PSYCHOLOGY EDITION

POST TRAUMATIC STRESS DISORDER (PTSD)

"We have all been touched by trauma. Our psychological courage has been broken," he said, in a rough translation of the local Khmer concept known as "baksabat". 

(Chhim Sotheara, head of TPO Cambodia, quoted by IRIN).
 
The previous episode mentioned that even 3+ decades after the genocide, 11+% of the adult, supposedly healthy population were identified as potentially having PTSD in a national sample. The study is worth quoting:

"...the 1-month (ie, current) prevalence of probable PTSD in noninstitutionalized adults older than 18 years in Cambodia was 11.2% (95% CI, 8.6%-13.9%). Although substantially lower than the prevalence of PTSD reported in a Cambodian refugee community in the United States, this figure is still almost 5 times higher than the 1-month prevalence of PTSD of 2.3% in the United States, estimated from the National Comorbidity Survey."

For those who think that cultural differences mean PTSD is an invalid diagnosis in Cambodia, it's time listen up. Personal communication (14/7/12) with the first author of that study advised that the strong link between PTSD and disability would not have been found in their participants if PTSD was not valid amongst Khmers, and that other researchers have also found that the diagnosis is valid in the same population (for example The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5).

The recommended, evidence based treatment for PTSD is cognitive behaviour therapy (CBT). This, however, has also been questioned by some people here, such as those who seek to offer art and drama therapy (discussed below) on the assumption that cultural differences renders CBT unsuitable. Regarding cross cultural validity of CBT, the individual I described above advised I contact the author of the DSM-5 study he referred to, who is an expert on the use of CBT outside the West. He responded (18/7/12), advising that CBT amongst Khmers has been found to be effective compared to other treatments and a waitlist control. A waitlist group controls for maturation effects, where a disorder may improve of itself over time. Furthermore, this individual stated that art therapy alone would not be recommended by anyone, except perhaps as an adjunct, as there is no support for efficacy. When pressed on the possibility that his findings may not be generalisable beyond the Khmer refugees he describes as participants in this study, he responded that efficacy had been demonstrated in non refugee Khmers and referred to another study. Note that this contains the following comment:

"A number of investigators have suggested that CBT may be a particularly useful therapeutic modality for Southeast Asian refugees owing to the similarity of Buddhist principles to core aspects of CBT" (p. 617).

SUMMARY

PTSD exists amongst Khmers, at 5x the rate of the US, 3 decades on from the genocide. CBT is the best known intervention. No support has been found for the efficacy of other treatments such as art or drama therapy, which may be used as an adjunct at best, until scientific studies suggest otherwise. Case closed.
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The most credible mental health service in Cambodia appears to be Transcultural Psychosocial Organisation Cambodia. They appear to endorse the existence of PTSD and do not appear to offer art or drama therapy. This is a good thing, as you will see below.
 
Other webpages about mental ill health in Cambodia:

War Wounds - Cambodia (Christopher Toms and Associates blog):
"Perhaps no country in Asia needs mental-health care more than Cambodia, a tormented nation where the scars of the 1975-79 Khmer Rouge regime are still fresh even a quarter-century later. According to a survey conducted by the Transcultural Psychosocial Organization (TPO), an NGO with ties to the WHO, 75% of adult Cambodians who lived through the Khmer Rouge era suffer from either extreme stress or post-traumatic stress disorder..."

Analysis: What ails Cambodia's mental health system? (IRIN):
"PHNOM PENH, 12 March 2012 (IRIN) - In Cambodia, the psychological fallout from one of the world's heaviest bombing campaigns, genocide and two decades of conflict, coupled with chronic poverty, have left a heavy mental health burden that medical services are ill-equipped to
handle, say experts..."

Mental Health in Cambodia (I'm in Cambodia. What?):
"So, there's this man in my Wat. (A Wat is a large complex that holds the local buddhist temple, monks' housing, maybe a small school, some places to put cremated people, and such stuff). This man has been there for months. He is tethered to a post. Yepp, tied by rope like a dog. He has maybe a 2 meter radius to walk around. Sometimes I see the monks take him out for a walk. I asked my khmer tutor why the man was tied to a post everyday and he replied that the man had a nervous issue. In other words, someone decided he was mentally ill..."
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ART AND DRAMA THERAPY

Excuse the lengthiness of this post, but the issues raised must be addressed in full. I now include the following art therapy research critiques, not written by myself.

The following website provides a subjective point of view of an art therapist who decided to look at the research. I have also attached the "American Art Therapy Association Research Committee - Art Therapy Outcome Bibliography". This claims to be a document reviewing all research for Art Therapy, to be used in advocating for funding for Art Therapy. Page 22 reviews art therapy for PTSD and found the following:

1) Chapman et al. (2011) found no significant difference in PTSD symptoms, between the Art Therapy group and the Control (nil treatment?) group. Chapman, L. M., Morabito, D., Ladakakos, C., Schreier, H., & Knudson, M. M. (2001). The effectiveness of art therapy interventions in reducing Posttraumatic Stress Disorder (PTSD) symptoms in pediatric trauma patients. Art Therapy: Journal of the American Art Therapy Association, 18(2), 100-104.

2) Howard (1990) showed the results of art therapy on a single woman (thus, a case study, not an experiment) with PTSD. There was a reduction in BDI-II scores from borderline to mid-range severity. However, there appear to be some problems with this study: The measuring tool, (BDI-II, or the Beck Depression Inventory) measures severity of Depression not PTSD, thus there is no evidence that art therapy was helpful for PTSD symptoms. Additionally, the reduced score is still within the clinical range of depression.

Howard, R. (1990). Art therapy as an isomorphic intervention in the treatment of a client with Post-traumatic Stress Disorder. American Journal of Art Therapy, 28(3), 79-86.

3) Lyshak-Stelzer (2007) found a greater reduction in PTSD symptoms when using 1 hour weekly appointments over 16 weeks, vs treatment as usual (whatever that was. Might be worth checking if it was CBT or not). The conclusion stated "Results indicate that TF-ART

may be a promising adjunctive treatment for inpatient adolescents with PTSD symptoms", which I can agree with. Art-therapy may be an appropriate adjunctive therapy for CBT, if used within a CBT framework alongside a therapist who is also providing CBT. There is not enough evidence to show it is an appropriate therapy for PTSD by itself.

Lyshak-Stelzer, F., Singer, P., St. John, P., & Chemtob, C. M. (2007). Art therapy for adolescents with Posttraumatic Stress Disorder symptoms: A pilot study. Art Therapy: Journal of the American Art Therapy Association, 24(4), 163-169.

 4) Morgan and Johnson (1995) addressed nightmares in two people with PTSD, and found a significant reduction in some symptoms. However, the article was a case study (only 2 clients, and thus not a controlled and repeated experiment). The measures they used were self-report, and thus not empirically validated or generalisable. The measures did not show a significant reduction in PTSD symptoms. And the therapists were treating nightmares and not PTSD. Although I did not track down the article, there was no mention of any long-term gain in regards to the nightmares (which is why CBT is considered the best treatment, due to less chance of relapse). Lastly, there was not comparison between art-therapy and CBT or any other empirically validated treatments.

Morgan, C. A., & Johnson, D. R. (1995). Use of a drawing task in the treatment of nightmares

in combat-related Post-traumatic Stress Disorder. Art Therapy: Journal of the American Art Therapy Association, 12(4), 244-247.

5) There are other research articles that were mentioned on the bottom, but were not commented on. You may wish to look into these.

Morgan, K. E., & White, P. R. (2003). The functions of art-making in CISD with children and youth. Int J Emerg Ment Health, 5(2), 61-76.

Orr, P. P. (2007). Art therapy with children after a disaster: A content analysis. The Arts in Psychotherapy, 34(4),350-361. (Posttraumatic Stress Disorder & Trauma/Meta-Analyses) (PSJ).

Pepin-Wakefield, Y. (2008). The use of projective drawings to determine visual themes in young

Kuwaiti women impacted by the Iraq invasion. International Journal of Art and Design Education, 27(1), 70-82. (Posttraumatic Stress Disorder & Trauma/Qualitative) (SD)

Schreier, H., Ladakakos, C., Morabito, D., Chapman, L., & Knudson, M. M. (2005). Posttraumatic stress symptoms in children after mild to moderate pediatric trauma: A longitudinal examination of symptom prevalence, correlates, and parent-child symptom reporting. Journal of Trauma-Injury Infection & Critical Care, 58(2), 353-363. (http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-20052000-00021 6/29/05).

 Overall, there appears to be a small amount of research currently available, for the effectiveness of art therapy on PTSD. From what is available, only one study (Lyshak-Stelzer, 2007) appears to be an experiment rather than a case-study. Even if we take this one study as valid, we will still need more research to support it. I assume that further reading of other research articles (not hand-picked by the american art therapy association) may provide conflicting information.

At this time, art-therapy for PTSD does not appear to be empirically supported, and evidence-based practioners (such as the National Institute for Clinical Excellence) warn against using art-therapy for PTSD.

There may be evidence of the effectiveness of art therapy to treat people without PTSD. However, there is not enough evidence to say it is effective as a treatment for PTSD. Thus, if an individual may have PTSD, the current evidence appears to suggest that the individual would be better treated within a CBT context, particularly involving exposure therapy components.

Although there is current insufficient evidence for using art-therapy for individuals with PTSD, it may be possible for the art-therapist to consult with a CBT therapist to determine whether it would be appropriate for art-therapy to be provided as an adjunct therapy alongside CBT. When used correctly within a CBT context, art therapy could possibly be an appropriate tool to support exposure to avoided trauma memories.However, it would be important to remember that this is one of many important components of CBT for PTSD, and the other important components should not be neglected.
 
Has all of this whet your appetite for more psychology in Cambodia? If so:

INFRA HUMANISATION

I remember watching an Australian Story documentary about two Australian Muslim comedians and an interesting observation was made about audience members sometimes being pleasantly surprised that Muslims told jokes and, unexpectedly, laughed. The infra-humanisation (being a less severe, more everyday form of dehumanisation) of outgroups, here expressed as the belief that they don't have fun or laugh, has been explored by a few researchers (a great review, see p. 255 under Infra-Humanisation especially). Given different belief systems and upbringings, there's plenty of potential for perceptions of in-group and out-group memberships to appear in a cross cultural setting. Laughing together, and thereby affirming the possession of secondary emotions or sentiments in each other, seems to have been an efficient way to bolster perceptions of me and counterparts belonging to an in-group. Leyens et al. (2001) advise that one way in which infra-humanisation occurs for members of out-groups is through refusal by in-group members to recognise that they experience (both positive and negative) secondary emotions, whilst still recognising primary emotions. According to Leyens et al., there are six of the latter – anger, joy, sadness, surprise, fear and disgust, whilst secondary emotions are more like sentiments. Examples of these are affection, cheerfulness, exasperation and optimism. Successfully sharing in an experience making us both cheerful therefore seems like a good way to address this challenge of maintaining a good relationship with a counterpart by reducing infra-humanisation on both parts.

COGNITIVE DISSONANCE IN CAMBODIA

Too much reading? I made a silly little video about this section. I am going to take the liberty of writing about the following because many people besides myself share these thoughts, but very few people seem talk openly about it, or as much about it as its importance suggests to me. It’s as though there is a stigma surrounding making the following observations and this is why I seek to explain the phenomena in terms of cognitive dissonance. There appear to be too many mansions, Range Rovers and other luxury SUVs here for Cambodia’s position (around 150 according to the three sources) in the GDP/capita world league table. This creates cognitive dissonance for me because on the one hand I have the belief that mansions and luxury SUVs are a sign of great wealth and success, whilst on the other hand I have the beliefs that the general state of the economy and standard of living is very poor and that Cambodia requires a great deal of foreign aid to solve these problems. I have observed some curious ways in which others have resolved the dissonance caused by these opposing cognitions. A veteran expat sought to justify the worryingly high proportion of Range Rovers in Phnom Penh by saying that there used to be very many Land Rover Defenders here and so it was sensible to keep buying vehicles from Land Rover as there was a healthy supply of spare parts. A second’s glance at a Range Rover beside a Defender will reveal how heroic this effort is to resolve the dissonance of seeing so many of the former here. I am seeking to resolve the dissonance in another way.

When cognitive dissonance arises you can try to modify a belief, abandon it, change one’s focus away from dissonant beliefs or reduce its significance so that there is less dissonance. Here, 'The Defender Solution’ involves modifying the belief that a Range Rover is the product of very great wealth and success. It does this by suggesting that the possession of a Range Rover in Cambodia is also a product of ease of access to spare parts. I propose a more reasonable solution. This is to modify the belief that the aid should be foreign. Call it the ‘Local Charity Solution’, if you will. There is plenty of evidence in the high number of luxury cars (often driven by government workers, observe the high number that have government plates on the windshields) here to support the idea that a significant number of people have a large amount of expendable capital.

In the Phnom Penh Post (article link) PM Hun Sen has commented how important it is for the culture of dependency on foreign aid in Cambodia to end, and that their running the upcoming June 2012 commune elections without international funding was a demonstration of this happening. I’ll take this as a sign of recognition amongst the wealthy and powerful of the need for internally sourced charity in Cambodia. I hope that this will eventually lead to money that might otherwise have gone to luxury vehicles being spent on items for the public good. Numbers of Range Rovers may go down, or the standard of living may go up. Either way, my cognitive dissonance will reduce.

This can also be related to the humanisation issue discussed above. If you read the earlier cited Haslam (2006) you may recall that people are possibly humanized by two means – observing in them uniquely human traits or aspects of human nature (summary in the humanness and forms of dehumanisation diagram above). An influential, internally funded charity may be a way for rich Khmers to display their humanity, which I suspect many foreigners do not recognize fully. This because it will involve displays of such uniquely human traits as moral sensibility and civility and aspects of human nature such as emotional responsiveness and interpersonal warmth. There is a lot of this on display from foreigners via foreign funded charity, and I think an opportunity exists for rich locals to do the same, with associated increases in national pride and sense of independence.