In Cambodia, mind cannot be separated from spirit or body, and the individual cannot be separated from the collective. Treating trauma literally takes a village. Village elders or traditional healers may initiate mental health interventions, and treatment incorporates the cultural and religious beliefs by including Buddhist monks in group sessions and using meditation and healing ceremonies.

In Vietnam, the family is a source of healing and strength--relatives often accompany patients for inpatient mental health treatment and take care of them when they are released.

Learning about these different cultures' treatment of trauma motivated a group of psychologists that recently visited Cambodia and Vietnam. Led by former APA President Norine G. Johnson, PhD, 70 psychologists and 10 guests participated in a professional delegation organized by People to People International--a nonprofit organization established by President Dwight D. Eisenhower to promote international peace through cultural exchange and understanding.

Delegation members prepared by studying the history of the two countries, but still felt they didn't truly comprehend the level of societal trauma inflicted by Cambodia's Khmer Rouge and the Vietnam War until they visited and talked to people. They found in fact that the very notion of "trauma" may be different for Vietnamese andCambodians than it is for Americans.

Legacy of the killing fields

Cambodians have endured over 30 years of turmoil and outright horror. A French colony from the late 1800s to the 1950s, occupied during World War II by Japan and then bombed by American forces during the Vietnam War, Cambodia experienced its bloodiest years during the reign of Pol Pot and the Khmer Rouge from 1975 to 1978.

In an attempt to establish a utopian agrarian communist society, Pol Pot, the Khmer Rouge's leader, wanted to eliminate anything that was urban or modern. His forces emptied out the cities and villages, forcing citizens to abandon their homes and walk for miles into the countryside. Many people who were educated, had a professional job, spoke a foreign language, worked with foreign occupiers, appeared Western in any way, or even wore glasses, were executed.

Many were driven to what would become known as "the killing fields"--large sites where mass executions and burials took place, and where you can still see bones poking out of the ground today. In those three years, 1.2 to 2 million people--out of a population of more than 7 million--died from execution, starvation or exhaustion. In late 1978, Vietnam invaded Cambodia, ending the Khmer Rouge's reign, but setting off a civil war that continued on and off until 1998.

"In Cambodia, everyone we talked to had lost at least six or seven family members to the Khmer Rouge," notes delegation leader Johnson.

The delegation visited three facilities in and around Phnom Penh: the Khmer-Soviet Friendship Hospital, the Cambodian Women's Crisis Center and the Royal University of Phnom Penh.

What few mental health resources had been established in Cambodia were decimated during the reign of the Khmer Rouge, notes Johnson. At the hospital, the medical director explained that most physicians were killed during the genocide, including all of the psychiatrists. There were no psychologists in Cambodia before 1994.

In the early 1990s, several foreign nongovernmental agencies began training doctors in psychiatry. The psychology program at the Royal University began granting bachelor degrees in 1994. These enthusiastic professionals and volunteers have established a network of care throughout Cambodia, note delegation members.

"They are very sophisticated in treating trauma in a collective way," notes Louise Silverstein, PhD, a member of the delegation and psychology professor at Yeshiva University in New York. Mental health professionals have used the resources built into village life by incorporating elders and traditional practitioners into treatment, training them to integrate modern psychotherapy principles with more traditional practices, she explains. The students at Royal University will get their degrees and go out into the villages to educate communities about dealing more constructively with anger without resorting to violence or alcohol abuse, says Crowley.

Other resources, such as the Women's Crisis Center, have sprung up to treat victims of domestic violence and exploitation. In many villages, it is still culturally accepted for men to beat their wives, says Johnson. And a newer form of abuse--trafficking in women and children for the region's thriving sex trade--is common. The precise numbers aren't known, but the Crisis Center reports seeing hundreds of formerly traded women and girls with sexually transmitted and other diseases every month. Facilities like the center give the women and their children a safe place to stay, mental health counseling and job training.

Recovery and renewal

Vietnam was also colonized by the French and then the Japanese during World War II. Then, nationalist forces won independence from the French, leading to their withdrawal and the division of the country between north and south. Years of war followed, including extensive American involvement from 1954 until the 1973 cease-fire when North Vietnam invaded South Vietnam. Finally, Saigon fell in 1975.

The end of hostilities didn't mean the end of trauma for many Vietnamese. Citizens of South Vietnam were often perceived as American collaborators and sent to labor camps to be "re-educated" notes Johnson. There were also skirmishes between communist forces on the Cambodian-Vietnamese border, leading to the Vietnamese invasion of Cambodia.

The turmoil and the country's isolation contributed to the economy's collapse in the mid-1980s. The establishment of private business and trade with Western Europe and the United States during the 1990s reinvigorated Vietnam's financial system although the scars of war linger, notes Silverstein.

"I was stunned by how much psychological devastation remains in the aftermath of the war," she says.

The country's mental health services appeared woefully inadequate to the delegates. For example, Benh Vien Tam Than Hospital is the only inpatient mental health facility serving the eight million people of Ho Chi Minh City, notes Johnson. The 317 staff members of the psychiatry department are responsible for treating the one million citizens with mental health conditions, she adds. They provide for patients as best they can, but are working with "really ancient" equipment and an inadequate amount of first generation psychotropic medicine. The hospital doesn't have enough money for newer medications, so the staff dispense amitryptiline instead of SSRIs and older neuroleptics such as Haldol, and the heavily sedating Thorazine, explains delegation member Shoshana Kerewsky, PsyD, an assistant psychology professor at the University of Oregon College of Education in Eugene.

However, it's not something that the Vietnamese like to dwell on or really talk about, notes Johnson. "We saw a total denial of post-traumatic stress disorder," she says. "In fact, one of our guides actually said, 'No, we don't have that.'"

Hospitals and universities do not focus on trauma, Johnson explains, and in schools psychological services place more emphasis on the work ethic.

The delegation toured the inpatient ward, which mostly houses people with schizophrenia and other psychotic disorders. There is not enough medicine and only three psychologists, the visitors found. The hospital is too understaffed to provide therapy for inpatients, says Johnson. So they treat inpatients until they move beyond an actively psychotic state, and then release them to their families, says Crowley.

"A great strength of Vietnamese society is that the family feels the need to support and help the patients," she says.

Family members often live on the ward as well, taking care of their loved ones, Johnson explains.

The hospital needs so much--more staff, training in psychotherapy, medications and even sheets for the beds, says Silverstein.

Students at the university are anxious to finish their training and help heal their fellow citizens so that Vietnam and its economy will continue to grow and eventually thrive, says Crowley.

Both the university and hospital personnel and students expressed a desire for connection with their American counterparts to exchange information, notes Johnson.

Giving back

Establishing such affiliations with American universities is just one post-trip goal for Johnson. Several of the delegates are already lobbying their department chairs to affiliate with one or both of the universities. Others are raising money to improve or build new facilities. Johnson and others are working with university officials in both countries to see if, with funding, it will be possible to give them Internet access. She also plans to suggest that People to People send a psychiatry delegation to Vietnam to assess the need for modern medicine and equipment and to facilitate collaboration with U.S. medical schools.

Members of the delegation will present more about their trip at APA's Annual Convention in San Francisco, August 17-20, in hopes of getting more people involved.

The notion of the collective asnecessary for healing in Cambodia; the zeal for economic rebirth in Vietnam; and the spirit of rebuilding in both countries will stay with many of the delegates.

In Cambodia, for example, people told Kerewsky that Pol Pot and the leaders of the Khmer Rouge orchestrated the genocide and forced others to participate. Most people just did what they had to in order to survive, and they can live with--and even forgive--that, she concluded.

The historical background in this piece was drawn from the U.S. Department of State country backgrounds, the CIA World Factbook and the Library of Congress's country profiles.