meditation as well as performing purifying chants and prayers. Although mental health professionals agree that such traditional and religious remedies can
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be beneficially and effectively integrated within the Western-based methodology of treatment,82 sometimes alternative practices not only end up deferring a needed clinical care, but might also entail physical pain or emotional distress.83 As a result, they may end up exacerbating the disorder they are called to address. Most often, especially when the cases are more severe, the sole use of traditional treatment options might be inadequate. People with mental disabilities are therefore abandoned to their overwhelmed families and communities where they are marginalized and often tethered and caged,84 if not referred to the police to be brought to extrajudicial detention centers.85 According to the traditional beliefs, mental health problems and developmental disabilities are considered to be contagious,86 hereditary87 or the result of black magic.88 So, if traditional rituals might be able to ward off a sorcerers curse, caging seems the most natural option to prevent contagion and social embarrassment.89 In order to understand the significance of cultural beliefs within the Cambodia context, the next section will inspect further some of such deeply rooted convictions.
Traditional Beliefs and Cultural Syndromes

According to traditional beliefs, individuals who suffer from severe psychotic disorders (such as schizophrenia) or developmental disabilities are believed to be possessed by a demon or cursed by a sorcerer. The word Chhcuot is used to describe madness derived from the possession of ghosts and evil spirits.90 People also believe that if a pregnant woman fails to stay awake during a solar or lunar eclipse, the angered Rea, the theological demon responsible for the event, would curse the babies with mental problems and intellectual disabilities.91 Furthermore, the concept of Trov am Peou, describes the process in which an individual might become physically or mentally ill as a result of a curse placed by someone he/she had a conflict with.92 Lastly, the popular Cambodian interpretation of the concept of Karma, the Buddhist law of cause-andeffect, results in the widely accepted belief that people who suffer from mental disability must have done something wrong in their past lives which justifies their current living conditions.93 On the other hand, when dealing with neurotic disorders, such as depression or anxiety, Cambodians often interpret such conditions as a physiological imbalance of inner wind. Cultural syndromes such as the one of Khyal Goeu (Wind Overload) are schema of particular complexity and they are shared by urban and rural Cambodians alike, including those with high levels of education.94 To better understand the salience of cultural syndrome and how they generate catastrophic cognitions, let us examine the ethnophysiology of a typical khyal attack, studied in depth by Harvard psychiatrist Dave Hinton.95
The images below come from Google and may be subject to copyright. All rights belong to their respective owners.
Coining
Cupping
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High levels of trauma and stress have been shown to result in changes in the nervous system and psychological state that produces a constant state of anxiety and a tendency for rapidly induced arousability (i.e. being easily startled). Arousability can be triggered by a variety of emotions, such as anxiety, stress, anger, and even pained, nostalgic recall of the dead. A high state of autonomic-arousal can lead to a variety of psychosomatic symptoms such as palpitations, shortness of breath, dizziness (from the effects on the balance system), neck soreness (from muscle tension), and cold extremities (from vasoconstriction). All of the aforementioned symptoms, completely normal and innocuous if perceived for example by a westerner, are thought by Cambodians to possibly indicate the onset of a khyal attack, or wind overload, and these concerns are particularly great when the person is in a self-perceived vulnerable state. The ethnophysiology of cultural syndromes, leads Cambodians to be hyper vigilant to these somatic symptoms and as a result, when even a slight symptom like orthostatic dizziness is perceived, the symptoms appear increased though a process of somatic amplification. The anxiety experienced upon noticing one of the feared symptoms, may introduce other expected somatic events by the physiology of fear. The result is a vicious cycle of worsening of somatic symptoms and worsening of fear and anxiety. Additionally, certain symptoms that are linked to the biology of trauma and stress might also be amplified by metaphoric resonance and trauma association (e.g. dizziness may remind of slave labor, head blows and malaria events).
DIZZINESS, TINNITUS, BLURRY VISION EXP: Khyal entering the cranium, pressurized khyal exiting through ears and eyes FEAR: Syncope/death, permanent loss of hearing and vision
NECK SORENESS EXP: Khyal distending the neck vessels FEAR: Vessel rupture, death.
PALPITATIONS, SHORTNESS OF BREATH EXP: Khyal pushing up against the chest cavity which results in less space for heart and lungs. FEAR: Asphyxia, heart arrest.
STOMACH DISCOMFORT EXP: Wind preparing to flow upwards FEAR: Consequences of rising wind (see above)
COLD OR SORE EXTREMITIES EXP: Vessel blockage / Reduced khyal flow FEAR: Permanent loss of limb function
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In a healthy state, Cambodians believe in a downward flow of khyal, a wind-like substance which circulates in the body. Khyal should normally exit the body through the extremities, the skin pores and the gastrointestinal tract. However, when the body is weakened (normally by worrying too much, poor appetite or poor sleep or during a period of low luck), blood and khyal surge upward toward the head, causing various bodily catastrophes on the way. When Khmer experience cold extremities or sore limbs, they interpret it as vessel blockage and reduced khyal/blood flow, which may ultimately result in the loss of limb function. If they experience palpitations or shortness of breath, it means that the khyal is pushing upward from the stomach compressing the chest cavity; the heart and the lungs would therefore function poorly due to the compression, exacerbating the inadequate circulation and the blood thickening. When the khyal reaches the head, it can cause dizziness, from the wind entering the cranium, tinnitus and blurry vision from pressurized wind exiting the body from the ears and eyes respectively.
In sum, the importance and complexity of traditional concepts and beliefs must not be underestimated. The need to understand such cultural symptoms and syndromes will become apparent when dealing with the proper injection of traditional concepts within the therapeutic method. (See Part 2).96
The importance of the concept of wind in the Khmer context constitutes an example of the deeply-rooted beliefs deriving from the pre-existing Animistic culture.96
Figure 6: Small temples like this one are often found outside homes and businesses. They are dedicated to the spirits who protect the house and the family. These shrines are a clear example of the legacy of the ancient animistic religion.
Figure 7. : From Left to Right-- A. Monk performing purification ritual with jasmine buds and blessed water. B. Woman chanting during a religious ritual of blessing. C. A monk ties the symbolically protective red string around a participants right hand.
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PART 2
The Role of Alternative Therapies
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2.1
The Importance of Utilizing Alternative Treatment Approaches

There are many things that can and should be done to improve mental health in Cambodia. First and foremost, the financial resources allocated to the mental health sector must be increased. There is the need to raise the awareness among the international donors regarding the significance and priority of mental health care in Cambodia. Furthermore, the International community should put forth more effort in ensuring the enforcement of the oftenviolated international policies and provisions in the country. At a domestic level, the percentage of the government allocations devoted to mental health should be at least raised to the minimum amount in line with the WHOs recommendations.97 Even assuming that new funds would be allocated for the sector, it is also extremely important for both the governmental and nongovernmental agents working in-country to operate with more coordination and efficiency, thus being able to achieve broader and more sustainable results in the fight to promote mental health and the rights of people with mental disabilities. In this sense, Cambodia suffers from a lack of leadership and vision, which has been paralyzing progress in the sector with internal disputes.98 NGOs in particular should improve the existing but lacking referral network and should set forth more effort and attention to the selfsustainability of their grant proposals and projects which unfortunately often end up terminating once the project-specific funds are depleted.99 The aforementioned provisions, however, are likely to take time; meanwhile, millions of Cambodians suffer incapacitating mental disorders. It is therefore of the utmost importance to determine immediate treatment methodologies that will need to circumvent the many problems faced by the mental health sector in Cambodia. Such problems, as discussed in Part 1, include the non-sustainability and detrimental effects of a purely biomedical approach, the dearth of trained specialists, the lack of infrastructure and their urban locations, which hinder the possibility for long-term treatment especially for Cambodians living in the rural areas. Additionally, these alternative methods of treatment will need to consider the fabric of Cambodias culture and society, namely the distressful socio-political situation and the countrys traumatic history, cultural and spiritual beliefs, and the populations lack of understanding of mental health issues, cause of stigma, abuse and neglect. Part 2 will build upon the findings of Part 1 in determining the consequent desirable characteristics of potential therapeutic approaches. We will examine how easily implemented alternative methods of treatment might avoid the specific problems faced by the mental health system in Cambodia (Part 1) and how such methodologies might be an effective tool for the improvement of the well being of Cambodians, in the short and in the long-term alike.
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2.2
Desirable Characteristics of Potential Therapeutic Approaches
Desirable Characteristics of Potential Therapeutic Approaches
Shortage of Trained Professional
Inaccessibility of Treatment Facilities and Predominantly Rural Demographic
Shortages of ,medications and Over-reliance on Pharmacotherapy
Brief (in number and in length of sessions)
Brief (in number and in length of sessions)
Priority to psychosocial and psychotherapeutic approaches
Easily mastered by nontherapists
Stimulating and give a sense of efficacy (in order to encourage continued participation)
Take into account the local traditional beliefs and spirituality Effectively employ the therapeutic benefits of Buddhist concepts Target the specific mental health needs of the Cambodian population
High therapists to clients ratio
Non pharmacological (which require constant monitoring and responsible administration of medications).
Practical Limitations
Lack of Resources and Trained Specialists First of all, any potential therapeutic techniques must take into consideration the current shortage of trained professionals.100 This might be accomplished by implementing therapies that involve a relatively short training period as well as ones that operate with a high therapists to clients ratio, such as group therapies. By utilizing a community-based psychosocial model, compared to psychotherapeutic approaches, group-based alternative treatments can address common issues faced in developing country, such as limited resources and shortage of trained specialists, whom are often only able to see the survivors a few times on an individual basis. Inaccessibility of Treatment Facilities and Predominantly Rural Demographic In addition, we need to take into account the elevated number of patients belonging to the rural demographic. As currently communitybased mental health care and support is extremely limited, if actually non-existent, patients typi-
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cally cannot afford long-term treatment.101 Additionally, as demonstrated by the high rates of drop-outs, many Cambodians have poor understanding of the importance of therapy and of the gradual nature of its effectiveness.102 Stimulating approaches that would quickly give a perceived sense of efficacy and enjoyment would encourage continued participation.
Drugs Vs Therapy
Furthermore, the public mental health services should more fully acknowledge the psychosocial nature of many determinants of mental health in Cambodia, moving away from the predominant biomedical model, which relies overwhelmingly on the use of pharmaceuticals. Instead, mental health services should redirect their attention towards a more holistic model of mental health care and support. The purpose of a biomedical approach is to diminish and control disturbing symptoms which hinder the individuals ability to function normally in society. Although patients afflicted by more severe psychotic illnesses (such as schizophrenia) may require medications to function in society, in many cases psychotropic drugs might cause more harm than good. The fundamental presence of continuous treatment and monitoring associated with the prescription of these categories of drugs is especially problematic in countries like Cambodia. Sporadic availability of treatment, the poor quality of the medications and the irresponsible use deriving from poor understanding of mental health and education about psychotropic drugs, result in the patients suffering more from the drugs side effects than enjoying their benefits.103 While studies have demonstrated that the most effective method of treating mental health
disease worldwide consist of a combination of drugs and psychotherapyor complementary/alternative medicine (CAM)104a purely biomedical approach, even when properly administered, temporarily obfuscate certain side effects of the disease, leaving the underlying causes largely unresolved. Many of the mental health problems in Cambodia are the result of psychosocial issues or traumatic events that are not addressed by pharmaceutical treatments.105 Cambodian refugees treated for kyhal goeu panic attacks in a Southeast Asia clinic near Boston with a combination of anxiolytics and antidepressants (Clonazepam and Selective Serotonin Reuptake Inhibitors) have shown only a temporary remission of symptoms. New stressors, such as problems with children or with the family finances, resulted in the reactivation of the syndrome.106 Furthermore, studies have even questioned whether any western biomedical approach would be appropriate in South Asia. Trauma-induced distress in Cambodia needs indeed to be understood from a non-western perspective.107 In this context, it is therefore important to comprehend the collective dimension of suffering, the place of traditional healing techniques within the therapeutic process and the efficacy of a thoughtful integration of Buddhist spirituality.
Tradition and Spirituality

As suffering is believed to be collective in cultures with a community-oriented self, in contrast to cultures oriented toward an independent self, a collective approach to promote healing is believed to be more effective in those kinds of cultures, such as the ones in South Asia.108 In such countries, although physical and psychological distress is experienced individually, it often arises from and is worked out or resolved, in a social
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context. The role of the healer therefore is to aid in reestablishing equilibrium between the survivor and his/her environment.109 Furthermore spirituality and tradition, which have been neglected in the western understanding of trauma, represent fundamental coping strategies that can enable and channel long-term healing and positive therapeutic outcomes.110 Cultural features are therefore not only a major factor in the correct clinic interpretation of the illness111 but a rationalized used of spiritual rituals may be the most efficient catalyzing element for recovery. Researchers have found for instance, that more Cambodians had access to spirit protective rituals, the more their anxiety was contained; there was less panic over the potential harm by roaming ancestors.112 Moreover, the importance of cultural ceremonies and holistic approaches to support the healing process of survivors of organized violence and human rights violations has been often reiterated. Researchers believe encouragement of indigenous coping strategies, support of cultural rituals and ceremonies, and community interventions (including support groups and the use of expressive methods) to be the necessary and most effective approaches when assisting survivors.113
They also emphasize the physical, mental, social and spiritual improvements associated with mindfulness meditation and relaxation techniques. These practices, not only reduce stress, but also tap into past childhood, community and religious roots and thus release a rich source of associations that can be helpful in the healing process.114 This is particularly significant given that one of the main challenges faced in the treatment of traumatized individual consists in the prevention of re-traumatization. Researchers note that mindfulness, yoga, and spiritual practices serve to engage observational capacities while regulating physiological arousal by means of activities such as breath work, movement, and reverential practices.115 According to them, these practices allow the survivor to more easily face disturbing images and memories while facilitating an interoceptive process and a sense of being a part of a larger context.116
Interoception is the self-observation of internal sensations, images, and affects in the here and now, and appears to be an important means to promote healing after psychological trauma.166
As a testament to their efficacy, western medicine has begun to incorporate such practices within the therapeutic process. Acceptance and Commitment Therapy (ACT),117 Dialectical Behavior Therapy (DBT),118 Mindfulnessbased stress reduction (MBSR)119 and mindfulness-based cognitive therapy (MBCT),120 all tap into Eastern traditions and spiritual practices, such as mindfulness, meditation, Buddhism and yoga. But why are these practices so effective in psychotherapy?
Figure 8: Community ritual at the Pagoda
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Buddhist Psychotherapy
Buddhist concepts and ideas, profoundly different from the ones of Western religions, have been found to be deeply effective in improving psychological well-being as they are founded on the belief that the most important aspect of human life is mental cultivation.121 Although the popular practice of Buddhism in Cambodia reveals religious dogmas and purely ritual practices,122 the original teachings of Siddhartha Gautama should not be confused with Buddhisms current adaptation and practice in different cultures and societies. The Dharma, the teachings of the Buddha, should not be considered a belief, an ideology or a philosophy. Rather, as Kabat-Zin describes it, dharma is a coherent phenomenological description of the nature of mind, emotion, and suffering and its potential release, based on highly refined practices aimed at systematically training and cultivating various aspects of mind and heart via the faculty of mindful attention.123 In that sense, dharma is at its core universal and not exclusively Buddhist. An interesting aspect of Buddhism is that it stresses the importance of personal understanding and the power of personal transformation, which are independent from an external allpowerful God (as opposed to the Abrahamic religions for instance) empowering the individual to personal change. Ven Nyanaponika Thera points out that It is a significant fact and worth pondering upon that the Bible commences with the words: In the beginning God created the heaven and the earth....", while the Dhammapada, one of the most beautiful and popular books of Buddhist Scriptures, opens with the words "Mind precedes things, dominates them, creates them". These momentous words are the quiet and uncontending, but unshakeable reply of the Buddha to that Biblical belief. Here the roads of these two religions part: the one leads far away into an imaginary Beyond, the other leads straight home, into man's very heart. 124 According to Buddhist scholars, suffering does not derive from an unintelligible plan to which humans are merely subject, but it derives from a twisted interpretation of reality problems and solutions are both our creations. The key idea of Buddhism is that the ultimate liberation from suffering (Dhukka) can be achieved through understanding the 4 noble truths and practicing the eightfold path, which leads to Nirvana. According to one translation, the word literally means Un (nir) + binding (vana).125 Thus, freedom is defined not in terms of what it is but in terms of what it is not: freedom means being unbounded by patterns and habits that lead to dukkha, ultimately exiting the unhelpful cycles of interdependent arising.126127
The 4 Noble Truths

1. Dukkha: Life is suffering/dissatisfaction 2. Samudya: The origin of suffering are cravings, attachments and delusions 3. Nirodha: It is possible to obtain the cessation of suffering 4. Magga: The path to cessation of suffering is the 8 fold patch leading to Nirvana
Using a Medical Model 128

1. 2. 3. 4. Disorder Etiology Health Treatment
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The Eightfold Path

Wisdom: 1. complete view, or understanding 2. skilful intention, choice or aspiration
The schematization of the 8 fold path originally appeared in Huxter, M. J. Mindfulness as Therapy From a Buddhist Perspective 128
Meditation or Mental Development: 6. balanced eort or energy 7. right mindfulness 8. right concentration or focus
Lifestyle or ethics: 3. skilful speech 4. skilful action 5. appropriate livelihood or occupation
Figure 9: Reflection of sunrise clouds on the pond at Angkor Wat
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The path described by Buddha more than 2000 years ago presents striking similarities to modern cognitive behavioral techniques (not to mention the therapeutic approaches more directly inspired by Buddhism). Just like CBT, the Buddhist approach involves a dual process of passive awareness and purposeful action.128 Once the individual gains the ability to take a step back from the delusions that color his/her perception of the world, when he/she is able to see clearly the disruptive patterns of thought, new behavioral and cognitive possibilities become available that would more positively affect the well-being of the individual and of others. During a first stage, both techniques advise for pure non-judgmental awareness, insight and understanding of the present situation and personal actions and emotions. This is achieved by Buddhism through training the mind to pay attention with meditation,129 and by CBT through exercises and journaling encouraged by the therapist.130 As they both believe that behaviors, thoughts and emotions will modify and strengthen future instances of the same patterns, they both conclude that the individual should make an effort to change the disruptive patterns of behavior and cognitionafter having acknowledged them. Neuroscience also augments the efficacy of this method. The concept of neuroplasticity, used to describe the brain changes that occur in response to experience, illustrates how our common patterns of behavior and thought affect the neural connections and synapses, physically strengthening certain more utilized tracks, which in turn are more likely to be utilized the next time a similar situation presents itself. In other words, neurons that fire together, wire together, as described by the Hebbian theory of leaning.131 132
The brain may determine the content of our experience, but the mind chooses which aspect of that experience receives attention. 132 --J. M., & Begley, S. (2004)
Moreover, Buddhist practice offers an acute and necessary insight into human narcissism and delusions. In addressing the so called narcissistic dilemma the sense of falseness or emptiness that propels people either to idealize or to devaluate themselves and others traditional psychotherapy has historically been able to identify the problem but never to deliver freedom from narcissistic craving, source of neurotic misery. Buddhist psychology, on the other hand, not only describes the struggle to find the true self in terms that have impressed Western psychologists for decades, but also offers a method of analytic inquiry unavailable to the western traditionmeditative practice.133 In sum Buddhism allows for a better and more useful, in terms of personal well being as well as society benefit, understanding of life and of the laws of nature, enshrined in the surprisingly scientific concept of Karma, or law of cause-andeffect (often misinterpreted in Western contexts). Through a more holistic understanding of the interconnectedness of nature and through the destruction of the illusion of self, Buddhism enables individuals to be happier, compassionate, calm and ready to face difficulties. The core of Buddhist practice is meditation , which is seen as the way to develop wisdom the ability of the individual to pay attention. Meditation promotes an interoceptive process (the self-observation of internal sensations, images and thoughts in the present moment)
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otherwise described as mindfulness, or awareness. Historically, mindfulness has been called the heart of Buddhist meditation134 and it resides at the core of the teachings of the Buddha135 (despite the actual practices and emphases may vary from one Buddhist tradition to the other).136 An operational working definition of mindfulness is: the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.137 Mindfulness meditation is known among the scientific community for its striking psychological benefits and it has been successfully employed in clinical and non-clinical contexts,138 showing promise as an intervention for general stress reduction,139 prevention of depression and substance abuse relapse,140 reducing chronic pain and related impairment,141 enhancing immune function,142 promoting adaptive emotional regulation,143 and improving attentional control.144 Studies have also demonstrated that the positive effects of meditation extend to physical well being, at the biological and cellular level. Although different types of meditation incite different anatomical changes in the brain, all have some similar effects. The practice of mindfulness meditation for instance has been shown to increase the number of neurons and synaptic connections in the pre-frontal cortex (involved in the executive control of attention), the right insula (related to emotional self-awareness and empathy), and the right parietal and temporal lobes (related to touch and sound).145 A recent study also demonstrated that after eight weeks of meditation brain imaging showed reduction in the volume of the amygdala, related to anxiety and stress, and an increase in the number of
neurons in the hippocampus, related to learning and memory.146 Another significant recent study showed that with the practice of any meditation technique, there is increased folding of the cortex, which is thought to increase processing of information, and that this increased gyrus formation was more prominent the longer people had practiced meditation throughout their lives.147 But its not only neurons that are affected by meditation. Recent studies have focused on the influence of meditation on telomeres length, the portions of repetitive DNA at the ends of our chromosomes that are responsible for dictating cell age, death and mutation. In a study of people taking part in a three-month meditation retreat, researchers have found a remarkable increase in telomerase activity, the (usually inactive) enzyme responsible for rebuilding and lengthening our chromosomal telomeres.148 However, there are important notes to be made with regards to the application of such concepts within the Cambodian context. Sin Kong, a former monk and current teacher of Buddhist studies and Buddhist psychotherapy, points out that in Cambodia there are 4 different facets of Buddhism: popular buddhism, traditional buddhism, research/academic buddhism and practical buddhism.149 150
Buddhism, alone among the worlds religions, has taken a characteristically middle path, recognizing the need to be freed from destructive emotions while at the same time seeing that such freedom comes through non-judgmental awareness of just those emotions from which we seek freedom. 150
-- Epstein, M.
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Buddhism in Cambodia
Popular Buddhism is practiced by many Cambodians who look up to key religious actor to bestow blessings, healing and purification rituals upon them. Certain individuals, monks and traditional healer might suddenly become, by a word of mouth process, highly sought-after in light of their superior mystical powers. Their popularity however, dies just as fast as their booming success. The second approach to Buddhism is referred to as traditional Buddhism . Even though, originally, Buddhism was not a religion, it has now become one. Many Buddhist monks and pagodas today do not uphold the needed perseverance for self-cultivation. Instead, Buddhist practices have become mechanical rituals, practiced by generation after generation. Cambodians who practice traditional Buddhism believe the sole presence at a pagoda ceremony, the presentation of offering to monks and Buddha statues and the act of praying for blessings and fortune, to be the only necessary practices. The research approach, or Academ ic Buddhism , involves the analytical, and often detached, study of Buddhism. People belonging to this category include students and professionals associated with the academic field of Buddhism studies, often more interested in completing their degree than in practicing the principles of what they consider merely a philosophy. Although the philosophical aspect of Buddhism is undeniable, Buddhist principles can and should be more actively applied in the resolution of problems and in the realization of personal wellbeing, through the deep understanding of human nature. The last kind of Buddhism is practice Buddhism . This term emphasizes the core aspect of Buddhism, namely the constant and
Figure 10: Example of religious representations of the Buddha in a pagoda. Brightly colored plastic decorations, gold Buddhas and psychedelic LED lights are the norm.
never-ending practice needed to educate one self with regard to the understanding of the true face of life and the universe originally intended by Shakyamuni Buddha. Unfortunately, the authentic Buddha's education is rare nowadays, and difficult to encounter. The remaining types of Buddhism are more or less distortions of the original teachings. According to the monks interviewed for this report, this last kind of Buddhism is rarely encountered in Cambodia.151 Instead the vast majority of the population practices the first two approaches of popular and traditional Buddhism.
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As a result, despite 90% of Cambodian officially practicing Buddhism,152 the core therapeutic principles of such beliefs are often lost on them. When treating and helping patients [through the education on Buddhist principles], I have to mainly focus on Westernersexplains former monk and Buddhist psychotherapist Sin Kong as the deeply-rooted traditional ideas associated with Buddhism in the country hinder the ability of Cambodians to openly adopt new unfamiliar concepts. On the other hand, he points out that Westerners are characterized by an aptitude that favors critical thinking and that enables them to be more open and receptive to the fundamental, and therapeutic, teaching of Buddhism.153 In light of these findings, the utilization of Buddhist principles and meditation techniques, which as we have seen has tremendous therapeutic potential, should be re-conceptualized to fit the cultural context. Two examples about how to make it easier for Cambodians to appreciate Buddhist concepts could be to change the person who delivers the message (by secularizing the therapist) or to somehow re-package the ideas within the familiar framework of traditional beliefs. For instance, mental health staff (as opposed to Buddhist monks) could benefit from brief training programs on Buddhist psychotherapy and mindfulness meditation. At TPO, only 5-10 minutes breathing relaxation techniques and simple grounding exercises (e.g. look around and describe what you see) are applied during even the most troubling counseling sessions. TPO
director Dr. Sotheara Chhim, admits that despite the efficacy of Buddhist interoceptive concepts and mindfulness meditation, staff members have no applicable knowledge or training needed to perform such techniques or to utilize such principles during the psychotherapy process.154 Venerable Saokhuan, a nationally esteemed Khmer monk who resides in Lowell, Massachusetts, offered a surprising description of his personal way of avoiding khyol goeu attacks.155 In order to prevent and resolve dangerous accumulations of inner wind, the monk often performs a wind dispelling ritual which is described as laying down while paying attention to the breath, visualizing the unobstructed traversing of wind as it repeatedly moves up and down through the vessels of the body, in continual motion, from foot to head and then head to foot. As he imagines the air flowing downward, he envisions a prominent exiting of wind through the feet. According to him, this technique allows the wind to flow smoothly and without obstruction in the body and helps it to exit the feet as it should. It is easy to note the obvious similarity of such a ritual with traditional meditation practices. By re-packaging such helpful practices within the context of the deeply rooted and widely accepted convictions relating to the importance of avoiding wind build-up, meditation could become more easily and broadly performed by individuals suffering from mental and emotional disorders.
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The following chapters will explore some alternative treatment options and the suggestions and recommendation related to their implementation. First we will describe two particular methodologies specifically targeted towards Khmer Rouge survivors, namely the Testimonial Therapy method and the Victim-former KR dialogue
project. We will then describe group-based treatment options, such as self-help groups and art therapy. Finally, we will explore the benefit of Eye Movement Desensitization and Reprocessing technique (EMDR) and the educational power and therapeutic potential of Forum Theater.
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2.3
Testimonial Therapy & Victim-Former KR Dialogue Project

As we have described previously, some Khmer Rouge survivors are still plagues by their inability to let go of their traumatic past. Without a feeling of retribution, the lack of a sense of acknowledgment only increases their emotional traumatic burden. The following two approaches, deal specifically with this need for recognition as the mean to sublimate their painful memories though through a sense of perceived justice.
Figure 11: Woman receives support and encouragement as she hears her story read out loud during a TT ceremony.
Figure 12: Woman who survived the KR participates in the TT ceremony held at the Killing Fields Memorial
Testimonial Therapy
Testimonial therapy is defined as an individual psychotherapy method for survivors of human rights violations. It is a brief psycho-legal approach to trauma, which involves the narration the survivors traumatic experiences.156 In cooperation with a counselor the clients are enabled to restore their painful memories and convert them into a written document, the testimony, which is later handed out to the client during a cathartic honoring ceremony. This
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practice allows survivors of human rights violations to express and process painful experiences, to restore their dignity and to document the violations. According to the researcher who was responsible for introducing TT in Asia, the primary goal of Testimonial Therapy is to transform the trauma story from an account of shame and humiliation into one of dignity and virtue.157 Another paper, published in 1990, further describes the method as a ritual both of healing and of condemnation of injustice: When political refugees give testimony to the torture to which they have been subjected, the trauma story can be given a meaning, can be reframed: private pain is transferred into political dignity.158 In addition to promoting community support and symbolic amends,159 testimony giving can also be of assistance in the creative mediation of traumatic memories. Researchers have highlighted the importance of helping the survivor during the editing of the narrative by assisting the inclusion of healing metaphors and strategies of positive-coping which prevent the narrative from becoming toxic for the person narrating the story and for people listening to it.160 Testimonial Therapy (TT) was developed in Chile in the 1970s under the Pinochet dictatorship by Lira and Weinstein (published under the pseudonyms Cienfuegos and Monelli, 1983).161 The aim of the testimony was to facilitate integration of the traumatic experience and restoration of self-esteem. Over the last 40 years the effectiveness of Testimonial Therapy has been demonstrated applicable to a large variety of cultures and contexts with positive indicators and reductions of trauma symptoms.162 In order to adapt it to the Asian context, from May 2008 through April 2010 the testimonial therapy method was reconceptualized and implemented by the Rehabilitation and Research Center for Torture Vic-
tims (RCT) in Copenhagen, Denmark, and further developed in cooperation with the Asian partners. In contrast with previous uses of the testimony method in other regions of the world, this version of the process was develop to take into account the local cultural and spiritual dimensions, by incorporating country-specific coping-strategies, such as traditional healing rituals and honoring practices. During the delivery ceremony, performed in symbolic locations, embodied spirituality is employed in various forms, such as songs, dances, religious purification rituals, meditation, the sharing of meals as well as public expression of love and compassion.163
Figure 13: Survivor of the regime (center) listens to her testimony being read out loud.
The Testimonial Therapy method presents a number of benefits. First and foremost, the process emphasizes the denunciation of human rights violations and advocacy to obtain justice, which has been demonstrated to be an effective therapeutic strategy to catalyze the healing process in people who have been victims of human rights abuses.164 Referring in particular to survivors of organized violence, researchers have criticized a purely biomedical approach, highlighting the importance of truth and justice, achieved by means of truth-telling narratives.165 They believe that first and foremost, survivors need social awareness and recognition which allows them to re-connect with their community. The
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ceremonial element ensures acknowledgment of the survivors suffering which marks the transition of a private truth to a part of social memory.166 Furthermore the method involves a process that is both brief (the whole process is concluded in a time span of about 4 days) and relatively easy to master.167 Lastly, studies have stressed the crucial role of integrating traditional ceremonies which may facilitate an individuals capacity to contain and integrate traumatic memories, promote restorative self-awareness and spirituality, and engage community support.168 In Cambodia, as well as in many cultures in South and Southeast Asia, a person is seen as a permeable being who is constituted through transactions in which the giving and receiving of material and nonmaterial elements occur.169 Therefore these ceremonies, by conforming to the local meaning of person, may also function as rites of passage,170 aiding the narrator in the transition from the role of victim to an empowered survivor who can support others.171
Testimonial Therapy has been implemented in Cambodia since 2010 by the Transcultural Psychosocial Organization (TPO), the leading Cambodia NGO specialized in mental health, which has organized several Testimonial Therapy sessions for civil parties of the ECCC Trials. However, the effectiveness of the current version of the TT method within the Cambodian context is a subject for debate and certain limitations and shortcomings should be noted. Firstly, the study which describes the applicability of the TT method in the Asian context, reports on how the participants unanimous voiced their support for the project, expressing how the process had enabled them to successfully come to term with their traumatic past and to finally gain a sense of closure. However, no evidence of statistical significance has been reported. In dealing with an uncomfortable lack of improvement in the symptoms from the International Classification of Functioning, Disability and Health (ICF), the authors argue that the Monitoring and Evaluation questionnaire is likely to have not be well understood by the community workers, due to poor wording, formulation and/or validation of the questions.172 Furthermore, the participants of TT ceremonies in Cambodia come from the pool of civil parties in the ECCC proceedings, whose number is in the thousands.173 Each mass ceremony involves several dozens of people and the current state of mental health services in Cambodia is predictably incapable of providing proper follow-up care to such an elevated number of patients, who are often abandoned to their own devices following the ceremony. It is therefore important to evaluate whether such highly condensed and emotionally intensive methods would not result in further re-traumatization of the individuals instead.
Figure 14: Some argue that the TT might cause re-traumatization in survivors who had 30 years to develop coping mechanisms.
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Victim-Former KR Dialogue Project

The Victim-Former Khmer Rouge Dialogue Project aims at encouraging dialogue between victims and their direct perpetrators and it is the result of a collaboration between the International Center for Conciliation (ICfC) and Transcultural Psychosocial Organization (TPO).174 The primary objective of the project was to initiate dialogue between former Khmer Rouge and victims such that understanding and empathy can continue to be built in the future years. The reconciliation promoted by the project works on multiple levels: it is reconciliation within ones past, between victims and their perpetrators and reconciliation at the community level as a whole. Victims are released from anger and pain following acknowledgement and apology; perpetrators face their own history of wrongdoings, while recognizing the surrounding factors that led to those actions; the understanding and empathy resulted from the dialogue help strengthening community relationships in order for villagers to move forward together towards social cohesion. Over a period of seven months, from March 2011 to September 2011, two victims and their direct perpetrator were encouraged to exchange video-messages with one another. Their discussion topics included their expectations from the process, their experiences during the KR time and the emotional impact their pasts had on their lives. In addition, reactions by each party to the video messages were filmed and exchanged. At the end of the process both parties agreed to meet face to face. The goal of this stage was to create a shared understanding of what happened and what they can do together to rebuild their relationship. Finally they participated in a culmination activity aimed at building reconciliation and peace, namely the construc-
tion of a stupa to honor the spirits of those who passed away during the KR regime. After the completion of the process, members of the victims group indicated that they felt released from their anger and pain. The former Khmer Rouge cadre indicated that the project helped him better relationships in the community, as exemplified by his new participation in various community events and Buddhist ceremonies, which he was used to avoid. Local facilitators also expressed their thoughts on the projects success and how the project helped them better understand conflict resolution techniques. Other members of the community, including family members, village and commune authority, respected religious leaders, and elders expressed their belief in the projects success and contributions to the community at the commune level.175 Although all of the participants have voiced their appreciation for the project, there is a major limitation. The project has been solely implemented in its pilot form. Further applications are awaiting funds that are likely to take time to be found. The video that is supposed to promote the process may actually disappoint potential donors and future participants. It shows a lack of any detectable remorse by the former KR cadre. On one hand this might be due to the uncomfortable feeling of being filmed as well as to the long time that has passed, which allowed him to assume strong defensive mechanisms. On the other hand, a comparison with the written report on the project, demonstrates how poorly the video has been edited. In conclusion, the potential of this project has yet to be fully exploited but, if properly executed, this process might help improve the quality of life of people living in rural areas in direct contact and proximity with their perpetrators.
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Testimonial Therapy Pros

The focus on human rights advocacy catalyzes the healing process. Promotes social awareness, recognition and reconnection with the community. Includes traditional ceremonies and culture-specific coping strategies. Inexpensive. Brief (4 days). Procedure is easily mastered by the local staff. Proven effective in a large variety of contexts. Procedure needs further validation as far as its applicability in Cambodia. Might cause unnecessary re-traumatization of the participants. Implemented in Cambodia since 2010 for survivors of the KR who are civil parties of the ECCC trials.
Cons Status
Victim-Former KR Dialogue Project Pros

Promotes much needed reconciliation within ones past and between victims and their perpetrators. Encourages understanding, empathy and collaboration at the personal and at the community level. Pilot has been successful. Former KR cadres had 30 years to develop defensive mechanisms which makes it harder for them to offer acknowledgment and apology. Procedure only implemented once and promotional video might disappoint potential donors and future participants. Only executed once in its pilot form. Awaiting funding.
Cons
Status
Figure 15: 49% of Cambodians would not want their offspring to marry the offspring of a former KR cadre. In the image, children living in the same village, play through the fence which divides their homes.
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2.4
Self-Help Groups and Art Therapy

The next section will analyze two group-based interventionsself-help groups and art therapy. Studies have suggested that such psychosocial approaches might help in modeling coping abilities, normalizing feelings and improving relaxation skills, as well as increasing a sense of security and stability by establishing social support networks.176 By being particularly effective with regard to trauma and unresolved psychological conflicts, and by promoting the restoration of a broken interconnectedness between individuals, such methodologies reveal themselves as exceptionally relevant to the Cambodian context. As it would be expected, the utilization of self-help groups and art therapy techniques, have been proven to be very effective in Cambodia. Such therapies have been shown to help people in coping with their traumatic memories, to support each other in new ways, and, consequently, to take care of their children and overcome social isolation.177
Figure 16: Group meeting at TPO Cambodia
Group Therapy (Self-Help Groups)

Group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group, which has the additional benefit of making this approach a very cost effective option. Although the specific manner in which the session is conducted depends largely on the goals of the group and the style of the therapist, studies have consistently shown that group therapy can be an effective treatment choice for many problems, including depression178 and traumatic stress.179 In The Theory and Practice of Group Psychotherapy, Irvin D. Yalom outlines the key therapeutic principles of this approach, which include the
instillation of hope and a sense of universality (helps people see that what they are going through is universal and that they are not alone), as well as an opportunity for interpersonal learning and altruism (supporting others can help foster feelings of success and accomplishment).180 Group therapy provides a safe environment in which members work to establish a level of trust that allows them share feelings and experiences honestly, which in addition to providing a cathartic expression of grief, can help in promoting adaptive mourning responses.181 Furthermore, unlike individual psychotherapeutic sessions, this approach allows people to receive the support and encouragement of the other members of the group, which can serve as role models, while allowing the person to develop new ways of relating to others, practicing new behaviors in a supportive environment, without the fear of failure.182 To this date, group therapy, referred to as selfhelp groups, has arguably been the most effectively implemented non-pharmacological treat-
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ment in Cambodia. The Transcultural Psychosocial Organization (TPO), the leading Cambodian NGO in the field of mental health and psychosocial interventions, has implemented several projects that make use of the group therapy process. Since 2011, TPO facilitates self-help groups to assist civil parties in the ECCC proceedings.183 In addition to providing the benefits of group therapy, these sessions also served as an educational forum, where TPOs facilitators can communicate any updates about the courts proceedings and answer questions that Civil Parties might have. Group members have been reported to express their appreciation towards the process, which enabled them to share their experiences with and have emotional support from others who have experiences similar tragedy. The sessions are supplemented by the teaching of stress reduction techniques and they are concluded with a shared meal, with each member preparing a dish to share with the rest of the group. Similar meetings have been focused on female survivors of the Khmer Rouge who experienced Gender Based Violence under the regime.184 As part of their Access to justice for Women project, initialized in January 2012, TPO has also established self-help groups where women victims of violence and abuse, can express feelings, build confidence, find effective ways to solve conflicts, and support each other. Self help-groups empower women and girls who are living with violence to understand more about themselves and their rights, and provide the opportunity to learn from each other and to experience mutual support.185 Finally, as part of their community mental health program, since 2011 TPO has implemented projects aimed at improving the mental health and livelihood opportunities for vulnerable people. TPO counselors in collaboration
with key resource people in the community set up self-help groups in the provinces directed towards alcoholic men and women victim of domestic violence. The fourteen symptom indicators measured by TPO before and after the treatment (headache/dizziness, poor sleep, excessive worrying, fear, irritability/ easily angry, nightmares, sadness/low mood, hopelessness about future, conflict in family/domestic violence, drinking alcohol, gambling, difficulty conducting daily activities, difficulties participating in social events and talking to someone about your difficulties), all showed significant improvement following the group therapy sessions. In addition, approximately 70% of target villagers have shown a significant increase in understanding of mental health and psychosocial problems, following the group therapy process.186 In sum, the NGO has found that self-help groups have proven to be a very successful and cost-effective method in helping individuals find ways to solve problems and to cope with emotional stress. This form of community-based intervention enjoys a high acceptance among beneficiaries, particularly among socially isolated individuals and those whose human rights have been abused. Participants can benefit from sharing their experiences with others and also by learning from each other. Self-help groups help to empower marginalized individuals and destigmatize mental health problems.187
Figure 17: Participant in TT assessment at TPO Cambodia.
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Art Therapy
The American Art Therapy Association describes art therapy as "a mental health profession that uses the creative process of art making to improve and enhance the physical, mental and emotional well-being of individuals of all ages. It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behavior, reduce stress, increase self-esteem and self-awareness, and achieve insight. [] Through creating art and reflecting on the art products and processes, people can increase awareness of self and others, cope with symptoms, stress and traumatic experiences; enhance cognitive abilities; and enjoy the life-affirming pleasures of making art.188 During the art therapy session, which may involve a variety of creative mediums, such as drawing, painting, sculpture and collage, the therapist guides the client through the artmaking process while helping the individual in finding personal meaning and self-expression. In line with Carl Rogers idea of person-center therapy,189 the therapist recognizes that it is the client who is the expert on their life, and that it is they who can discover why they suffer and, in alliance with the therapist, find a path to recovery, through a healing partnership.190 While people have been using the arts as a way to communicate and express themselves for thousands of years, art therapy only began to formalize during the middle of the 20thcentury.191 As doctors realized how often individuals with mental disabilities expressed themselves through drawings and other artworks, they begun to research and explore the use of art therapy as a healing strategy. Indeed scientific research suggest that traumatic memories are stored and processed in the right hemisphere of the brain, which can make verbal-
ly elaborating related thoughts and emotions, particularly difficult.192 A non-verbal expressive therapy, such as art therapy, dance/movement therapy or music therapy, therefore bypasses such verbal defenses193 allowing individuals to communicate emotions and events that they cannot easily express in words.194 The purpose of art therapy is essentially one of healing and its efficacy has been widely documented in a variety of contexts, including ones frequently encountered in Cambodia, such as clients who have experienced severe emotional trauma, physical, sexual violence and domestic abuse, as well as the ones suffering from neurotic disorders such as anxiety or depression.195 The Ragamuffin Project is a State Registered INGO (International Non-Governmental Organization) based in Phnom Penh who begun its work in Cambodia in 2001. Ragamuffin has since introduced Creative Arts Therapy to a broad range of organizations in the psychosocial sector and has established certificate level training courses. The organization believes creativity to be universal and natural way of restoring broken hearts and shattered minds and that creative expression, which mirrors our inner world, enables us to see and understand the cause of our suffering and express our pain. By exercising creativitys powerful connection with both the conscious and unconscious issues that lead to the debilitating symptoms, the client and the therapist are allowed to determine the source of distress whilst enabling the expression of chaotic and painful feelings within a safe environment. Each little revelation makes restoration possible and the pain can ultimately be transformed into power and self-affirmation.196 Ragamuffin offers Art Therapy sessions, both in an individual and a group context, to clients, mainly referred from partner NGOs, who experienced a wide rage of traumatic experiences and
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human rights violations and/or who suffer from debilitating neurotic disorders, such as depression or anxiety. After an evaluation session, which is aimed at assessing the problem and determining the most effective approach, the clients have the option to participate in an array of different creative activities, such as drawing, sandbox-creation, writing of poetry, drama, music therapy and songwriting. These different vocational methodologies, allow for a personalized expression of trauma: clients can draw, or dance or act or make their own fictional stories through which their difficult words can be explained and expressed. Unfortunately, however, Ragamuffins art therapy sessions might not meet the affordability needed in terms of time and cost. Healing from deep emotional and psychological wounds takes time, and the more serious the condition, the more time is needed. The sessions last approximately one hour and they take place between twice a week, for the more severe cases, to once a month, for people living in the rural areas.197
As the grant funds for the original project are now depleted, Ragamuffin is forced to charge the referring NGOs a fee of $35-$40 per session which may redirect the organizations attention elsewhere.198 Hopefully, the newly implemented fund raising strategies, such as renting an office space to creative professionals, would eventually allow the organization to drastically diminish the costs. In addition to art therapy, Ragamuffin has also recently initiated two other projects. The Lighthouse project will focus on for music therapy, while the Wilderness project, set in Koh Kong, will feature an immersion in nature, supplemented by outdoor activities, meditation and counseling.199 As opposed to non-verbal creativity-based approaches, the wilderness immersion program is particularly interesting, in that it draws from the emerging field of ecophilosophy and nature-immersion therapies, which believe in the significant psychological benefits derived from rekindling the long-lost symbiotic connection with the natural environment.
Figure 18: Carvings of dancing Methodologies apsaras at the Angkorian temple of Bayon Mental Health in Cambodia: The Role of Alternative Treatment
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Self-Help Groups Pros

Very cost effective (high therapists/clients ratio). Well implemented and very successful in Cambodia. Promotes altruistic collaboration, mutual support and trust. Helps in education and de-stigmatization of mental health problems. Some people might not be comfortable in a group setting. Probably the most effectively implemented treatment in Cambodia.
Cons Status
Art Therapy Pros Cons

Efficacy of non-verbal therapies applied to victims of trauma has been widely documented Enjoyable process drastically lowers drop-out rates Therapy process might be long Currently the original project funds are depleted and each session costs the referring NGOs $35 dollars. Available in Cambodia. However not many NGO are willing to pay the fee required.
Status
Figure 19: TPO counselor comforts a client as she remembers her traumatic experiences during the KR
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2.5
Other Techniques: Forum Theater and EMDR

This chapter will discuss two other interesting techniquesForum Theater and EMDR. Forum Theater has been used in Cambodia to increase awareness of mental disorders. Although awareness-raising methods are outside the scope of this research, Forum Theater presents significant therapeutic implications and a clinical potential that goes beyond its current use in Cambodia. Eye Movement Desensitization and Reprocessing is a relatively new technique to treat trauma patients and unlike all the other alternative treatment methods described in this research, has yet to be implemented in Cambodia. branches of his "Theatre of the Oppressed", which uses theatrical techniques as means of promoting social and political change. During Forum Theater, the actors perform a play with a scripted core, in which an oppression relevant to the audience is played out. Once the play reaches a significant climax, the audience is invited to participate in the unfolding of the story by offering suggestions, ideas and strategies to the oppressed individual or by entirely replacing him/her on stage. The other actors improvise the reactions of their characters facing each new intervention, so as to allow a sincere analysis of the real possibilities of using those suggestions in real life.201 If and when the oppression has been successfully overthrown, the production changes again: the spect-actors now have the opportunity to replace the oppressors, and find new ways of challenging the oppressed character. In this way a more realistic depiction of the oppression can be made by the audience, who are often victims of the oppression.202 The whole process is designed to be dialectic, coming to a conclusion through the consideration of opposing arguments, rather than didactic, in which the moral argument is one-sided and pushed from the actors with no chance of reply or counterargument.203
Forum Theater
Raising public awareness about mental health is one of the key elements in the promotion of mental wellbeing and increasing the understanding of these issues is fundamental in targeting the abuse and stigma faced by mentally disabled people. Whereas the government and the international organizations in Cambodia have the important responsibility of disseminating mental healthr information, these practices fall out of the scope of this paper.200 Nevertheless, the author of this manuscript has identified an awareness-raising approach, among the ones implemented in Cambodia, which presents strong therapeutic aspects. This next section will inspect such procedure, referred to as Forum Theater. Forum Theater is a form of Drama Therapy characterized by active interaction between the actors and the so called spect-actors (i.e. actively participating spectators). It was developed by Augusto Boal in the 1960s as one of the major
Figure 20: The villagers enjoy the Forum Theatre performance
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Figure 21: TPO staff member invites the audience to participate
whether they have experienced similar instances in their village life. Following the first act, villagers are invited to actively participating in the performance, role-playing their or others possible point of views and encouraged to act out what they believed should be done in a similar situation. During a second day, TPO staff members would typically explore, in a more analytical way, the core issues related to mental illness and stigma, advising on how the villagers might handle being confronted by similar situations and how they can seek help, for themselves of for others, from TPO or partner organization.208 The author of this manuscript had the opportunity to participate in one of such events in a rural community of the Siem Reap province and has observed a surprising level of enthusiasm and participation from the villagers. In light of this finding, this approach to psychosocial education may very well be one of the most effective methods of providing families and individuals at the community level with an understanding of psychosocial problems, stress and trauma effects. By enabling them to see the unstigmatized rootcause of present mental health issues, people learn how mental health problems can strongly affect and be affected by the community environment, highlighting the responsibility to enhance well being and promotion of mental health for all members of their congregation. Moreover, drama-based therapies have been shown to be effective psychotherapeutic tools and further application of the forum therapy method may offer new therapeutic possibilities.209 Forum Theater sessions could for instance be focused on different issues and they could potentially be re-conceptualized to integrate some of the elements of group therapy that promote psychological healing with the benefits of the aforementioned raising of awareness.
When they are faced with a similar scenario in real life, people who experienced forum theater result more proactive and confident, having previously rehearsed the possible resolution of such conflicts.204 The general objective of the Theatre of the Oppressed is the development of essential Human Rights and such techniques are now being used in approximately half the nations around the world.205 Forum Theater is especially helpful as a tool for the making of discoveries about oneself and about the Other and for empowering a change of circumstances which produce unhappiness and pain.206 In Cambodia, Forum Theater has been introduced a year ago to the Transcultural Psychosocial Organization. Since then TPO has implemented such approach in a number of rural villages, aiming at promoting the psychological wellbeing and support networks of victims of Gender Based Violence.207 The core of the performance currently revolves around the present-day stigma and lasting emotional trauma faced by a woman who had been raped during the KR time. The villagers are invited to interact with the play; they are asked questions regarding what they think is happening, what are their feelings about it and
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Eye Movement Desensitization and Reprocessing (EMDR)

Eye movement desensitization and reprocessing (EMDR) is a fairly new psychotherapeutic technique, the popularity of which has been recently growing particularly in reference to the treatment post-traumatic stress disorder, anxietybased conditions and psychosomatic distress.210 The technique involves the unusual and little understood therapeutic benefits derived from the clients rapid and rhythmic eye movements, which are believed to dampen the power of emotionally charged memories of past traumatic events.211 During EMDR memory reprocessing, the client is asked to recall a traumatic event for a short period of time (e.g. 30 seconds) while simultaneously undergoing bilateral stimulation that can consist of moving the eyes from side to side, tapping movements on different sides of the body, or tones delivered through one ear, then the other, via headphones.212 Gradually, the therapist will guide the client through a shift in perspective towards more pleasant and selfaffirming concepts. According to psychologist Francine Shapiro, the pioneer of the method, this technique occurred to her as she realized how her own negative emotions lessened as her eyes darted from side to side. Intrigued, Shapiro tried out variants of this procedure with her clients whom confirmed her theory. Since the formalization of the method in 1989, EMDR has been administered by more than 20,000 practitioners to approximately two million clients.213 EMDR therapy is recommended as an effective treatment for posttraumatic stress disorder in the practice guidelines of a wide range of organizations, like the American Psychiatric Association (in 2004), the Department of Veterans Affairs and Department of Defense (in 2010), the International
Society of Traumatic Stress Studies (in 2009), and other organizations worldwide, including in Britain, France, the Netherlands and Israel.214 Still, despite its increasing use, EMDR has been object of an animated controversy among mental health practitioners.215 The predominant theory advanced by advocates of the method, proposes that such eye movements may reduce anxiety by diverting the attention from the emotional consequences of recalling distressing events. According to the EMDR International Association the model on which EMDR is based, Adaptive Information Processing (AIP), posits that much of psychopathology is due to the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences. This impairs the clients ability to integrate these experiences in an adaptive manner.216 Furthermore this treatment approach, by targeting past experiences, current triggers and future potential challenges, results in the alleviation of presenting symptoms, a decrease or elimination of distress from the disturbing memory, improved view of the self, relief from bodily disturbance, and resolution of present and future anticipated triggers.217 In other words, advocates of the method believe that unprocessed traumatic memories may alter the way in which we perceive and process new information, coloring new perceptions with the unresolved negative emotions of the past.218 Through the utilization of dual focus of attention and alternating bilateral visual, auditory and/or tactile stimulation, the therapist may guide the client through an effective reprocessing and integration of traumatic events and associated beliefs, towards an adaptive resolution.219 The working mechanisms that underlie the effectiveness of EMDR have yet to be fully understood and agreed upon.220
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Synchronization of the brains two hemispheres interfering with the working memory processes221 and link into the same processes that occur during R.E.M. sleep,222 have emerged as candidates for the explanation of EMDRs effectiveness223 in reducing anxiety levels and promoting the restoration of an adaptive information processing. In support of these theories, lateral eye movements have been shown to reduce the selfrated vividness or emotional effect of unpleasant autobiographical memories.224 Critics of the method, on the other hand, focus predominantly on the lack of consistent evidence for the beneficial effects of lateral eye movements,225 arguing instead that the efficacy of EMDR should be attributed to the inclusion of exposure and desensitization techniques, common practices in cognitive behavioral approaches.226 In the words of Harvard psychologist Richard McNally, they believe that what is effective in EMDR is not new, and what is new is
not effective. 227 What we do know, however, is that EMDR, even if it has failed in exceeding the achievements of cognitive-behavioral therapy, results in unquestionable therapeutic benefit. As a matter of fact, studies have ruled out the placebo effect and client expectations as factors to which the effectiveness of EMDR might be attributed.228 Furthermore, studies that evaluated the participants perceptions of E.M.D.R. compared with other therapies, concluded that survivors narratives indicate that E.M.D.R. produces greater trauma resolution.229 As traditional cognitivebehavioral therapies typically entail longer treatment times,230 a substantial amount of homework231 and present significantly higher drop out rates than EMDR (30% to zero),232 their application may be ill-suited to the Cambodian context. The practice of EMDR could therefore emerge as a more practical solution of comparable efficacy.
Forum Theater Pros Cons

Empowers people victim of oppressions. Raises public awareness and understanding of mental health issues. Surprisingly high levels of enthusiasm and participation among Cambodians. Not strictly speaking a therapeutic technique. Although it is mainly used for awarenessraising, it has unexplored therapeutic potential. As of today, it has only dealt with Gender Based Violence issues. Further applications could target a wider array of psychosocial issues. Implemented in Cambodia but just as a teaching tool. Further applications could be oriented towards a more specifically therapeutic process (similar to group therapy).
Status
EMDR Pros
Comparable efficacy to CBT. Shorter treatment times than CBT. No homework. Considerably lower drop-out rates (0 to 30% for CBT) It has never been implemented in Cambodia. EMDR has yet to be implemented in Cambodia.
Cons Status
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Conclusion
Figure 22: Siem Reap province
Cambodia suffers from an alarming treatment gap in the field of mental health. The Cambodian mental health care systems struggles to meet the overwhelming needs of the population. Shortage of trained professionals, the predominantly rural demographic and the over-reliance on pharmacological therapy (along with all the respective consequences) call for treatment options which feature brief therapeutic approaches, techniques easily mastered by non-psychotherapists, and the complete avoidance of a purely bio-medical approach. Additionally, traditional and cultural beliefs as well as Buddhist spirituality should be taken into account when determining the most effective culturally appropriate treatment options.
The desirable characteristics of potential therapies are featured in the alternative and culturally sensitive approaches described in this paper, which include testimonial and dialogue approaches, art and group therapies, forum theater and EMDR techniques. While the broader issues of government and international funding, low levels of awareness regarding mental health, lack of trained staff, facilities and resources are being addressed, the success of mental health treatment in Cambodia depends upon the short and long-term results of an effective and thorough implementation of such alternative strategies.
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Endnotes
1
The World Health Report 2001: Mental Health; New Understanding, New Hope, 23. [hereinafter WHO REPORT 2001]
2
McLaughlin, D. & Wickeri, E (2012). Mental Health and Human Rights in Cambodia. Leitner Center for International Law and Justice, Fordham Law School, New York City. [hereinafter LEITNER REPORT].
3
World Health Org. Europe (2003). What are the Arguments for Community-Based Mental Health Care? 5. WHO (2008). The Global Burden of Disease: 2004 Update, 51.
D. Chisholm et al., World Health Org. (2006). Dollars, Dalys and Decisions: Economic Aspects of the Mental Health System,21.
6
World Health Organization (2003). Investing in Mental Health. Retrieved April 3 2013 from http://www.who.int/mental_health/media/investing_mnh.pdf. [hereinafter INVESTING IN MH].
7
Reicherter, D. & Aylward, A. (2011). The Impact of War and Genocide on Psychiatry and Social Psychology, in Cambodias Hidden Scars: Trauma Psychology in the Wake of the Khmer Rouge. Autumn Talbott et al, eds. [hereinafter CAMBODIAS HIDDEN SCARS].
8
See INVESTING IN MH, supra note 6.
According to the WHO, 80% of people suffering from mental disorders live in low and middle-income countries. World Health Org. (2010). Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group, 2. Retrieved April 6 2013 from http://www.who.int/mental_health/policy/mhtargeting/development_targeting_mh_summary.pdf
10
See LEITNER REPORT, supranote 2. Ibid.
11
12
Brinkley, J. (2011). Cambodia's Curse: The Modern History of a Troubled Land. New York: PublicAffairs, Print. [hereinafter CAMBODIAS CURSE].
13
Kiernan, B. The Pol Pot regime: Race, power, and genocide in Cambodia under the Khmer Rouge 1975 79. New Haven: Yale University Press; 2002.
14
Mollica RF, Mcinnes K, Poole C, Tor S. (1998). Dose-effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. British Journal of Psychiatry;173:482 488. [PubMed: 9926076]
15
W.A.C.M. Van de Put & Maurice Eisenbruch (2002). The Cambodian Experience, in Trauma War and Violence: Public Mental Health in Socio-Cultural Context. Joop de Jong ed., 93, 95.
16
CAMBODIAS CURSE, supra note 12.
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17
De Jong, J, I Komproe, and M van Ommeren 2003 Common mental disorders in postconflict settings. The Lancet 361: 21282130.
18
Falsetti, S.; Resnick, H.; Dansky, B.; Lydiard, B.; Kilpatrick, B. (1995). The relationship of stress to panic disorder: cause and effect?. In: Mazure, C., editor. Does stress cause psychiatric illness. Washington, DC: American Psychiatric Press. p 111-148.
19
Chhim, S. (2012). Baksbat (Broken Courage): The Development and Validation of the Inventory to Measure Baksbat, a Cambodian Trauma-based Cultural Syndrome of Distress. Cult. Med Psychiatry. 36:640-659. DOI 10.1007/s11013-012-9279-6. [hereinafter BASKBAT].
20
Hinton, D., Um, K., & Ba, P. (2001c). A unique panic-disorder presentation among Khmer refugees: The sore neck syndrome. Culture, Medicine, and Psychiatry,25, 297316.
21
The highest rate ever registered. Hinton, ED, V Pich, D Chhean, and HM Pollack (2005). The Ghost Pushes You Down: Sleep Paralysis-Type Panic Attacks in a Khmer Refugee Population. Transcultural Psychiatry 42(1): 4677.
22
See CAMBODIAS HIDDEN SCARS, supra note 7. See LEITNER REPORT, supra note 2.
23
24
World Health Org. (2009). Mental Health, Poverty and Development. Retrieved March 4 2013 at http://www.who.int/nmh/publications/discussion_paper_en.pdf. Funk, M., Drew, N., Knapp, M. (2012). Mental health, poverty and development. Journal of Public Mental Health, Vol. 11 Iss: 4, pp.166 - 185. Lund, C. et al. (2010). Poverty and Common Mental Disorders in Low and Middle Income Countries: A Systematic Review, 71 Soc. Sci. & Med., 517.
25
Studies have shown a strong correlation between the inability to afford an appropriate diet with sufficient caloric intake, and an increased risk of developing intellectual disabilities. See Thomas, P. (2005). Disability Knowledge and Research, Poverty Reduction and Development in Cambodia: Enabling Disabled People to Play a Role, 7.
26
See LEITNER REPORT, supra note 2, describing how the high treatment costs of mental disabilities are largely borne by patients.
27
McDaid, D. et al. (2008). Barriers in the Mind: Promoting an Economic Case for Mental Health in Low and Middleincome Countries, 7; World Psychiatry 79. In LEITNER REPORT, supra note 2.
28
U.N. Dev. Programme (2009). Human Development Report 2009: Overcoming Barriers; Human Mobility and Development, 177.
29
Glr, L. (2000). Evaluating the Role of Gender Inequalities and Rights Violations in Womens Mental Health, 5 Health & Hum. Rts. 46, 54.
30
Surtees, R. (2003). Negotiating violence and non-violence in Cambodian marriages. Gender and Development, 11(2), 30-41.
31
See CAMBODIAS CURSE supra note 12. p 233.
32
In 2007, after urging from the Ministry of Womens Affairs, the Chbab Srey was pulled from schools curriculums. Yet, for many Cambodian women, and especially in the rural areas, its admonitions still run deep. See Cambodian Women's Crisis Center (2010). Volunteer Handbook: Helping Women Help Themselves. Retrieved April 2 2013 at http://www.cwcc.org.kh/wp-content/uploads/2010/09/CWCC-Volunteer-Handbook-2010.pdf
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33
See LEITNER REPORT, supra note 2.
34
Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S.G., Chun, C.A. (2005). Mental health of Cambodian refugees 2 decades after resettlement in the United States. Journal of the American Medical Association;294:571579. [PubMed: 16077051]
35
Hinton, D. E., Chhean, D., Pich, V., Pollack, M. H., Orr, S. P., Pitman, R. K. (2006). Assessment of post-traumatic stress disorder in Cambodian refugees using the Clinician-Administered PTSD Scale: Psychometric properties and symptom severity. Journal of Traumatic Stress;19:405411. [PubMed: 16788999]
36
Hinton, D. E., Ba, P., Peou, S., Um, K. (2000). Panic disorder among Cambodian refugees attending a psychiatric clinic: Prevalence and subtypes. General Hospital Psychiatry; 22:437444. [PubMed: 11072060]
37
The applicability of PTSD as a cross-cultural diagnostic tool has been a source of debate within the scientific literature. See The Impact of War and Genocide on Psychiatry and Social Psychology, in CAMBODIAS HIDDEN SCARS, Supra note 7, stating that much of the psychological distress and social dysfunction resulting from war violence is poorly captured in the studies that examine the mental health pathology of post-conflict populations with Western PTSD model. See also BASKBAT. Supra note 19. A better diagnostic tool might be the newly developed Cambodian Symptom and Syndrome Inventory (C-SSI), developed by David Hinton. This addendum to the existing assessment surveys, takes into account the culturespecific idioms of distress. See Hinton, D., Hinton, A., Eng., K. T., Choung, S. PTSD Severity and Key idioms of Distress Among Rural Cambodians: the Results of a Needs Assessment Survey. in CAMBODIAS HIDDEN SCARS. supra note 7.
38
Sonis, J. et al. (2009). Probable Post-traumatic Stress Disorder and Disability in Cambodia: Associations with Perceived Justice, Desire for Revenge, and Attitudes Toward the Khmer Rouge Trials, 302 JAMA 527, 527; [hereinafter SONIS 2009].
39
See WHO REPORT 2001, supra note 1. Schunert, T., Khann, S., Kao S., Pot C., Saupe, L. B., Sek, S., Nhong, H. (2012). Cambodian Mental Health Survey
40
2012. Royal University of Phnom Penh Department of Psychology. [hereinafter RUPP SURVEY]. It should be noted that the same survey estimates the prevalence rate of probable PTSD for the total population aged >21 years, at of 2.7%. Despite still being 7 times higher than in the general population worldwide, the authors of the manuscript admit that the incoherence with previous findings which showed a much higher prevalence of the disorder, should be attributed to the use of the Harvard Trauma Questionnaire, which has been shown to not be a reliable diagnostic tool in the Cambodian context.
41
Kessler, R. C., et al. (2009). The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiol Psichiatr Soc;18(1):2333.
42
Kessler, R. C., Chiu, W.T., Demler, O., Merikangas, K. R., Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry;62:617 627. See also WHO REPORT 2001. Supra note 1.
43
Dubois, V. et al. (2004). Household Survey of Psychiatric Morbidity in Cambodia, 50(2) Int'l J. Soc. Psychiatry 174. See RUPP SURVEY, supra note 40.
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48
45
World Health Organization: Suicide prevention. Retrieved March 19 2013 at
http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
46
Cambodia Demographics Profile 2012. Retrieved March 26 2013, from Index Mundi Web Site: http://www.indexmundi.com/cambodia/demographics_profile.html.
47
Versus 14.2% of those aged above 35 - a cohort that directly experienced the KR. See SONIS 2009, supra note 38.
48
Field, N. P. Intergenerational Transmission of Trauma Stemming from the Khmer Rouge Regime: An Attachment Perspective, in CAMBODIAS HIDDEN SCARS, supra note 7.
49
Stammel N., Heeke C., Bockers E., Chhim S., Taing S., Wagner B., Knaevelsrud (2013). Prolonged grief disorder three decades post loss in survivors of the Khmer Rouge regime in Cambodia. Journal of Affective Disorders 144 (2013) 8793.
50
Boehnlein, J. K & Kinzie, J. D. The Effect of the Khmer Rouge on the Mental Health of Cambodia and Cambodians, in CAMBODIAS HIDDEN SCARS supra note 7, at 33, 34.
51
Giry, S (2012, July 23). Necessary Scapegoats? The Making of the Khmer Rouge Tribunal. retrieved March 4
2013, from The New York Review of Books Web Site: http://www.nybooks.com/blogs/nyrblog/2012/jul/23/necessaryscapegoats-khmer-rouge-tribunal/. [hereinafter NECESSARY SCAPEGOATS]. The article details the Khmer Rouge past of members of the CPP.
52
Ibid. Noting how among several of this issues, the strongest accusation yet that the Cambodian government has been trying to sabotage the tribunals work, came from the Swiss judge tasked with investigating other former Khmer Rouge officials. On the very first day of Duchs testimony, Laurent Kasper-Ansermet, resigned citing egregious dysfunctions at the court. As he quit, the judge said that for months he received constant and active opposition from his Cambodian counterpart who had had stonewalled his efforts to pursue two cases against five mid-level Khmer Rouge officials (Cases 003 and 004).
53
LICADHO (2010). Freedom of Expression in Cambodia: The Illusion of Democracy. Retrieved March 1 2013 at http://www.licadho-cambodia.org/reports/files/148LICADHOIllusionDemocracy2010.pdf. See also CAMBODIAS CURSE supra note 12.
54
Srun, R., Tim, M., Strasser, J., Muny, S., Chhay, M., Yourn, S. (2011). Victim-Former Khmer Rouge Dialogue Project: Lessons Learned. Phnom Penh. [hereinafter DIALOGUE PROJECT]
55
Agger, I., Igreja V., Kiehle R., Polatin., P. (2012). Testimony ceremonies in Asia: Integrating spirituality in testimo-
nial therapy for torture survivors in India, Sri Lanka, Cambodia, and the Philippines. Transcultural Psychiatry; 49(3-4): 568589. DOI: 10.1177/1363461512447138. p.579. [hereinafter TESTIMONY IN ASIA]
56
See LEITNER REPORT, Supra note 2. Pennebaker, J. W., Zech. E., & Rime, B. (2001). Disclosing and sharing emotion: Psychological, social, and health
57
consequences. In M. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbood of bereavement research: Consequences, coping, and care (pp. 517543). Washington, DC: American Psychological Association. Lepore, S. J., Silver, R. C., Wortman, C. B., & Wayment, H. A. (1996). Social constraints, intrusive thoughts, and depressive symptoms among bereaved mothers. Journal of Personality and Social Psychology, 70, 271282.
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49
However, there is not full agreement among theorists as to the beneficial effects of disclosure It may simply be that those who remain less resolved on their past trauma (i.e., are more vengeful) have a greater tendency to discuss it. See Stroebe, W., Schut, H., & Stroebe, M. S. (2005). Grief work, disclosure and counseling: Do they help the bereaved? Clinical Psychology Review, 25, 395414.
58
Nigel, F. P. & Sotheara, C. (2008). Desire for Revenge and Attitudes Toward the Khmer Rouge Tribunal Among Cambodians. Journal of Loss and Trauma,13:4,352 372
59
Saxena, S. et al. (2007). Resources for Mental Health: Scarcity, Inequity, and Inefficiency, 370 LANCET 878, 886.
60
Cambodia is a party of the International Covenant on Economics, Social and Cultural Rights (ICESCR). Article 12 of the covenant proclaims the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Under the ICESCR, Cambodia is required to take immediate steps towards the realization of the right to health with compliance measured in light of its available resources, including those available from the international community. Even taking into account its limited resources, Cambodia is falling short of its right to health obligations. see LEITNER REPORT, supra note 2.
61
Todd, W. E. "Mental Health Care in Cambodia" The Cambodia Herald. http://www.thecambodiaherald.com/opinion/detail/3?token=OTZkNzFlNzI3ZjdmOTM0ZWU4YmEzZDhhMzdhNTlk (accessed March 24 2013).
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63
See LEITNER REPORT, supra note 2. Ibid.
64
Cambodia. (n.d) retrieved March 26 2013, from Sustainable Development Department, Food and Agriculture Organization Web Site: http://www.fao.org/sd/WPdirect/WPre0106.htm.
65
ADHOC, CDP, LICADHO, TPO, CHRAC (2010). Joint Cambodia NGO Report on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in the Kingdom of Cambodia. [hereinafter JOINT NGO REPORT]. See also, personal communication with TPO Director, Dr. Sotheara Chhim, April 8 2013.
66
Somasundaram, D. J. et al (1999). Starting Mental Health Services in Cambodia, 48 SOC. SCI. & MED; p1037. [hereinafter STARTING MH SERVICES]. Reporting the drop-out rate at 39%-52%.
67
See JOINT NGO REPORT, supra note 65.
See also Maramis, A. et al. (2011). Mental Health in Southeast Asia, 377 LANCET 700, 701.
68
See LEITNER REPORT, supra note 2. See STARTING MH SERVICES, supra note 66; p1030. Ibid. Noting how doctors salaries in Cambodia are on average US$20 per month. Youn Sarath, KRT Project Manager at TPO. Personal Communication, March 2013. See LEITNER REPORT, supra note 2.
69
70
71
72
73
Ibid. Noting how the medication shortage likely reflects both the lack of financial resources allocated to the mental health sector and the sectors over-reliance on prescription, rather than psychosocial, interventions.
50
50
74
75
Pcoul, B. et al. (1999). Access to Essential Drugs in Poor Countries: A Lost Battle?, 281 JAMA 361, 36165.
See LEITNER REPORT, supra note 2. Among the more successful of these nongovernmental organizations are TPO Cambodia, Social Services of Cambodia, the Center for Child and Adolescent Mental Health, Psiclogos Sin Fronteras, the Ragamuffin Project, and Louvain Coopration.
76
Ibid. Cambodians who can afford it, may also resort to the largely unregulated private health sector. Given the general low level of mental health training, there is also an increased risk of misdiagnoses and inappropriate or even harmful treatment.
77
Wahl, O.F. (2012). Stigma as a barrier to recovery from mental illness. Trends in Cognitive Sciences, 16(1): 9-10. See STARTING MH SERVICES, supra note 66; p1029. Ibid.
78
79
80
Boehnlein, J. K & Kinzie, J. D. The Effect of the Khmer Rouge on the Mental Health of Cambodia and Cambodians, in CAMBODIAS HIDDEN SCARS supra note 7.
81
Ibid. See STARTING MH SERVICES, supra note 66; p1029.
82
83
Some Patients were forced to drink mixed stool, urine; they were even beaten/or chained. See Savuon, K. (2010). Kingdom of Cambodia, Summary Country Report on Community Mental Health 4. Retrieved April 7 2013, at http://mhtech.dmh.moph.go.th/blog/wp-content/uploads/2010/03/country-report-cambodia.pdf. [hereinafter KINGDOM OF CAMBODIA]
84
Health professionals, cited in the Leitner report, estimate that between 10 and 40 percent of those suffering from severe mental disabilities tethered and caged in hidden recesses beneath stilt houses. See LEITNER REPORT, supra note 2.
85
Ibid. Noting how the lack of mental health services often results in patients being incarcerated in prisons, compulsory drug treatment centers or social rehabilitation centers, which operate outside of the criminal justice system, and in which the living conditions are notoriously brutal.
86
Ibid. Children with mental disabilities are not welcome to join integrated programs within the community as the parents of other children fear contagion.
87
Ibid. Mental illness as a genetic trait can work both ways. If parents have a mentally disabled child they are embarrassed and they fear people might think they have it as well. If a mother has schizophrenia, men wont ask the daughter in marriage expecting her to eventually present the same disorder.
88
See KINGDOM OF CAMBODIA, supra note 83. Ibid. See also LEITNER REPORT, supra note 2. See KINGDOM OF CAMBODIA, supra note 83. Ibid. Ibid.
89
90
91
92
51
51
93
Ibid. See also personal communication with Ven. Saphea. February 2013.
94
Dr. Sotheara Chimm, DIrector of TPO Cambodia. Personal Communication. April 8 2013. Dr. Sotheara says he frequently has coining performed on himself.
95
Hinton, D., Hinton, A., Eng., K. T., Choung, S. PTSD Severity and Key idioms of Distress Among Rural Cambodians: the Results of a Needs Assessment Survey. In CAMBODIAS HIDDEN SCARS. supra note 7. Hinton, D. Pich, V., So, V., Pollack, M., Pitman, R., & Orr, S. (2004). The psychophysiology of orthostatic panic in Cambodian refugees attending a psychiatric clinic. Journal of Psychopathology and Behavioral Assessment, 26(1), 113. Hinton, D., Um, K., & Ba, P. (2001a). Kyol goeu (wind overload) part I: A cultural syndrome of orthostatic panic among Khmer refugees. Transcultural Psychiatry, 38, 403432. [hereinafter KYOL GOEU PART 1] Hinton, D., Um, K., & Ba, P. (2001b). Kyol goeu (wind overload) part II: Prevalence, characteristics and mechanisms of kyol goeu and near-kyol goeu episodes of Khmer patients attending a psychiatric clinic. Transcultural Psychiatry, 38, 433460.
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See CAMBODIAS CURSE, supra note 12. See also KYOL GOEU PART 1, supra note 95. See LEITNER REPORT, supra note 2. Dr Sotheara personal communication, supranote 94. Zoe Szwarcbord, International Advisor at TPO Cambodia. Personal communication, March 2013. See Chapter 1.3 under The Public Mental Health Care System. Ibid. Ibid. Ibid.
97
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Boehnlein, J. K & Kinzie, J. D. The Effect of the Khmer Rouge on the Mental Health of Cambodia and Cambodians, in CAMBODIAS HIDDEN SCARS supra note 7, at 33, 34.
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See Chapter 1.1, Determinants of Poor Mental Health in Cambodia. See KYOL GOEU PART 1, supra note 95.
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Ibid.
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Sin Kong, personal communication; supra note 122. Sotheara Chhim, personal communication; supra note 94. See KYOL GOEU PART 1, supra note 95 See TESTIMONY IN ASIA, supra note 55. Ibid.
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Ibid. p205. Interviews with human rights activists reveal that it is easier for survivors who have gone through testimonial therapy to give coherent legal testimony.
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187
TPO Cambodia. (n.d.). Community mental health. Retrieved from http://tpocambodia.org/index.php?id=33 American art therapy association. (n.d.). Retrieved from http://www.americanarttherapyassociation.org/
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Cepeda, L. M. & Davenport, D. S. (2006). Person-Centered Therapy and Solution-Focused Brief Therapy: An Integration of Present and Future Awareness. Psychotherapy: Theory, Research, Practice, Training (Educational Publishing Foundation) 43 (1): 112.
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Stronach-Buschel, B. (1990). Trauma, Children and Art. American Journal of Art Therapy, 29(2):48-52.
195
American Art Therapy Association Research Committee. (2012) Art Therapy Outcome Bibliography. Retrieved April 2 2013 at http://www.arttherapy.org/upload/outcomebibliographyresearchcmte.pdf.
196
Ragamuffin project, creative arts therapy. (n.d.). Retrieved March 20 2013 from http://www.ragamuffinproject.org/services/creative-arts-therapy/
197
Panchakna Khlok, Art Therapist at Ragamuffin. Personal communication April 2013.
198
Ibid. In addition to providing individual and group therapy, Ragamuffin has also initiated the free Open Art Studio, during which children are invited to utilize the organization space and resources to play with the artistic mediums, free of charge.
199
The emerging field of ecophilosophy sees wilderness immersion, and the re-connection to the natural environment, as a treatment methodology with immense therapeutic implications.
200
To date, the government has done little, if anything, to distribute mental health information. See LEITNER REPORT, supra note 2. TPO psychosocial education is conducted in the communities, pagodas, schools, and other public places. TPO Cambodia is further using radio and information material to raise awareness on mental health and psychosocial issues. Radio programs are broadcast on FM 96 Mhz, FM 99.5 Mhz and 102 Mhz. An extensive package of information material, including posters, leaflets, banners; has been developed and distributed to the general public. See TPO Cambodia. (n.d.). Community Mental Health. Retrieved from http://tpocambodia.org/index.php?id=33
201
International theater of the oppressed organization. (n.d.). Retrieved March 3 2013 from http://www.theatreoftheoppressed.org/en/index.php?nodeID=1. [hereinafter T.O. WEB]
202
Basting, A., Biechler, M., Hoffman, T., Leigh, B. (2009). Dialogue in Best Practice - White Paper. The Power of Theatre in Health Education. UWM Center on Age & Community. p 9.
203
Ibid.
204
Wardrip-Fruin, N. & and Montfort, N. (2003). From Theatre of the Oppressed. The New Media Reader. Cambridge, Mass.: MIT. ISBN 0-262-23227-8, p. 339-52. Print.
205
See TO WEB, supra note 201. Ibid. Thida Kim, Psychologist at TPO Cambodia. Personal communication March 2013. Ibid.
206
207
208
209
Malchiodi, Cathy A. (2003), Expressive Therapies , New York: Guilford, ISBN 1-59385-379-3. See also Mckenna P, Haste E. Clinical effectiveness of drama therapy in the recovery from neuro-trauma. Disabil Rehabil. 1999;21 (4): 162-74.
210
EMDR (Eye Movement Desensitization and Reprocessing) therapy has been declared an effective form of trauma treatment by a wide range of organizations. In the United States these include the American Psychiatric Association, the International Society for Traumatic Stress Studies, and the Departments of Defense and Veterans Affairs. See Shapiro, F. (n.d.). Can you benefit from emdr therapy?. Retrieved April 26 2013 from http://psychcentral.com/lib/2012/can-you-benefit-from-emdr-therapy. [hereinafter SHAPIRO WEB].
211
Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, 2nd edition, N.Y.: The Guilford Press.
58
58
212
The New York Times. (2, March 12). The evidence on emdr. Retrieved April 16 2013, from http://consults.blogs.nytimes.com/2012/03/02/the-evidence-on-e-m-d-r/ [hereinafter NYT EMDR]
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Lilienfeld, S. O., & Arkowitz, H. (2008, January 3). Emdr: Taking a closer look. Retrieved April 25 2013, from http://www.scientificamerican.com/article.cfm?id=emdr-taking-a-closer-look&page=2. [hereinafter SA EMDR]
214
The one exception is a report published in 2007 by the Institute of Medicine that stated that more research was needed to establish efficacy. Since that time, six more randomized E.M.D.R. therapy studies have been conducted. See NYT EMDR, supra note 172.
215
Herbert, J., Lilienfeld, S., Lohr, J., Montgomery, R., O'Donohue, W., Rosen, G., Tolin, D. (2000). Science and pseudoscience in the development of eye movement desensitization and reprocessing: implications for clinical psychology. Clinical Psychology Review 20 (8): 945971. doi:10.1016/S0272-7358(99)00017-3. PMID 11098395.
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EMDR International Association. (2012, February 25). Definition of emdr. Retrieved from http://www.emdria.org/associations/12049/files/EMDRIA Definition of EMDR.pdf [hereinafter EMDRIA DEF]
217
Ibid. See SHAPIRO WEB, supra note 210. See EMDRIA DEF, supra note 216.
218
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Fletcher, K., Greenwald. PRO and CON -- Eye Movement Desensitization and Reprocessing. The Child Survivor of Traumatic Stress. Coetzee, R. H. & Regel, S. Eye movement desensitization and reprocessing: an update. Advances in Psychiatric Treatment 11: 247354.
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Van den Hout, M., et al. (2011). EMDR: Eye movements superior to beeps in taxing working memory and reducing vividness of recollections. Behavior Research and Therapy, 49, 92-98.
222
Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58, 61-75. Stickgold, R. (2008). Sleep-dependent memory processing and EMDR action. Journal of EMDR Practice and Research, 2, 289-299. The theory that eye movements link into the same processes that occur during R.E.M. sleep is supported by research demonstrating the effects of eye movements on physiological states and memory retrieval. Eye movements have been demonstrated to induce a state of relaxation, or decreased psychophysiological arousal. See Elofsson, U.O.E., Von Scheele, B., Theorell, T., & Sondergaard, H.P. (2008). Physiological correlates of eye movement desensitization and reprocessing. Journal of Anxiety Disorders, 22, 622-634. Sack, M., Lempa, W. Steinmetz, A., Lamprecht, F. & Hofmann, A. (2008). Alterations in autonomic tone during trauma exposure using eye movement desensitization and reprocessing (EMDR) results of a preliminary investigation. Journal of Anxiety Disorders, 22, 1264-1271.] Barrowcliff, A.L., Gray, N.S., Freeman, T.C.A., & MacCulloch, M.J. (2004). Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories. Journal of Forensic Psychiatry and Psychology, 15, 325-345. Schubert, S.J., Lee, C.W. & Drummond, P.D. (2011). The efficacy and psychophysiological correlates of dualattention tasks in eye movement desensitization and reprocessing (EMDR). Journal of Anxiety Disorders, 25, 1-11.] studies using physiological measures. Further support for the R.E.M. theory is found in numerous randomized trials that indicate that bilateral saccadic eye movement enhances retrieval of episodic memory, increases recognition of true information and improves certain measures of attention
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See Christman, S. D., Garvey, K. J., Propper, R. E., & Phaneuf, K. A. (2003). Bilateral eye movements enhance the retrieval of episodic memories. Neuropsychology. 17, 221-229. Christman, S. D., Propper, R. E., & Brown, T. J. (2006). Increased inter-hemispheric interaction is associated with earlier offset of childhood amnesia. Neuropsychology, 20, 336. Kuiken, D., Bears, M., Miall, D., & Smith, L. (2001-2002). Eye movement desensitization reprocessing facilitates attentional orienting. Imagination, Cognition and Personality, 21, (1), 3-20. Kuiken, D., Chudleigh, M. & Racher, D. (2010). Bilateral eye movements, attentional flexibility and metaphor comprehension: The substrate of REM dreaming? Dreaming, 20, 227247. Parker, A., Relph, S. & Dagnall, N. (2008). Effects of bilateral eye movement on retrieval of item, associative and contextual information. Neuropsychology, 22, 136-145. Parker, A., Buckley, S. & Dagnall, N. (2009). Reduced misinformation effects following saccadic bilateral eye movements. Brain and Cognition, 69, 89-97. Parker, A. & Dagnall, N. (2007). Effects of bilateral eye movements on gist based false recognition in the DRM paradigm. Brain and Cognition, 63, 221-225.
223
See SA EMDR, supra note 213.
224
Barrowcliff, A.L., Gray, N.S., Freeman, T.C.A., & MacCulloch, M.J. (2004). Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories. Journal of Forensic Psychiatry and Psychology, 15, 325-345. Barrowcliff, A.L., Gray, N.S., MacCulloch, S., Freeman, T. C.A., & MacCulloch, M.J. (2003). Horizontal rhythmical eye-movements consistently diminish the arousal provoked by auditory stimuli. British Journal of Clinical Psychology, 42, 289-302. Engelhard, I.M., van den Hout, M.A., Janssen, W.C., & van der Beek, J. (2010). Eye movements reduce vividness and emotionality of flashforwards. Behaviour Research and Therapy, 48, 442447. Engelhard, I.M., et al. (2011). Reducing vividness and emotional intensity of recurrent flashforwards by taxing working memory: An analogue study. Journal of Anxiety Disorders 25, 599603. Kavanagh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks on desensitization to emotive memories. British Journal of Clinical Psychology, 40, 267-280. Maxfield, L., Melnyk, W.T. & Hayman, C.A. G. (2008). A working memory explanation for the effects of eye movements in EMDR. Journal of EMDR Practice and Research, 2, 247-261. Schubert, S.J., Lee, C.W. & Drummond, P.D. (2011). The efficacy and psychophysiological correlates of dualattention tasks in eye movement desensitization and reprocessing (EMDR). Journal of Anxiety Disorders, 25, 1-11. Van den Hout, M., Muris, P., Salemink, E., & Kindt, M. (2001). Autobiographical memories become less vivid and emotional after eye movements. British Journal of Clinical Psychology, 40, 121-130. Van den Hout, M., et al. (2011). EMDR: Eye movements superior to beeps in taxing working memory and reducing vividness of recollections. Behaviour Research and Therapy, 49, 92-98.
225
Chemtob, C. M., Tolin, D. F., van der Kolk, B. A., & Pitman, R. K. (2000). Eye movement desensitization and reprocessing. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 139155, 333335). New York: Guilford Press. Davidson, P.R., & Parker, K.C.H. (2001). Eye movement desensitization and reprocessing (EMDR): A metaanalysis. Journal of Consulting and Clinical Psychology, 69, 305-316.
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Salkovskis, P (2002). Review: eye movement desensitization and reprocessing is not better than exposure therapies for anxiety or trauma. Evidence-based mental health 5 (1): 13. doi:10.1136/ebmh.5.1.13. PMID 11915816.
227
See SA EMDR, supra note 213.
228
Gosselin, P., & Matthews, W. J. (1995). Eye movement desensitization and reprocessing in the treatment of test anxiety: A study of the effects of expectancy and eye movement. Journal of Behavior Therapy and Experimental Psychiatry, 26, 331337. Van der Kolk, B., Spinazzola, J. Blaustein, M., Hopper, J. Hopper, E., Korn, D., & Simpson, W. (2007). A random-
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ized clinical trial of EMDR, fluoxetine and pill placebo in the treatment of PTSD: Treatment effects and long-term maintenance. Journal of Clinical Psychiatry, 68, 37-46.
229
Edmond, T., Rubin, A., & Wambach, K. (1999). The effectiveness of EMDR with adult female survivors of childhood sexual abuse. Social Work Research, 23, 103-116. Edmond, T., Sloan, L., & McCarty, D. (2004). Sexual abuse survivors perceptions of the effectiveness of EMDR and eclectic therapy: A mixed-methods study. Research on Social Work Practice, 14, 259-272.
230
See NYT EMDR, supra note 212. Ibid.
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232
Ironson, G.I., Freund, B., Strauss, J.L., & Williams, J. (2002). Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58, 113-128.

Mental Health in Cambodia: The Role of Alternative Treatment Methodologies

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MENTAL HEALTH IN CAMBODIA

The Role of Alternative Treatment Methodologies

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Figure 1: Wild lotus flower