Fifteen psychiatrists, including Prof. Yim Sobotra, head of mental health and substance abuse, treat 800 to 1,000 psychiatric outpatients every day and six emergency inpatients for up to two weeks.

At Siem Reap Provincial Referral Hospital, Prof. Uy Chan Thol, the hospital’s deputy director and a psychiatrist with one year of cardiology training, admits psychiatric emergencies in the intensive care unit.

In 1975 to 1979, when the Khmer Rouge still ruled the country, Cambodia’s only two psychiatrists at that time perished along with their mental hospitals and hundreds of patients. A real-life Thanos, Pol Pot annihilated half of the population, especially the most educated.

It was only in 1998 that Cambodia had its first 10 new psychiatrists, trained in Oslo University with funding from the International Organization for Migration. They included Prof. Kim Souvan, now the deputy director of the Department of Hospital Services at Cambodia’s Health Ministry.

Cambodians experienced a massive traumatic event, defined by the Diagnostic and Statistical Manual for of Mental Disorders as “a direct or indirect exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence”.

This can cause intrusions of unwanted memories, heightened arousal (manifested from being easily startled to aggression), depressive thoughts or feelings and the tendency to try to avoid any reminders.

A diagnosis of post-traumatic stress disorder (PTSD) requires one symptom from each of these, causing distress/dysfunction for over a month, with other potential causes excluded. PTSD may include an “inability to recall key features of the trauma, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma”, as well as feeling isolated.

The concept of trauma, however, does not do justice to the pain of the Cambodian people. Instead, Chhim Sotheara, a senior consultant psychiatrist and executive director of the Transcultural Psychosocial Organization (TPO) Cambodia, emphasizes baksbat (loss of spirit or broken courage), where “terror-stricken” persons lose their identity and fighting spirit, silenced to follow orders. During his PhD research at Monash University in Melbourne, Australia, he was part of a second batch of psychiatrists from 2001 to develop the Baksbat Inventory, which measures the loss of courage, psychological distress and depersonalization in thousands of Cambodians.

Baksbat is akin to American psychologist Martin Seligman’s “learned helplessness” findings, which discovered that dogs that receive random electric shocks remain in their cage after the door is opened. Soethera describes how baksbat makes people “exhausted, passive, reluctant to fight/resist. [They] dare not complain [and] prefer to stay mute, their faces turned downward.

“When seeing powerful people make mistake, they dare not criticize, because of fear. When [the] boss fart[s], baksbat people say, ‘Your bowel movement is good, Sir!’ People are afraid that if powerful people hate [them], they will disappear.” (Kong Bunchoeun, 2003).

Hollywood movie The Killing Fields, globally memorializing the genocide. It won three Oscars, including one for Haing Ngor as best supporting actor. Ngor’s secret was that he was not acting; he was reliving his own experience. Despite being an obstetrician-gynecologist, Ngor could not perform a cesarean to save his wife and unborn child, which could have exposed and endangered them all. Such helplessness gives birth to baksbat.

Soethera describes it as “planting the kapok tree” (May Ebihara, Carol Mortland and Judy Ledgerwood, 1994), where one feigns being deaf-mute.

“Say nothing, hear nothing and understand nothing’’ (Pin Yathai 1987).

Kor in Khmer means both kapok (cotton) and mute. Interestingly, Indonesians often use the word kapok to refer to avoidance from “having learned one’s lesson” through a traumatic experience. Perhaps there are etymological links, if not psychological similarities.

To overcome baksbat, the TPO’s Justice and Relief for Khmer Rouge Survivors Project includes culturally adjusted testimonial therapy. Pich Panha, the project’s coordinator and clinical supervisor, described how persons who could not join the Khmer Rouge Tribunal at the Extraordinary Chambers in the Courts of Cambodia could tell their story to a specially trained psychologist over several days. Then, on a special day, the entire village gathers to listen to the testimonies being read out loud, followed by a blessing by a religious leader. This integrates the fragmented memory into the individual’s and collective psyche, giving the person a sense of relief and social acceptance.

Indonesia may also suffer baskbat, which blinds us to our own traumatic history. Many Indonesians seem to only remember army generals murdered during the Sept. 30 Movement blamed on the now-defunct Indonesian Communist Party (PKI), failing to acknowledge the subsequent bloodbath of possibly millions (mis) labeled as communists and the trauma depicted in Robert Lemelson’s video documentary 40 Years of Silence: An Indonesian Tragedy.

Will Indonesia ever have tribunals or community reconciliation for the 1965 and 1998 tragedies? Perhaps, as Nova Riyanti Yusuf, head of the Indonesian Psychiatric Association’s Jakarta chapter, suggests, we may need our own TPO.

Beyond their history, Cambodians today are more stressed for financial reasons. Cambodia is plagued by corruption and heavily relies on tourism and local agriculture. Phally, a Siem Reap guide, spoke of obtaining electricity from car batteries in rural areas, debts to pawn shops and young Cambodians leaving to become laborers and domestic workers in neighboring Thailand.

When asked if he knew of anyone who was mentally ill, he said no. But when asked about stress, he said everyone there was stressed.

Abang Ismail, our Cham Muslim Indonesian-speaking guide in Phnom Penh, emphasized: “It is not malaria that is the number one health problem in our country. It is stress.”

Both Indonesia and Cambodia can work toward a long-term collaboration to help each other heal from deeper wounds. As Phally, who was always laughing and making sure we were happy said, “You will never know our sorrow, because we smile all the time.”

_________________

Member of the Indonesian Psychiatric Association. She was part of a delegation that recently visited Cambodia.

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