Khm Trauma Book

UNDERSTANDING TRAUMA IN CAMBODIA

Basic Psychological Concepts

e)aHBum<elIkTI2 2nd Edition

TABLE OF CONTENTS

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Greetings from the Director of Deutscher Entwicklungsdienst (DED) in Cambodia It is my pleasure to endorse this first volume of the “Handbook on Trauma” as an outcome of our cooperation with the Center for Social Development (CSD). Within its special program “Civil Peace Service” (ZFD), Deutscher Entwicklungsdienst (DED, German Development Service) is supporting CSD’s public forums on justice and reconciliation. These events are organized throughout Cambodia. They aim to promote outreach for the Khmer Rouge Tribunal and to involve the whole population in the process. Therefore, I warmly congratulate and thank CSD’s Executive Director, Theary C. Seng, and all employees of the organization including DED’s expert on trauma therapy, Mr. Matthias Witzel, for publishing this valuable book. With human compassion and by learning together we have the chance to overcome the remnants of the past. Wolfgang Möllers Director Deutscher Entwicklungsdienst (DED)

Acknowledgements We are indebted to all the Cambodians who have supported us with their time, expertise and knowledge. We are especially grateful to those who shared their personal experiences about their suffering during the Khmer Rouge years, and gave the Handbook’s authors invaluable insights into the complex processes of Cambodian trauma. Our debt to them is substantial. We express our sincere thanks to trauma-therapist Roswitha WITZEL, editors of the English text Holly TELERANT, and Erin PULASKI. Our special gratitude goes to those who have assisted in editing the Khmer text, especially to Ms. Theary C. SENG, Dr. CHEK Sotha, and Mr. SEOUNG Sothearwat. Translating and editing these psychological concepts into Khmer was not only labor-intensive, but also a long-term process, requiring outstanding and serious engagement. Finally, we are indebted to the German Development Service (DED) and the German Civil Peace Service (ZFD), the donors of this publication. YIM Sotheary (Translation, Design), OM Chariya (Translation), SAM Sarath (Illustrations) Matthias WITZEL (Text, Graphics, Design, Photos)

Introduction from Executive Director, CSD Phnom Penh, 8 October 2007 I am deeply proud of this Understanding Trauma in Cambodia Handbook! I believe this Handbook is a must-read for every Cambodian – not only for specialists, NGO workers or the expatriate community – who has been touched by immense loss, and trust that in the process of reading comes understanding, and with understanding comes healing. Some 18 months ago, I was thrilled when the Center for Social Development (“CSD”) was approached by Mr. Wolfgang Möllers of the German Development Service (“DED”) to do collaborative work with DED on issues of justice and reconciliation in light of the Khmer Rouge Tribunal; I was doubly elated to hear that DED would additionally support us with a consultant, and not just any consultant, but one with expertise in trauma and psychology. Immediately, CSD exploited the expertise and generosity of our new consultant, psycho-therapist Matthias Witzel by engaging him in many activities and projects. For me, at the very top of the list of priorities of great urgency was the creation of a handbook on introduction to psychology and trauma, as I had yet to know or read of such a book with basic psychological concepts that was written for and about Cambodians. From our knowledge of our society (in terms of literacy, attentiveness, particularly to unexplored topics such as trauma and psychology) and based on our experience of having created other handbooks in the past, we knew that this handbook has to be accessible and practical for every Cambodian – light in text, free of convolution, attractive and presentable with illustrations, photos and colorful, creative layouts. I believe we have succeeded brilliantly with this Handbook. I can be unabashedly proud of this work because my only contribution is the idea for its inception and language editing. All the credit of the Handbook first and foremost goes to Mr. Matthias Witzel, the author, layout designer, friend, counselor extraordinaire; then there are the superb CSD staff of whom I cannot name all here, but would like to highlight: Ms. YIM Sotheary and Ms. OM Chariya, the ever thoughtful and caring psychology assistants; Mr. SAM Sarath, the brilliant illustrator; and the all-around rock star of an employee, my ever tireless executive assistant, Mr. IM Sophea. Of course, we would not be able to produce this Handbook without the moral and financial support of DED, particularly the encouragement and enthusiasm of its Director, Mr. Wolfgang Möllers. I was most fortunate to have grown up for some years in the United States where I could and did seek out materials (even if on my own) on trauma and psychology to help me make sense of my tumultuous inner life and recurring nightmares as a consequence of the Khmer Rouge years. I am excited and more at peace that now there is this Handbook to help guide my fellow Cambodians through the turbulent emotional terrain of the head and heart and to aid them in making sense of the continuing internal disturbances. Part of the healing process is to understand and to know that we are not alone. I pray that this Handbook will do just that. Theary C. SENG Executive Director

1 A study funded by the United States National Institutes of Health (NIH) National Institute of Mental Health (NIMH) and National Institute on Alcohol Abuse and Alcoholism (NIAAA): Mental Health Services Research at the National Institute of Mental Health (2003): www.nimh.nih.gov/publicat/pubListing.cfm

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1: What Is the Purpose of This Handbook?

In the past year, sixty-two percent of Cambodians living in the United States have suffered from Post-Traumatic Stress Disorder (PTSD) and fifty-one percent have suffered from depression, seventeen times that of the US national average of adults.1 Regarding the prevalence of PTSD within Cambodia, serious research does not exist until now. Although we have to discriminate between local Cambodians and those living overseas, perceptions of psychiatrists and psychologists are that local Cambodians also face a high prevalence of these psychosocial diseases. It is now obvious that many Cambodians today are suffering in their hearts from their previous traumatic experiences. In this Understanding Trauma in Cambodia Handbook, we would like to emphasize that symptoms of trauma are neither a sign of character weakness nor a reason to be deprecated. Understanding the origins, reasons, symptoms, impacts, and potential treatments of such trauma is essential for everybody in Cambodia. Even many years after the Khmer Rouge atrocities, the trauma in the hearts of many Cambodians is still unresolved. The legacy of this suffering is apparent in personality attributes, attitudes, and behaviors of the young generation in Cambodia. The main purpose of this Handbook is to provide an introduction to and basic knowledge of a complex psychological issue in an understandable way. Because the Extraordinary Chambers in the Courts of Cambodia, informally the Khmer Rouge Tribunal, is finally getting underway; many non-governmental organizations and many Cambodians are becoming more engaged in the process of national reconciliation and development, and therefore have to deal with many traumatized people. Reconciliation between individuals, regions within the nation, and between victims and perpetrators in Cambodian villages are among the main issues being tackled by many NGO outreach projects. Although these issues are relevant for all Cambodians, current knowledge in Cambodia concerning psychological effects of the Khmer Rouge years is largely superficial. Therefore, this Handbook seeks to provide a compassionate and professional approach to dealing with traumatized people by presenting more detailed psychological and therapeutic knowledge. We believe greater consciousness about the sociopolitical and individual aspects of trauma is one of the first steps towards individual and national reconciliation. The path to reconciliation cannot exist in this country until there is inner peace in the hearts of individuals and more conscious communication between couples and amongst families, villages, and towns. The glossary at the end of this Handbook defines technical terms from trauma psychology used in the text of this Handbook. Our team worked hard to find suitable Khmer definitions for words such as dissociation, de-realization, freezing, and fragmenting because, to date, there is no comprehensive psychological dictionary in the Khmer language. Although a draft of an EnglishKhmer-French Psychology Dictionary exists, written in 1996 by a team of psychologists at the Royal University of Phnom Penh, this draft is limited and does not contain any explanations of the concepts. Some of these words are still not well known in English and are difficult to define in any language.

This Handbook seeks to present a more detailed psychological and therapeutic knowledge in order to provide a compassionate and professional approach in dealing with traumatized people.

Greater consciousness about the sociopolitical and individual aspects of trauma is one of the first steps towards individual and national reconciliation.

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A study funded by the United States National Institutes of Health (NIH) National Institute of Mental Health (NIMH) and National Institute on Alcohol Abuse and Alcoholism (NIAAA): Mental Health Services Research at the National Institute of Mental Health (2003): www.nimh.nih.gov/publicat/pubListing.cfm

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trauma

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See: http//de.wikipedia.org Last visited on 10 February 2007. See: www.thefreedictionary.com Last visited on 15 December 2006.

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Pearlman, L.A. & Saakvitne, K.W. (1995): Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: W.W. Norton & Company. See: Giller, E., in: www.sidran.org Last visited on 8 November 2006.

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Ibid Allen, J. & Lewis, L. (1996): A conceptual framework for treating traumatic memories and its application to EMDR. Bulletin of the Menninger Clinic, 60(2). 7

2: Where Does the Word “Trauma” Come From and What Does It Mean? Trauma is an

Trauma, a medical term referring to an injury or wound, originates from the Greek language. It is derived from the Greek verb titrosko meaning to pierce, but can also mean damage or defeat. 2

emotional wound or shock that creates substantial and lasting damage to a person’s psychological development.

In the language of daily life, a “trauma” normally refers to a highly stressful event. The noun trauma has two meaning: 1. Physical damage to the body caused by violence or other physical impact, e.g. an accident, 2. An emotional wound or shock, often with long-lasting effect. According to the second meaning, trauma is an emotional wound or shock that creates substantial and lasting damage to a person’s psychological development, often leading to neurosis. Trauma may result from an event or situation that causes great distress and disruption.3 Psychological trauma is essentially a normal response to an extreme event. It involves creating emotional memories about the distressful event that are stored in structures deep within the brain. In general, it is believed that the more direct the exposure to the traumatic event, the higher the risk of emotional harm.

The Noun Trauma Has Two Meanings

Psychological trauma is the unique individual experience of an event or conditions in which: (i) The individual’s ability to integrate his/her emotional experience is overwhelmed, and/or (ii) The individual (subjectively) perceives a threat to life, bodily integrity, or sanity. 4 This definition of trauma is fairly broad. It includes responses to powerful isolated incidents like accidents, natural disasters, crimes, surgeries, deaths, and other violent events. It also includes responses to chronic or repetitive experiences such as child abuse, neglect, combat, urban violence, concentration camps, violent relationships, and enduring deprivation.5

1. Physical bodily damage caused by violence or other physical impact 2. An emotional wound or shock, often with long-lasting effect.

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See: http//de.wikipedia.org Last visited on 10 February 2007. See: www.thefreedictionary.com Last visited on 15 December 2006. Pearlman, L.A. & Saakvitne, K.W. (1995): Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: W.W. Norton & Company. See: Giller, E., in: www.sidran.org Last visited on 8 November 2006.

Some key points to understanding the meaning of psychological trauma: Traumatic experiences shake the foundations of a person’s beliefs about safety, shatterring their assumptions about trust. Stress generally confuses and distracts a person’s nervous system - but only for a relatively short period. Within a few days or weeks, the nervous system tends to calm down and people generally revert to a normal state of equilibrium. However, returning to normalcy is not the case where the person underwent extreme distress, either in duration (i.e., prolonged stress) or impact (i.e., result of traumatic event). A trauma can be re-experienced at any time – even after many years – if left unresolved. Regaining mental health means regaining peace of mind and body. Therefore, it is necessary to be aware of both trauma’s processes and its impact. There are no clear divisions between stress which leads to trauma and stress which leads to adaptation. These aspects of the phenomenon of trauma will be discussed in more detail within the following chapters.

It is an individuPsychological Trauma

al’s subjective experience that determines whether an event is or is not traumatic.6

Essential Aspects of Psychological Trauma

An individual’s unique experience of an event or enduring condition, in which: 1) The individual’s ability to integrate his/her emotional experience is overwhelmed, and/or 2) The individual (subjectively) perceives a threat to life, bodily integrity, or sanity.

• It is the subjective experience of objective events that constitutes trauma. • The more a person believes s/he is endangered, the more traumatized s/he will be. • Psychologically, trauma is overwhelming emotion and a feeling of utter helplessness. • There may or may not be bodily injury, but psychological trauma is often coupled with a physiological upheaval that plays a leading role in the long-range effects.7

As traumatic as single shocking events are, the traumatic experiences that result in the most serious mental health problems are prolonged and repeated, sometimes extending over years of a person’s life – for example in Cambodia during the years of the Khmer Rouge Regime.

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Ibid Allen, J. & Lewis, L. (1996): A conceptual framework for treating traumatic memories and its application to EMDR. Bulletin of the Menninger Clinic, 60(2). 7

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DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, published by the American Psychiatric Association, USA (2000).

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Hermann, J.L. (2003): Die Narben der Gewalt, Paderborn: Junfermann.

3: What Is a Traumatic Event?

A traumatic event is an event or series of events that causes moderate to severe stress reactions.

Traumatic Event:

Traumatic events are those that create a sense of horror, helplessness, serious injury, or threat of serious injury or death. Therefore, most of the daily experiences during the Khmer Rouge years can be defined as traumatic events.

An event outside

Traumatic events affect survivors, rescue workers, and friends and relatives of those who have directly suffered injury or loss. They may also affect people who have witnessed the event either firsthand or on television. Stressful reactions immediately following a traumatic event are very common. However, such reactions usually diminish or are resolved within ten days. Evidence from studies of trauma victims demonstrate that people react to the same traumatic event differently. Some are proactive, while others merely react. Some are so overwhelmed that they are unable to act, and consequently, do nothing. Proactive people creatively seek to control a situation, causing something to happen rather than waiting. These people tend to overcome and cope well in extremely stressful situations. People who merely react tend to cope less well. Moreover people who are neither proactive nor reactive tend to develop serious physical or psychological symptoms or to die with no noticeable coping actions.

the range of usual human experience which would be markedly distressing to almost anyone. 8

Traumatic events are extraordinary, not because they occur rarely,

Trauma results when an experience is so

but rather

overwhelming that

because they

people freeze, go numb,

overwhelm the ordinary

or disconnect from what’s happening. While this

Traumatic events involve threats to life or bodily integrity or a close personal encounter with violence or death. They confront human beings with helplessness and terror, and evoke catastrophic responses. 9

human adaptations

automatic response

to life.

protects people from the terror they feel, it also prevents them from moving on.

A traumatic event is an event, or series of events, that cause moderate to severe stressful reactions.

Some people are proactive (creative seeking to control a situation, causing something to happen rather then waiting), some people only react, and some people are overwhelmed to the point of doing nothing.

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DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, published by the American Psychiatric Association, USA (2000). 9 Hermann, J.L. (2003): Die Narben der Gewalt, Paderborn: Junfermann.

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4: What Is Individual and Psychosocial Trauma in the Cambodian Context? Trauma has a

Research reveals that trauma manifests itself in two forms: individual trauma and psychosocial trauma.

double manifestation: individual trauma and psychosocial trauma.

The term psychosocial trauma is used to describe the social impact of political, cultural and economic oppression. While some individuals witness or endure more than others, pervasive fear, grief and poverty take their toll on the wider community. Psychosocial trauma refers to both its impact on individuals and on society as a whole. In order to be understood, a psychosocial trauma must be considered and analyzed regarding a very specific socio-cultural context. During the Khmer Rouge regime, nearly the entire population experienced long-term exposure to a “disaster made by their own people,” a man-made or human-caused disaster which included nationwide atrocities. The whole civil society was destroyed, people lost their friends and relatives, and because people lived in extreme fear, relationships between people changed dramatically.

The term “psychosocial trauma” is used to describe the social impact of political, cultural and economic oppression. While some individuals witness or endure more than others, pervasive fear, grief and anger etc. take their toll on the wider community. Psychosocial trauma refers to both its impact on individuals and on society as a whole. When Cambodians began to suffer from these destructive events – and for many people this began long before the Khmer Rouge became the supreme authority - most of them faced three common elements of psychosocial trauma with impacts on the individual and social context: (i) Most Cambodians did not expect that there would be a civil war; (ii) Cambodians were not prepared for these egregious events; and (iii) Cambodians could do nothing to prevent the traumatic events from happening. • Cambodians did not expect that there would be a civil war. • Cambodians were not prepared for these egregious events. • Cambodians could do nothing to prevent the traumatic events from happening.

Due to the complete upheaval of Cambodian society, most people were forced into collective and unique individual experiences of events in which: 1) their daily experiences threatened life, bodily integrity, or sanity; and 2) the ability to integrate their emotional experiences was overwhelmed.

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Figure 4.1: Double manifestation of a trauma experience, as individual trauma and as psychosocial trauma. Within a specific socio-cultural context people are confronted with impact on the individual and social level.

The impact on the whole Cambodian society still persists: • • • • •

destruction of peer groups and relationships on many levels distrust and fear destructive communication pattern social disengagement domestic violence, etc.

This is caused by and corresponds with immature pattern and structures in the level of personality development of many Cambodians, who were traumatized during the Khmer Rouge years: • lack of self esteem • lack of anger management • lack of creativity • lack of compassion • lack of peaceful communication skills • lack of physical health • lack of morality and positive ethic principles, etc. Most Cambodians survivors of the Pol Pot era experienced or witnessed many awful events, events which would normally overwhelm a person’s capacity to cognitively and emotionally process their experiences. Many Cambodians were emotionally shocked over those years, which understandably led to a breakdown in cognitive processing. Despite such dire trauma, many survivors remain healthy and continue to be a source of emotional support and encouragement for others.

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5: How Does Trauma Effect the Brain?

Recent technology allowing us to view brain activity reveals that trauma can change the structure and function of the brain. Studies found that brain scans of people with relationship or developmental problems, learning problems, or social problems resulting from Post-Traumatic Stress Disorder (PTSD) have similar structural and functional irregularities.

Trauma can change the structure and function of the brain.

Prefrontal lobe (Part of the Cerebral cortex) Future awareness, empathy and moral sense

Figure 5.1: The structure of the human brain is composed of four main parts: Cerebral Cortex, Limbic system, Cerebellum, and Brain stem.

Cerebral cortex (also known as neocortex): The cerebral cortex, the most recently evolved portion of the brain, is located in the upper part of the brain and includes the frontal cortex. This is where the higher-level skills of thinking occur, such as logic and reason, understanding the cause and effect of our actions, and conscious realization of movements. Limbic system: The limbic system sits on top of the brain stem and is buried in the center of the brain. It represents a more primitive brain structure than the cerebral cortex. The limbic

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Much of why traumatic events have such powerful effects on us is because they act directly on the brainstem and limbic structures, and override the more conscious control and rational thought process of the cortex.

system is the source of our emotions and motivations, especially those linked to survival, i.e. fear, anger, hunger and sexuality. The reason traumatic events have such powerful effects on us is because it acts directly on the brainstem and limbic structures and overrides our cerebral cortex, which is responsible for conscious control and rational thought processes. Cerebellum: (also known as Hindbrain). The cerebellum is located at the back base of the brain. Representing 1/8 of the brain’s mass, it maintains our balance and posture. Moreover, the cerebellum coordinates our skilled repetitive movements. Brainstem: The brainstem connects the brain to the spinal cord. It controls many basic functions, i.e. heart rate, breathing, eating, and sleeping.

Figure 5.4 : Evolutionary process of the development of the brain from the oldest structure (brain stem) to the prefrontal lobe within the neocortex: Traumatic events have such powerful effects on us because they act directly on the early developed brain structures such as brain stem and limbic structures. They override the more conscious control and rational thought process of the cerebral cortex with the prefrontal lobe, which are developed later in our evolution. The goal of this extreme reaction of the brain is to keep the capacity to act.

How Does the Human Brain Process Threatening Information? 1. Normal and healthy impulses from outside the human organism (such as a friendly question, an interesting piece of information) are assimilated and pooled within the thalamus. Then they move to the hippocampus. The hippocampus is able to evaluate the impulses and sort tem-

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porally and specially. This structure, like a librarian, helps the brain organize, regulate, and evaluate: “I can recognize, I can understand.” From the hippocampus the information moves to the cerebral cortex, also known as neocortex. Within the cerebral cortex, higher level of thinking skills occurs, i.e. logic and reason, cause and effect of our actions, and conscious understanding. This structure of the brain functions like a disc and saves all information and experiences. The Broca’s area (in the inferior frontal gyrus of the frontal lobe – view graphic, p.21) sorts information linguistically. When exposed to traumatic events, the Broca’s area is inhibited. In turn, people stagger and become silent. 2. Over-stimulating (unhealthy) impulses (like those received during traumatic events) are directed to the amygdala, a tiny but important structure within the limbic system, which acts as the early warning system of the brain. Within the amygdala, the brain evaluates the incoming impulses as to whether they are dangerous for the body or the soul. This accounts for the organism’s over-stimulation during traumatic events. The amygdala is unable to associate and cannot make rational combinations or undertake logical thinking. However, this brain function was important to the historical development of the human race, as it was the origin of the “fight and flight” reaction (e.g. a person in an outburst of rage acts on the level of amygdala and the access to the cerebral cortex is blocked). If the amygdala reacts with alarm during a severely stressful or traumatic event, the information will not be sent to the hippocampus (at least not at the moment of shock). The event remains saved as “hot” (cannot be processed) on the amygdala level as a fragmented experience (See Chapter 7, Fragmenting). Emotions, sentiments, images, behavior, thoughts are recorded in fragments. These unprocessed fragmented experiences, in turn, prevent new information from being saved. Therefore, chronic stress, such as being exposed to prolonged traumatic events, causes destructive structural changes in the brain, which can be seen in computer topography. The result is not only that “old information” cannot be processed, but also that new information is delayed.

Chronic stress, such as being exposed to prolonged traumatic events, causes destructive structural changes in the brain, which can be seen in computer topography. The result is not only that “old informa-

If information cannot be classified, it will be assessed incorrectly from the early warning system (amygdala). This may be prolonged “forever”. Furthermore, the amygdala triggers flight or fight (See Glossary) response, which explains why traumatized people tend to be very scared, quick, irritable, and nervous. This often causes suspicious and aggressive behavior as well as a permanent anxiety and alertness.10 Two main responses in the brain and their effects on mental health:

tion” cannot be processed, but also that new information is delayed.

• The brain is a network which is able to structure itself and orient itself along the inputs of new information. The brain is able to process new information, to change and to modify at any time. Thus, for traumatized people an adequate therapeutic approach is necessary and also promising. New information, such as adequate therapeutic intervention, can help to process the blocked “old” frightening information. • For traumatized people many situations are too loud, hectic, or frightening. If they are further exposed to such loud, hectic, and frightening stimuli, which the Hippocampus cannot process, people often adapt in an unhealthy manner to the environment. They themselves become an “incorporation” of their incorporated stimuli. This means that they become loud, nervous and frightened. 10

Discussions with Dorsch Witzel, R. (2006), Trauma-Psychotherapist, Zürich/Switzerland.

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Huber,M. (2003): Trauma und die Folgen, Trauma und Traumabehandlung Teil 1, Paderborn: Junfermann.

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Ibid

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6: What Is the Process of Coping with Traumatic Events? Understanding the “flight or fight” stress response and the processes of “freezing” and “fragmenting” Trauma involves an unique physical and/or emotional shock that pressures the brain, obliging it to deal with the situation in a very specific way. The information system of the brain is flooded in such a way that no usual coping mechanisms remain.

Stress confuses and distracts our nervous system - but only for a relatively short period. Within a few days or weeks, our nervous system calms down and we revert to a normal state of equilibrium. However, this return to normality is not the case when we have been traumatized.

Trauma is stress run amok.

Freezing means a kind of paralysis. The brain says: I defend the aggressive stimulus and give myself the permission to dissociate inwardly to

Our brain, particularly our brainstem (See Chapter 5), is equipped to deal with deadly threats. When flooded with stress, we automatically and unconsciously react in one of two ways: flight or fight. This is guided by our brainstem. This situation escalates the fight or flight stress response (feeling angry or scared) into super-stress (feeling terrified, stunned, horrified, overwhelmed, blanking out). This so-called “flight or fight” phenomenon means that our brain unconsciously decides to fight against the stress factor or, if fighting is not a good idea, to flee the situation (e.g., if the perpetrator seems to be much stronger). In many stressful situations a person is able to successfully prevent a trauma by fighting or fleeing. In a very traumatic situation such as torture or rape, where neither flight nor fight is possible, the brain might react with freezing or with fragmenting. From the moment we freeze we know unconsciously that the event is traumatic and no longer “just” a very stressful situation. Freeze means a kind of paralysis. It is as if the brain says: I don’t have the ability to guide the organism out of this situation securely, and I am not able to fight this external aggression. Therefore, I have to defend the aggressive stimulus and give myself (my organism) the permission to dissociate inwardly ( See Chapter 7: Dissociation ). A huge amount of endorphin (a pain-anaesthetizing opiate produced naturally in the body) allows the person to “mentally disappear” and “neutralize” an acute death threat. Also, the noradrenalin from the suprarenal gland, which organizes the so called “tunnel view” blocks the naturally integrative perception, if enough of it rushes through the organism. The natural reaction of a person who faces a traumatic event would be to scream, cry for help, collapse or weep.

from fear and

However, very often, the freezing reaction enables one to alienate oneself from the terrifying event. Many people will respond much later with normal reactions. If they regain security and their brain is “charged down” and relaxed again, they suddenly collapse, scream, and cry. But most people do not immediately respond in this manner. Their first reaction is to freeze.

pain. 11

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mentally escape

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Huber,M. (2003): Trauma und die Folgen, Trauma und Traumabehandlung Teil 1, Paderborn: Junfermann.

The brain has another mechanism called fragmenting: The threatening experience will be splintered into many pieces, which will be suppressed in such a way that the external event can no longer be remembered cohesively without a very focused effort at a later time. This reaction is like a mirror which splinters at the very moment of the peak of the traumatic stress: The remaining splinters of the mirror don’t reveal a full picture (of the traumatic event). Thus, they do not allow the brain to recognize what kind of event happened, only that something happened.

Fragmenting:

We have to discriminate: Just as the brain employs to protect a person from psychological and physical pain, the psychological (survival) mechanisms of dissociation (such as freezing and fragmenting), which initially helps people cope with an unbearable moment, may lead to unhealthy long-term effects. This tends to happen when people do not process and integrate their trauma within some weeks or month after it occurs (See Chapter 8).

pieces, which will

The threatening experience will splinter into many be suppressed in such a way that the external event can no longer be remembered cohesively without a very focused effort at a later time. 12

Figure 6.2 : The unhealthy process of coping with traumatic events and developing a trauma: If “flight” or “fight” is not possible, “freezing” will be a common reaction and the organism adds another mechanism which is called “fragmenting”. 12

Ibid

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Huber,M.(2003): Trauma und die Folgen, Trauma und Traumabehandlung Teil 1, Paderborn: Junfermann.

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7: How Does “Dissociation” Help to Survive Trauma?

Dissociation, a mental process produces a lack of connection in a person’s thoughts, memories, feelings, actions, or sense of identity. During the time a person is dissociating, certain information is not associated with other information as it normally would be. If a person is dissociating, s/he seems to think and behave not logically and emotionally incoherent. Why does the brain react to stressful situations with dissociation? Normally, it is not very useful if we are not able to think logically and coherently. However, extreme situations call for extreme measures. If we are in a state of traumatic shock, our nervous system and our brain react intensely; the only goal is to regain the capacity to act. However, the cost is an experience of alienation in which we lose the ability to classify the actual event in a temporal, linguistic, and emotionally coherent manner. 13

Dissociation, mental process, produces a lack of connection in a person’s thoughts, memories, feelings, actions, or sense of identity. During the time a person is dissociating, certain information is not associated with other information as it normally would be. Dissociation is the process of becoming

The brain may respond to a very traumatic situation with dissociation. It is as if the brain says: “I don’t have the ability to guide the organism out of this situation securely, and I am not able to fight this external aggressive stimulus. Therefore, I have to defend the aggressive stimulus and give the organism the permission to dissociate inwardly”.

physically and/ For example: Two rice field workers stepped on a mine. Fortunately they didn’t lose any limbs, but both workers seriously injured both of their legs. One worker lost a lot of blood and collapsed unconscious. The other one acted in a manner of self-alienation. He behaved very calmly, shouldered his colleague and walked for some hundred meters to the next village, where they were able to seek a doctor. One could define this as self-alienation because he had very large gashes on both legs, such that his leg bones could be seen. Obviously, this second worker was in a state of dissociation as he didn’t realize what happened to him. He didn’t notice the large gashes on his legs. The dissociation helped him to stay calm and do his best to save the life of his colleague.

or physiologically disconnected with the internal and external effects that occur during events: “I don’t feel any pain”. “This doesn’t

The coping strategy of dissociation allows people to struggle with unfathomable, unbearable circumstances, but with detachment and suppression of feelings.

happen to me”. 13

“This isn’t me”.

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Huber,M.(2003): Trauma und die Folgen, Trauma und Traumabehandlung Teil 1, Paderborn: Junfermann.

The dissociation phenomenon happens through brain processes in the amygdala-system (part of the limbic system, responsible for processing feelings) and through a comprehensive breakdown of the hippocampus, the speech center, and the frontal lobe (within the cortex).

Description of Some States of Dissociation: 1. Dissociation as a phenomenon of daily life 2. De-Realization 3. Chronic De-Realization, 4. Depersonalization and 5. Dissociative Identity Disorder (See Glossary)

1. Dissociation may be a phenomenon of daily life, where the capacity to dissociate is ordinary, like driving a car and after arriving at home not remembering what happened on the streets. It may also be an attribute of personality. A person who has the ability to dissociate is more capable of “beaming away” from his or her comprehensive perception of the reality of daily life. A person who lacks the ability to dissociate will have problems blocking out their perceptions if he or she is overwhelmed with stimuli. This may lead to headaches or other symptoms of stress such as racing heart, muscle tension, breathing difficulties, etc.

If we are in a state of traumatic shock our nervous system and our brain react intensely. The only goal of our nervous system is to regain the capacity to act.

Where extremely stressful traumatic events cannot be adequately

2. For some people, De-Realization is an automatic reaction in cases of external or internal stress. They respond with a kind of “tunnel vision” (See Glossary), whereby they lose awareness of all elements of the event that they normally would perceive. People who experience this state of dissociation report feeling like there is an invisible wall between them and the world, that they feel like they are always day-dreaming or that their ears and eyes don’t function as well as before. Sometimes, it is as if their mind takes them to another place.

processed, the

For example: A women is walking through the rice fields absorbed in thought. Suddenly she sees two aggressive men in front of her. One man tries to hold her arms back and the other starts to tear her clothes. She realizes that they want to rape her. She sees the hatred in the eyes of her perpetrators. But in the next moment her perception changes. She thinks to herself: “I have seen this once in a film. This is not reality. This is not now”.

disappear from

De-Realization is the inner voice that says: “All this is not true. This has nothing to do with me. This is not my life.” With traumatic stress, many people experience events in this way. Later, the brain will try to regain the suppressed impressions and to allow the realization to occur: “Surely this is true. This really happened to me.”

The more stress

3. It may be that this realization cannot happen for a long time, because the brain refuses to let the suppressed impressions - which are still threatening - emerge. This may lead to Chronic De-Realization which is important in the context of Post-Traumatic Stress Disorder (PTSD). Thus, what was once a mechanism to protect a person from overwhelming impressions becomes a problem.

brain uses dissociation to survive and to overwhelming pain.

a person has, the more likely he is to dissociate.

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Dissociation enables one to avoid cognition at the very moment

For example: A former soldier witnessed many atrocities and was also forced to participate in some of the cruel behavior. He often feels depressed, but mostly he doesn’t feel anything. He normally sits inside his house and stares at the walls. He often doesn’t realize what happens around him. He perceives the events in his family life as through a glass wall. To get out of this state of intense De-Realization, he sometimes intentionally burns his skin with his cigarette because a painful feeling is better than no feelings at all.

of the trauma, where it is too

De-Realization, one status of Dissociation

dangerous to face the reality of the atrocity in all its dimensions.

I feel like living in a dream I have gone through torture while my mind was telling me: ”That is not me”

I feel that my tortured body is often disconnected from the feelings of pain I feel that I can turn off or detach from my emotions

Without the capacity to dissociate, many people couldn’t survive traumatic events. If people are unable to

“It is as if there is a wall of glass between me and the world. It seems that often my body, my feelings and my mind are anaesthetized.”

integrate the trauma within some weeks or months, they will suffer from the destructive long-term impact of dissociation.

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4. There is also the phenomenon of Depersonalization. This occurs when a person is no longer able to perceive him-or herself; for instance, they are no longer able to feel parts of his or her own body. In this state, the person doesn’t feel pain. Rather, the person feels like s/he is stepping outside of his or her own body. For example: A victim of torture feels the painful shocks and kicks inflicted on his body by the torture. When it becomes more brutal, he thinks: “This is only a dream”. Before he loses consciousness, he feels detached from his body. He only feels slaps and pressing, nothing else. As if from very far away, he hears the crying of the torturers and a groaning sound, but he doesn’t perceive that it comes out of his own mouth.

5. The most intensive state of dissociation is called the Dissociative Identity Disorder. This is a very serious psychiatric disease. In the past, this disease was known as Multiple Personality Disorder. If a person is “multiple traumatized”, his whole personality can break to pieces. In this dramatic process, the different pieces of an individual’s personality are developing their autonomous life. A person who suffers from this sort of impact of a trauma can behave like many different persons, without realizing it. For example: A person with this disease does not realize that sometimes s/he behaves as if s/he is addicted to alcohol and sometimes as if s/he never drinks alcohol. Neither part of his personality knows about the existence of the other part. The first personality fragment may sometimes beat his wife and his children after drinking alcohol, and another personality fragment may be very engaged against domestic violence. His family and friends realize his disease, whereas he himself does not. Beside the different kinds of dissociation, there are a number of other unhealthy and painful effects from traumatic experiences. (See Chapter 10 and 11).

Figure 7.1: Limbic system with Amygdala, Hippocampus and Hypothalamus. If the brain responds to a very stressful situation with dissociation, these brain structures are especially involved.

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8. Can an Unhealed Trauma Be Re-experienced After 30 Years? A trauma can be re-experienced many times throughout one’s life. It is not true that time heals all grief and pain. But just as the brain employs to protect the person from psychological and physical pain, the psychological mechanism of “dissociation”, which initially helps people to cope with an unbearable moment, may lead to unhealthy long-term effects. This tends to happen when people do not integrate their trauma within some weeks or months after it occurs. Many Cambodians who lived through the Khmer Rouge years did not have the chance to integrate their trauma. They repeatedly had to face traumatic events, and then experience the continuous intrusion of new traumatic events. Without any possibility of finding a safe place to integrate their feelings of fear and pain, and without any support from people who were not traumatized (because everyone else was traumatized as well), these Cambodians did not have an opportunity to heal during these times. The consequence for most was to remain in a state of dissociation. Thus they were unable to avoid feeling the full depth of the pain from the trauma they experienced: The pain would have been too overwhelming. The coping strategy of dissociation allows people to struggle with unfathomable, unbearable circumstances, but with detachment and suppression of feelings. A common result of this phenomenon is that from time to time, the tremendous suppressed grief, sadness, and anger erupts in problematic ways. We know from studying the experiences of survivors of the Holocaust in Germany that there are always exceptions: Some people respond to traumatic experiences with compassion and are able to keep in contact with their feelings, even when it seems impossible. However, despite the power of dissociation as a coping mechanism, daily life provides a number of opportunities for grief and other feelings to emerge. The stimuli which are responsible for the emerging of these feelings are called triggers. A trigger is an event, an object, a person, or a sensation that sets a series of thoughts in motion or reminds a person of some aspect of his or her traumatic past. A person may be unaware of what is triggering the memory (e.g., loud noises, a particular color, piece of music, odor, etc.). But becoming aware of these triggers, and learning not to overreact to them, is an important therapeutic task in the treatment of traumatized people In Cambodian society, daily life remains filled with triggers. Every frightening personal or social situation may wake the “sleeping dogs” of trauma. This could be the unstable political situation, the insensitive statements of Cambodian leaders, or one’s own personal experiences related to corruption, land grabbing, land mines, rape, domestic violence, unprofessional and unjust courts and many more societal problems. As long as life in Cambodia continues to lack real security and reliability, every single moment can trigger memories of old traumatic experiences and feelings. To handle the challenges of Cambodian life, people have had to develop specific psychological and behavioral coping strategies, which are pervasive throughout the country. These coping strategies can be constructive but are mostly destructive, depending on personal and environmental conditions (e.g., avoidance of talking, emotional detachment - see below)

A trauma can be re-experienced many times throughout one’s life. It isn’t true that time heals all grief and pain.

A trigger is an event, an object, a person, etc. that sets a series of thoughts in motion or reminds a person of some aspect of his or her traumatic past.

The goal of these coping strategies is to avoid the emergence of too much grief and anger related to past traumatic events.

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Every frightening personal or social situation may wake the “sleeping dogs” of trauma. This could be: • the unstable political situation • the insensitive statements of Cambodian leaders • one’s own personal experiences related to corruption, land grabbing, land mines, rape, domestic violence, unprofessional and unjust courts • many more societal problems

Unfortunately, there has yet to be any systematic research into typical Cambodian coping strategies. Nevertheless, there are tendencies that are unique to Cambodia, as there are in all countries attempting to reconcile their specific history after civil war.

It can be re-experienced even 50 or 60 years later because the perpetrators have still not accepted their guilt. I still have nightmares some nights. When I see a few pieces of rice on the table or on the mat while my children have their meal, it reminds me of the time that I was so starving, when I did not have any rice to eat and did not even know what rice was. This sight pushes me to give advice to my children and tell them about the Khmer Rouge era.

VANN Nath, 61 years, one of twelve survivors of Tuol Sleng.

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When I see people with black clothes, it triggers my memory of every event that I experienced in the Khmer Rouge era. When I go to visit my home district in Battambang, I remember every memory I had there. When I walk along the riverside, I remember the fun times when I walked with many friends of mine. I also remember my past when I see the rice fields at my hometown. I always tell myself: Be the owner of your emotions; don’t let your emotions own you. By this I mean that we cannot let our emotions control our body and behavior; we must be the owner of our emotions. I do not let my emotion do what it wants because I am afraid that then people will say I am crazy. We cannot deal with those emotions, but we can have prevention.

Interviewed by YIM Sotheary and M.Witzel, April 18, 2007

To avoid triggers, people with background trauma often A women is triggered by perceiving the situation of domestic violence

Some common tendencies, respectively coping mechanisms in Cambodia are:

“choose” to avoid the grief and despair of

Avoidance of talking about recent Cambodian history (whether personal, autobiographical events or comprehensive Cambodian history).

strangers.

Emotional detachment, which is characterized by a lack of compassion for the suffering of the weak, the disabled or displaced people. The fact that Cambodians take extremely good care of their relatives and friends reveals that compassion is often fragmented. Being in touch with one’s own feelings is only possible within the shelter of one’s own family. To avoid triggers, people with background trauma often “choose” to avoid the grief and despair of strangers. Unfortunately, the coping strategies they use to deal with trauma often malfunction, due to the large amount of triggers in daily life. Many people channel the trig-

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gered energy of grief and anger through domestic violence, alcohol, drug abuse, and other destructive coping mechanisms. Former victims treating other people as they were treated in the time of the atrocities. Even if they never act as cruelly as they themselves were treated, some of the behavior patterns, the pervasive threat of violence, and the tension within professional relationships often evoke the behavior or some aspects of behavior of the former perpetrators. A real alternative to these mostly unconscious methods of coping with the traumatic past is to integrate the past trauma through a healing process within a psychological or psychiatric treatment. Traditional Cambodian approaches to reconciling the past are also available (See page 114).

Emotional support for victims of the Khmer Rouge years during outreach activities.

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9: What Are the Most Common Symptoms of Emotional Trauma in Cambodia? Reactions to acute trauma can be extremely varied, emerging in each person in a different combination. Related changes to the body, mind, and emotions may gradually disappear over time. However, if the symptoms do not disappear or become more intensive, the person may have developed a serious mental health disease which requires special treatment and support. Sometimes the responses to a traumatic event are delayed for months or even years after the event. Often people do not initially associate their symptoms with the precipitating trauma.

Sometimes the responses to a traumatic event are delayed for months or even years after the event. Lack of ability to deal with fear of ghosts

Often people do not initially associate their symptoms with the precipitating trauma.

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Figure 10.2 : All of the symptoms depicted here could be aspects of a normal reaction to trauma, and could be part of the natural healing process, as long as they only last for a brief time.

In order to focus on the trauma symptoms we can identify within Cambodian society, we must consider the special circumstances of the Cambodian situation, where the major traumatic events occurred more then 25 years ago. Therefore, the approach discussed herein is specifically orientated towards symptoms that have lasted a long time. We can classify them into three categories of symptoms: (i) symptoms related to re-experiencing the trauma, (ii) symptoms related to emotional numbing and avoidance, and (iii) symptoms related to increased or decreased arousal.

Re-experiencing the Trauma: • Intrusive thoughts (See Glossary) • Flashbacks and nightmares (See Glossary) • Sudden floods of emotions or images related to the traumatic events Emotional Numbing and Avoidance: • Amnesia • Avoidance of situations that resemble the initial event • Avoidance of reality through different kinds of addiction • Depression • Emotional Detachment • Feelings of guilt • Grief reactions • An altered sense of time Increased Arousal: • Hypervigilance (See Glossary) • An extreme sense of being on guard • Overreactions, including sudden unprovoked anger • General anxiety • Insomnia • Obsessions with death

All of the symptoms described here could be aspects of a normal reaction to trauma, and could be part of the natural healing process, as long as they only last for a brief time. Whether a person will respond with prolonged traumatic symptoms or with symptoms, which are normal emotional reactions during a process of integrating traumatic events depends on several factors, including the individual’s ability to cope with the traumatic event (See Chapter 15).

Trauma symptoms are often functional, and can be seen as signs of a trauma survivor’s system trying to reestablish its balance. They should be viewed as signs of health, not illness.

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Tedeschi, R.G., and Calhoun, L.G. (1996): The post-traumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, Vol. 9, 455–71. Chesler, M. (2003): Post-traumatic growth, in: Prevention Researcher Vol. 10, 2003, Michigan/ USA.

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Tedeschi, R.G., Park, C. and Calhoun, L.G. (eds): (1998) Post-traumatic Growth: Theory and research in the aftermath of crisis, Mahwah: Erlbaum. 18 ibid

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Seng, Theary, C. (2005): Daughter of the killing fields. Asrei’s story, London: Fusion, p. 259. Seng, Theary, C. (2005): Daughter of the killing fields. Asrei’s story, London: Fusion, p. 262.

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10: What Kinds of Mental Health Impacts Might Develop from Traumatic Events? Post-Traumatic Growth (PTG) is the experience of expression of positive life change as an outcome of a trauma or life crisis. This does not mean that anyone is ”glad that they had to experience traumatic events”, but that they report ”having experienced benefits” or ”having made something positive out of it.” 16

There are some common misunderstandings about trauma. The most common myth is that trauma symptoms are always a sign of pathology. To the contrary, trauma symptoms are often functional, and can be seen as signs of a trauma survivor’s system trying to re-establish its balance. They should be viewed as signs of health, not illness. They serve important functions that reflect the victim’s dual need to recognize the reality and impact of their trauma, while denying what is overwhelming and unbearable. The variety of positive changes that individuals may experience in their struggles with trauma are described by psychological models of post-traumatic growth15. These changes include improved relationships, new life options, a greater appreciation for life, a greater sense of personal strength, and a deepened sense of spiritual development. This reflects a basic paradox or irony: trauma survivors often find that their losses have produced valuable gains.

Figure 10.1 : People have different personal histories, different personality patterns, different coping skills, and different health conditions before a traumatic event happens. These preconditions influence the individual’s physical, emotional, and mental responses to a prolonged traumatic event such as a civil war. (See picture, page 57) 15 16

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Tedeschi, R.G., and Calhoun, L.G. (1996): The post-traumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, Vol. 9, 455–71. Chesler, M. (2003): Post-traumatic growth, in: Prevention Researcher Vol. 10, 2003, Michigan/ USA.

Research also shows that other paradoxes arise. For example, many trauma survivors report that they feel more vulnerable, yet also stronger. While they may have an increased sense of vulnerability, due to their experience of suffering from forces they may not have been able to prevent or control, these same people may also experience an increased sense of their own capacities to survive and prevail17. There is a wide spectrum of responses, from Many trauma survivors also report a need to talk about their traumatic brief emotional reactions to prolonged seexperiences. Through this, they may also find an increased comfort with rious mental health symptoms, which may intimacy, and a greater sense of compassion for others who experience arise from exposure to traumatic events. life’s difficulties. Individuals who have faced trauma may be more likely to engage with fundamental existential questions about death and the purpose of life. Others commonly report a greater appreciation for the smaller things in life, and a heightened sensitivity to the religious, spiritual, and existential components of life18

“I do not believe the tribunal itself will bring about personal healing. That takes place in the quietness of one’s soul. For me, there has been no tribunal but nonetheless I have emotional health. Healing came with time, grace, space, distance and an incredible support structure of loving family members, friends and community…” 19 “Who is this savage, the Khmer Rouge? Is she not I, but only one degree removed at birth? Is her baseness not within my capability? Do we at times not find ourselves standing at the edge of a precipice? Life is but a breath. Live passionately. Love deeply. Pray unceasingly.” 20

SENG Theary

Another common misunderstanding is that loss, grief and trauma are the same things. They frequently look similar, especially in the acute phase immediately following a traumatic event. However, they also involve different processes and require treatment appropriate to each. Trauma is frequently an overlay on the grief process, and may interfere with grieving and mourning if it is not perceived and addressed separately. 17 18 19 20

Tedeschi, R.G., Park, C. and Calhoun, L.G. (eds): (1998) Post-traumatic Growth: Theory and research in the aftermath of crisis, Mahwah: Erlbaum. ibid Seng, Theary, C. (2005): Daughter of the killing fields. Asrei’s story, London: Fusion, p. 259. Seng, Theary, C. (2005): Daughter of the killing fields. Asrei’s story, London: Fusion, p. 262.

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Trauma symptoms are probably adaptive, and originally evolved to help people recognize and avoid dangerous experiences. Nevertheless, there are a wide spectrum of responses, from brief emotional reactions to prolonged serious mental health symptoms, which may arise from exposure to traumatic events. For example, individual responses may range from brief reactive conditions, such as mild anxiety, to Post-Traumatic Stress Disorder (PTSD), or major psychiatric illnesses, such as schizophrenia or personality disorders. Some are more serious than others, and people who suffer from more severe disorders like PTSD definitely require professional help, and should seek psychological or psychiatric treatment.

Figure 10.2 : Possible healthy and unhealthy reactions after a person is exposed to a traumatic event. The healthy process also can be called “ Process of Integration of the experience into personality”.

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Mental Illnesses Resulting from War and Displacement Anxiety disorders Any disorder in which anxiety is the primary feature or in which anxiety appears when the individual tries to resist a phobia. Mood disorders - especially depression Psychological disorders involving intense and prolonged shifts in mood. A person with a mood disorder might feel very happy or very sad for long periods of time, and for no apparent reason. Because of this, their moods affect the way they perceive everything in their daily lives, making it very difficult to function well. There are two main categories of mood disorders; Depressive Disorders (major depression, dysthymia) and Bipolar Disorders (also known as manic depression; mood swings from euphoria to depression). Post-Traumatic Stress Disorder (PTSD) An anxiety disorder based on a lasting response to a traumatic event. According to DSM-IV, specific criteria must be met (See Glossary). Socialization to violence Socialization is the process by which children learn during the early stages of their life to adopt the behavior patterns of their parents or other caregivers. In an insecure and brutal environment, like in civil war or within a family with a lot of domestic violence, individuals often develop violent and unsocial behavior patterns and are not engaged to develop peaceful social skills. Exacerbation of pre-existing disorders A pre-existing disorder (e.g. anxiety, mood disorder such as depression or substance abuse disorder) significantly increases the risk of a subsequent exacerbation of this disorder after being exposed to traumatic events. Major Depression In a major depression, more of the symptoms of depression are present, and they are usually more intense or severe. A major depression can result from a single traumatic event in your life, or may develop slowly as a consequence of numerous personal disappointments and life problems. Personality disorders They form a class of mental disorders that are characterized by long-lasting rigid patterns of thought and actions. Because of the inflexibility and pervasiveness of these patterns, they can cause serious problems and impairment of functioning for those afflicted with these disorders. Conversion disorder This disorder is characterized by the loss of a bodily function, for example blindness, paralysis, or the inability to speak . The loss of physical function is involuntary, but diagnostic testing does not show a physical cause for the dysfunction. Dissociation This is a psychological state or condition in which certain thoughts, emotions, sensations or memories are separated from the rest of the psyche. (See Glossary). Depersonalization This is the experience of feelings of loss of a sense of reality. A sufferer feels that he or she has changed and the world has become less real (See Glossary). Psychoses This disorder is a generic psychiatric term for a mental state in which thought and perception are severely impaired. Persons experiencing a psychotic episode may experience hallucinations, hold delusional beliefs (e.g., grandiose or paranoid delusions), demonstrate personality changes and exhibit disorganized thinking.

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Victims of the Khmer Rouge year visiting the Toul Sleng Genocid Museum in Phnom Penh

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Adapted from: David Satcher et al. (1999): “Chapter 4.2”, Mental health: A Report of the Surgeon General, in: http://en.wikipedia.org/wiki...last visited on 19 February 2007.

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Academy of Family Physicans: www.familydoctor.org ...last visited on 4 February 2007. Adapted from: National Institute of Mental Health, Bethesda, USA: www.nimh.nih.gov

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Baldwin, D.V. (1997): Innovation, Controversy, and Consensus in Traumatology . In: The International Electronic Journal of Innovations in the Study of the Traumatization Process and Methods for Reducing or Eliminating Related Human Suffering, Vol. 3:1; Article 3.

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11: What is Post-Traumatic Stress Disorder?

Post-Traumatic Stress Disorder (PTSD) is a term for certain psychological consequences of exposure to, or confrontation

In their most severe form, psychological and physical symptoms can accumulate to form a condition known as Acute-Stress Disorder (ASD) (if the symptoms occur within the first four weeks post-trauma), or Post-Traumatic Stress Disorder (PTSD) (if the symptoms persist for longer than one month). These conditions require professional assistance and treatment. Post-Traumatic Stress Disorder (PTSD) is a real mental illness which is characterized by an emergence of specific emotional, mental, somatic and behavioral symptoms in a distinctive combination and with a serious intensity and duration. People may develop PTSD after living through a very frightening event, or after a series of frightening events, like the Cambodian civil war. They have often gone through the traumatic stress of witnessing killings, witnessing other atrocities, and living in fear of violence and death. Long after the traumatic events have subsided, people who develop PTSD often have nightmares and scary thoughts about the experiences they went through.

with, stressful experiences which an individual experiences

Treatment and avoiding treatment: Those who suffer from PTSD can get relief through a specialized treatment that includes psychotherapy and medication. PTSD is a long-term problem for many people. An estimated 40 percent of people being treated for PTSD were still experiencing symptoms more than a year after the traumatic event. Unfortunately, it is common for those with PTSD to avoid treatment. Without treatment, many people may continue to have PTSD symptoms for decades after the traumatic event.

as highly For most people the symptoms of PTSD arise within about three months of the triggering event. For some people the symptoms of PTSD don’t show up for years. It is very important for people with PTSD to stay away from anything that reminds them of their traumatic experiences. It is not true that time heals all the wounds. Symptoms may become less evident over time, and more subtle, but in most People wish PTSD may experience feeling angry for cases the suffering will increase. Some people have very good no reason, and an inability to trust or care about othsupport from their family, good coping skills, and inner reer people. They are often hyper-vigilant, and seldom sources, but despite this, untreated PTSD can cause a lot of feel secure. They may be easily upset when something emotional and physical problems, such as psychosomatic reachappens suddenly or without warning. tions. Without an adequate treatment many people may continue to have PTSD symptoms even decades after the traumatic event.

traumatic. 21

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Adapted from: David Satcher et al. (1999): “Chapter 4.2”, Mental health: A Report of the Surgeon General, in: http://en.wikipedia.org/wiki...last visited on 19 February 2007.

M

M

A diagnosis of Post-Traumatic Stress Disorder requires that four criteria be met: 1. The individual must have been exposed to an extremely stressful and traumatic event beyond normal human experience. 2. The individual must periodically and persistently re-experience the event. This re-experiencing can take different forms, such as recurrent dreams and nightmares, an inability to stop thinking about the event, flashbacks during which the individual relives the trauma, and auditory hallucinations. 3. There is persistent avoidance of events related to the trauma, and psychological numbing that was not present prior to the trauma. 4. Enduring symptoms of anxiety and arousal are present.

Symptoms of PTSD may include: • • • • • • • •

Having trouble sleeping. Being irritable, angry or jumpy. Being depressed. Addiction problems (abusing alcohol or drugs). Having flashbacks, nightmares, bad memories, or hallucinations. Trying not to think about the trauma or avoiding people who trigger those memories. Not being able to recall parts of the event. Feeling emotionally numb or detached from others.

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Whether a person develops Post-Traumatic Stress Disorder may depend partly on how severe and intense the trauma was and how long it lasted.

Did you live through frightening and dangerous events during the Khmer Rouge years? Please check the box next to any problem you still have: Sometimes, all of a sudden, I feel like it is happening over again. Sometimes I have nightmares and bad memories of the past. I stay away from places and situations that remind me of the event. I am easily surprised and feel very upset when something happens without warning. I have a hard time trusting or feeling close to other people. I get mad very easily.

People who have anxiety, depression or other mental disorders are more likely to develop PTSD.

People who have been victims of previous trauma are also at greater risk. 22

I feel guilty because others died and I lived. I have trouble sleeping and my muscles are tense. If you put a check in the box next to all or most of these problems, you may have PostTraumatic Stress Disorder.23 Reactions that may predict Post-Traumatic Stress Syndrome Flashbacks Altered states of consciousness in which the individual believes s/he is again experiencing the traumatic event. It is a type of “spontaneous abreaction” of bad memories common to victims of acute trauma also known as “intrusive recall” (See Glossary). Traumatic dreams Dreams of particular intensity, with content that the sleeper finds disturbing, related either to physical causes, such as a high fever, or to psychological ones, such as unusual trauma or stress in the sleeper’s life. Memory disturbances Self-medication A substitution with alcohol and drugs to compensate for flashbacks and major emotional disturbances. Anger, irritability, hostility which is difficult to control Persistent depression Social withdrawal

22 American 23

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Academy of Family Physicans: www.familydoctor.org ...last visited on 4 February 2007. Adapted from: National Institute of Mental Health, Bethesda, USA: www.nimh.nih.gov

PTSD is a real illness that needs to be treated. It is not your fault, and with adequate treatment you won’t have to suffer forever. And: Most people in Cambodia who have experienced the atrocities during the Khmer Rouge years still have some of the symptoms, but they didn’t “automatically” or necessary get Post-Traumatic Stress Disorder. However , if they still suffer from symptoms of PTSD it would be helpful to get a psychotherapist’s or psychiatrist’s opinion. The three main symptom clusters in PTSD are: • Intrusions, such as flashbacks or nightmares, where the traumatic event is re-experienced. • Avoidance, when the person tries to reduce exposure to people or things that might bring on their intrusive symptoms. • Hyperarousal, meaning physiological signs of increased arousal, such as “hyper-vigilance” (See Glossary) or increased “startle response” (See Glossary). 24

FlashBacks and Traumatic Dreams

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Baldwin, D.V. (1997): Innovation, Controversy, and Consensus in Traumatology . In: The International Electronic Journal of Innovations in the Study of the Traumatization Process and Methods for Reducing or Eliminating Related Human Suffering, Vol. 3:1; Article 3.

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With the help of counseling or couple-therapy interpersonal conflicts can be resolved and destructive behavior pattern can be changed.

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12: How Does Emotional Trauma Effect Interpersonal Relationship? Besides anxiety and depression, suppressed or frozen anger is one of the primary emotional responses to the traumatic events in the recent Cambodian history, resulting in the prevalence of domestic violence. The environment in Cambodia is still very insecure and high tension can be felt throughout civil society. Traumatic experiences can be triggered at any time and a person might be overwhelmed with feelings s/he is unable to handle, i.e. anger. Even when unrecognized, emotional trauma can create lasting difficulties in our closest relationships. Aside from extreme violence, there are other destructive results of unhealed trauma, such as an inability to solve interpersonal conflicts, lack of compassion and social withdrawal.

Some common effects of emotional trauma on interpersonal relationships: • Inability to maintain close relationships or choose appropriate friends and mates • Violent tempers, impulsive reactions • Hostility • Arguments with family members, employers or co-workers • Social withdrawal • Sense of being constantly threatened • Inability to solve interpersonal conflicts • Inability to listen and to concentrate • Lack of compassion and introspection • Lack of interest in communicating with close, personal friends • Sexual problems

Even when unrecognized, emotional trauma can create lasting difficulties in our closest relationships.

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26Adapted

from : International Organisation for Migration (2006), Module 6: Mental Health, Phnom Penh: IOM

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27Erikson,

E. (1963): Childhood and society, New York: Norton

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28Loung

Ung, 2005, Lucky child. A daughter of Cambodia reunites with the sister she left behind, New York: Harper,

p. 123-124.

13: What Are Mental Health Problems of Children, Which Emerge and Are Caused by Traumatic Events? From the first day of their life, all children have to struggle with their own developmental tasks, with the normal limitations of their parents, and with the destructive human behavior in their social world. Even in so called “times of peace”, daily interactions with tension and unhealthy patterns in their personal and material environment have the potential to cause a number of mental health problems. These psychological and social factors may be exacerbated by biological factors like genetic predisposition, anatomical abnormalities, or neurological problems.

Each traumatized

In times of war, civil war, or other “man-made disasters”, children tend to be exposed to extremely overwhelming stimuli that may lead to suffering and specific mental health problems. Some children have a severe reaction to trauma, which is similar to the symptoms of Post-Traumatic Stress Disorder (See Chapter 11).

and reaction

child will have his or her own experience to trauma.

Each traumatized child will have his or her own experience and reaction to trauma. Despite their extreme vulnerability, children have very specific coping strategies, which protect them from the impact and threat of atrocities in their environment. Children with this ability create their own inner world, enriched with idealized persons, powerful beings, guardian angels, and fairy-tale figures. Within this inner world they are able to create a safe place where the traumatic events lack the power to destroy their trust in life and in the people they are dependent on. However, this coping strategy also is very fragile, and nothing can guarantee that it will prevent a child from suffering from psychosomatic symptoms, grief, or even mental health disorder.25

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Discussions with Dorsch Witzel, R., Trauma-therapist and Children-therapist, Zuerich 2006

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Children will often respond to trauma with the same symptoms as adults, but because their perception of the world is different, and because they cannot understand the traumatic events as adults sometimes do, they may respond more vulnerably and spontaneously. Like adults, many children do not like to talk about their traumatic experiences. Very often they are afraid to share their feelings, especially if close relatives are involved, because they might feel guilty for their failure to prevent the traumatic event and to prevent the suffering of their parents and siblings. This can even occur in response to an event as great as a civil war.

Those who experienced or witnessed traumatic events in their childhood are at increased risk for a host of psychological problems, impacting all areas of functioning. For example: • Impaired emotional, social, cognitive, and physiological functioning. • Issues such as teenage pregnancy, adolescent drug abuse, failure in school, victimization and anti-social behavior. • Medical problems, such as heart disease and asthma. Childhood trauma has also been linked to increased risk for cigarette smoking. • A higher incidence of neuropsychiatric conditions, such as Post-Traumatic Stress Disorder, Dissociative Disorder, and, • A higher incidence of domestic violence. The incidence of domestic violence in child survivors of trauma is particularly troubling. For boys, witnessing violence as a child greatly increases the chances that they will grow up to act violently with their partners. For girls, it increases the chances that they will accept violence in her dating and/or marital relationships. Children who grew up in violent environments are intensively taught that violence is an effective way to gain power and control over others. Thus, children from violent homes are more prone to accept excuses for violent behavior, and are at increased risk of acting aggressively toward their peers and adults.

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Children will typically suffer and respond to traumatic events with the following symptoms: 1. Very young children (ages 0-4): • Fear of being separated from their parents • Problems sleeping alone in their beds • Fear of darkness • Fear of strangers • Regression to earlier developmental stages (so-called “regressive” behaviour, such as thumbsucking or bedwetting) 2. Kindergarten- and School children: • “Dissociation” (Becoming physically and/or psychologically disconnected with one’s experiences during traumatic events – See Glossary) • Disruptive and aggressive behavior • Withdrawal • Irritability • Inability to pay attention or concentrate • Somatic complaints and bodily symptoms • Sleeping problems and nightmares (See Glossary) • Re-experiencing the trauma during play or dreams • Recreating the traumatic scene in play-time scenarios

Children who grew up in violent environments are intensively taught that violence is an effective way to gain power and control over others.

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3. Adolescents: • “Dissociation” (Becoming physically and/or psychologically disconnected with one’s experiences during traumatic events – See Glossary) • Flashbacks (See Glossary) • Social withdrawal • Depression • Avoidance of any stimuli that are closely related to the traumatic experience (traumatic triggers – See Glossary). • “Self-medication” with alcohol and drugs to compensate for flashbacks and major emotional disturbances • Other symptoms like adults (See Chapter 9) 26 During childhood every individual must successfully navigate a series of psychosocial stages. At each stage, a particular developmental challenge (a so-called crisis or conflict) comes into focus. Although each conflict never completely disappears, it needs to be sufficiently resolved at a given stage if an individual is to cope successfully with the conflicts of later stages. For example E.Erikson27 identified eight stages in the whole life cycle of an individual. He identified five stages until adolescence and, as shown in Figure 13.1, at each stage a particular developmental crisis comes into focus:

Figure 13.1.: Five psychosocial stages of the childhood with the particular developmental challenges of each stage, adapted from Erikson (1963). 26Adapted 27Erikson,

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from : International Organisation for Migration (2006), Module 6: Mental Health, Phnom Penh: IOM E. (1963): Childhood and society, New York: Norton

In his first proposed stage an infant needs to develop a basic sense of trust in his or her environment through interaction with caregivers. Trust is a natural accompaniment to a strong attachment relationship with a parent who provides food, warmth, and the comfort of physical closeness. But a child whose basic needs are not met, and/or who experiences inconsistent handling, lack of physical closeness and warmth, and the frequent absence of a caring adult, may develop a pervasive sense of mistrust, insecurity and anxiety. During the Khmer Rouge time, young children’s basic needs were often unfulfilled, resulting in an inadequate development of a basic sense of trust.

During the

With the development of walking and the beginning of language in the second stage, there is an expansion of a child’s exploration of objects and people. With these activities should come a comfortable sense of autonomy and sense of being a capable and worthy person. Extensive restrictions, which are common in times of war and starvation, may lead to severe self-doubts.

often unfulfilled,

Children, who grew up during such times of permanent insecurity and lack of warmth - like during the Khmer Rouge time - may not resolve adequately this crisis or the crisis associated with the next (third, etc.) phases of development. When previous crises are left unresolved, aspirations remain unfulfilled, and the individual experiences futility, despair and self-depreciation.

development of

Khmer Rouge time, young children’s basic needs were resulting in an inadequate a basic sense of trust.

Extensive restrictions, which are common in times of war and starvation, may lead to severe self-doubts.

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“…After dinner, we all move to the living room. Meng and Eang sit on the couch while Maria plays with a doll between them. I’m lying on my side on the floor, when the trailer for The Killing Fields splashes across our TV screen. The commercial begins with a group of helicopters flying into view like a swarm of dragonflies, then cuts to scenes of bombs dropping onto Cambodia, and the Khmer rouge soldiers storming into Phnom Penh…

Loung Ung, Author of the book “First they killed my father”

28Loung

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From somewhere inside my brain, the smell of putrid flesh leaps off the television and fills my nostril. I blink but the smell remains and attacks my eyes, making them water. My scalp starts to sweat, while my heart squeezes into a tight fist. Lightly, I scratch my feet and crack my toes to distract myself from the smell. ‘Americans won’t remember the smell, the sound, or the heat. For two hours they’ll sit in the dark and watch but they’ll never know what it was like to be there for three years, eight months and twenty-one days. What it was like thinking everyday that I was going to die and not knowing if the war would ever end. When the credits roll after two hours, the lights will come back on, and they’ll leave the war. But I can’t. I shift my eyes to the corner of the living room without moving my head. I don’t want Meng and Eang to see how upset and worry that I still feel and remember. I have to be strong because if I let myself cry, I‘m afraid I’ll never stop. So I force my body to be still while the actors dressed in black cry and scream…” Loung Ung28

Ung, 2005, Lucky child. A daughter of Cambodia reunites with the sister she left behind, New York: Harper,

p. 123-124.

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29 30

Lichtmann, H. (1984): Parental communication of Holocaust experiences and personality characteristics among second-generation survivors. Journal of Clin. Psychol. , Vol.4: 914-24. ibid

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(

(

)

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OM Chariya (2006) : Bachelor Thesis. Children´s perception of Parental Trauma on their perceived care and overprotection, Phnom Penh: Unpublished Document. KIM Thida (2006) : Bachelor Thesis. Role Reversal of Traumatic Parents from Khmer Rouge Regime, Phnom Penh: Unpublished Document.

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14: Is It Possible for Trauma Symptoms to Be Transmitted to the Second Generation?

Studies on children of trauma survivors have found some evidence that the trauma symptoms from first generation trauma survivors are often passed down to their children. Understanding the role of parental trauma can help to improve individual functioning as well as functioning within the family.29

Children who saw their parents as hypervigilant and socially mistrusting responded with their own levels of hypervigilance and mistrust.

In some cases, children think that their parents do not love them if they are not there to protect them or offer explanations.

Such studies show that children who perceived their parent’s anguish and responded to it with empathy or over-identification experienced trauma symptoms, such as intrusion, avoidance, and hyperarousal. In addition, children who saw their parents as hypervigilant and socially mistrusting responded with their own levels of hypervigilance and mistrust. Finally, children whose parents communicated about their traumatic experiences in an open manner were found to experience less overall PTSD and fewer symptoms of avoidance than those whose parents were silent about their past experiences.30 Cambodian mothers, who were traumatized during the Khmer Rouge Years • tend to be overprotective of their children • tend to unconsciously influence their children to fulfil their own needs rather than being aware of the needs of their children and instead of fulfilling such needs • tend to fail to fulfil the developmental needs of their children. Most children who lived in the Khmer Rouge era did not get adequate physical and emotional care, as their parents were not able to spend the time and energy required to fulfil their needs. For example, one of the most important needs of a young child is to feel secure and to be able to find a safe place if they are scared. But during the Khmer Rouge regime parents lived permanently under the threat of being punished, being separated from their families, or being killed. Thus, they were unable to provide the peaceful and relaxed atmosphere children need to grow up healthy. Also, many children were taken away from their families and forced to live in children’s camps, where nobody took care about their psychological and physical needs. Another issue is that, in some cases, children think that their parents do not love them if they are not there to protect them or offer explanations. The overprotective education patterns of the parents toward the child are significant obstacles for the children’s ability to develop independence and grow up without unhealthy behavior patterns.31 Research in Cambodia also revealed that there is a significant correlation between overprotective and role reversing mothers (tendency of the mother to unconsciously influence their children to fulfill her own needs rather than being aware of the needs of her children and fulfilling her children’s needs adequately) and psychological problems of the children, such as depression and anxiety.32 29 30 31

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Lichtmann, H. (1984): Parental communication of Holocaust experiences and personality characteristics among second-generation survivors. Journal of Clin. Psychol. , Vol.4: 914-24. ibid OM Chariya (2006) : Bachelor Thesis. Children´s perception of Parental Trauma on their perceived care and overprotection, Phnom Penh: Unpublished Document. KIM Thida (2006) : Bachelor Thesis. Role Reversal of Traumatic Parents from Khmer Rouge Regime, Phnom Penh: Unpublished Document.

Children of Cambodian parents, who were traumatized during the Khmer Rouge years: • tend to of over-identify with their parents’ trauma • experience a significant amount of their own trauma symptoms, including intrusion, avoidance, and hyperarousal • see their parents as hypervigilant and socially mistrusting, and respond to this with their own levels of hypervigilance and mistrust.

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RF Mollica, R.F., Wyshak, G., Lavelle, J.(1987): The psychosocial impact of war trauma and torture on Southeast Asian refugees . Am J Psychiatry 1987; 144:1567-1572. Experiences of the author during his work as a psychotherapist at the Psychiatric University Hospital in Switzerland.

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15: Why Did the Khmer Rouge Years Cause Emotional Trauma in Some People and Not in Others? It is important to emphasize that not all survivors of traumatic events respond to their experiences in the same way. While some Khmer Rouge survivors developed serious mental health issues due to the pain, devastation and loss they experienced, others say that living through these traumatic events also made them re-evaluate their priorities in life (acquire new values) and change their lifestyles, thus bringing about substantial change and renewal in their lives. This doesn’t mean that such people never had symptoms such as nightmares, sleep disturbances, or sudden outbursts of grief and sadness. Although there have not been any comprehensive studies of survivors of the Khmer Rouge in Cambodia, a study of Cambodian refugees who resettled in the United States revealed that 62% suffered from Post-Traumatic Stress Disorder (PTSD) and 51% from depression.33

Figure 15.1: The quality and the result of individual inner-psychic evaluation processes is very important. Consciously and/or unconsciously, a person realizes whether he or she lacks adequate coping strategies. The results of the evaluation processes influence emotionally and physically the quality of physical and psychological tensions and the individual’s perception of suffering. 33

RF Mollica, R.F., Wyshak, G., Lavelle, J.(1987): The psychosocial impact of war trauma and torture on Southeast Asian refugees . Am J Psychiatry 1987; 144:1567-1572.

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Whether a person will respond with prolonged traumatic symptoms or with normal emotional reactions during a process of integrating traumatic events depends on several factors, including the individual’s ability to cope with the traumatic events.

Every person in Cambodia who lived through the Khmer Rouge atrocities responded with immense and often endless grief, anger and deep suffering. Whether a person will respond with prolonged traumatic symptoms or with normal emotional reactions during a process of integrating traumatic events depends on several factors, including the individual’s ability to cope with the traumatic event. This applies not only to victims of the Khmer Rouge regime, but also to perpetrators. Case studies from therapists have shown that perpetrators often develop strong tendencies and patterns of memory suppression, numbing of their feelings and other kinds of unconscious coping mechanisms. The result is that they often suffer less consciously and feel depressed less often than victims, and therefore fail to develop healthy compassion.34 It is likely that many factors are involved in explaining why responses to traumatic events are so different in different people. Much of the variation relates to the various circumstances and personalities involved.

Figure 15.2: The results of this individual evaluation processes (thinking and awareness processes) are dependent on: e.g., former positive or negative experiences, many personality factors such as thinking pattern ( positive or negative thinking tendencies) or the extent of anxiety, the anticipation of the future, and the evaluation of the actual situation (See picture on page 57). 34

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Experiences of the author during his work as a psychotherapist at the Psychiatric University Hospital in Switzerland.

Some factors determining different responses to traumatic events:

Coping skills

Circumstances which may influence or intensify the response

are behavioral

• Stability and security of the socio-political context (e.g., during KR years: Civil War, fear of authorities, suspicion of fellow villagers). • Severity of the events (KR years can be described as “extreme traumatization”) • Duration of exposure to traumatic events (the KR years were a prolonged exposure for many people) • Situation of peer group or family (during KR years people were in a state of permanent fear, families were torn apart, there were spies in the neighborhood) • Support from family, friends, and/or professionals (during KR years there was no professional support available, and little support from family members because everybody was struggling with the same situation; but sometimes, family members gave heroic support to one another. • Access to supportive and secure contexts (during KR years: no adequate access to hospitals, or safe places to relax, rebalance, regain inner peace; but in some cases: family members, friends and villagers helped to create a healthy atmosphere.

tools used by individuals to deal with stressful situations.

Aspects of PERSONALITY which may influence or intensify the response • The individual’s personal history: e.g., whether a person grew up in a healthy, emotionally stable, and supportive social context; whether a person developed a balanced personality; whether they received inner strength from his or her former life experiences; whether s/he learned to be flexible and to adapt quickly to changes in circumstances. • Individual’s personality pattern: e.g., whether the person was emotionally stable before the event, was a relaxed and balanced person, was a person who never gave up, was someone who could gain trust from other people. • Values and beliefs held by the individual: e.g., whether the person had deep general trust in life, had inner strengths developed through Buddhist or other religious and spiritual approaches, had faith in overcoming horrible events, possessed the motivation to seek relief even where the situations seemed hopeless. • Coping skills: e.g., ability to manage extreme situations, survival techniques, good instincts; ability to deal with difficult and overwhelming feelings, and to manage anger, sadness, grief; ability to anticipate the thoughts and behavior patterns of the perpetrators; ability to keep inner distance from the overwhelming events; ability to maintain mental control; ability to dissociate for a while (creating a supportive inner world, “leaving” the body, numbing). (See picture on page 57)

Lack of adequate coping skills ?

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Foa, E.B.(1997): Physiological processes related to recovery from a trauma and an effective treatment for PTSD. In: Yehuda, McFarlane, 1997: p.416.

36

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Model translated and adapted for the Cambodian context from: Butollo, W.al. (1999): Kreativität und Destruktion posttraumatischer Bewältigung, Stuttgart: Pfeiffer, p.185.

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16. Is Psychotherapy Necessary and/or Appropriate in Cambodia? Realistic aims of trauma therapy are to help clients to regain confidence, self-esteem, dignity, and hope, and to provide professional support to develop skills to accept the

Two conditions should motivate people in Cambodia to seek professional support: 1. They are suffering permanently from specific symptoms, such as nightmares, psychosomatic symptoms, depression, or anxiety. 2. They are suddenly overwhelmed by flashbacks, or traumatic events are triggered by reminders in daily life, for example, seeing young people wearing clothes with the same black color as the clothes of Khmer Rouge soldiers. Psychotherapists know that the healing process cannot wipe out the cause or most of the impact of a suffering soul. They know that they cannot guide a traumatized person to forget all of their grief and pain, and cannot erase their traumatic experiences. But a sustainable healing process provides individual skills for individuals to live with the trauma they have experienced and recognizes each individuals own efforts to survive the trauma with dignity. Therefore, the realistic aims of trauma therapy are to help clients to regain confidence, self-esteem, dignity, and hope, and to provide professional support to develop skills to accept the conditions and realities of the person’s life. Helping people find a positive sense of their life, despite their extreme suffering, and to reconnect people with their deepest and most beautiful sources of their personalities is a prominent focus of psychotherapy and counseling. However, there is no guarantee that these results will be achieved in every case.

conditions and realities of the person’s life.

124 This person needs professional help and/or adequate support from his social network.

Before talking more concretely about therapeutic trauma approaches within the Cambodian context, it is useful to emphasize the following conditions: ♦

♦

♦

♦

♦

A sustainable

An universally valid trauma approach does not exist. Therefore is no “one general approach” in treating trauma victims that individual therapists should acknowledge or embrace.

healing process

The knowledge about development and processes of trauma, especially brain processes with their implication for the human behavior is still limited, even a huge amount of research is permanently published.

skills for

Every cultural context, every specific situation and particularly every individual person requires an individualized treatment, because of their own character. There are as many approaches to trauma therapy as there are trauma therapists or counselors. .

with the trauma

This means that every single trauma therapeutic process has his own unpredictable dynamic because of the unique interaction of the specific persons coming together as client and therapist. This requires that we exercise caution around making generalized comments about the possibilities, limitations and technical approaches related to an adequate treatment of trauma.

Nevertheless, an approach appreciating these preconditions and the specific cultural context of Cambodia should integrate the considerations discussed below.

provides individual individuals to live they have experienced and recognizes each individuals own efforts to survive the trauma with dignity.

The main approach of therapists all over the world is to guide their suffering clients to new healthy experiences, because these new experiences may have the power to override the prior traumatic experiences of trauma and help their clients regain inner peace. In this process, therapists talk with clients intensively about the details and the feelings of their experiences during the past events. This re-experiencing within a healthy and secure atmosphere often has the power to provide relief, for example due to the following effects: 1. Clients will be engaged to overcome their speechlessness and numbness. They will regain the ability to express themselves in a more open, precise, relaxed and trustful way. 2. They will be aware and reconnected with their “freeze” feelings and will be guided through deep grief and sadness. Because this coincides with the safe atmosphere, compassionate presence and authentic resonance of the therapist, it furthers the healing process. 3. Clients get specific skill training to perceive the difference between the state of helplessness within the traumatic experience of the past and the ability to have “control” in the present (be able to function consciously), even if flashbacks from the past start to overwhelm the individual with painful feelings and thoughts. For example, clients learn to relax deeply and to intentionally focus on the reality of the present (“Here and now there is no civil war”, “Here and now I am secure”, “Here and now I can trust people”). 4. Clients are empowered to perform their daily life in a more balanced manner. Therefore, they will gain skills to reconnect with their sources, their creative potentials and their power.

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A sustainable healing process has to approach new and “corrective” experiences.

Even in light of theses benefits, we have to acknowledge some potentially problematic side effects. As we know from recent brain research, we have to be very careful with any therapeutic approach. Even if it is helpful to give traumatized people the opportunity to share their suffering within a healthy and secure setting, it can sometimes trigger very intense feelings. The trauma of the treated person could become worse if the treatment is only focused on “storytelling” and does not add a specific process to address the trauma. Therapists know that our brain cannot differentiate between a real traumatic event and a comprehensive imagination of a traumatic event. They know from research about mental health that a sustainable healing process has to approach new and “corrective” experiences (to correct the old, unhealthy experiences). Otherwise, the human brain will react with the same coping strategies as if the person would experience the traumatic event repeatedly. This is not supportive for the healing of a suffering soul. The fact is that without a real corrective experience, there is no healing process.

An appropriate trauma treatment approach includes the following interventions: Education about common reactions to trauma; breathing retraining; prolonged, repeated exposure to memory (reliving); and repeated in vivo exposure to situations the client is avoiding because of assault-related fear.35 Therefore, it is fundamental that a treatment be related to the results of brain research and employ approaches, such as relaxation, reconnecting clients with their sources, learning additional coping strategies, and specific techniques like “Eye Movement Desensitization and Reprocessing” (EMDR)36, “Screening techniques” ( Learning to take control over your frightening thoughts, imaginations and flashbacks) and other new methods. A storytelling approach, which does not integrate these psychological methods could be problematic.

Clients will be aware and reconnected with their “freeze” feelings and will be guided through deep grief and sadness. They will be engaged to overcome speechlessness and numbness. They will regain the ability to express themselves in a more open, precise, relaxed and trustful way.

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35

Foa, E.B.(1997): Physiological processes related to recovery from a trauma and an effective treatment for PTSD. In: Yehuda, McFarlane, 1997: p.416.

36

EMDR - Eye Movement Desensitization and Reprocessing is a tool used in certain forms of psychotherapy that intends to relieve the symptoms of post-traumatic stress disorder (PTSD) and other mental health problems using eye movements similar to those which occur naturally in REM sleep. This eye movements seem to stimulate the memory network where the trauma is stored. The eye movements may also activate the informational networks that can restore a traumatized person’s ability to process an event fully. When both networks operate simultaneously during the eye movement sets, it appears that the traumatic information is rapidly processed.

Figure 17.1: An example of a psychotherapeutic trauma treatment approach with four stages37 :

This model starts from the assumption that comprehensive trauma treatment should include confrontation with the traumatic experiences and the traumatic changing. This approach proceeds from the assumption, that an emotional confrontation with the irreversibly results of the life changing caused by traumatic events supports the healing process. This last assumption is controversial within the scientific community. However, the first, second, and fourth stage of this model, (1) perceiving and consolidating security, (2) perceiving and overcoming instability and (4) acceptance of trauma and acceptance of the new life circumstances are part of all modern trauma therapy approaches throughout the world. Here in Cambodia we have to focus on stages one and two in particular: It is perceivable, not only for well-trained diagnosticians, that Cambodians with past-traumatic experiences feelings of insecurity, and rarely trust themselves and others. Despite the relatively secure living standard, one could assume that many Cambodian's behavioral patterns reflects that they are still living in a survival mode. The issue becomes how to stabilize people, when the socio-political situation is so unstable and the lives of Cambodians are filled with so many instabilities. 37

Model translated and adapted for the Cambodian context from: Butollo, W.al. (1999): Kreativität und Destruktion posttraumatischer Bewältigung, Stuttgart: Pfeiffer, p.185.

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Simple but powerful reminders

Figure 16.1.: Healing and protective factors of a psychotherapeutic process 38

An understanding of rudimentary trauma healing concepts is especially necessary in the Cambodian context. In 2008, there are far too few qualified trauma therapists in Cambodia. Thus, it is crucial that social workers and other NGO staff who deal with traumatized persons have a basic understanding of trauma, healing techniques, and therapeutic approaches discussed in this book. Only then can trauma be managed and the healing-process begin. • • • •

Access to appropriate support and healing approaches is for everyone. There is no reason for shame since trauma symptoms are neither a sign of character weakness nor a reason to be depreciated. Each trauma is always two-sided, even if the constructive side is more hidden. Healing and reconciliation requires individual engagement. 38

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See also: Petzold, H., et al., Integrative Traumatherapie. Modelle und Konzepte für die Behandlung von Patienten mit posttraumatischer Belastungsstörung (Integrative trauma therapy. Models and concepts for the treatment of patients with PTSD). In: Van der Kolk, B.A. et al., Traumatic stress. Paderborn: Junfermann, p.499ff.

ESSENTIALS A diagnosed trauma client in need of counseling or psychotherapy must work closely with his/her therapist to conceptualize and create an individualistic approach because each client is unique and has specific needs requiring individualized therapeutic aims and strategies. In creating this therapeutic framework, the therapist must utilize protective factors (identified in the graphic above), the psychological resilience of the client and to minimize risk factors (such as weak social networks, negative valuations and negative self-image, and lack of resources). The Healing process involves elements that build trust, promote a feeling of security, promote self-awareness, and help the individual reintegrate into society. Without these therapeutic elements traumatized people cannot be healed from their often huge and unconscious lack of trust in oneself, in life and in others. Absent these essential therapeutic factors, reconciling one’s own history, loving oneself and other living creatures can never be accomplished.

Psychological resilience refers to an individual’s capacity to withstand stressors and destructive stimuli, and not manifest psychological

In such matters, therapeutic aims are often analogous to many religious approaches, i.e., spiritual growth.

dysfunction .39

10 steps towards healing from trauma40 (not meant to be a linear process)

10. Providing resources and skills for reintegrating into daily life. 9. Gently exposing the traumatic experiences and reconciling with the past.

8. Developing trust. 7. Developing inner security. 6. Developing trust. 5. Developing inner security. 4. Developing trut. 3. Dveloping inner security. 2. Developing trust. 1. Developing inner security. 39 40

This definition of resilience results from personal therapeutic experiences of the author The author’s experiences from long-term therapeutic processes, with multiple traumatized patients (Drug addicted people, tortured politic prisoners, abused children).

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38 39

Van der Kolk, B. et al. ( 2000): Traumatic Stress, Paderborn: Junfermann, p.18. KAIROS: Philosophical technical term from Greek language: It means the absolute right moment, the “time-window” when a particular developmental step is possible to be done

Traditional Cambodian approaches to help people who are suffering from traumatic events.

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Malkani, V. (2002): Enlightenment made simple. Understanding man’s quest for divinity. India: New Dawn Press, p.144.

133 Religious beliefs to bring peace into the hearts of Cambodians

Epilogue

The way that victims of trauma are treated in a society is an indication of that society’s attitude towards and appreciation of its citizens in general.38 Along with other developing countries, Cambodia in particular still has to learn the basics about the impact, and especially the long-term results, of trauma, as well as the ability of victims to regulate their physical and psychological homeostasis. This requires the realization and acknowledgement that even years after a traumatizing event – for example, thirty years after the Khmer Rouge atrocities – the memory of such an event continues to dominate the mind and the behavior of those who experienced it. Consequentially, those responsible for Cambodian society have to learn how to support these victims and to help them regain power and ownership over their lives. If this doesn’t happen in an appropriate time frame, often described as the KAIROS 39 , it will inhibit the healthy and humanistic development of the whole country. But what is the appropriate time frame? Certainly, foreign specialists must be careful in defining the right moment, and not push development. But Cambodians, too, should have an understanding of the KAIROS and realize that there is a need for a nationwide healing process in order to heal the hearts of many Cambodians. Without this consciousness, a sustainable process of reconciliation is not possible. The process of healing and gaining peace in one’s heart most likely entails the same “problems” as attaining spiritual enlightenment: Once a man came up to Buddha and asked him: “You know, I have heard you many times, and every time you tell us that enlightenment is possible for all of us. But I haven’t seen anybody here get enlightened.” Buddha replied, “Do me a favor. In the evening, today, go to every house in this village – to the men of the house – and ask him what is it that he desires.” The man went around in the evening, to every house in the village, and the following morning, he was back with Buddha. Buddha asked him to read the list of desires. The man started reading: “House number one, his desires are to acquire land, to marry his daughter into a rich family, to pass on land and money to his sons. House number two, the man’s desires are so and so. Not in any of these houses has anyone said that he desires enlightenment.” Buddha then told him, “I have told you that enlightenment is possible for all of us, and it is. But how many of us really desire it?” 40 Fortunately, trauma issues are now receiving attention by young psychologists, social workers and others who feel deeply concerned about the mental health situation in Cambodia. In the near future these compassionate citizens will surely pass this knowledge on to the rest of society because of their commitment to progress in the science of trauma. For example, there is increased awareness among these individuals that being exposed to traumatic events may have severe and long-term impacts such as changes of the regulation of stress hormones, or permanent changes within the endocrine system as well as in the function and structure of certain areas of the brain. Recognizing this and other phenomenon is a necessary precondition to understanding the severe impact of such widespread unhealed trauma on the “peace of the hearts” of individuals and on the process of reconciliation in Cambodia. 38 39

40

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Van der Kolk, B. et al. ( 2000): Traumatic Stress, Paderborn: Junfermann, p.18. KAIROS: Philosophical technical term from Greek language: It means the absolute right moment, the “time-window” when a particular developmental step is possible to be done Malkani, V. (2002): Enlightenment made simple. Understanding man’s quest for divinity. India: New Dawn Press, p.144.

Now that we have highlighted the basic psychological concepts about trauma in Cambodia in the present publication, we will focus on incorporating more practical applications how to support Cambodians who suffer from trauma in our second handbook. Readers will find information related to issues such as: • • •

When is it necessary to seek professional help? What can therapists do to help different target groups of traumatized people in Cambodia? What can people do to support their family and friends who suffer from trauma?

One of the major messages of the second publication will be: Nobody needs to feel ashamed, guilty or weak for asking for help. Everybody has the right to seek help if s/he need it.

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DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, published by the American Psychiatric Association, USA (2000).

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Psychological Glossary Related to Trauma Issues

Complex Trauma or Complex PTSD (See also: PTSD): Is best understood as a condition that results from prolonged exposure to prolonged social and/or interpersonal trauma (e.g., physical and/or emotional abuse, chronic early maltreatment in a care-giving relationship, domestic violence, torture civil war). Some of the core characteristics of Complex PTSD are the loss of a sense of safety, trust, and self-worth, as well as the tendency to be victimized, and, most importantly, the loss of a coherent sense of self. Coping skills: Are behavioral tools used by individuals to deal with stressful situations. Focusing on coping skills may help a person face a situation, take action, and be flexible in solving problems. For example one kind of coping skills are coping mechanisms, defined as the skills to reduce stress, anger or interpersonal conflicts (stress- and anger-management, conflict-resolution techniques). Depersonalization: The feeling that one is detached from their body or the world. The person will feel that they have lost their sense of reality and will often claim that life “feels like a movie,” or that things seem unreal. Derealization: Is a state of dissociation (See below). For some people it is an automatic reaction in cases of external or internal stress. They respond with a kind of tunnel vision (See below), whereby they lose awareness of all elements of the event that they normally perceive. People report feeling like there is an invisible wall between them and the world, that they feel like they are always day-dreaming, or that their ears and eyes don’t function as well as before. Dissociation (See also: Fragmenting, Freezing): A perceived detachment of the mind from the emotional state or even from the body. If someone dissociates, s/h get the feeling of being alienated, and that the situation isn’t real. The threatening experience is split away from the consciousness. Dissociative Identity Disorder: A very serious psychiatric disease, formerly called “Multiple Personality Disorder.” A person who experiences multiple traumas can cause a person to dissociate completely, forming different personalities, each of which have their own autonomous life. A person with this disorder does not even realize they are behaving like many different people. Distress: The “bad” type of stress, which occurs when a person has excessive demands placed on them. When the demands are too great, they can lead to physical and mental damage (diseaseproducing stress). Fight/Flight Response: An automatic response to an experience that is perceived to be a life threat. The part of the brain that regulates autonomic and metabolic functions prepares the muscles to either fight or flee. A person experiencing repetitive traumatic experiences where there is no opportunity to fight or flee can remain in a chronic state of physiological arousal, which is very stressful to the body. Flashbacks (Intrusive Recall): An altered state of consciousness, during which the individual believes they are experiencing a traumatic event all over again. Flashbacks are memories of past

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traumas. They may take the form of pictures, sounds, smells, body sensations, feelings or the lack of them (numbness). Flashbacks are sudden abreactions experienced often by victims of trauma. Fragmenting (See also: Freezing, Dissociation): Just as freezing a kind of alienation from a traumatic event within the process of dissociation. It is a kind of protective reaction to deal with a terrific situation, in which flight or fight is not possible. In the moment of the peak of traumatic stress, the threatening experience will splinter into many pieces, which will be suppressed in such a way, that the external event can no longer be remembered cohesively without a very focused effort (e.g. within therapy). The benefit of this strategy is, that through the remaining fragments or splinters it is not any more perceptible what happened, only that something happened (as well as that we are not any more able to recognize a face in the splinters of a broken mirror). The fragments are like little parts and single pictures of the trauma experience. Therefore the suffering will be less painful. Freezing (See also: Fragmenting, Dissociation): Just as fragmentation a psychological defense mechanism within the process of dissociation to mentally escape from fear and pain. It is a kind of paralysis where the brain (the frontal lobe is turned off) defends the person against threats by internally dissociating from the trauma. Endogenic morphines helps to “disappear mentally”. Hyper-vigilance: A symptom of PTSD where the person is overly sensitive to sounds and sights, scans their surroundings for expected danger, and feels edgy and nervous. A hypervigilant person have an exaggerated startle response. Intrusive Thoughts: Unwelcome, involuntary thoughts, images, or unpleasant ideas that can become obsessions; they are associated with depression or PTSD. They are upsetting and can be hard to manage and eliminate because they are persistent, paralyzing and anxiety-producing. Post-Traumatic Growth: When a person experiences positive life change because of a trauma or life crisis. Although trauma is often negatively perceived, it also has positive aspects. Many people who have overcome trauma move on to be inspirational figures. This growth involves a change in self-esteem, relationships with others, and profound spiritual or philosophical changes. Post-Traumatic Stress Disorder: An anxiety disorder concerning a person’s response to trauma. The DSM-IV lists these criteria as required for PTSD: (1) The person has experienced trauma involving an actual or perceived threat of death or serious bodily injury to oneself or others, and their response was intense fear, helplessness, or horror; (2) The trauma is re-experienced in certain ways, such as recurrent and intrusive memories or dreams; (3) Persistent avoidance of stimuli associated with the trauma, or general unresponsiveness; (4) Persistent symptoms of increased arousal, like hyper-vigilance or irritability; (5) The disturbance lasts longer than one month; (6) The disturbance causes clinically significant distress or impaired functioning.41 Resilience: The ability to recover from (or to resist being affected by) some shock, disturbance or trauma. Startle response: Traumatized people tend to be more easily startled by “normal” environmental stimuli (e.g. loud voices, bangs, sudden fast movements). Trauma: The medical term refers to a wound or injury, but the psychological term refers to an emotionally painful, distressful, or shocking experience, often resulting in lasting mental or physical effects. 41

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, published by the American Psychiatric Association, USA (2000).

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Traumatic Dreams: Particularly intense dreams that disturb the sleeper, either because of illness or high fever, or psychological trauma or stress. Trigger: An event, object or person that sets a series of thoughts in motion or reminds a person of their traumatic past. Tunnel Vision: When a person loses peripheral vision but retains central vision, resulting in a constricted view. It can be caused by eye disease, alcohol consumption, or stressful and traumatic situations.

Post-traumatic growth

People who experienced terrific situations during many years and who have overcome trauma moved on to be inspirational figures and role models: They become powerful human right activists, peaceful leaders in civil society, compassionate grandmothers, engaged dancing teachers at orphanages, writers, musicians etc.

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(A) =

/Available in Cambodia

Boyden, J., Gibbs, S. (1097): Children of war. Responses to psycho-social distress in Cambodia, Switzerland: UNRISD. Danieli Y, ed. (1998): International Handbook of Multigenerational Legacies of Trauma, New York: Plenum Press. Herman, J. (1992): Trauma and Recovery, New York: Basic Books Lafreniere, B. (2003): Musik through the Dark. A tale of survival in Cambodia, Chiang Mai: Silkworm (A) Linton, S. (2004): Reconciliation in Cambodia, Phnom Penh: DC-CAM (A) Loung Ung (2005): Lucky Child. A daughter of Cambodia reunites with her sister she left behind, New York: Harper. (A) Seanglim B. (1991): The Warrior Heritage. A Psychological Perspective of Cambodian Trauma, California. (A) Seng, C.Theary (2005): Daughter of the killing fields. Asrei’s story, London: Fusion (A) Tedeschi, RG and Calhoun, L.G.: (1995) Trauma and Transformation: Growing in the aftermath of suffering, New York: Sage. Transpersonal Psychosocial Organization (TPO), Cambodia (1997): Community Mental Health in Cambodia, Phnom Penh. (A) Van der Kolk, B.A. et al. (1996): Traumatic stress, New York: Guilford.

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We believe in a Life Span Development approach. In other words, Cambodians at all stages of life can become more consciously aware and learn to help one another to integrate their traumatic past.

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www.prayerguide.org.uk Last visited on 31 March 2008 Translation into Khmer by CSD

The illustrator, SAM Sarath, at work

YIM Sotheary, Translator, Graphic Designer Working with the “Emotional Support Group” at CSD to introduce the Trauma Book in Ratanakiri Province.

OM Chariya, Translator An Emotional Support Group member using the Trauma Book to help explain trauma and its effects to indigenous people in Ratanakiri Province.

Matthias Witzel, Author, Graphic Designer and Photographer Psychologist and Psychotherapist, member of the German Development Service (DED) and the Civil Peace Service (ZFD), delivering the Trauma Book to former Khmer Rouge soldiers in Otdar Meanchey Province.

The book is dedicated to our parents. Having experienced the traumas of war firsthand either in Germany or Cambodia, they have taught us to develop compassion for people who suffer from atrocities and mental health issues.

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“Peace I leave with you; my peace I give you. I do not give to you as the world gives. Do not let your hearts be troubled and do not be afraid.” Jesus Christ (John 14: 27)

Prayer For Peace 45 The suffering of Cambodia has been deep. From this suffering comes great compassion. Great compassion makes a peaceful heart. A peaceful heart makes a peaceful person. A peaceful person makes a peaceful community. A peaceful community makes a peaceful nation. And a peaceful nation makes a peaceful world. May all beings live in happiness and peace. Maha Ghosananda

“In one sense one could describe compassion as the feeling of unbearableness at the sight of other speople’s suffering, other sentient beings’ suffering. And in order to generate that feeling one must first have an appreciation of the seriousness or intensity of another’s suffering. So, I think that the more fully one understands suffering, and the various kinds of suffering that we are subject to, the deeper will be one’s level of compassion.” Dalai Lama 46 43

The New Testament in Today´s Khmer Version, United Bible Societies, Paris/Hong Kong 1993.

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www.buddhanetz.org/projekte/mahaghos.htm Last visited on 26 March 2008. Translation into Khmer: CSD. H.C.Cutler&HH Dalai Lama, The Art of Happiness. A Handbook for Living. London: Hodder&Stoughton, p.94.

How You Can Help Our goal is to make this book available to all Cambodians. Whether you appreciate its contents or are merely in a giving spirit, please make a financial contribution towards having this book reprinted. Each book costs approximately 7 USD to print. If you or your organization would like to play a more prominent role in alleviating trauma in Cambodia, an entire edition of 1000 or more books will be published acknowledging your contribution either by name and/or logo.