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. 2015 Aug;52(4):543–560. doi: 10.1177/1363461514568336

Calming the mind: Healing after mass atrocity in Cambodia

Inger Agger 1,✉
PMCID: PMC4532676  PMID: 25653141

Abstract

After catastrophic events in which people’s survival has been threatened, as happened during the Khmer Rouge regime in Cambodia 1975–1979, some continue to suffer from painful mental symptoms. Surveys carried out in Cambodia based on Western diagnostic categories have found a high prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in the population. This study explored Cambodian approaches to healing trauma, examining the ways in which Cambodians appeal to elements of Buddhism in their efforts to calm their minds, situating this mode of coping in the context of broader Khmer Buddhist practice and understandings. Western psychology may have much to learn from local, contextualised methods of dealing with the aftermath of trauma, including Khmer understandings of distress and approaches to relief. Methods of assessment and treatment of distress cannot be transposed wholesale from one cultural setting to another but require considerable cultural adaptation. This kind of cultural interchange may give rise to innovative, hybrid discourses and methods that may have much to offer in the support of victims of organised violence.

Keywords: Cambodia, cultural adaptation, healing, mindfulness, Theravada Buddhism, trauma

During the Khmer Rouge regime (1975–1979), Cambodia endured systematic and massive human rights violations that included torture, executions, slave labour, starvation, and illness. Nearly one fifth of the population is reported to have died in this period (Chandler, 2008). Although 35 years have now passed since these tragic events, Cambodians are still struggling to understand how they could have happened and how to cope with their painful legacy. While more than 90% of the population claim to be Theravada Buddhists, during the moral chaos of the Khmer Rouge regime, Buddhism was systematically and in most cases brutally dismantled. Over the last 20 years Buddhism has gradually reemerged and many Cambodians pin their hopes of coping with the past and restoring “moral order” in the future on Buddhism. Buddhist rituals and techniques of meditation may enhance feelings of security and wellbeing and thus help survivors cope with residual distress (Kent, 2006).

Cambodia lacks a developed mental healthcare system similar to that in the West. Western psychological approaches to managing the effects of trauma therefore began to be introduced to Cambodia in the nineties to address this void (Mollica, Brooks, Tor, Lopez-Cardozo, & Silove, 2014). However, there exists a range of indigenous practices that Cambodians can call upon to help calm the distressed mind and, indeed, elements of these practices, particularly meditation and mindfulness, have helped inform Western psychological practice.

In this article the point of departure is some of the recent work in the field of transcultural psychology and psychiatry on survivors of the Khmer Rouge regime that argues for greater cultural sensitivity in approaches to their mental health and is critical of “the Euro-Western universalized semiotics of suffering” (Kidron, 2012, p. 723), emphasizing the importance of understanding the cultural meaning of symptoms (Stevens, 2001). Langford (2009) argues for the importance of understanding the cultural significance for Khmers of ancestor veneration and the “social existence of the dead” (p. 705). This literature suggests that the mental effects of trauma may be experienced and expressed in markedly different ways in different cultural contexts and that much may be learnt by also exploring what cultural tools may be available to address posttraumatic distress (Hinton, Hinton, Eng, & Choung, 2011; Hinton, Kredlow, Pich, Bui, & Hofmann, 2013).

The concept of mindfulness is central to the Theravada Buddhist tradition. Khmer Buddhism, an amalgam of preexisting animist and Hindu traditions onto which Buddhism was later grafted, also offers numerous other approaches to healing, such as through medicinal herbs, spirit possession, and various “magical” practices. However, approaches to calming the mind—through meditation, knowledge, and understanding—are particularly well-developed within the Buddhist canon and traditions.

The primary aim of this study therefore was to explore the ways in which Cambodians appeal to this element of Buddhism in their efforts to calm their minds, and also to situate this in the context of broader Khmer Buddhist practice and understandings. Considerable space is given to Cambodians’ own voices and formulations as well as to observations of their practices. The objective is to thus enable the reader to engage closely with the culturally shaped experiences and ideas of Cambodians who are trying to alleviate their posttraumatic suffering. By suspending some of our own preconceptions about suffering and mental health, and learning what we can of reality as it is experienced by our informants, we may gain insights that can help us critically evaluate and enrich our own models.

Discourses of suffering

A large percentage of the Cambodian population has been diagnosed using Western psychiatric diagnostic frameworks as suffering from posttraumatic stress disorder (PTSD), depression, and/or anxiety since the mass atrocities that occurred before, during, and after the Khmer Rouge regime.1 However, Eisenbruch (1991) has noted the limitations of simply transposing Western diagnostic categories to characterize the distress experienced by Cambodian refugees. He points to the importance of including people’s own ways of formulating their experience: what the trauma meant to them, their cultural recipes for signalling their distress, and the coping strategies they adopt. He suggests that some of those who were diagnosed with PTSD according to the criteria of the Diagnostic and Statistical Manual-III (DSM-III; American Psychiatric Association, 1980) can be better understood as undergoing a process of “cultural bereavement” and that their responses may include constructive elements that help them heal after devastatingly traumatic experiences.

Chhim (2012, 2013) also questions whether the PTSD diagnosis can adequately capture the symptoms of distress as they are experienced by many Cambodian survivors of the Khmer Rouge regime and suggests that the cultural idiom of distress known as Baksbat2 (broken courage) should be recognized by mental health professionals in order to “provide appropriate support for traumatized Cambodians” (2013, p. 160). He describes the symptoms of Baksbat as a lack of trust in others, submissiveness, feeling fearful, and being “mute and deaf” (Khmer: dam doeum kor).

Hinton and colleagues (Hinton, Hinton, et al., 2011; Hinton, Kredlow, et al., 2013) also found that the questionnaires used in many studies of the psychological health of Cambodians were not culturally sensitive and did not consider the ways in which Cambodians themselves experience, understand, and cope with their distress. Hinton’s team therefore developed the Cambodian Somatic Symptom and Syndrome Inventory (CSSI) which includes indigenous symptoms and causal explanations such as: “wind attack,” “thinking too much,” “sleep paralysis,” and “weak heart.” They found that “thinking too much” was a key indicator of distress and those who scored highly for symptoms of PTSD according to the DSM-IV (American Psychiatric Association, 2000) also had high CSSI scores. The interviewees themselves, however, expressed more concern about the somatic and culturally familiar syndromes captured by the CSSI than they did about the psychological problems identified using foreign norms.

One of the most prominent and commonly occurring problems found by van de Put and Eisenbruch (2002) and by Hinton and colleagues (Hinton, Hinton, et al., 2012; Hinton, Kredlow, et al., 2013) was “thinking too much” (Khmer: kut caraeun). This includes thinking about upsetting topics, past traumatic events, and separation (by death) from loved ones. Kut caraeun may lead to headaches, dizziness, “wind attacks,” depletion of bodily energy, heart weakness, and even “overheating of the brain” (memory loss, insanity). Hinton, Nickerson, and Bryant (2011) found that “thinking too much,” often called “worry,” was common among Cambodian refugees in the United States, exacerbated their PTSD symptoms, and provided a key target for intervention.

In interviews with Cambodians undertaken for the study reported in this paper, “thinking too much” was frequently identified by the interviewees as a problem that could give rise not only to personal distress but also to anger, which, if not controlled, might be expressed in violent and antisocial behaviour. Similarly, Nickerson and Hinton (2011; Hinton, Kredlow, et al., 2013) noted that anger reactions are a common problem among Cambodians who have resettled in the United States. Nickerson and Hinton (2011) also note that many turn to Buddhist monks for advice about managing their feelings and that all of the monks they interviewed cited mindfulness and meditation as key methods for regulating anger.

A second significant mental health problem among Cambodian survivors of the Khmer Rouge period is that of recurrent, disturbing dreams about loved ones who died untimely or violent deaths during the regime. In Cambodia, it is widely believed that the spirits of those who die a violent death may be unable to find peace. For example, the spirits of women who have died in childbirth are known in Khmer as bray and are thought to be maleficent unless they are tamed within the confines of the pagoda, where they become transformed into beneficent parami spirits.3 The problem of restless and hungry ghosts is exacerbated when funeral rites were not performed according to proper Buddhist custom—something that was impossible under the Khmer Rouge, who banned Buddhism.

It is against this cultural and historical background that Cambodians’ dreams about the disconsolate ghosts of their dead can be understood as symptoms not simply of individual mental disturbance but also of a spiritual disruption of the relationship between the living and the dead arising in particular historical circumstances. Psychological diagnostic and therapeutic methods that fail to appreciate the cultural significance of these dreams may result in a form of “category fallacy” (Hinton, Peou, Joshi, Nickerson, & Simon, 2013) and thereby fail to offer appropriate support to sufferers. Better diagnostic assessment and treatment interventions depend on paying closer attention to what Cambodians themselves have to say, in their own words, about the explanatory models and coping strategies they find intelligible and helpful.

Method

The project followed the principles of the World Medical Association Declaration of Helsinki and was reviewed and approved by the Danish Council for Independent Research in Culture and Communication. The findings presented here derive primarily from a study conducted by the author on local approaches to healing trauma. The study included 7 months of fieldwork in Cambodia from 2011 to 2012. The author cooperated closely with a local organisation, Transcultural Psychosocial Organisation (TPO), to make contact with and interview 27 survivors (18 male and 9 female) of the Khmer Rouge regime who had received psychosocial support from TPO. Each interview took about 1 to 2 hours to complete and all interviews were audiotaped. At the beginning of each interview, signed informed consent was obtained. The author explained to participants that the objective of the interview was to understand how survivors had experienced their life during and after the Khmer Rouge, which kind of mental support they had received (if any), and, if so, how they had experienced it, with the objective of developing better methods for assisting survivors, if needed. The author, furthermore, explained that the intention was to publish the results but that names of participants would not be mentioned, and their identities disguised. Each participant received a US$5.00 gift voucher as a token of appreciation. All interviews were carried out in the village homes of the survivors.

The author also interviewed nine members of victim associations (seven from the “Ksem San Association” and two from the “Association of Khmer Rouge Victims in Cambodia”). Staff members of five nongovernmental organisations providing psychosocial assistance to survivors were also interviewed as well as six staff members of the Extraordinary Chambers in the Courts of Cambodia (ECCC), also called the “Khmer Rouge Tribunal.” The author was also present as an observer at the trials.4

An important part of the study was learning about Buddhist healing practices and, to this end, the author interviewed 10 Buddhist monks, four Buddhist nuns (donchee), and six traditional healers (kruh). The author found these interviewees by asking around when she was out in the villages to interview survivors. She also had the opportunity to observe a number of religious ceremonies and rituals.

A Cambodian psychologist acted as interpreter and all interviews were tape-recorded and later transcribed and translated once more into English. The interviews were open-ended and qualitative. In the interviews with survivors the emphasis was on exploring how they had coped with their experiences and memories from the Khmer Rouge period. With monks, nuns, and traditional healers the emphasis was on their approaches to the suffering of survivors who consulted them for support.

The results presented are based on analysis of the interview transcripts, field notes, and a review of relevant documents and literature. Thematic analysis of these materials focused on local cultural techniques for coping with trauma and its aftermath.

Results

Cambodian methods for calming the mind

Meditation

Various forms of meditation are practiced in Cambodia, but two of the most commonly mentioned during the fieldwork were samadhi (stilling the mind through mental concentration) and vipassana (insight) meditation, which involves the acquisition of self-knowledge and insight into the true nature of reality. In interviews, people who had experienced Khmer Rouge atrocities sometimes described how they used meditation as a coping strategy. For instance, a middle-aged male survivor in Pursat Province described how he practiced samadhi

[T]o calm my feelings and to cool my body. I noticed that if I was thinking too much I felt so hot in my head. Now it is released, even though there are still some family problems which make me feel a little bit of headache, but I can solve this.

A male teacher at a meditation centre in Siem Reap province explained how meditation can help survivors:

They do meditation or relaxation with breathing exercises until their breath becomes normal again. They come here to calm their feeling, so it can lead them to gain more energy inside and to push their nervous system to run more smoothly.

As was the case among the Khmer refugees Nickerson and Hinton (2011) studied in the United States, most of the informants turned to monks for advice about how to deal with mental suffering. A monk from a village pagoda in Kampot Province explained how he assists members of his congregation in calming their minds and gaining insight when they feel upset by their memories about the Khmer Rouge period:

They come here because they want to forget their problems, to observe morality and perform religious concentration… they want to calm down their feelings.… They cross their legs and fold their arms; they close their eyes to control their self-possession, because people who have mental problems, their feelings are very stuck. So they select one object for mental concentration, for example a Tevada [angel]. They keep on quietly reciting this word, Tevada, in order not to be overwhelmed by feelings about the past… Tevada is a Pali word.

By concentrating on a word in the Pali language, such as Tevada, one can recall the goodness of the Buddha. The very fact that something was expressed in Pali meant it had a protective power (monakum). The monks used Pali chanting from an old palm leaf manuscript to enact healing rituals, although they often did not know how to translate the Pali into Khmer. They also had Pali stanzas tattooed as a form of protection.

While meditation may help reduce distress, Buddhism also recognises that suffering (Pali: dukkha, literally “unsatisfactoriness”) is an intrinsic feature of the human condition. The objective of meditation is therefore not to abolish suffering but to transcend it. As the same monk explained,

This [meditation] can help reduce their suffering, but not a hundred percent. All people are born with suffering. Tevada means that we recall the goodness of the Buddha. If the person understands the Buddha’s teachings about the life cycle we all must go through of birth, ageing, illness, and death, then the person can live. When the person has meditated on the Buddha’s teaching, she will feel fresh. She no longer suffers.

Cambodians hold that meditating helps cultivate a calm “mind” (Khmer: chet sngap; Kent, 2006). However, the Khmer word chet is derived from the Pali citta and refers both to the mind and the heart, the intellect and the passions. Wellbeing (Khmer: sok) in Cambodia depends upon training the mind/heart (Khmer: sok phluv chet) according to the dictates of the Buddhist canon, the dhamma. Meditation and mindfulness not only alleviate the suffering caused by “thinking too much” but also lead to moral behaviour in line with the Buddha’s teachings. It follows also that when an individual pursues the Noble Eightfold Path of Buddhism,5 they reduce not only their own suffering but also the chances of causing suffering for others by performing wrong actions. Ultimately, then, this helps heal relationships and build trust within the community (Kent, 2006).

The Khmer term generally used for wellbeing or peace of mind is sekkadai sok. The word sok is derived from the Pali term sukkha, which means pleasure or bliss. It is the opposite of dukkha, which results from craving (Pali: tanha) and which can be vanquished not by succumbing to or gratifying the craving, but by understanding the Buddhist principles of impermanence and practicing its virtues of self-control (Kent, 2006, pp. 351–352).

An elderly monk from a rural pagoda in Kampot province explained how he approached the suffering of the Khmer Rouge survivors as follows:

Buddha is the only way that can help them release the tension in their minds. I ask them to do meditation. I explain the natural law of human beings: we are born, get old, get sick, and die. Every family experiences separation and the past is already gone, so you should calm your feeling, so as not to suffer any more. If you did not die during the Khmer Rouge times, you will die later. I explain to them that life is unstable, about the suffering of human beings, we all have suffering, so if we want to release our suffering we have to consider other families who face the same problems as we do. So the victims can find a way to deal with their unstable minds.

Making merit for the deceased

The notion of merit (Khmer: bon) is fundamental to an understanding of Khmer Buddhist practice. When individuals visit the pagoda, make offerings to the monks, observe the Buddhist precepts and meditate, they accumulate stores of bon, which will benefit their own karmic progress and help ensure that they will be reborn into a better next life.

Khmer Buddhism is an amalgam of pre-Buddhist Hindu and animist practices onto which Theravada Buddhism was later grafted. Buddhist meditation practices therefore exist in Cambodia within a broader cultural framework of ancestor and spirit worship. While Western notions of healthy grieving are rooted in Abrahamic religious ideas of life terminating upon death, Hindu and Buddhist traditions see death as a transition into the next life. Indeed, even in the West, the idea that healthy grieving requires reaching a sense of “closure” and the acceptance of the ending of a relationship has begun to be problematized by Western scholars (e.g., Berns, 2011). In Cambodia, it is recognized that healthy grieving involves maintaining a good relationship with the dead and perhaps assisting the dead towards rebirth. The spirits of those who died a violent death or whose bodies were not ritually handled by monks may continue to experience distress and unfulfilled needs even after death and they may continue to disturb their surviving relatives. Therefore, efforts to “calm the mind” may need to be directed not simply to the living individual but also to their relationship with the dead.

This means that the dead are treated as an extension of the moral community of the living and attending to their wellbeing and tranquility is integral to the wellbeing of the living as well. The “currency” by which this is achieved is that of bon. After performing meditation, it is common practice for Cambodians to pour a cup of water onto the earth while thinking of their dead. This symbolically enacts the transfer of the merit accumulated through meditation to the spirits of the dead, thus enhancing their karmic status and aiding their passage along the chain of being.

A middle-aged female survivor of the Khmer Rouge regime from a village in Takeo Province explained,

They died and there were many victims killed during the Khmer Rouge regime. (So we are here at the pagoda) to let them know that the survivors care for them, to help their souls calm down and to assist them to find a place and be reborn. So we pray for them and make offerings to them.

Similarly, a middle-aged man from the same village said,

Because we are Khmer Rouge victims and thinking too much about the past, about family members who were killed, they have rituals to make us feel calm and relief from pain and relief from grief. This is also to calm the spirit of the dead.

Another male survivor from the village elaborated,

I think the dead are still here, because I often dream of them and maybe we have not offered enough for them to be reborn. They were killed, they are still out there, but if they had died naturally they could have been reborn. They are still calling for us, because we think of them and dream of them. Sometimes we sleep well, and sometimes we dream that they come to see us. Those who were killed, their souls are still out there and cannot find a place to be reborn.

Dreams of the deceased and concerns about their spiritual status play an important role in the grieving process in Cambodia. These dreams are often upsetting (Hinton, Hinton, Pich, Loeum, & Pollack, 2009; Hinton, Field, Nickerson, Bryant, & Simon, 2013; Hinton, Peou, Joshi, Nickerson, & Simon, 2013). A female survivor in the village explained how she handled the dream visit of her husband,

I had a dream about my husband. He came to see me as a shadow, because he is a ghost now. I just saw his shadow, but he would not say anything. I felt better after I had conducted a ceremony for him. I have never dreamed about him again.

The fact that the deaths of the Khmer Rouge victims were not ritually attended to by monks was also alluded to by many informants. A middle-aged male survivor from a village in Pursat Province explained,

The purpose of the monks’ praying and chanting is to make all the dead people and the victims calm down their feelings. It helps us to feel relief to offer to the dead, relief from grief, because our relatives were killed during the Khmer Rouge regime, because the dead people died without the monks chanting for them. They were just abducted and killed.

Another male survivor from the same village concurred,

We do rituals to calm the spirits of the dead, and I think that the ceremony can also calm down my feeling, so that I am not furiously mad at the cruel behaviour of the Khmer Rouge. I think only Buddha can make me feel stable like this.

According to Hinton et al. (2009; Hinton, Field, et al., 2013; Hinton, Peou, et al., 2013), Cambodians are particularly afraid that those who died under the regime of Khmer Rouge may become “dream visitors,” or malevolent ghosts who try to harm the dreamer, indicating that the deceased have not moved on to reincarnation or that they have not been ritually buried.

Of particular interest regarding traumatic memory and commemorative practices for the Khmer Rouge dead is the ritual performance known in Pali as the pansukula (bangsoekool in Khmer), the “gift-bestowal ritual” (Hinton, Peou, et al., 2013), which forms part of the funeral rites in Cambodia and elsewhere in Theravada Buddhist Southeast Asia (Davis, 2009; Phra Khru Anusaranasanakiarta & Keyes, 1980). The term pansukula refers specifically to a white cloth that is used to cover the corpse and that represents asceticism,6 but also refers more generally to the ritual process that includes a particular form of rhythmic chanting by the monks: “the chant of death” (Davis, 2009, p. 136). This chanting follows the rhythm of the breath and is held by many Cambodians to have a powerful, calming effect on the audience—especially if it is followed by a special type of mourning songs (smot) that are performed by lay persons. The pansukula chant is one of the many means by which the Cambodian clergy ritually enable the laity to transfer merit to their dead relatives, thus assisting their progress through the cycle of death and rebirth. This is done to placate both the minds of the living and the spirits of the dead (see also Hinton, Field, et al., 2013). A translation of the main section of the text from this chant shows how it promotes reflection upon the impermanence of life:

All conditioned things are impermanent

With the nature to arise and to pass away

Having arisen they cease

And in their passing is the highest happiness.7

Few Cambodian lay people understand Pali, but interviewees nevertheless claimed that simply listening to the rhythm and melody of the chanting gave them a feeling of inner peace.

Festival of the dead

The most spectacular instance of social healing that involves the dead is the annual festival of the dead, p’chum ben, during which ritual merit-making for the restless souls of the dead continues for a full 2 weeks (Holt, 2012). This is also an important opportunity to perform rituals that may alleviate complicated grief among Khmer Rouge survivors (Hinton, Peou, et al., 2013). P’chum ben is celebrated in pagodas throughout the country, with local variations, and takes place in accordance with the lunar calendar in September–October, beginning on the full moon of the month of photrobot and continuing throughout the moon’s wane. During this festival, the gates of the underworld are opened and the hungry ghosts are given a fortnight’s release. These insatiate spirits are thus able to commune with the living and beseech their living relatives to feed them through the mediation of Buddhist monks (Kent, 2007, pp. 340–342; Ladwig, 2012).

The festival enables the living to ease the suffering of those who have died with stores of bad kamma by transferring merit to them in the form of the specially prepared rice balls. On the final day of the fortnight, people gather at the temple to distribute the rice to the spirits by throwing it over the sima (ritual boundary) of the vihara (ordination hall), out into the surrounding area where the spirits are said to gather. This is conducted as day breaks and afterwards the families return home to prepare offerings of food on a straw mat with which they ask their ancestors for protection. The festival ends with the return of the ghosts to their infernal home, often by floating their symbolic representations on a hollowed banana tree stem along the river, back to the underworld. The gates of hell then close upon them once again. The rapid revival of p’chum ben since the end of the war may be understood partly as an attempt to ritually reinstate the distinction between the realms of the dead and of the living, and thus to bring both social order and peace of mind to those who experienced the country’s traumatic history (Kent, 2007).

Healing the wider community

Since Cambodia’s past has affected many survivors deeply, collective rituals that take place in symbolic locations, where spiritual power is managed to heal and reinstate order, play an important role. These include the erection of state-sponsored memorials, as well as village rituals, for example at mass burial sites. Guillou (2012) has investigated informal peasant healing practices related to mass bereavement and the cult of tutelary spirits (Khmer: neak ta) and has shown how, over the years, villagers have made use of their popular religious system to heal social suffering; this involves alternately forgetting and remembering the Khmer Rouge atrocities and ritually transforming the spirits of the dead into tutelary spirits who protect the community.

By meditating and participating in the various memorial events and ceremonies, victims (and perpetrators) can engage with traumatic memory involving the dead, build shared memory, and make sense of tragedy within the framework of an overall process of cultural recovery.

Survivor associations

Cambodian civil society organizations, including survivor associations and religious institutions have initiated a wide variety of culturally relevant psychosocial and spiritual activities, in parallel with the ongoing justice process at the Khmer Rouge Tribunal. The tribunal process itself is viewed by some as an attempt to encourage a collective healing process at the national level, a “ritual of purification,” during which the Khmers can obtain “justice” for the living and the deceased.

Mr. Chum Mey is one of the 12 known survivors of “S-21,” the Khmer Rouge torture and interrogation facility at Tuol Sleng in which 16,000 people were killed, and is now head of one of the associations of Khmer Rouge survivors, which was started during the first trial at the tribunal (of Duch, the former chief of office for S-21). The goal of the Ksem Ksan Association is to “seek justice in the trials by setting up strong voices of the victims” (C. Mey, personal communication, October 25, 2011). Mr. Chum Mey related in an interview,

We held a Buddhist ceremony in S-21, and the idea of having a ceremony there was to dedicate to those who died in S-21. We would like the dead people to know that we are going to seek justice for them.

An elderly male member of the association from Pursat Province explained,

In 1979–1980 I really wanted to take revenge, I felt very angry because they arrested me and tortured me, but now I think about the dharma of the Buddha, and then I don’t want to take revenge because Buddha says malice can be pacified by not taking revenge on each other.

Some leading members of the association also provide psychological support to members. One of the key women members explained,

I teach them to do meditation… we do it once a week. We also do relaxation exercises and wake up every morning to exercise… It helps them to calm down their feelings, because some people have had a nervous disease since the Pol Pot regime. They cannot sleep and they hurt their muscles. I also tell them not to keep the suffering in their bodies, but to speak it out so that they will not feel tension… some people cry while sharing their suffering experiences and I tell them to keep crying if they want to, because that will make them feel better.

Theary Seng, the head of another survivor association, the Association of Khmer Rouge Victims in Cambodia, explained how the associations help people feel that they are not alone and that they can learn what it means to be a citizen with rights and responsibilities (T. Seng, personal communication, February 20, 2011). One of the members of her association explained how the association supports survivors: “They come to us and talk about their past, we can share it among us, and I discovered that they felt relief by doing that.”

A monk from Phnom Penh explained that the trial at the tribunal could help survivors feel released especially if they combined testifying at the court with a visit to the pagoda:

For people who know how to use the court, the court could be divine medicine for them. Buddhism is just to console them and to calm their feeling. The people who also go to court get better more quickly.

Discussion

This Cambodian material shows that the semantics of Buddhist mindfulness are interwoven into a broader cultural fabric that extends well beyond the calming of the individual’s emotions and includes enhancing the kammic status of others, including the dead. In the Khmer context, practicing mindfulness is inextricably linked to other cultural notions, particularly that of merit-making, and its objectives are both to bring psychological benefit to individuals and to support cultural regeneration.

The data presented here build on a brief survey administered with the help of a translator, and are based on a small sample. The Buddhist-informed practices mentioned in this preliminary ethnography need further investigation and should be examined in more detail in future studies. It would also be relevant to explore in more depth how Western notions of psychological health and methods for achieving it are being transposed into the Asian context, possibly giving rise to innovative, hybrid discourses and therapeutic methods. For instance, some Cambodian mental health professionals have been inspired by the Western “third wave” cognitive approaches, which they combine with indigenous traditions in collaboration with Buddhist monks.8,9

Western “third wave” cognitive methods (Kahl, Winter, & Schweiger, 2012) have, on the other hand, been inspired by Buddhist practices and combine elements of meditation and mindfulness with cognitive-behavioural therapy (CBT). “Third wave” methods include a heterogeneous group of approaches such as acceptance and commitment therapy (ACT; Fung, 2015; Walser & Westrup, 2007), dialectical behaviour therapy (DBT; Linehan, 1993), compassion-focused therapy (CFT; Gilbert, 2009), mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002), and culturally adapted cognitive-behavioural therapy (CA-CBT; Hinton, Rivera, Hofmann, Barlow, & Otto, 2012; Hinton, Pich, Hofmann, & Otto, 2013).

This might indicate that Western psychological methods are becoming more readily transposable onto work with Buddhist trauma sufferers such as the Cambodians discussed here. Cambodians’ efforts to “cool their body” and stop “thinking too much” (Hinton, Nickerson, et al., 2011) correspond well with Western notions of core “emotion regulation and distress tolerance skills” (McKay, Wood, & Brantley, 2007, p. 2), how to “restore self-regulation” (Levine, 2010, p. 13), and “how to tolerate feelings and sensations by increasing the capacity for interoception” (van der Kolk, 2009, p. 12; van der Kolk, 2014, pp. 337–354). However, as the data show, Khmer Buddhism is a syncretic cosmological system within which practices such as meditation and mindfulness derive particular meanings.

Western practitioners of psychological support for survivors of mass human rights abuses still have much to learn by paying close attention to the way in which survivors themselves formulate and seek to address their distress. Others, such as Hinton and his colleagues, who developed CA-CBT (Hinton, Rivera, et al., 2012), have begun doing pioneering work using culturally sensitive methods of both assessment and treatment of distress among Cambodian refugees. However, further studies of local therapeutic processes of healing are needed (Hinton & Kirmayer, 2013).

The use of the ethnographic methods allowed the informants to speak for themselves about their reality. The voices of the Cambodians cited here tell us much about the relationship between indigenous understandings of wellbeing and their complex cultural and historical context. The Cambodians in this study describe an approach to wellbeing that extends beyond the individualistic focus of Western approaches to include the relationship between the living and the dead and between the individual and his/her karmic position in the great chain of being.

In much of the Western use of meditation/mindfulness techniques, if Buddhism is mentioned at all, it tends to be portrayed as a psychology closely akin to cognitive psychology (Kirmayer, 2015). Western cognitive therapists and users of mindfulness perhaps seek legitimacy by stressing the “scientific” and evidence-based nature of their methods and distancing themselves from religion. Some suggest that incorporating Buddhist practice in a more wholesale manner into Western contexts could be reacted to as an affront to Christianity (Crosby, 2013). However, the scientific community would benefit from taking religious worldviews seriously and using what they learn of these to reflect upon the limitations of the scientific episteme.

Straightforward transposition of therapeutic models developed within the scientific paradigm onto survivors of mass atrocity, for whom religion often plays a consequential role in wellbeing, may result in the kind of “category truncation” to which Hinton, Peou, et al. (2013, p. 428) allude. Furthermore, because of the high status awarded to Western positivist science as yielding modern “knowledge,” “non-western and folk medical systems are regarded as systems of ‘belief’ and subtly discounted” (Good, 1994, p. 248). This may mean that when Western psychological “knowledge” is introduced in countries like Cambodia, it is interpreted by locals as superior to their own knowledge even though it may be quite dissonant with their experience.

Conclusion

In conclusion, although elements of Eastern traditions, such as meditation and mindfulness techniques, are becoming incorporated into the Western psychological paradigm, it is important to understand such elements as part of the broader cultural and historical totality that shapes people’s lives and experience. The reflections of the participants in this study illustrate some of the ways in which individual suffering is experienced as relating to the Cambodian nation’s shared history of grief and traumatisation and its shared cultural universe. Moreover, they underscore the fact that the Western and Eastern uses of mindfulness are framed by significantly different systems of meaning that must be considered in the cultural adaptation or transposition of interventions.

Acknowledgements

An earlier version of this paper was presented at the workshop: “Mindfulness in Cultural Context,” organized by the Division of Social and Transcultural Psychiatry, McGill University, Advanced Study Institute, Montreal, June 4–5, 2013. Inger Agger’s research in Cambodia was carried out in cooperation with the Transcultural Psychosocial Organisation – Cambodia (TPO) with the assistance of Taing, Sopheap. She wishes to thank the survivors, civil society organizations, venerables at the Buddhist pagodas, and staff of the Extraordinary Chambers in the Courts of Cambodia (ECCC) who generously shared their experiences with her. Inger Agger is also very thankful for comments and suggestions to earlier versions of this article by Alexandra Kent. She is furthermore grateful for the support provided by Dignity – Danish Institute Against Torture, Copenhagen where her research project was based.

Biography

Inger Agger, PhD, licensed clinical psychologist, is a senior expert and NIAS Associate of the Nordic Institute of Asian Studies in Copenhagen. Recently, she concluded a research project in Cambodia in which she explored local Buddhist approaches to healing of violence-related trauma. She also directed a documentary film, Justice and Healing in Cambodia (2012, with S. Roerdam), which she screened and discussed in 2013 in a number of Southeast Asian countries. Dr. Agger has worked extensively with testimony as acknowledgement and healing of violence-related distress and has published two books, The Blue Room: Trauma and Testimony Among Refugee Women (1994), and Trauma and Healing Under State Terrorism (1996, with S. B. Jensen).

Notes

1

For instance, in a randomly selected sample of 613 Cambodians, 28.4% met the criteria for PTSD (De Jong et al., 2001). In a randomly selected household survey of 1,320 Cambodians, 7% met the criteria for PTSD, 42% for depression, and 53% for anxiety (Dubois et al., 2004). And in a national, longitudinal study that covered a randomly selected sample of 813 Cambodians, 14% met the criteria for PTSD (Sonis et al., 2009). In a comparative community survey, Mollica et al. (2014, p. 6) found that the Cambodian population continues to suffer “psychiatric morbidity and poor health” 25 years after the Khmer Rouge regime.

2

For transliteration of Khmer words the author has used a phonetic system or, when referring to the work of other authors, has adopted that used in those original works.

3

The term parami is a Buddhist technical term meaning literally one of the 10 perfections of the Buddha. However, in common parlance in Cambodia, it is used to refer to a sacred force or energy.

4

The tribunal was established in 2006 after more than 10 years of negotiations between United Nations and the Kingdom of Cambodia in order “to bring to trial senior leaders and those most responsible for crimes committed during Democratic Kampuchea, known as the Khmer Rouge regime, from 17 April 1975 to 6 January 1979” (ECCC, 2011, March, p. 1). In the ongoing Case 002, four (now two) former Khmer Rouge leaders have been accused of “genocide, crimes against humanity, grave breaches of the 1949 Geneva conventions and murder, torture, and religious persecution under Cambodian law” (ECCC, 2004, p. 8).

5

Right view, right intentions, right speech, right action, right livelihood, right effort, right concentration, right mindfulness.

6

The Pali term pansukula originally meant “dusty rags” and referred to rags that were used to wrap the corpse for taking it to the cremation grounds. Today, lay people donate a clean white cloth to the monks at a funeral ceremony instead.

7

Translation by David Wharton, personal communication (February 15, 2013).

8

For example, Professor Ka Sunbaunat of the National Mental Health Programme has collaborated with Buddhist monks to integrate spirituality into a comprehensive approach to trauma-related mental health for Cambodians (Reicherter, Boehnlein, & Stewart, 2011).

9

The author has, in an action research project with different Asian nongovernmental organisations including TPO-Cambodia, developed a culturally adapted version of “Testimonial Therapy (TT)” that involves a Buddhist “testimony ceremony” as a significant element of its practice in Cambodia, creating a sense of closure and transformation and linking the trauma with a positive memory state (Agger, Igreja, Kiehle, & Polatin, 2012; Hinton, Rivera, et al., 2012). Testimonial therapy has also been adopted by the Khmer Rouge Tribunal as one of the reparations made available to 200 civil parties from Case 002/01 (ECCC, 2014).

Funding

This research was supported by a grant from the Danish Council for Independent Research in Culture and Communication (FKK) from 2010–2012.

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