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Medical Anthropology: Cross-Cultural
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Baksbat (Broken Courage): A Trauma-
Based Cultural Syndrome in Cambodia
Sotheara Chhim
a
b
a
Transcultural Psychosocial Organization, Phnom Penh, Cambodia
b
Monash Asia Institute, Monash University, Caulfield East,
Melbourne, Australia
Accepted author version posted online: 19 Mar 2012.Published
online: 13 Feb 2013.
To cite this article: Sotheara Chhim (2013): Baksbat (Broken Courage): A Trauma-Based Cultural
Syndrome in Cambodia, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 32:2,
160-173
To link to this article: http://dx.doi.org/10.1080/01459740.2012.674078
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Baksbat (Broken Courage): A Trauma-Based Cultural
Syndrome in Cambodia
Sotheara Chhim
Transcultural Psychosocial Organization, Phnom Penh, Cambodia, and Monash Asia Institute,
Monash University, Caulfield East, Melbourne, Australia
Whether posttraumatic stress disorder (PTSD) sufficiently explains and encompasses the symptoms
experienced by people from non-Western cultures is debatable. The etymological, social, and histori-
cal contexts of idioms of distress experienced by Khmer, known as baksbat, were studied through
interviews with 53 Cambodian experts. Phey-khlach (double fear), bor-veas-cheas-chgnay (wishing
that the trauma would go away), dam-doeum-kor (planting a kapok tree—remaining mute),
chos-nhorm (submissive, easily giving in), kob yobal (ideas are buried), and loss of togetherness,
were all identified as specific symptoms of baksbat. Similarities and differences between symptoms
of baksbat, PTSD, anxiety, and depression indicate that baksbat is a Cambodian idiom of distress
with sufficient characteristics to be recognized as a formal cultural trauma syndrome distinct from
PTSD. Increased awareness of its criteria and phenomenology may help clinicians provide appropri-
ate support for traumatized Cambodians.
Keywords Cambodia, cultural syndrome, idiom of distress, PTSD, trauma response
The phrase ‘idioms of distress’ describes specific expressions of psychological disorder that occur
and are recognized by members of particular cultures. These have been described extensively by
scholars of anthropology, psychiatry, and psychology, especially in the context of research on cultu-
rally informed assessment and treatment of various conditions. According to Mark Nichter (2010),
primary idioms of distress, referenced often as somatic-based disorders in Asia, have been common
for 30 years and have clearly taken on a life of their own. The term is used in the Diagnostic and
Statistical Manual IV (DSM-IV), and will likely be used again in the forthcoming DSM-V. Idioms
of distress have refined global understanding of psychological, social, and somatic expressions of
distress and mental illness, while providing a blueprint for researchers and clinicians across countries
to account for the phenomenology of distress in specific cultural settings.
SOTHEARA CHHIM, MD, is a psychiatrist, Executive Director of the Transcultural Psychosocial Organization, Cambodia
(TPO Cambodia), and a lecturer of psychiatry, Royal University of Phnom Penh, Cambodia. His areas of interest are
community mental health, trauma, transcultural mental health, and transitional justice. He received a Human Rights Award
for 2012 from the Leitner Center for International Law and Justice, Fordham Law School, New York City, in recognition of
his work promoting the rights of people with mental health problems in Cambodia.
Address correspondence to Sotheara Chhim, TPO Cambodia, No. 2 & 4, Oknha Vaing Road, Sang Kat Phnom Penh
Thmey, Khan Sen Sok, PO Box 1124, Phnom Penh, Cambodia. E-mail: sotheara@tpocambodia.org
Medical Anthropology, 32: 160–173
Copyright # 2013 Taylor & Francis Group, LLC
ISSN: 0145-9740 print/1545-5882 online
DOI: 10.1080/01459740.2012.674078
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Scholars define idioms of distress in different ways but stress similar themes. Hollan
(2004:63), for example, regarded idioms of distress as ‘‘culturally shared symbols, behaviors
and language that express, explain and=or transform peoples’ experience of distress and suffer-
ing.’’ In some cases, such idioms are interpersonally effective ways of expressing and coping with
distress; in other cases, they indicate psychopathological states that undermine individual and col-
lective states of well-being (Nichter 2 010). Hinton and Lewis-Fernandez (2010) have classified
idioms of distress and related prototypes to incl ude psychological or somatic complaints, eating
abnormalities, cultural illness syndromes, zealous-religious involvement, and acting-out beha-
viors. Several idioms of distress have been described within the Cambodian refugee context such
as ‘weak heart’ (Hinto n et al. 2002), ‘khyaˆl attack’ and ‘khyaˆl goeu’ (wind overl oad; Hinton,
Khin, and Ba 2001), and ‘the ghost pushes you down’ (sleep paralysis; Hinton et al. 2005).
My own research brought to light a perhaps peculiarly Cambodian idiom of distress called baks-
bat. This literally means ‘broken courage’ and describes psychological responses to the severely
traumatic events experienced by Cambodian people in the past decades. While this term has been
described by Kong (2003) and Huot and LeVine (2000), there has been no systematic phenomeno-
logical study. Previous studies, such as those by Devon Hinton and colleagues (2010) on idioms of
distress and local cultural syndromes among Cambodians in the United States, Maurice Eisenbruch
(2000) on traditional healings and rituals in Cambodia, Peg LeVine (2010) on spirit-based anxiety
among survivors of the Khmer Rouge, and Joop De Jong and colleagues (2003) on psychosocial
and mental health problems in postconflict Cambodia, have not included baksbat.
Baksbat appears to be an idiom of distress with some degree of overlap with post-traumatic
stress disorder (PTSD), anxiety, depression, and = or dissociative features, but further research is
required to flesh this out. Baksbat appears to be unique to the Cambodian population because of
the complexity of traumatic and phenomenological experiences that people have endured. It is
particularly evident when studying those who survived the Khmer Rouge regime (1975–1979).
My study on baksbat, on which this article is based, is unique, too, because of my own position
as a Cam bodian national, who experienced trauma under the Khmer Rouge and has treated sur-
vivors of the Khmer Rouge regime for more than a decade. Accordingly, I brought to the study
insight both as a clinician and a participant observer, with the ability to reflect on what had hap-
pened during and after the Khmer Rouge regime. Given my personal history, a peer debriefing
process was employed to mitigate against any risks to the validity of the study.
In this article, I draw on multiple sources of explanation across etymological, social, and his-
torical contexts to explain what baksbat means to Cambodians. In addition, I draw on ethno-
graphic interviews to describe its presentation. I conclude by discussing the phenomenon of
baksbat within the debate of idioms of distress, cultural syndromes, and the presumed univer-
sality of PTSD, anxiety, and=or depression.
UNDERSTANDING BAKSBAT
Etymology
The concept of baksbat expres ses most fully the fear that follows a distressing or life-threatening
situation. Chourn Nath (1967), the late Supreme Head of Monks and an author of the first Khmer
Dictionary, wrote that baksbat comes from the word bak (noun), which means break=broken,
IDIOMS OF DISTRESS IN CAMBODIA 161
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and the word sbat (noun), meaning body or form. Baksbat literally means broken body or form.
In the Khmer language, people often use compound nouns or use alliteration to strengthen mean-
ing and allow for flow in their expression. The word sbat can also be used as sbat-sbov; in this
instance, sbat (adjective) means thick or dense while sbov (noun) means thatch or the type of
grass that rural Khmer use for roofing. Combined, the expression means thick thatch. Chourn
Nath (1967) gave an illustration that once an elephant steps on this sbat-sbov (thi ck thatch),
the original form of the thatch is broken forever. So, baksbat is literally translated as the perma-
nent breaking of the body or spir it. The former Supreme Head of Monks referred to this as ‘‘the
psychological break down of courage’’ or ‘‘broken courage.’’ This etymological explanation is
couched in lay terms, such as sbov (thatch) and elephant; by drawing on images common in the
daily life of Cambodian villagers, the idea is easier to understand.
Huffman and Im (1977:68) trans lated baksbat into English as ‘‘terror-stri cken,’’ whereas Sos,
Kheang, and Erham (1975:192) have translated baksbat into English as ‘‘ being afraid forever,’’
which suggests that people who suffer from this condition will never regain their previous level
of calm, functioning, or courage. In common terms, baksbat means fear related to bad experi-
ences. People with baksbat feel reang-charl; they sense that they will not or dare not do some-
thing ever again. In this contex t, baksbat or broken courage is a condition that has a broader
meaning than baksbat as used in everyday spoken Khmer.
Baksbat is also used collectively. For instance, a group of villagers who experience the same
terrible event may not dare to do something or take a particular action ever again. The terrible
events significant to this study include the sudden loss of a loved one, combat shock, a landmine
accident, being frightened by spirits or ghosts, or being chased by wild animals. The research
study, which I describe next, was designed to sort out the difference between casual analogy
and actual distressing experiences of baksbat with informants.
Ethnomedical Origins
Some traditi onal healers in Cambodia refer to baksbat when describing an illness in which symp-
toms relate to intense phey-khlach or khlach (fear); this fear is attached to the ways one’s soul
can get lost, or to fears that lead one to scream out in the night when having a bad dream. ‘Soul
loss’ is categorized as (1) lours-praling (some of the souls jump out of the body): or (2)
paling-chong-sak (souls run to the extremity of the hairs on the body; Ly 2006). According
to Ly and Thompson (2005), and from the personal accounts of elderly Cambodians, there
are 19 small souls and one large soul (or crystal soul) in our body. Lours-praling refers to
the condition when the majority of these 19 souls are lost, or the large soul is lost, when
a people’s consciousness is partly or completely lost as well. On a clinical note, this lost-
soul=lost-consciousness phenomenon resembles the DSM definition of dissociation. The lost
soul can be regained through a method that is called hav-prali ng (calling back the soul; Ly
2006; Thompson 2005). The loss of the large soul may lead to individuals becoming mad,
with symptoms that appear psychotic, or they may give an appearance of dying. These kinds
of symptoms occur more often after a person experiences an extremely frightening situation
or is shocked suddenly. The clinical condition of baksbat is more serious than baksbat as used
in everyday language. A person may tell a friend that he or she is baksbat, whereas clinicians
would see baksbat as a condition akin to PTSD.
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In the Khmer language, when emphasis is placed on something more severe or more endur-
ing, people usually add the prefix chumgneu (illness or disease) and attach another word in order
to strengthen the meaning. Examples are chumgneu kcheul (lazy illness), chumgneu puk-roloury
(rotten illness or corruption illness), and chumgneu sangkum (social illness). People use the term
chumgneu baksbat (baksbat illness) to emphasize that baksbat has resulted in a severe, debilitat-
ing form of illness after experiencing fright.
According to a Cambodian scholar, Meas Nee (personal communication, December 22,
2008), baksbat takes two forms: normal reactions, and pathological, exaggerated reactions. In
normal baksbat reactions, symptoms relate directly to the situati on or event. With pathological
baksbat, the symptoms become more enduring and behavior becomes increasingly maladaptive.
Symptoms continue long after the event has been resolved. Some Cambodian psychiatrists and
psychologists equate the concept of baksbat to that of PTSD because of the overlaps in features
related to psycho-emotional distress. Nevertheless, they acknowledge that there are underlying
differences, such that Khmer with baksbat give in easily, are submissive, mistrust people, or are
mute. Again, to date there has been no research on this idiom of distress or its relationship to
PTSD, anxiety, and=or depression.
Social and Historical Origins
The concept of baksbat dates from the collapse of Angkor and the Khmer Empire in 1413, fol-
lowing the invasion of Siamese from the West (Corfield 2009:11). These ancient events may have
induced baksbat in Cambodians, and this baksbat may have been transmitted to the next gener-
ation of Cambodians. Some Cambodian historians describe Indigenous Khmer as the ‘ethnics
with baksbat’ because Cambodia has suffered for centuries from war with its neighbors, as well
as horrific living conditions under oppressive regimes and forced colonialization. Many respon-
dents interviewed in this study believe that baksbat has been transmitted intergenerationally,
undermining and demoralizing people, leading them to be more passive and reluctant to stand
up for their rights. In some ways, this is akin to the descriptions of generational trauma that have
been identified among displaced people and indigenous people globally, such as First Nation
People in North America and Aboriginal Australians. Rohr (2004) argued that the pain that is
not transformed is transferred, reflecting transmission of trauma across generations. Many neuro-
biological studies on the offspring of Holocaust survivors also support this view (Brand et al.
2006; Broekman, Olff, and Boer 2007; Davidson and Meller 2001; Yehuda et al. 1998, 2000).
In his epic poem, Kong Bunchoeun, a renowned nati onal author and poet, categorized 41
types of Khmer illnesses; baksbat was one:
Those people who witnessed Pol Pot’s militia tying up and killing people, those who witnessed Pol
Pot militia marching people to the Killing Fields, those who witnessed people killed by bombard-
ment, these people still have baksbat today.
Those people, ordinary people of all levels, who, when meeting people with greater power,
stand bent, their hearts beating faster and their bodies trembling with fear, they never dare to make
comments due to their fear of blame and retribution.
Those people who want to complain but dare not do so, who prefer to stay shy, their faces
downturned, when they see powerful people make mistakes, they dare not blame them, because they
fear hatred.
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When powerful people fart, ordinary people say it has a good smell: they bear the smell and say
it smells like perfume, because baksbat illness follows them everywhere. People fear that, if powerful
people hate them, they will disappear. (Kong 2003:26)
Because of baksbat, Cambodians often feel exhausted, and are passive and reluctant to fight
back. This explains why, over a three-day period on April 17–19, 1975, there was so little resist-
ance in Phnom Penh and other major cities to the Khmer Rouge troops who came to the city and
forced the evacuation of millions of people. No one dared to stand up and resist the Khmer
Rouge security guards, some as young as their children, who tied up people, marched them like
animals to the Killing Fields, and then executed them one by one. The killing under the Khmer
Rouge, the subsequent civil war against the Khmer Rouge guerillas, and random postregime
violence, leaves people continually vulnerable to baksbat.
I have worked for 16 years as a psychiatrist in community mental health, and lived throu gh
four regimes in Cambodia—including the genocidal Pol Pot regime. My observations validate
the existence of baksbat, alongside the nonsolicited use of this term by my patients who describe
their condition as baksbat. It is plausible that baksbat , together with the history of patronage in
Cambodia, has created an environment in which it is impossible to imagine the future or to ident-
ify and defend human rights. As a result, people are much more likely to become victims of
exploitation and abuse by authorities. Because passivity is at its core, baksbat may be a major
stumbling block to social development and prosperity. When people dare not support what is
just and fair, they are at risk of being exploited across generations.
1
On the basis of the previous descriptions, baksbat resembles an idiom of distress that is more
defined than an everyday metaphor. In particular, baksbat fits well with the definition of idiom
of distress by Hollan (2004) and De Jong and Reis (2010), that is, a culturally shared set of
symbols=metaphors (broken body or form), behavi ors (being submiss ive, easily giving in),
language, or meaning (the psychological state of ‘broken courage’) that are used and understood
by Cambodian people to express distress or psychosocial suffering. In this regard, baksbat may
be used to express trauma responses as well as the cultural syndrome itself.
METHODOLOGY
The study on which this article is based was conducted in Cambodia using ethnographic meth-
ods, as descri bed by Hubbard (2007), to understand the concept of baksbat from the perspective
of experts or key informants with knowledge of this concept. Verbal informed consent was
sought from the experts in advance of each interview. These experts included traditional healers,
mediums, religious people, elderly people , mental health professionals, historians, linguists, and
other academics. Some of the experts were interviewed on multiple occasions, using information
from previous interviews to elicit further infor mation, clarify, and gain deeper responses upon
re-interview. I conducted all interviews and focus group discussions.
Sampling was purposive and convenient (Teddlie and Yu 2007) in order to assist the under-
standing of the concept of baksbat and trauma-related issues from experts’ points of view. Snow-
ball sampling was used to find additional experts with knowledge of baksbat and establish
regional and different points of view. Fifty-three experts were selected and interviewed individu-
ally or in focus group discussions. There were two groups of expert participants: first a group of
victims of trauma=torture who had direct experiences of trauma and were likely to have
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experienced baksbat themselves; and a second g roup of people who had observ ed and had
knowledge of baksbat. The latter group included health and mental health workers, psychiatrists,
psychologists, teachers, linguists, historians, university professors, and villagers with status in
their villages as traditional healers, medi ums, prit-theacha (elderly people), and achar (priests).
Although participants were divided into two groups, all had experienced trauma and hardship
during the period of the Khmer Rouge; all participants in the first group had experienced baksbat
to some extent.
The main questions for individual interviews and focus groups included: What is baksbat?
Please tell me about symptoms of baksbat of persons you know (you don’t need to tell me
the name) (e.g., their behavior, attitude, relationship, function)? Subsidiary questions included:
What are the causes of baksbat? Is baksbat transmitted to the next generation? What can be done
to prevent baksbat? Open and selective coding techniques were used to analyze the data (Strauss
and Corbin 1998:102).
RESULTS—ETHNOGRAPHIC FINDINGS ON BAKSBAT
Although I divided the respondents into two groups, there appeared to be no differences in terms
of responses to or understandings of the concept of baksbat, because all participants had, to some
extent, experienced hardship and torture under the Khmer Rouge and many had experienced
baksbat as victims of trauma. Brief information from the ethnog raphy is summarized next.
Symptom Features
The majority of respondents stated that the very first sign of baksbat is phey-khlach (fear-fear),
related directly to the shocking events that they experienced. This phey-khlach reaction leads the
person who experienced the events to become reang- charl (to resolve to cease doing anything;
Sath and Chhit 2001), khlach ro-arh (being fearful or feeling dread, and wishing never to experi -
ence the event ever again), and bor-veas-chea-chgnay (wishing the traumatic event would go
away). Many reported a loss of courage and an inability to confront others. Most were afraid
to disclose their identity to anyone or talk to others about what they had experienced
(dam-doeum-kor, planting the kapok tree or mute tree; Ebihara, Mortland, and Ledgerwood
1994:82), and some pretended to be dumb or deaf: ‘‘ Say nothing, hear nothing and understand
nothing’’ (Yathai 1987:63). The y also felt unable to speak about their fears (kob yobal—idea is
buried), and experienced this as a kind of fear about fear (or double fear). People with baksbat
would avoid anything that reminded them of the event. They sometimes experienced extreme
fear associated with losing their soul (lours praling) or believed that their soul would go out
to the ends of the hairs on their body (praling-chong-sak). In lours -praling, with the loss of
the majority of souls, people often went into a trance, as if they were in a dissociative state,
and so reacted as if in a state of depersonalization and derealizat ion.
People with baksbat have a problem trusting others, and they easily give in or accept defeat
(chos-nhorm—submissive), feel or act in a cowardly manner (kam-saak ), and cannot stand up
for themselves and confront others. Baksbat has an impact on one’s sense of integrity. One often
becomes afraid of helping others, and finally appears to others as selfish, leading others to cri-
ticize them and how they live their lives in their communities.
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People with baksbat often have physical symptoms such as headaches, poor sleep, poor atten-
tion, and they report ‘thinking too much’ (ruminat ing), feeling emotional ly and physically weak,
and experiencing digestive problems. They often have repeated bad dreams about past events.
They become withdrawn and isolated, do not go outside, and fear that something might cause
them problems. The y often feel anxious, shaky, lose control, and may appear to be pale and have
cold extremities. In addition, respondents reported that people with baksbat experience loss of
self-confidence, feelings of loneliness, irritability, and anger, have reduced contact with former
relations, and avoid meeting others or avoid socializing.
Perceived Causes
Respondents reported that experiencing traumatic events at an individual, community, or societal
level can cause baksbat. These events make individuals frightened or bak smaradey (broken con-
sciousness or alertness). These events include genocide, war, bombardment, torture, domestic
violence, breakdowns in marital or fami ly relationships, and being attacked by animals. Specific
to (and normalized in) the Southeast Asian region are events that include supernatural forces, for
example, being haunted by ghosts or frightened by evil spirits. Many believed that the break-
down in culture and family structure of Cambodian society, witnessed after the Khmer Rouge
regime, had made people even more vulnerable to baksbat. Some referenced Buddhism and
believed that the lack of knowledge or understanding about Dharma, excessive desires, the
inability to accept the reality of impermanence , and going against the reality of the natural life
cycle (birth, old age, illness, and death), may also lead to baksbat and other mental illnesses (per-
sonal communication, December 23, 2008, Venerable Yos Hut Khemacharo).
Some respondents explained that according to Khmer traditional beliefs, reasey
2
(bad luck,
fortune, or supern atural luck), can cause such problems (Hinton et al. 2009). Once a person
has reasey dak (one’s fortune is low), he or she may have met or will be likely to meet kruah
(bad experiences=dangers), which will lead to baksbat. There are two types of bad experiences
or bad luck: kruah dach sangreng (people without clear reason become more irritable with
others in the house) and kruah kambot kaˆ (the bad luck cuts off the head); in this latter case
people may be predicted to meet with danger that will lead to death. A few respondents sug-
gested that baksbat could run in the family, as they described that the children of parents with
baksbat may have baksbat too, but it is not clear whether they felt that there was a genetic or a
common personality trait among people who were therefore especially vulnerable to baksbat.
Opinions vary, however, on whether baksbat can be transmitted generationally. Many people
believed that the history of Cambodia had proven that this was possible, but others saw it as
an individual problem, and only those who experienced a specific traumatic event would suffer
from baksbat.
Treatment and Protection
Most respondents agreed that the following treatments were successful for baksbat. The first was
education about baksbat, helping people to unders tand the context underlying their problems and
encouraging them to feel supported and to feel stronger. With reassurance, people may become
more self-aware and better able to cope with baksbat.
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The second was the use of traditional methods. For example, monks or traditional healers can
help correct kruah (bad luck or danger) through water blessings. Rumdaˆh kruah ceremonies (to
divert danger; Hinton et al. 2009) help individuals not only recover from baksbat but also avoid
potential danger in the future. Of the many forms of rumdaˆh kruah ceremonies, one used by hea-
lers is to make a small statue or model symbolizing the person with baksbat. The healer tells the
spirit that there are two bodies, the real one (the person with baksbat) and his statue. The healer
asks the spirit to pick up the statue and take it away, so enabling the person with baksbat to
remain at home, safely, with his or her family.
3
The third is hav-praling (calling the souls back). Ceremonies, which vary in detail across
regions, are held to call back souls that have becom e lost, because fearful situations have forced
them to leave the body of the individual. The ceremonies help people recover their lost soul or
souls, so ensuring a speedy recovery and healing baksbat. Wit h children, a simple way of calling
the soul is to embrace the child who is frightened and say, ‘‘EH ! Let the complete 19 souls EUY
come back into the body.’’ After calling the souls back, the caller blows air onto the head of the
child, so calming the child. In the event of a major loss of souls, especially for adults, the caller
performs a ceremony and sings to call the soul back. The content of the song reminds the soul
that ‘‘the individual (who has baksbat) is the real body; do not let the evil spirit cheat you; here is
your real house; do not get lost; here is your own banana tree in your house.’’ The medium or the
person who calls the soul describes all types of trees or materials that belong to the house of the
individual with baksbat (Hinton et al. 2009; Ly 2006; Thomps on 1996, 2005). By doing so, the
soul will hear, remember, gain insight, and return. Afterwards, the person recovers from baksbat.
The fourth approach, one favored by mental health professionals, is to treat attitudes and
behavioral changes associated with baksbat. Such cognitive reframing can be difficult and time
consuming, although it may be helpful if the person has a supportive environmen t from family
and community. Mental health professionals can also be helpful by offering support additional to
the traditional approaches mentioned previ ously.
A fifth approach is korl-kar samaki (to encourage solidarity). A sense of feeling part of a solid
community and a sense of social togetherness among Cambodians in turn decreases baksbat.
Solidarity relates to the cohesiveness and capacity of people to live together well as good neigh-
bors and friends. In the words of one respondent, ‘‘If Khmers have solidarity amongst them-
selves, Khmer will survive, if not, Khmer will die’’ (Ouk Chorn, August 20, 2009, pers. comm.).
The final approach is by resort to medical interventions. Medication that treats anxiety can
help reduce those psychological symptoms of baksbat similar to anxiety, depression, or PTSD.
Such medication is not accessible to the majority of Cambodians living in rural Cambodia.
CASE STUDIES
The two case studies next, presented pseudonymously for confidentiality, were chosen to illus-
trate two dimensions of baksbat. Each case describes typical symptom s of baksbat, although
these may not cover all symptom clusters of baksbat.
Mr. Sam is 56 years old and a former military commander who was stationed in the 1980s in Stung
Treng province in northeastern Cambodia. One day, five of his soldiers went to the forest in order to
hunt animals for food. In the forest, they suddenly encountered a troop of roughly 20 wild elephants.
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The elephant herd chased them and they feared being stampeded to death. Everyone ran away sep-
arately in order to divert the elephants and escape this near death situation. They were not trampled
by elephants, but all of them were lost in the forest for four to five days before they returned to their
base. They were ill upon the return: They seemed to have lost self-control; they could not speak
coherently; were not able to eat or sleep; had hair loss; and eventually they all died. Mr. Sam said
that the soldiers suffered from baksbat in which extreme fear caused their souls to go out of their
bodies or lours-praling. The souls did not return and so they died. Mr. Sam said that a Kru Khmer
(traditional healer) tried to perform a ‘‘calling the soul’’ ceremony, but he was not able find the souls
of the soldiers as they had been out of their bodies for too long.
Mr. Sourn is 56 years old and a married veteran with seven children, who lives in Pursat Province,
central Cambodia. During the time of the Khmer Rouge, his family was allowed to live in his village
instead of being moved elsewhere. The family was accused of being ethnic Khmer Krom (a term
identifying Cambodians who live in the lower Mekong delta, now in the southern part of Vietnam)
and thus automatically they were regarded as enemies of Angkar (the Khmer Rouge administration).
Consequently, Mr. Sourn’s parents and other family members were killed and he was imprisoned. In
prison, he was beaten and electroshocked severely, but was rescued after the arrival of Vietnamese
troops in 1979. Mr. Sourn now describes himself as bak (broken), a short form of baksbat; he feels he
exists in only half of his body. The other half has been broken (loss of self), making him feel very
insecure. Thus he is overly cautious and does not easily trust people. He expresses this state of ‘bak’
by saying that he has become reang-charl; he dares not speak or express his feelings to others. Dur-
ing the Khmer Rouge times, Mr. Sourn remembers talking with an old man who told him not to
complain about anything, otherwise he might die. Now Mr. Sourn thinks that his survival was
due directly to keeping his mouth closed and being submissive. This, in turn, has led to him being
fearful that the Khmer Rouge regime might return, and he would not know how to deal with this.
DISCUSSION
The descriptions of symptoms and case studies suggest that baksbat could be considered as an
idiom of distress, a culturally specific trauma response experienced by Cambodians residing
inside or outside Cambodia. Most often survivors consult a doctor with culturally specific symp-
toms more frequently than with PTSD. This idiom of distress baksbat may help clinicians to
understand trauma responses expressed by sufferers (Hinton and Lewis-Fernandez 2010). Since
this study was designed and implemented from the perspective of Cambodian experts, it pro-
vides a culturall y sensitive perspective from which to make comparisons between PTSD and
baksbat. The case studi es illustrate two key features of baksbat. The first case, Mr. Sam, shows
the relation between baksbat and loss of soul (lours-praling). This type of baksbat is more acute,
caused by more sudden and extreme fear leading to loss of soul, which is difficult to handle and
may lead to death. This type of baksbat may be similar to an illness from fright or soul loss
called kesambet, a North Balinese syndrome, described by Wikan (1989), or susto and soul loss
among Mexicans and Mexican Americans (Glazer et al. 2004).
The symptoms revealed in the case of Mr. Sourn are more common than soul loss. They are
usually caused by prolonged trauma and are relatively common among survivors of the Khmer
Rouge genocide. The trauma does not cause the soul to jump out of the body, and so this type of
baksbat does not result in sudden death. This type of baksbat, in contrast, is chronic, persistent,
and may be difficult to deal with, as evidenced by the many survivors of the Khmer Rouge
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regime who continue to live with baksbat. The features of baksbat in Mr. Sourn’s case, such as
reang-chal (‘plant the kapok tree’; that is, see nothing, hear nothing, and speak nothing), submis-
siveness and acceptance of defeat, are common among Cambodian survivors today.
Baksbat resembles the anxiety-based compo nents of PTSD, yet there are differences.
Bor-veas-cheas-chgnay or ‘wishing the trauma event would go far away’ in baksbat is similar
to avoidance as included in criterion C of PTSD. Although people with baksbat do not have spe-
cific features of avoidance such as avoiding thoughts, feelings (criterion C1), activities, places,
or people (criterion C2), they will avoid anything that serves as a reminder, as occurs in PTSD
too. Another baksbat feature, ‘fear of helping others,’ c aptures people’s reluc tance to help others
because this could be detrimental to their own safety; therefore they choose to remain passive
and silent. Consequently, they lose a sense of identity and connectedness, as occurs with feeling
‘detached or estranged from others’ in criterion C5 of PTSD. Symptoms of baksbat like
‘withdrawal,’ ‘isolation,’ ‘do not go outside due to the fear that something may cause them prob-
lems’ would be similar to the symptoms of ‘markedly diminished interest’ or ‘participation in
significant activities’ in criterion C4 of PTSD. In addition, baksbat symptom features such as
‘repeated bad dreams about the past,’ ‘feel ing anxious, shaky,’ and ‘losing control’ or ‘appearing
to have pale color and sweating,’ are similar to criterion D of increased arousal symptoms of
PTSD.
Individuals with baksbat who present with lours-praling (the majority of souls are lost) may
present in a trance-like state in which they act or behave as if in a dissociative state similar to
depersonalization and derealization. This would be similar to criterion B3 of PTSD. While the
perceived causes of PTSD were not mentioned in DSM-IV, criterion A of PTSD could be similar
to the perceived causes of baksbat, as respondents stated that a variety of traumatic events could
lead people to have baksbat.
However, several features of baksbat, such as being overly submissive and mute (‘planting
the kapok tree,’ literally refraining from speaking), do not exist in PTSD. And while a
high-level mistrust of others is very common in baksbat symptoms among respondents, this
mistrust is less specific in those with PTSD and mistrust of the spirit domain is part of this
feature among Cambodians. Cultural norms, such as the Cambodian culture of hierarchy
and the value placed on obedience to parents and elder s, may cause submissiveness. However,
these cultural aspects appear to have become abnormally exaggerated under and after the
regime of the Khmer Rouge, when no one would dare to stand up to resist the guards who
could torture or kill any person they wished. The ‘planting the kapok tree’ feature of muteness
also became extreme during this period, as people mistrusted and would not speak even to
family members (see also Ebihara et al. 1994:85). Many other authors have identified symp-
toms other than PTSD symptoms that are common among traumatized groups. Reports of
idioms of distress by trauma survivors may indicate not only PTSD but also the presence
of other comorbidities, especially symptoms that are cult ure-bound like khyaˆl attack (Hinton
et al. 2010), kiyang-yang (De Jong and Reis 2010), ‘evil and bad though t,’ or ‘a burning
head,’ or having ‘cried the eyes out’ (Elsass 2001).
Baksbat includes neuro-vegetative symptoms, and therefore overlaps with anxiety. The first
symptom of baksbat, phay-khlach (fear-fear), relates to the fear symptom of anxiety. The fear in
baksbat is a kind of fear that is embedded in a survivors’ mind; it is a mixture of a sense of
remembrance (leading people to mark a stone or pierce their ears as a reminder) and wishing
all bad things to go away (bor-veas cheas-chhgnay). In addition, baksbat has many physical
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symptoms in common with anxiety, such as palpitations, trembling or shaking, difficulty
breathing, sweating, and pallor. Bak sbat is also similar to depression as it relates to mood fea-
tures: people with baksbat lose confidence and may be lonely, irritable and labile, and withdraw
from social relationships.
Although similar to PTSD, baksbat also has some similarity to the ‘weak heart’ syndrome
(Hinton et al. 2002) and khyaˆl attack (Hinton et al. 2010). But again, there are differences. Weak
heart is thought to be caused by fearful events and marked by extreme fear reactivity symptoms
only, while baksbat has persistent feelings and behavior of reang-chal and bor-veas-cheas-
chgnay, and symptoms of fear reactivity may or may not be present yet. Once exposed to the
trauma again, they may experience fear reactivity as they would with weak heart. In some
instances, one could say that baksbat could trigger ‘weak heart’ syndrome.
While Western-based diagnostic criteria and treatment provide foundational knowledge to
address mental disorder, cultural and phenomenological-based experiences most often take a
back seat. By placing indigenous criteria such as baksbat alongside the DSM criteria, there
is less danger that mental health clinicians will ignore the underlying causes that may manifest
in the metaphysical realm of souls and spirits. In countries like Cambodia where both financial
and professional services are limited, this puts an unnecessary burden on available resources.
By including cultural-specific concepts such as baksbat in assessmen t protocols, treatment
methods can be provided sequentially to assist and improve the rate of true recovery and prob-
lem resolution. Without the inclusion o f baksbat, individuals with this particular condition may
fail to receive targeted treatment, which may inhibit their healing from trauma. Teasing out
this concept is an important element to heal a complexly traumatized society. For mental
health professionals working with Cambodian clients, it is important to understand the concept
of baksbat and how it differs from the Western diagnosis of PTSD. Cambodian people may
self-identify as having baksbat, and while their symptoms may not fully meet PTSD criteria,
this does not mean that they are not suffering from trauma-related problems and do not need
assistance. An understanding of the meaning of this idiom of distress and its interpretation in a
Cambodian cultural context will help professionals deal more effectively with Cambodian
clients.
CONCLUSION
Khmer expressions of emotional problems are rich in meaning and metaphor, and it is difficult to
translate visceral and perceptual experiences into meaningful words: cultural meanings may be
lost in translation. Even so, the descriptive and phenomenological investigation into baksbat
reveals a significant idiom of distress, manifesting as a Cambodian cultural syndrome of com-
plex trauma. The aim of developing this cult ural syndrome is not to undermine PTSD but rather
to complement it in the Cambodian context. In this way, mental health professionals and para-
professionals will be able to pay clinical attention to the cultural aspects of trauma responses in
Cambodia. This idiom of distress baksbat may also help foreign researchers in fostering a
reliable link between cultural and mental health responses in Cambodia, making their research
more meaningful and relevant. This study will also open an avenue for younger Cambodian
researchers, and those in neighb oring countries, for more studies on mental health and culture
within their own cultural and historical framework.
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ACKNOWLEDGMENTS
I would like to sincerely thank the Australian Government and Australian people for awarding
me the Australian Leadership Award (ALA) scholarship to undertake my PhD degree at Monash
University. This research project was kindl y sponsored by a USAID grant via the Center for Vic-
tims of Torture (CVT) in Minneapolis, USA. I would like to express my profound gratitude to
the TPO Cambodia, friends, and collaborators, who loyally supported me during this study.
NOTES
1. The Venerable Yos Hut Khemacharo at Wat Lanka Pagoda in Phnom Penh, on December 23, 2008, told me
that due to baksbat, many of his fellow monks would not express their opinions and were very submissive toward their
superiors.
2. Traditional healers predict or diagnose their clients through looking at reasey. If someone’s reasey is low, they are
prone to illness; once their reasey is up, they can succeed in their life and resist illnesses, curses, and spells. Hinton and
colleagues (2009) found that having low reasey (riesey) increases patients’ vulnerability to illness.
3. See different descriptions of rumdaˆh kruah (Hinton et al. 2009).
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