Journey toward healing

Sam Keo speaks earlier this year about his experiences in Cambodia and his subsequent battle with post traumatic stress disorder.Photo courtesy of Sam Keo

Cambodian immigrant to speak in Stockton about struggles with PTSD

May 21, 2012
By Elizabeth Roberts
Record Staff Writer

At a glance

Author Sam Keo will speak, in Khmer and English, from 10 to 11 a.m. Friday at Stockton's Park Village Community Center, 3830 N. Alvarado Ave. Copies of his 2011 memoir, "Out of the Dark: Into the Garden of Hope," will be available for sale and signing afterward.

More information: (209) 944-1700.

STOCKTON - Under the murderous Khmer Rouge that ruled Cambodia in the 1970s, it was his entertaining storytelling for regime leaders that helped save young Sam Keo's life even as his father died after being severely beaten and four of his younger brothers succumbed to starvation or disease.

Years later, safe in the United States but racked by violent nightmares and crushing guilt, he had a post-traumatic stress disorder breakdown and twice came within seconds of committing suicide.

This time, it was telling his own story, more compelling than his most fantastic of tales, that helped save him: His 2011 memoir, "Out of the Dark: Into the Garden of Hope," was written after years of therapy, medication and soul-searching.

While his book joins a growing body of memoirs recounting the horrors of life under the communist Khmer Rouge regime, his is one of the first treatment-based approaches aimed at addressing Cambodian immigrants' struggles with post-traumatic stress disorder resulting from those experiences.

Dr Sam Keo Hopes To Shed Light Khmer Rouge Trauma

http://www.youtube.com/watch?v=mIaMgUYZwZo

PTSD from Cambodia's killing fields affects kids who were never there

Kunthea Sin, left, and Amanda Em (Jeff Gritchen / Press-Telegram)

April 22, 2012
By Greg Mellen, Staff Writer
Long Beach Press Telegram

LONG BEACH -- Wilson High student Kunthea "Meme" Sin often feels lonely. Amanda Em, a Poly High student, sometimes wondered what was wrong with her parents and why they acted as they did.

Sure, these could be the stories of almost any teenagers growing up through history.

The difference is that as Cambodian-Americans and children of refugees, Sin and Em carry a difficult legacy.

Many must deal with the fallout from a damaged generation of survivors who are now raising families, still struggling to fit into a new culture and inadvertently passing along much of the pain for their children to sift through.

Much of Long Beach's Cambodian population escaped from the genocidal Khmer Rouge regime that left about 2 million dead between 1975 and 1979. Virtually all of those survivors witnessed and suffered through unimaginable atrocities. They carry invisible scars and struggle with symptoms of post-traumatic stress disorder.

And their children have borne trauma passed on from parents. They experience symptoms that can range from extreme anxiety to emotional numbness, from violence to withdrawal, from hyper-arousal and activity to clinical depression.

"My parents gambled and drank," Em said. "I just thought they were being crazy Asians."

Em has since learned that her family displays many classic symptoms of PTSD.

At 92, she's still haunted by Khmer Rouge atrocities in Cambodia

LONG BEACH, CALIF. USA -- Sath Om Photo by Jeff Gritchen / Press-Telegram (Jeff Gritchen)

April 22, 2012
By Greg Mellen, Staff Writer
Long Beach Press Telegram

LONG BEACH -- The face of Sath Om reveals even more than her chilling words. The pain seems so immediate and real, it is as if time has stopped. 

"It's still real," the 92-year-old survivor of the Cambodian genocide says through translation as the tears flow. "It's like a stick in your eyes when it's remembered."

Om has harrowing stories of life during the brutal reign of the Khmer Rouge between 1975 and 1979 when upward of 2 million Cambodians died from malnutrition, disease and murder in the country's notorious Killing Fields.

Om was burned out of her house and had to run for her life.

She was imprisoned for a time.

Killing Fields' legacy

Sath Om, top left, Arun Va, top right, Roth Prum, bottom left, and Sam Keo. (Jeff Gritchen / Press-Telegram)

PHNOM PENH, CAMBODIA -- Depressions in the ground show the locations of mass graves at Choeung Ek, about 17km south of Phonom Penh, Cambodia. The site, now a memorial, is the best-known of the sites known as The Killing Fields, where the Khmer Rouge regime executed about 17,000 people between 1975 and 1979. Mass graves containing 8,895 bodies were discovered at Choeung Ek after the fall of the Khmer Rouge regime. Many of the dead were former political prisoners who were kept by the Khmer Rouge in their Tuol Sleng detention center. (Jeff Gritchen / Staff Photographer)

April 22, 2012
By Greg Mellen, Staff Writer
Long Beach Press Telegram

LONG BEACH - The pain stitches across the face of 91-year-old Sath Um as she recalls the horrors she witnessed and her brushes with death.

Roth Prum fingers the leaves of a small plant she holds as she talks about how "I became the cow" when relating her work pulling a plow through rice fields.

Arun Va says his memory is burned with the faces of five women he watched have their throats slit and bodies weighed down with rocks and sunk near the Tonle Sap lake.

"That one thing is in my eye all the time," Va says.

For years, Sam Keo was wracked by survivor guilt and shame for not sharing food with a sibling who died from starvation.

"I would wake up every night sweating," Keo says.

If one walks through the Cambodia Town area of Long Beach and spots an elder, the chances are they have similar stories. They have witnessed and were subjected to horrors that are incomprehensible to most Americans.

Author Hopes To Shed Light Khmer Rouge Trauma

“Out of the Dark: Into the Garden of Hope” by Sam Keo, a Cambodian psychologist. (Photo: Courtesy of Dr. Sam Keo)

Thursday, 26 January 2012
Men Kimseng, VOA Khmer | Washington, DC

“The disease that we endured during the genocidal Khmer Rouge regime cannot be completely healed.”

Click the control below to listen to the audio program:

Click here to download or listen to the audio program in MP3

Cambodians who survived the Khmer Rouge will have to live with the emotional scars of the regime, but staying positive can help them move forward, says Sam Keo a Cambodian psychologist who has written a new book.

“Out of the Dark: Into the Garden of Hope” is an attempt to help Cambodians move past the trauma, he said on “Hello VOA” Monday.

“The disease that we endured during the genocidal Khmer Rouge regime cannot be completely healed,” said Keo, who is a clinical psychologist in Los Angeles. “It stays on. But we can help them work as normal for certain periods of time, until they run into big stresses.”

Past War, Continued Poverty, Add to Mental Illness: Professor

Ka Sunbaunat, a psychiatry professor and dean of the faculty of medicine at the University of Health Sciences, in Phnom Penh, spoke to VOA Khmer recently.

Wednesday, 26 October 2011
Phy Sopheada, VOA Khmer | Washington, DC

"Currently, the main misery of [many] people, who have just recovered from war and violence, is poverty."

[Editor’s note: Mental trauma remains one of the main issues for Cambodia, a legacy of the Khmer Rouge and the country’s conflicts. Ka Sunbaunat, a psychiatry professor and dean of the faculty of medicine at the University of Health Sciences, in Phnom Penh, spoke to VOA Khmer recently. He says the lingering problem should be a top priority in a developing country like Cambodia.]

Cambodians suffered severely during the Khmer Rouge, so how does this affect the people and society today?

Cambodia was at war from 1970 to 1975, and under the Pol Pot regime from 1975 to 1979. The western part of the country continued to suffer by war, and it was not until 1998 that the country was totally at peace. This produces psychological effects, such as anxiety disorder, depression, and post-traumatic stress disorder, in Cambodians who directly suffered during those periods.

Due to the delay of its treatment for years, or even decades, PTSD has become another kind of disease. The symptoms are stomachache, headache, body-ache, depression and high blood pressure. For those who experience depression, they drink alcohol to release their depressed feeling, and this will affect society.

New Book Explores Cambodia’s ‘Hidden Scars’

Friday, 23 September 2011
Phy Sopheada, VOA Khmer | Washington, DC

"Many people who are affected by trauma would never think to go to a psychiatrist or a psychologist, but in fact they would go to a “kru” or go to a monk."

[Editor’s note: “Cambodia’s Hidden Scars” delves into the trauma caused to the Cambodian population by the Khmer Rouge, even today. One of the authors, Daryn Reicherter, is a professor of psychiatry at Stanford University’s School of Medicine. He has researched mental health and human rights issues in Cambodia, Haiti, Indonesia and other countries. He spoke to VOA Khmer about the reasons such study in Cambodia deserves closer attention.]

What is the book mainly about?

The book is about the idea that human rights violations, armed conflict and war cause psychological and psychiatric outcomes. Many Cambodian survivors were affected by the war and the trauma in terms of their psychological outcome. The book is really meant to be more an advocacy piece, not just to highlight statistics about how trauma has affected Cambodians but to start a dialogue on how psychology affects the [UN-backed Khmer Rouge tribunal] process and affects the victims as they go through the court’s process. The last part of the book looks at what measures have been done, and what measures can be done, to provide more resources for people who were affected psychologically by the war.

[Cambodian-American] Mother's chronic illness drains family funds

Thursday, December 10, 2009
The Mercury (Pennsylvania, USA)

Dahlia and her husband Ron have been struggling for years to support their two children ages 4 and 8.

Even though Ron has held down a steady job as a customer sales representative for 12 years, the family can barely make ends meet. Dahlia's health problems and the related medical bills have left them with touchy finances.

Their troubles started about seven years ago when their son, Jude, was only a year old.

Dahlia, an immigrant from Cambodia, began experiencing mysterious medical symptoms that made it difficult for her to walk. She visited her doctor, who, unable to make a diagnosis, sent her to a team of specialists in Philadelphia.

She underwent a battery of tests, and, over a period of three years, was seen by a number of doctors who ultimately concluded that Dahlia was suffering from post-traumatic stress syndrome.

"I grew up in Cambodia and went through the war," Dahlia explained in a recent telephone interview with The Mercury. "The doctors say I am lucky. Many people who have been through what I went through wind up in a mental institution."

Her childhood was marked by extreme poverty and abuse that left deep, emotional scars. She came to America in 1985, sponsored by a religious organization, and today she is grateful for the life she shares with her husband Ron and their two young children, Jude and Eleanor.

Ron has been deeply supportive of her.

He's worked for a large firm as a customer service representative for more than a decade, and sometimes puts in long hours.

He earns a decent salary, but it's not enough to fully support the family of four, especially since he is still paying off medical bills that were not covered by their insurance.

"My husband is a hard worker. He does what he can for our family, but it's a hardship for him to feed all four of us," Dahlia acknowledged.

She wishes she could help make ends meet in some way, but she still has symptoms that make it difficult for her to work. And right now, the family only has one car, so she also faces transportation difficulties, as well.

Therefore, she devotes herself fully to raising Jude and Eleanor. Jude is now in school full-time, but she can't afford to send Eleanor to a preschool. Instead, she teaches the 4-year-old at home daily to make sure she'll be ready for kindergarten next year.

The family has fallen behind on many of their bills, and even the rent on their small two-bedroom apartment is a month overdue. Dahlia knows she can't spend precious money buying her children toys for Christmas.

"My daughter, she has a long list of things she wants. Someone gave her a My Little Pony toy and now she wants all of them," Dahlia said, chuckling slightly. "But my son, he's grown so much this year, he just needs clothes. He especially needs a winter coat."

She's thankful that Operation Holiday can help her provide her children with a few gifts that she knows will be much appreciated on Christmas morning.

While Dahlia can see no immediate relief from their financial difficulties, she remains optimistic that the coming year will be a better one for her and her family.

"I'm hoping that we can get out of debt and move into a larger home someday," she said. "I don't give up hope and I don't give up faith."

The challenge for Operation Holiday is greater than ever in this 19th year of its existence. The program, which began in 1991 at The Mercury, has distributed more than $1 million in food and gifts to thousands of needy families during the holiday season, all through the generosity of readers.

Last year, Operation Holiday raised more than $59,000 to provide food and gifts to 150 families and 403 children. The program is completely managed and administered by employees of The Mercury. There is no overhead, and every dollar is distributed locally to families referred from local service agencies.

The program has been expanded this year to 200 families with more than 500 children. Each family will receive food for a holiday dinner and staples for the pantry. Gift cards will be provided to families to buy gifts for each child under the age of 17.

Operation Holiday is funded solely by readers' contributions. The names of all those who contribute except those who wish to remain anonymous will be printed in The Mercury between now and Dec. 24. All contributions are tax deductible.

Contributions may be mailed or brought to the offices of The Mercury, P.O. Box 484, Pottstown PA 19464. Make checks payable to Operation Holiday.

Cambodians Still Traumatized

Former Khmer Rouge prison commander, Kaing Guek Eav (C), sits in the Extraordinary Chamber in the Courts of Cambodia in Phnom Penh, Feb. 17, 2009. (AFP)

2009-08-27
Radio Free Asia

Will the long-awaited trial of Khmer Rouge leaders ease Cambodians' trauma, or stir painful memories?

PHNOM PENH—A Cambodian psychiatrist has testified at the trial of a confessed Khmer Rouge torturer that up to 40 percent of Cambodians suffer psychological trouble as a result of the faction’s brutal four-year rule.

“According to research conducted after the Khmer Rouge period, two out of five Cambodians have [suffered] mental problems and psychosocial crises. This figure is high—up to 40 percent” of the population, Chhim Sotheara said.

Studies this year also found that some 14 percent of Cambodians aged 18 and older have suffered post-traumatic stress disorder (PTSD), Chhim Sotheara testified at the trial of Kaing Guek Eav, alias Duch, who commanded a Khmer Rouge torture center when the group was in power from 1975-79.

“During the Khmer Rouge regime, people were trained not to trust each other. This has continued among Cambodians today,” said Chhim Sotheara, of the Transcultural Psychosocial Organization, which promotes community mental health programs,

He added that Duch’s trial offers a chance for Khmer Rouge victims to heal through the administration of justice.

Painful memories

The Journal of the American Medical Association this month published new research by experts at the University of North Carolina that found most Cambodians feared the tribunal would stir up painful memories.

Those who most wanted revenge were also likely to suffer PTSD, they wrote.

Some 87.2 percent of Cambodians 35 or older believed trying Khmer Rouge leaders would stir painful memories, they found, adding, "Now that the trials have begun, longitudinal research is needed to determine the impact of the trials on Cambodians' mental health."

Duch is the first of five senior Khmer Rouge figures scheduled to face long-delayed trials and the only one to acknowledge responsibility for his actions. His trial, which started in March, is expected to finish before the end of the year.

He could face life imprisonment. Cambodia has no death penalty.

Original reporting by Leng Maly for RFA’s Khmer service. Translated by Sothea Thai. Khmer service director: Sos Kem. Executive producer: Susan Lavery. Written and produced in English by Sarah Jackson-Han.

The Khmer Rouge Tribunal: the start of a very long reconciliation process?

Kambol (Phnom Penh, Cambodia). 25/08/2009: Sotheara Chhim, psychiatrist, during his testimony on a screen in the press room on Day 64 in Duch’s trial at the ECCC 
(Photo: John Vink/ Magnum)

25-08-2009
By Stéphanie Gée
Ka-set

Sotheara Chhim, Cambodian psychiatrist and director of the Phnom Penh based organisation TPO (Transcultural Psychosocial Organization), was heard as an expert on Tuesday August 25th. A testimony that was necessary to assess the trauma of the victims of the Khmer Rouge in the Cambodian society and its impact, both individual and collective. Unfortunately, the interpretation struggled, as some of the doctor’s answers were cut and the technical vocabulary was confused. The expert explained how the Khmer Rouge Tribunal could represent a starting point for healing and reconciliation and believed this process must be completed by another – later – mechanism on reparation.

The Khmer Rouge’s work of destruction

Dr Sotheara Chhim started by painting a very dark picture of the social situation under the Khmer Rouge, marked by a climate of distrust and fear resulting from a people categorisation in particular, the destruction of Khmer culture and its religious foundations, the ban on the freedom to worship decided by the new rulers of the country, keen to erase the past. “Cambodians thus suffered a massive psychological impact. People used their beliefs as a basis to solve their problems and confer a meaning and logical explanation to what happened around them. But the destruction of these beliefs resulted in a psychological deficit. So, when they encountered a problem, people could no longer find any solution. The Khmer Rouge did not allow them to pay tribute as they were taught by tradition or to practice their religion. The Khmer Rouge also forced families to separate. 
Children were taken away from their parents. While at a young age, they need their parents’ love, they were deprived of it. In addition, people were tortured, deprived of food, and this also contributed to the trauma. […] [Children] were also forced to spy on their own parents and some of them even killed them. This experience left a more than bitter taste in the mouth of these children, because the Khmer Rouge destroyed the health of each of these beings by forcing them to work excessively and not giving them decent enough accommodation. Also, there was the state of constant fear in which people used to live, over a long period of time.”

Click to Read More...

Tribunal Will Help Treat Victims: Psychiatrist

By Chun Sakada, VOA Khmer
Original report from Phnom Penh
25 August 2009

Cambodian psychiatrist Chhim Sotheara told the judges at a UN-back tribunal Tuesday that the trial of senior members of the regime will help treat mental wounds of the survivors of the regime.

The doctor was called as a witness in the trial of Duch, who is charged atrocity crimes allegedly committed when he ran two infamous Khmer Rouge prisons and an execution site on the outskirts of Phnom Penh.

“The victims from S-21 are still suffering, remembering the past killings and torture, having nightmares and depression, and difficulties of this lack of recovery affects their current living,” Chhim Sotheara said, referring to Tuol Sleng prison by its Khmer Rouge nomenclature.

Two out of five Cambodians suffer psychiatric problems as a result of the Khmer Rouge, Chhim Sotheara said.

“Our victims have suffered from various psychiatric problems, such as [post traumatic stress disorder], depression, pressure, bodily suffering and other troubles, including high blood pressure, chronic disease and diabetes, concerning the killing and torture by the Khmer Rouge,” he said.

“The trials can reduce the depression of the victims,” he said. “The recovery of psychiatric conditions of the victims of the Khmer Rouge depends on the loyalty of the accused, the former senior Khmer Rouge leaders to come out. The knowledge of facts, the acceptance of real justice and apologies are important factors helping treat the conditions of the victims.”

Duch, 66, whose real name is Kaing Kek Iev, faces charges of war crimes, crimes against humanity, torture and murder. Prosecutors say 12,380 people died in his prisons.

Duch told tribunal judges Tuesday he was “completely responsible” for psychological problems brought on by practices of the Khmer Rouge.

Cambodians unsure tribunals will heal wounds of mass killings, JAMA study suggests

Source: Washington U. in St Louis (USA)

Aug. 21, 2009 -- Lessons learned from research into the societal effects of post-Apartheid "truth and reconciliation" hearings in South Africa are now being applied to a U.S. National Institute of Peace-sponsored study of the long-term mental health impact on Cambodians from human rights tribunals targeting the killing of millions by the nation's former Khmer Rouge regime, says James L. Gibson, Ph.D., a professor of political science at Washington University in St. Louis and co-author of a study published Aug. 6 in the Journal of the American Medical Association (JAMA).

"This study is a collaboration between medical people, who are interested in problems like PTSD (posttraumatic stress disorder), and political scientists, such as me, who are interested in transitional justice," Gibson explains. "This initial paper focuses on PTSD, but the larger project (funded by a grant from the National Institutes of Health) addresses as well the question of whether the tribunal will create a collective memory in Cambodia and whether that memory will lead to some degree of reconciliation, both with each other and with the past."

Gibson, the Sidney W. Souers Professor of Government in Arts & Sciences at Washington University and a Fellow of the Centre for Comparative and International Politics and Professor Extraordinary in Political Science at Stellenbosch University in South Africa, is the author of "Overcoming Apartheid: Can Truth Reconcile a Divided Nation?" (2004, Russell Sage Foundation). He's been in South Africa this summer conducting further research on issues related to the truth and reconciliation process.

The JAMA study, which Gibson describes as "preliminary to our large, NIH-funded panel survey on the tribunal," explores a central medical question: As leaders of the former Khmer Rouge regime testify in a human rights tribunal, in harrowing detail, for the killing of more than a million Cambodians from 1975 to 1979, will the trials help a society heal or exacerbate the lingering affects of widespread trauma?

The study offers insight, but sustains the paradox: more than 75 percent of Cambodians believe the Khmer Rouge trials, formally called the Extraordinary Chambers in the Courts of Cambodia, will provide justice and promote reconciliation, but more than 87 percent of people old enough to remember the torture and murder during the Khmer Rouge era say the trials will rekindle "painful memories."

"Cambodians have high hopes that the Khmer Rouge trials will deliver justice. However, they also have great fears of revisiting the past," says Jeffrey Sonis, M.D., M.P.H., an assistant professor in the departments of Social Medicine and Family Medicine at the University of North Carolina at Chapel Hill School of Medicine, lead author of the JAMA study. "We just don't know how tribunals affect a society, whether they increase mental and physical disabilities or relieve them," Sonis says.

Sonis, Gibson and their colleagues are now conducting a longitudinal study, funded by the National Institute of Mental Health, to measure the effects of the trials on Cambodians over time.

Preparation for the trials, cosponsored by the Cambodian government and the United Nations, began in 2006, 26 years after the collapse of the Khmer Rouge under its leader, Pol Pot. The first public trial, of Kaing Guek Eav, leader of the notorious Tuol Sleng prison, where thousands were tortured and killed, began earlier this year. Accounts of the genocide estimate between one million and two million people were killed to create an "agrarian collectivism," a communist concept for an ideal society.

Between December 2006 and August 2007, Sonis, Gibson, and an international team of colleagues, including researchers from the Center for Advanced Study in Phnom Penh, conducted a national survey of more than 1,000 Cambodians age 18 and older; 813 were 35 and older and would have been at least 3 years old when the killings began.

Other co-authors on the JAMA study include Joop T. V. M. de Jong, M.D., Ph.D., a professor of cultural and international psychiatry at Vrije Universiteit Medical Center, Amsterdam; Nigel P. Field, Ph.D., professor at the Pacific Graduate School of Psychology; Sokhom Hean, Ph.D., president of Center for Advanced Study, Phnom Penh, Cambodia; Ivan Komproe, Ph.D., of HealthNet TPO, Amsterdam.

More than 14 percent of respondents over age 35, and 7.9 percent of people 18 to 35, suffered from "probable PTSD" (respondents met the criteria for PTSD on a common questionnaire, but did not receive an official clinical diagnosis), which resulted in significant rates of mental and physical disabilities. Previous studies have reported higher rates of PTSD in Cambodians, but were mostly conducted among Cambodia refugees, an atypical population. The rate (11 percent) of probable PTSD among all Cambodians over the age of 18 was more than 5 times the rate among U.S. adults, based on the National Comorbidity Survey.

Among the older group, half said they were close to death during the Khmer Rouge era and 31 percent reported physical or mental torture.

Respondents who did not believe justice had been served, up to the time of the survey, and those who felt the need for revenge were more likely to have PTSD. Also, people who had more knowledge of the trial had higher rates of PTSD. Yet most Cambodians had highly positive attitudes about the trials.

Another paradox emerged from the respondents: Almost half of the respondents in this overwhelmingly Buddhist country thought the trials "go against the teachings of Buddha." However, when asked about attitudes toward the Khmer Rouge, 63 percent of respondents strongly agreed, and 21 percent agreed with the statement, "I would like to make them suffer."

Tribunals to assess crimes of war and crimes against humanity are becoming more common. In June, Charles Taylor, former president of Liberia, answered questions in an international courtroom in Paris about his alleged role in genocide in Sierra Leone in the 1990s. The International Criminal Tribunal for the Former Yugoslavia, a UN-sponsored trial, has been underway since 1993 and the International Criminal Tribunal for Rwanda since 1995. The Nuremberg Trials is perhaps the most well known.

The Khmer Rouge trials offer the opportunity to better gauge the efficacy of these trials, and those lessons hold relevance across a spectrum of injustice. Sonis, Gibson, and their colleagues interviewed 1800 people earlier this year and will re-interview them this fall and again next year. They are currently at work analyzing the first-wave data.

"The larger question raised by our study is whether attempts to promote justice for survivors of violence — whether en masse or inflicted by one individual to another — can help lessen its psychological toll," Sonis says. "We simply don't know the answers yet."
# # #
Editor's Note: This release includes material provided by the news office of the University of North Carolina. For media assistance there, contact Media contact: Clinton Colmenares, (919) 966-8757, ccolmena@unch.unc.edu.

Khmer Rouge horrors still haunt victims 30 years on

Sunday, July 12, 2009
Joel Brinkley
San Francisco Chronicle (USA)

Kampong Speu, Cambodia -- They started arriving before 8 a.m., middle-aged men and women, poor rice farmers mostly - damaged survivors of the Khmer Rouge regime.

The Documentation Center of Cambodia, a private research organization that collects evidence on the Khmer Rouge regime that ruled Cambodia from 1975 to 1979, was bringing to this small provincial town a video projector and a DVD. It shows highlights of the testimony in a Khmer Rouge trial under way in Phnom Penh.

"I want to contribute to engaging the victims in the court process," explained Youk Chhang, the center's director. The founding agreements establishing the court opened the proceedings to victims of the Khmer Rouge. "Some Cambodians have moved on," he added. "But there are others who still suffer, and these are the ones we are targeting." That's just whom he got.

For an hour, about 75 people watched transfixed as Kaing Khek Lev, commander of S-21, the notorious prison-torture chamber where thousands of Cambodians died, described his crimes. He is better known as Duch, and he told how he supervised as his soldiers executed victims by whacking them on the back of the head with a hoe.

Duch is 66 now and looked directly at the judges with a calm and confident gaze, seeming to be the commander still, as he confessed to his terrible crimes, apologized and asked for forgiveness.

"I was given a directive to use a plastic bag to suffocate prisoners," he acknowledged.

When the video excerpts ended, the room sat silent - stunned, it seemed. A documentation center official asked audience members to talk about what they had seen.

The DVD was paused on a scene in which Duch seemed to be staring directly at the crowd with a stern, almost threatening, gaze.

The first woman who raised her hand took the microphone and promptly broke into tears.

"Forgiveness is not acceptable," she declared, wiping her eyes. "They killed my father and two older brothers."

Next a middle-aged man told of how six of his relatives died, and as he spoke his large brown eyes grew red and filled with tears. Still another man was choking up so that his words were hard to understand.

"I was a child, and I was starving," he stammered. "They gave us no food, and sometimes I would fall down and pass out and then wake up again." And so it went.

Cathartic? Perhaps. Injurious? Maybe.

The problem is, almost half the adult population of Cambodia, those older than 35 or 40, shows symptoms of post-traumatic stress disorder, a severe psychological condition that typically afflicts soldiers, but also civilians who live through trauma - like the horror here 30 years ago.

And for them, psychiatric experts say, watching a video like the one these people saw is like poking a stick in a hornet's nest. It triggers all of the symptoms: pain, rage - even violence.

One medical study of Cambodian refugees in Long Beach - the largest concentration of Cambodians in the United States - found that 62 percent of the adults had PTSD.

That and other studies found a generally dysfunctional population with high levels of alcoholism, drug use - and terrible violence.

Daryn S. Reicherter, a psychiatrist at Stanford University, served as a consultant to the Documentation Center here in the spring and came back concerned. "There needs to be some medical follow-up with these people" after the show has ended, he insisted.

So far, the Documentation Center has trucked more than 10,000 villagers to Phnom Penh to see the trial - or brought DVD excerpts to show in their own villages.

Youk Chhang understands the doctors' concerns but points out that he is a researcher, not a treatment specialist. The government, he says, should provide any needed psychiatric services. But then, Cambodia has only about 26 psychiatrists in the entire nation.

Yim Choy, a 44-year-old farmer, shouted at the crowd, saying that he had been conscribed to a child-labor team. "I cannot forgive Duch," he declared, his voice laced with bitter anger. "How can I when I saw him throw little boys against a tree?"

Afterward, he told me that, even now, he cannot talk about those times without growing angry. And yet he has a hard time keeping the thoughts out of his mind.

He even dreams of the horrors - a hallmark of PTSD. "I see myself with my hands tied behind me." All of that makes him angrier still.

After watching scenes like this, Reicherter posed a rhetorical question: "Why is this important?"

"Children are growing up," he explained, "with violent, PTSD parents who are drunk and beat them. That's the generation that is coming."

Joel Brinkley is a professor of journalism at Stanford University and a former foreign policy correspondent for the New York Times. To comment to him, e-mail brinkley@foreign-matters.com. Contact us at forum@sfchronicle.com.

Court video brings back horrors to thousands of Cambodians

Thursday, Jul. 9, 2009
By JOEL BRINKLEY
McClatchy-Tribune News Service

KAMPONG SPEU, Cambodia -- They started arriving before 8 a.m., middle-age men and women, poor rice farmers mostly - damaged survivors of the Khmer Rouge regime.

The Documentation Center of Cambodia, a private research organization that collects evidence of the Khmer Rouge regime that ruled Cambodia from 1975 to 1979, was bringing to this small provincial town a video projector and a DVD. It shows highlights of the current defendant's testimony in the Khmer Rouge trial under way in Phnom Penh.

"I want to contribute to engaging the victims in the court process," explained Youk Chhang, the center's director. "Some Cambodians have moved on. But there are others who still suffer, and these are the ones we are targeting."

That's just who he got.

For an hour, about 75 people watched transfixed as Kaing Khek lev, commander of S-21, the notorious prison/torture chamber where thousands of Cambodians died, described his crimes. He is better known as Duch, and he told how he supervised as his soldiers executed victims by whacking them on the back of the head with a hoe.

Duch is 66 now and looked directly at the judges with a calm and confident gaze, seeming to be the commander still, as he confessed to his terrible crimes, apologized and asked for forgiveness.

"I was given a directive to use a plastic bag to suffocate prisoners," he acknowledged.

When the video excerpts ended, the room sat silent - stunned, it seemed. A documentation center official asked audience members to talk about what they had seen. The DVD was paused on a scene in which Duch seemed to be staring directly at the crowd with a stern, almost threatening, gaze.

The first woman who raised her hand took the microphone and promptly broke into tears.

"Forgiveness is not acceptable," she declared, wiping her eyes. "They killed my father and two older brothers."

Next a middle-age man told of how six of his relatives died, and as he spoke his large brown eyes grew red and filled with tears. Still another man was choking up so that his words were hard to understand.

"I was a child, and I was starving," he stammered. "They gave us no food, and sometimes I would fall down and pass out and then wake up again." And so it went.

Cathartic? Perhaps. Injurious? Maybe.

The problem is, almost half the adult population of Cambodia, those over 35 or 40 years of age, shows symptoms of Post Traumatic Stress Disorder, a severe psychological condition that typically afflicts soldiers, but also civilians who live through trauma - like the horror here 30 years ago. And for them, psychiatric experts say, watching a video like the one these people saw is like poking a stick in a hornet's nest. It triggers all of the symptoms: pain, rage - even violence.

One medical study of Cambodian refugees in Long Beach, Calif. - the nation's largest concentration of Cambodians - found that 62 percent of the adults had P.T.S.D. That and other studies found a generally dysfunctional population with high levels of alcoholism, drug use - and terrible violence.

Daryn Reicherter, a psychiatrist at Stanford University, served as a consultant to the Documentation Center here in the spring and came back concerned. "There needs to be some medical follow-up with these people" after the show has ended, he insisted.

So far, the Documentation Center has trucked more than 10,000 villagers to Phnom Penh to see the trial - or brought DVD excerpts to show in their own villages. Youk Chhang understands the doctors' concerns but points out that he is a researcher, not a treatment specialist. The government, he says, should provide any needed psychiatric services. But then, Cambodia has only about 26 psychiatrists in the entire nation.

Yim Choy, a 44-year-old farmer, shouted at the crowd, saying that he had been conscribed to a child-labor team. "I cannot forgive Duch," he declared, his voice laced with bitter anger. "How can I when I saw him throw little boys against a tree?"

Afterward, he told me that, even now, he cannot talk about those times without growing angry. And yet he has a hard time keeping the thoughts out of his mind. He even dreams of the horrors - a hallmark of P.T.S.D.

"I see myself with my hands tied behind me." All of that makes him angrier still.

After watching scenes like this, Reicherter posed a rhetorical question: "Why is this important?"

"Children are growing up," he explained, "with violent, P.T.S.D. parents who are drunk and beat them. That's the generation that is coming."
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ABOUT THE WRITER

Joel Brinkley is a former Pulitzer Prize-winning foreign correspondent for The New York Times and now a professor of journalism at Stanford University. Readers may send him e-mail at: brinkley@foreign-matters.com

Understanding Trauma In Cambodia

Phnom Penh Post, Issue 16 / 25, December 14 - 28, 2007

On November 21, the Center for Social Development launched Understanding Trauma in Cambodia Handbook, beautifully and thoughtfully written by Matthias Witzel, a consultant of the German Development Service to CSD with 15 years experience as a clinical psychologist and psycho-therapist with traumatized people from all over the world (Germany, Switzerland), especially in countries with civil war (Yugoslavia, Iran, Iraq, Palestine, Liberia, Rwanda) before working in Cambodia for the last 2 years. He is also a second-generation traumatized person from a family displaced by World War II. The following are excerpts of Matthias' comments (with the full text available at www.csdcambodia.org " What's New at CSD"):

It is only appropriate to begin my presentation with some brief acknowledgements - especially for my Cambodian colleagues during the process of developing this Handbook.

First of all, our special gratitude goes to all the people who have supported us with their experiences and their knowledge, such as the participants at CSD public fora, who shared personal memories of their suffering during the KR years and gave us invaluable insights into the complex processes of Cambodian trauma. Our debt to them is substantial. In fact, this Handbook owes its existence to these Cambodians who suffered and still are suffering from past experiences.

Second, my very special gratitude goes to the CSD staff, particularly four individuals:

Foremost, there is Seng Theary, who came up with the idea to write this Handbook. During our discussions about psycho-social issues I am always deeply impressed by her precise and profound knowledge about psychological phenomena, especially about the coincidences among aspects of general human development, personality patterns and the situation of young Cambodians struggling with the socio-political reality in their lives. Her engagement of young employees is - from my perspective as a psychologist - outstanding and should be recognized as a role model for other leaders in this country.

Yim Sotheary: She mainly translated and edited the text into Khmer, helped to conceptualize and design the Handbook. Without her substantial engagement and deep commitment, not one single page could have been delivered today.

Sam Sarath, the brilliant CSD cartoonist: Even though unfamiliar with psychological topics, he obviously enjoyed transforming my stickman-drawings and creating the nice cartoons. He is one of the most humble and modest persons I have met in Cambodia.

Finally, Om Chariya: She worked very closely with us on the translation and editing and is the core of compassion within the CSD Emotional Support Group. During our reconciliation work in Cambodia's remote areas and the public fora, I was amazed by her skills to anticipate villagers' expression of grief and sadness and then to intervene with professional awareness and consciousness.

Everyone involved in the process of creating this Handbook made a conscientious (more or less), deep commitment to themselves to process personal life issues, recognizing it as a chance to develop their own personality pattern about how to deal with stress, overwhelming feelings and the tendency to avoid grief and anger. Dealing with trauma issues or with traumatized people implies a risk that can lead to being co-traumatized, or at least, mental and physical exhaustion, respective to burnout.

We write this Handbook for two principal reasons: to combat fear, and to address personal healing and national reconciliation.

Fear stems from lack of information

During our outreach activities and research, we quickly realized that fear is one of the most evident symptoms in Cambodia today, blocking a creative, engaged and healthy life of many people.

Fear is a lack of information (or knowledge, understanding).

In response to fear, the first step is to get control and ownership of one's own life in or after threatening situations, to get knowledge about the structure and content of the destructive circumstances. The second step is to seek new skills, and/or to reactivate earlier developed skills in order to cope and to reorganize life in a healthy way.

Step one is only a precondition; it does not give enough skills to deal with damaged self esteem, destructive behavior, lack of trust, or lack of ownership according to a self-actualized, creative, robust living.

For example, if family members do not understand that trauma can lead to an outburst of anger, panic or sudden grief (common symptoms) or that traumatized people change their communication pattern, are more suspicious and afraid, and tend to withdraw from society, how can they understand their suffering relatives, how can they appreciate them in their life struggle. Instead, oftentimes, they are labeled as "ch'kuet", crazy.

Lack of knowledge leads to lack of understanding, and consequently lack of empathy.

Again, how can people regain peace in their hearts if they are treated as abnormal for their grief, anger and depressive moods. With knowledge about common processes, they may seek help and may be more kind to themselves, because they will realize that their feelings are very, very normal and that the very first important approach to recovery is to treat yourself very kindly.

National reconciliation, personal healing

Parents, teachers, aid workers, politicians - the whole of society - have to impart not only knowledge and facts about history (which is fundamental), but need to understand that knowledge about human behavior, motivations, constructive and destructive personality patterns, the dark side of our souls, and even certain aspects of human behavior related to extreme aggression (unexplainable by psychological and sociological theories) is as fundamental.

The complicated process of reconciliation requires knowledge for each individual to understand their mental health situation and the internal turmoil in terms of spirituality and the meaning of life.

People with better knowledge, more informed, more sophisticated thinking patterns are more likely to forgive perpetrators, even murderers from the Khmer Rouge time. They are more able to differentiate pieces of information and ponder the circumstances, the conditions, the obstacles, and suffering of perpetrators; they can imagine the motives and purposes, and eventually, the traumata of the perpetrators. They don't label and stigmatize people as bad, if they behave badly; they can differentiate between a person's behavior and a person's personality.

PTSD

Post-traumatic stress disorder is a mental health disease with severe reaction of unprocessed trauma. Last year, 62% of Cambodians living in the US suffered from PTSD and 51% suffered from depression. Despite the difference in circumstances for overseas Cambodians, psychiatrists and psychologists perceive similar high prevalence of PTSD in Cambodia.

At present many organizations and many Cambodians are becoming more engaged in the process of national reconciliation and development. Inevitably, one of the results of the increase of outreach work will be that many Cambodians will face their personal and collective history of the KR years. Undoubtedly, a wide range of symptoms, such as grief, anger, and other expressions of trauma will emerge from the depths of people's sub-consciousness. Many years after the KR atrocities, the trauma in the hearts of many Cambodians is still unresolved.
Dissociation, avoidance, numbing

Time does not heal all grief and pain: trauma can be re-experienced many times throughout one's life.

The brain employs different strategies to protect us from psychological and physical pain. Survival mechanisms such as dissociation, avoidance and numbing can initially help us to cope with an unbearable moment. But if we do not integrate our pain within some weeks or months after it occurred, it can lead to unhealthy long-term effects.

Many Cambodians who lived through the KR 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 till today. Without a safe place to integrate their feelings of fear/pain and support from people who were not traumatized, these Cambodians did not have an opportunity to heal.

Hence, many Cambodians remain in a state of dissociation. They avoided feeling the full depth of the overwhelming pain. The coping strategy of dissociation allows people to struggle with unfathomable, unbearable circumstances, but with detachment and suppression of feelings. Consequently, from time to time, the tremendous suppressed grief, sadness, and anger erupt in problematic ways, e.g., high prevalence of domestic violence.
Unhealed trauma can be triggered anytime

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 their traumatic past. A person may be unaware of what is triggering the memory (e.g., loud noises, a particular color, piece of music, odor). But becoming aware of these triggers and learning not to overreact to them are important therapeutic steps in the treatment of people who suffer from anxiety, detachment, nightmares, increased aggressiveness, alcoholism, or even severe mental diseases such as PTSD.

In Cambodian society, daily life remains full of 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 personal experiences related to corruption, land grabbing, landmines, 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, seen pervasively throughout the country. These coping strategies could be constructive or destructive, depending on personal and environmental conditions. The goal is to avoid the emergence of too much grief and anger related to past traumatic events.

Unconscious tendencies

There is not yet any systematic research about the existence of typical Cambodian coping strategies. Nevertheless, there are unconscious tendencies that seem to be common in Cambodia, similar to other countries attempting to reconcile their specific history after civil war:

• Avoidance of talking about recent Cambodian history (personal or collective).
• Emotional detachment characterized by a lack of compassion for the suffering of weak, 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 triggered energy of grief and anger through domestic violence, alcohol, drug abuse, and other destructive coping mechanism.
• Former victims unconsciously treating other people as they were treated in the time of the atrocities.
• Post-traumatic growth.

The variety of positive changes that individuals may experience in their struggles with trauma are described in psychological models of post-traumatic growth. 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 sometimes find that their losses have produced valuable gains.

In addition to psycho-therapy and counseling, healing requires an active creating of peaceful, trustful, compassionate and secure atmospheres in the public domain, which is the necessary prerequisite in the nation-wide healing process.

Without a secure social environment, without trust in good leadership-and therefore a different leadership approach then experienced for decades-the traumatized souls will remain suspicious, avoiding healthy and creative life approaches and transmit their distrust and self-distrust to their children. And if a healthy developmental process of individuals is blocked because of the impact of fear and anger, everything in a country, especially the process of reconciliation is blocked.

Simple but powerful reminders

I always repeat the following sentences in my interaction with villagers:

• Everyone should have access to appropriate support and healing approaches.
• Nobody should be ashamed; symptoms of trauma are never a sign of weakness of character or a reason to be depreciated.
• Each phenomenon and symptom of trauma has two sides, even if the constructive side is more hidden.
• Healing and reconciliation requires personal, individual engagement.

We believe that a greater consciousness and knowledge about the socio-political and individual aspects of trauma is one of the first steps towards individual and national reconciliation. There will be no path to comprehensive reconciliation in this country until there is more inner peace in the hearts of individuals, more conscious and relaxed communication between couples as well as among people in families, villages, and towns.

Without consciously facing the phenomena, the traumatic legacy, the aggression and feeling of being lost will be unconsciously passed onto the next generations of Cambodians.

Matthias WITZEL
CSD-DED consultant
Psycho-therapist, clinical psychologist

To read past columns, please visit www.csdcambodia.org "Voice of Justice Program".