A qualitative and quantitative investigation into ethno-cultural framing of trauma in Cambodia : baksbat (broken courage), a Cambodian trauma syndrome akin to PTSD

The impact on the human psyche, body and emotions in those who endure major traumatic events is well documented, regardless of whether trauma is human induced or the result of natural disasters. In particular, symptoms leading to depression, anxiety, and posttraumatic stress disorder (PTSD) have been linked to traumatic events. PTSD was developed in the United States initially following the documentation of traumatic symptoms in Vietnam veterans after they returned home from the war. Similarly, the diagnosis of PTSD is widely used across Asian countries, and in Cambodia specifically. PTSD diagnoses are reinforced in medical, clinical and academic training programmes, as well as in research designs and outcomes. More profoundly, the diagnosis of PTSD was highlighted by foreign experts after their psychiatric, forensic evaluation of survivors of the Khmer Rouge genocide; their findings underscored testimonies during hearings in the Extraordinary Chambers in the Courts of Cambodia (ECCC). This study set out initially to determine the discrepancy between descriptive analyses of PTSD, and lived experiences of Cambodian survivors of the Khmer Rouge. Despite studies on idioms of distress in non-Western cultures, few ethno-cultural studies capture fully the trauma response set of symptoms in the context of Cambodians’ postgenocide history. Given the dearth of assessment infrastructure for the Cambodian context, this study was designed with three objectives: 1) to explore the meaning of trauma and the ethnocultural range of responses to distress, including baksbat (broken courage) for those living inside Cambodia; 2) to develop and validate an inventory to measure ethno-cultural conditions and expressions of baksbat; and 3) to increase the cultural competency in particular on baksbat to local and foreign mental health workers who are practicing and researching in Cambodia. This study used a progression of qualitative and quantitative mixed-methods that started with ethnographic interviews and focus groups in order to unfold the ethno-cultural meaning of trauma; validation of the inventory followed. The focus group discussions were conducted with 53 experts in order to understand the baksbat domain from their overlapping and individual perspectives of context, content, and process. Thematic analysis of the interview data assisted the item development of the first inventory designed to measure the baksbat complex. That inventory for baksbat was administered to a clinical sample inside Cambodia in order to validate the clustering of items. Cambodian psychiatric research is validated mostly on former refugee populations residing outside Cambodia, so a baseline sample taken from inside the country was essential to its cultural reliability. From these objectives, the author published three related articles in peer reviewed journals that are attached inside the thesis. The first article was about the understanding and the analysis of the ethno-cultural concept of baksbat from a social, historical, political, medical and etymological perspective. The author also compared the overlapping symptoms between baksbat and PTSD in terms of symptomatology, causation, and treatment. The second article described the development and validation of the baksbat inventory using statistical measures, exploratory factor analysis (EFA) to explore the factor loading, and confirmatory factor analysis (CFA) to confirm the validity of the inventory. This article establishes the development and validation of the baksbat inventory. The third article was written about the application of baksbat as an ethno-cultural condition. Herein, its use offered real practice potential in forensic, clinical, research, and education about transcultural trauma in Cambodia. The author cautioned that foreign experts used PTSD criteria to support their forensic evidence, but because of the lack of cultural sensitivity of PTSD criteria, it may have failed to capture trauma symptoms among survivors. In his third article, the author recommends the use of baksbat together with PTSD criteria in giving forensic evidence; also, the author demonstrated its use when testifying as an expert witness on psychological trauma on survivors of the Khmer Rouge regime at the Extraordinary Chambers in the Courts of Cambodia (ECCC) on the 4th and 5th June 2013. The three published articles presented in this thesis correspond to the three broad aims of this study. This study was exploratory and confirmatory, as there have been no prior systematic and in depth studies conducted on this topic among the Khmer population in Cambodia. The findings show that PTSD and baksbat criteria combined represent better Cambodian survivors descriptive symptoms of trauma. This ethno-cultural syndrome, baksbat provides new knowledge for application on cultural aspects of trauma and mental health in Cambodia. In addition, there is broad scope for other former Cambodian refugees who are living abroad, and for others living in non-Western or Buddhist contexts. These findings bring us another step closer to representing human experience more fully in this long journey across the fields of transcultural psychiatry and traumatic studies.