Nightmares Among Cambodian Refugees: The Breaching of Concentric Ontological Security

Abstract

This article explores the nightmares of Cambodian refugees in a cultural context, and the role of nightmares in the trauma ontology of this population, including their role in generating post-traumatic stress disorder (PTSD). Among Cambodian refugees attending a psychiatric clinic, we found that having a nightmare was strongly associated with having PTSD (χ² = 61.7, P < 0.001, odds ratio = 126); that nightmares caused much distress upon awakening, including panic attacks, fear of bodily dysfunction, flashbacks and difficulty returning to sleep; that nightmare content was frequently related to traumatic events; that nightmares resulted in a decrease in the sense of “concentric ontology security” (i.e., in an increased sense of physical and spiritual vulnerability in a culture that conceives of the self in terms of concentric, protective layers), including fears of being attacked by ghosts; and that nightmares frequently led to the performance of specific practices and rituals aiming to extrude and repel attacking forces and to create “protective layers.” Cases are presented to illustrate these findings. The Discussion considers some treatment implications of the study.

The Case of Thach: Nightmare as Khmaoch (“Ghost”) Assault

To depict Cambodian sounds, we use the transliteration system of Heder and Ledgerwood (1996).

At her medication appointment, Thach said she had not slept well, felt anxious, and had been having frequent palpitations. A “circular” mark on her forehead indicated she had been doing “cupping” to remove “khyâl” [a wind-like substance] from her body. The first author [D.H.] asked if anything had happened to make her feel worse. She attributed her worsening to a nightmare.

In the nightmare, a man strangled her soul’s neck [dreams are thought to result from the experiences of the wandering “soul,” the proleung, and patients refer to the dream protagonist as their “soul”] and asked for money; he said that if Thach’s soul did not give him money, he would kill it. After awakening, she had half an hour of flashbacks of various Pol Pot traumas: performing slave labor, being beaten, seeing people executed.

Thach thought that a khmaoch had attacked her soul as it wandered as she slept, making her ill. She feared having low riesey, that is, low “supernatural luck,” and that low riesey made her vulnerable to khmaoch attack. As a result of the nightmare, she performed a ritual at her altar (bân srân): she lit incense and candles, and asked the Buddha, her parents, and all deities to protect her from khmaoch attack, to make her have good dreams. She was planning to take food to the monk at the temple to make merit, hoping this would provide further protection, would increase her riesey, and was considering consulting monks to see if more elaborate protective rituals were needed.

In certain societies, dreams and related practices represent a prominent aspect of the self-concept, of personhood, of self-processes (Hollan 2004), with dream-related practices—based on a dream interpretation system, that is, the local oneirocriticism, to use Foucault’s term (oneiro, meaning “dream,” and criticism, “interpretation”)—forming extremely important “techniques of the self” (Foucault 1986, 1988, 2005). In many societies, dreams indicate the individual’s state of health—psychological, physical, spiritual—and reveal what a person should do to maintain health [see, e.g., the edited volumes of Lohmann (2003a) and Mageo (2003a)]. As this literature suggests, nightmares may play a key role in the constitution of trauma subjectivity, and should be examined with respect to not only beliefs, but also concrete practices performed in response to having the dream (Herr 1981; Hollan 2003). That is, in certain societies, owing to nightmare-related beliefs and practices, nightmares may form a particularly central part of trauma ontology, of trauma subjectivity, and may form a key aspect of the identity of the traumatized individual.

Cambodian refugees in the United States have passed through multiple traumas. On April 17, 1975, after a brutal civil war in which perhaps 500,000 Cambodians died and many more were injured, displaced or impoverished by the fighting, the Khmer Rouge took power. Over the next three and a half years, the Khmer Rouge, a group of Maoist-inspired radicals led by Pol Pot, implemented a series of radical socioeconomic reforms in an attempt to enable Cambodia, renamed Democratic Kampuchea (DK), to make a “super great leap forward” into socialism (Becker 1998; Chandler 1991; A. Hinton 2005; Kiernan 2002). Economic activity was dramatically reshaped as the means and mode of production were collectivized. Money, markets and courts disappeared. Freedom of speech, travel, religion and communication were severely curtailed.

In their effort to create a pure society of revolutionaries who would be loyal primarily to the state, the Khmer Rouge rusticated the cities, banned Buddhism and splintered families, who were often separated for long periods of time while they labored, sometimes both by day and by night, on starvation rations. Spies crept about at night searching for signs of subversion. Meanwhile, the Khmer Rouge established a security apparatus that targeted suspect groups—former soldiers, police, civil service personnel, professionals, the educated, the urbanites—for reeducation, imprisonment, torture and, often, murder. By the time the Khmer Rouge were overthrown in January 1979 by a Vietnamese invasion, almost a quarter of Cambodia’s 8 million inhabitants had died of disease, starvation, overwork and execution.

The hardship of Cambodian refugees in the United States continued after the fall, however. In the upheaval that followed the overthrow of the Khmer Rouge, many undertook a dangerous journey to Thailand, where they were placed, often for years, in large refugee camps. Life in the camps was often difficult and characterized by continuing fear, threat and violence. For the lucky ones who procured visas to go to the United States, France or some other country, the transition to a completely new way of life was also fraught with difficulties. Many Cambodian refugees arrived traumatized and had trouble adjusting due to language problems, disrupted family and social networks, low status and, for a long time, the lack of culturally sensitive mental health resources.

Many Cambodian refugees continue to evince signs of trauma-related disorder (D. Hinton et al. 2006; Marshall et al. 2005), including nightmares. In the Cambodian language, the word for “dream” is yualsâp, and that for “nightmare,” yualsâp agrâ, literally, “a bad-and-evil dream.” The nightmares of Cambodian patients frequently involve encounters with friends and relatives who died in the Pol Pot period and with malicious supernatural beings, not uncommonly the ghosts of those who died during the same period, ghosts made vicious and angry as a result of the horrible way in which they died. [On the supernatural-assault explanation of nightmare in other cultures, see Herr (1981) and Lohmann (2003b); on the notion of “bad death” in Vietnamese society, and the importance of “ghosts” and related rituals in trauma ontology of contemporary Vietnamese, see Kwon (2006, 2008)].

In this article, we argue that to understand the key role of nightmares in the Khmer trauma ontology, one must explicate the Cambodian conception of personhood: multiple “layers” protect the self and produce “ontological security” (Giddens 1984, 1991), a feeling of being safe and protected. Cambodians are extremely concerned about physical and spiritual strength and the soul’s degree of connectedness to the body; these are components of an elaborate conception of personhood, a layered self-image. The self is not just one’s clothing, skin, appearance, thoughts, group affiliations, and so on; it is a concentric, power-layer self, comprised of bodily and extrabodily power sources.² [This might be called a “mandala self.” Our analysis builds on Tambiah’s (1976, 1985) demonstration of the importance of the mandala, of multilayered concentric forms, throughout Indic Southeast Asia—in the domains of architecture, ritual and political and interpersonal structures. Here we extend the analysis of the mandala to the level of the conceptualization of the self and related practices].

For a Cambodian refugee, a nightmare raises concerns that a protective layer of the self is defective, that forces that should protect one are not intact—or at least are not the equal to the assaulting forces. It indicates low “good luck” (riesey), weakness and a dislodged soul; the nightmare itself, by bringing about fright, a dangerous emotion, may also weaken the body and dislodge the soul. After a bad dream, the patient will expect to be ill for several days. Hollan (2003) uses the term “selfscape dreams” to describe dreams that indicate the “state of the self,” that symbolize the person’s sense of threat, from physical health to interpersonal situation to self-esteem to spiritual situation. In a sense, the present article explores how selfscape dreams are interpreted in a particular context.

Among Cambodian refugees, the defensive barriers can be classified into 15 types, or spheres, and these 15 layers give rise to a feeling of “ontological security” (see Figs. 1 and 2). This is an ideal model, with patients having variable knowledge of these “layers.” Knowledge of these “levels” is dynamic, usually being obtained from various sources, in particular upon consulting elders, monks and healers after falling ill or after having a nightmare. [See Eisenbruch (1992) for one discussion of protective layers as conceived by traditional healers in Cambodia]. Because of the layered nature of these defensive barriers, we refer to this kind of ontological security as concentric ontological security, to differentiate it from Giddens’s (1984, 1991) term for the ontological security of the Western self: cocoon ontological security.

Fig. 1

Among Cambodian refugees, the 15 zones (or sources) of concentric ontological security

Fig. 2

Location of sources of ontological security: the geography of power

According to the Cambodian conception, if any one of these protective layers is compromised, the person in question is at great risk of assault by various forces, especially the “ghost” of a dead person, called a khmaoch, an attack of which often occurs during sleep, resulting in the nightmare—or sleep paralysis,³ which Cambodians refer to as the “khmaoch pushes you down.” Nightmares and sleep paralysis are interpreted as indicating that some of the protective layers are defective and need to be strengthened and repaired. [For a detailed discussion of these concentric layers, see Hinton and Hinton (2009)].

Each of these 15 layers, these ontological security zones, is activated by specific practices, what might be called “security techniques,” which also constitute “technologies of the self.” Certain activities may be engaged in immediately before going to sleep to activate these protective layers and prevent nightmare. At the house altar, one may light incense, bow to the Buddha in worship and invoke the house spirit, one’s mother and father, one’s ancestors and the local spirits, asking these multiple forces for protection and good dreams—all to prevent nightmares and khmaoch assault. Next one may chant or meditate for a short while and then pour water down onto a plate, asking that the earned merit—from doing the chanting and meditation—be given to all those who died in the Pol Pot period, to all the roaming khmaoch, so they will not assault one in nightmares. One may drink holy water, rubbing it on one’s face; this removes “bad luck,” increases merit and levels of riesey (“good luck”) and serves as a tonic. And finally, as one falls to sleep, one may recite a special Pali incantation—usually provided by a monk—that “creates a protective perimeter” (poat seymaa), a protective field of merit and Buddha power.⁴

In this article, we investigate whether there is a close relationship between nightmares and post-traumatic stress disorder (PTSD) severity among traumatized Cambodian refugees and whether this relationship is mediated to a significant degree by cultural factors. We attempt to illustrate that the emotional and psychological importance of nightmares among Cambodian refugees, and the treatments undertaken upon having a nightmare, can only be understood in the context of the notion of “concentric ontological security” and its related practices, as depicted in Figs. 1 and 2. More generally, we investigate a model (see Fig. 3) of how a sense of decreased concentric ontological security along with several other processes triggered by nightmares, such as flashbacks and fears of bodily dysfunction, result in nightmares causing great distress and worsened PTSD among Cambodian refugees.

Fig. 3

The nightmare-PTSD model. According to our model of how a nightmare worsens and perpetuates PTSD among Cambodian refugee patients, the nightmare may cause the patient to worry about his or her own physical and spiritual state, to be concerned about the spiritual status of deceased friends and relatives, to have trauma recall and to have a negative self-image. This leads to greater anxiety and PTSD. In turn, the worsening of anxiety and PTSD increases nightmares, creating a vicious cycle of worsening. As indicated, if the patient had a sense of impaired ontological security before the nightmare, then the nightmare is more likely to trigger all these processes: decreased ontology security leading to concerns that the soul may be attacked as it wanders during sleep, that the body is vulnerable, so that such an attack may dislodge the soul, may cause inner hotness, may drain the body or may cause a khyâl attack

To investigate these hypotheses, we conducted several studies. Studies I and II examine the association of nightmares with PTSD and the degree of distress experienced upon awakening from a nightmare, as indicated by somatic symptoms, fear of those somatic symptoms and flashbacks. To further investigate how the nightmares caused distress, we conducted four studies (i.e., Studies III through VI). In Study III, we determined the relationship of nightmare content to past traumas and to the traumatic events recalled upon awakening. Study IV examined what patients thought caused their nightmares, and—if a nightmare was attributed to assault by a malevolent being—we asked about the nature of that being. Study V determined the subtypes of nightmares according to the local system of dream interpretation and the metaphoric meanings of and trauma associations with those dream subtypes in order to further explore the affective dimensions of those nightmares. Study VI investigated the extent to which nightmares were construed as indicating bodily and spiritual vulnerability. In the final study (Study VII), we determined what patients did as a result of having a nightmare, in particular, whether they performed rituals aiming to bolster the “protective layers.”

The studies were conducted at an outpatient clinic in Lowell, Massachusetts, and all participants were being treated by the first author. Lowell is home to more than 30,000 Cambodians, the second-largest Cambodian refugee community in the United States. The vast majority of patients (>95 percent) present to the clinic with PTSD, and all are survivors of the Pol Pot period (1975–1979) who were old enough during that time to remember it; that is, they are currently at least 40 years old. The majority of patients at the clinic are female (~60 percent), unemployed (with many receiving disability benefits) and spend much of their time caring for children and grandchildren. Most (>percent) of the patients were rice farmers before the Pol Pot period, almost all (>80 percent) received only a few years of education in Cambodia and none speak English fluently.

Study I: Nightmare Frequency and Association with PTSD

The first author, who is fluent in Cambodian, assessed consecutive patients for the presence of PTSD by using the PTSD module of the Structured Clinical Interview for DSM-IV (SCID), an instrument we have used extensively with this population (Hinton et al. 2006). To assure blindness to nightmare status in assessing for PTSD presence, the nightmare-criterion question of the SCID module was asked by a bicultural worker who was blind to the patient’s response to the other SCID questions.

In total, 40 men and 60 women were surveyed. The average age was 47.2 (SD = 6.2). As assessed by the SCID module, 44 percent (44/100) of the patients had PTSD. Among the patients with PTSD, almost all had experienced a nightmare in the last month (42/44, or 96 percent); among the patients without PTSD, few had had nightmares in the last month (8/56, or 14 percent). The difference in the rate of nightmares in the PTSD versus the non-PTSD groups was highly significant (χ² = 61.7, P < 0.001), with an odds ratio of 126. Among the PTSD patients with nightmares, the mean number of nightmares was 5.7 (SD = 6.9). As further illustrated in Fig. 4, the PTSD patients with nightmares had very frequent nightmares, with most (64 percent) having four or more nightmares in the previous month. Rates of nightmares or PTSD frequency did not differ by gender.

Fig. 4

Monthly rates of nightmares for Cambodian PTSD patients (N = 44), showing percentages of various rates

Study II: Degree of Distress Experienced upon Awakening from a Nightmare

To profile the distress caused by a nightmare upon awakening from it, we surveyed 100 patients who had had nightmares in the previous month. We determined the following about the most recent nightmare: after awakening from the nightmare, (1) how many of the DSM-IV panic attack symptoms were experienced; (2) how long had those symptoms lasted, (3) whether fear of bodily dysfunction was experienced; (3) if fear of bodily dysfunction was experienced, what kind of bodily dysfunction was feared; (4) whether a flashback was experienced; (5) if a flashback was experienced, what transpired (in all sensory modalities) in the flashback; and (6) how long it took to fall back asleep. To assess for presence of panic attacks, we used the SCID module (First et al. 1995). To assess for flashbacks, we used the CAPS Flashback Severity Scale (Weathers et al. 2001), with the recall having to be at least a “2” in severity to be counted as a flashback.

We found that every patient had a panic attack after awakening from the most recent nightmare, that panic attack lasting from minutes to hours (M = 32 min, SD = 22 min). During that panic attack, 85 percent (85/100) of the patients feared imminent bodily dysfunction. Upon awakening from a nightmare, patients often had flashbacks (72 percent; 72/100). The flashbacks were usually of Pol Pot events but, in some cases, were of events that occurred later in time: some female patients reported memories of being beaten by a boyfriend or husband here in the United States. Often patients had a flashback of three or four distinct Pol Pot events, one after the other, each flashback lasting several minutes. After awakening from a nightmare, patients had difficulty falling asleep again. Fifty-two percent could not fall asleep again for one to two hours, and 31 percent were unable to fall asleep again for the rest of the night. Several patients spontaneously mentioned not going back to bed again for fear of having another nightmare. We will now examine in more detail what kind of bodily dysfunction was feared upon awakening from a nightmare.

Of those patients who feared bodily dysfunction upon awakening from a nightmare, almost all (89 percent; 76/85) mentioned a “khyâl attack” (kaeut khyâl), stating that they feared that symptoms experienced upon awakening were caused by such an attack, and that the attack might cause physical disasters of various types. According to the Khmer ethnophysiology, a khyâl attack occurs when khyâl (a wind-like substance) and blood do not flow normally outward along the limb vessels, causing limb coldness and, potentially, loss of limb function (the local understanding of stroke-caused paralysis). The attack also may cause khyâl and blood to rise upward in the body to produce various symptoms and physical catastrophes—into the chest, bringing about asphyxia, possibly cardiac arrest; into the neck vessels, causing soreness, possibly a bursting of those vessels; and into the head, producing dizziness, blurry vision, and tinnitus, possibly syncope, blindness and deafness (see Hinton et al. 2001).

During the nightmare-caused panic attack, many patients (71 percent; 60/85) also feared having a “weak heart” (khsaoy beih doung), a disorder that may cause multiple symptoms and physical disasters: palpitations, cardiac arrest and, owing to poor circulation, a khyâl attack and all its disasters (e.g., loss of the use of the limbs) as described above. Many patients (69 percent; 59/85) worried that the nightmare had caused fright to the point of “soul loss,” and many (65 percent; 55/85) feared that the fright might result in the illness called “fright-to-the-point-of-fever” (khlaach dâl krun)—like soul loss, a potentially fatal disorder. And several patients (47 percent; 40/85) attributed the panic attack symptoms to an episode of “inner hotness” (krun khnong), a kind of inner boiling that may send blood and “steam” (choemhaay) upward in the body. The rising blood and “steam” cause symptoms, and potentially physical disasters, by the pathomechanics described above for a khyâl attack.

Study III: The Relationship of the Nightmare Content to Past Traumas and to the Type of Trauma Recall upon Awakening

To explore why nightmares caused such upset and such a high rate of trauma recall, we conducted a further study. For the nightmares of 100 patients, we asked about the relationship of the dream content to past traumas and the relationship of the dream content to any trauma recall that occurred upon awakening. The analysis of the relationship of nightmares to past traumas resulted in the typology reported in Table 1. Not surprisingly, after awakening from a total-reliving nightmare, patients almost always thought about the trauma depicted in the nightmare, and that recall was not uncommonly followed by recall of other traumas. Theme-reliving nightmares not only seemed to be associated with particular traumas but also often evoked flashbacks of those traumas upon awakening. Abstract-theme-reliving nightmares might evoke various traumas, as discussed below.

Table 1 Nightmares classified by their relationship to traumatic events (N = 100)

The most common of the theme-reliving nightmares consisted of being chased, and this theme is connected to many traumas: running when one’s village was invaded in the pre-Pol Pot period by Khmer Rouge, fleeing from Phnom Penh (and other cities) when the Khmer Rouge forced everyone to the countryside, running from Khmer Rouge police when caught trying to steal food at night (a crime often punished by death), running from the fighting between the Khmer Rouge and Vietnamese in 1979 and fleeing from the Khmer Rouge to reach Thailand. [Aron (1996) found that chasing dreams are common among Central American refugees and that, although the dream was often not a “replay” of a trauma, it did evoke recall of traumatic memories upon awakening].

Nightmares involving asphyxia not uncommonly constituted theme-reliving nightmares: a patient may dream of being dropped into the sea and drowning, when, in fact, he or she was never dropped into the sea but, rather, suffered one or more suffocation traumas, which are recalled upon awakening. Some typical asphyxia traumas that a dream involving shortness of breath may recall are the following: seeing a person killed by having a bag placed over the head, being tortured by having the head pushed under water and accidental drowning experiences, which were surprisingly common.⁵ And any trauma in which the person was frightened to the point of extreme shortness of breath may be recalled.

As indicated in Table 1, on a very abstract level, no nightmare could be classified as a non-reliving nightmare in this highly traumatized sample. At the very least, all nightmares evoke trauma experiences through fear, the abstract level of similarity being that of fear, threat and/or danger; owing to this abstract level of similarity—the appraisal of danger, the emotion of fear—such nightmares constitute reliving and trigger trauma recall, even if that reliving is only the emotion of fear. Other very abstract themes—seeing a deceased relative, conjuring a sense of loss, evoking memories of all the deaths that occurred in the Pol Pot times, of the loss of loved ones and family—in the nightmares also had trauma associations, evoked trauma recall, for the surveyed Cambodian patients.⁶

For this reason, in this sample, we classified all the nightmares that were not total-reliving or theme-reliving as “abstract-theme-reliving nightmares,” which might be considered a subtype of theme-reliving nightmare. One patient dreamed of walking on a high mountain, which was not an actual Pol Pot experience, but upon awakening the nightmare evoked various Pol Pot memories, seemingly owing to its meaning of “imminent threat.” Or a patient dreamed of meeting a relative who died in the Pol Pot period while walking down a road, and upon awakening this caused the patient to recall the circumstances of that relative’s death; in this case, just seeing the relative in a dream was sufficient to evoke a trauma memory.⁷

Study IV: The Local Interpretation of the Cause of Nightmare

We surveyed 60 patients as to the cause of nightmares and what kinds of assaulting beings were present in their nightmares.

What Causes Nightmares

Most often patients gave the following explanation of how dreams occur: that the soul, or proleung, wanders outside of the body during sleep and visits various localities, and that the dream is an actual experience of the soul as it wanders outside the body. Thus, if one dreams of a particular locality in Cambodia, the soul has journeyed to that actual site. In keeping with this explanation of dream causation, whenever a patient referred to his or her representation in a dream, the patient used the term, “proleung khoenhom,” meaning “my soul,” and never “I.” While describing a dream, a patient will say, “‘My soul’ was chased by a demon,” not “I dreamed I was chased by a demon,” or a patient will say of a dream, “‘My soul’ went to a rice field in Cambodia,” not “I dreamed I went to a rice field in Cambodia.”⁸ [The wandering-soul explanation of dream experiences is common when seen from a cross-cultural perspective; see the books edited by Lohmann (2003a) and Mageo (2003a)].

Patients gave various explanations of how the events in the nightmares occurred as the soul wandered on its nightly journey. As the soul wandered, it might be assaulted by a khmaoch or another type of supernatural being (e.g., an aap; see below); meet the khmaoch of a deceased relative or friend; encounter the soul of another living person who is dreaming; be assaulted by the magical actions of a sorcerer; or meet the manifestation of “bad luck” (kruah), which both immediately endangers the soul as it wanders during the dream state and prognosticates imminent disaster, a lurking danger owing to high bad luck and low “good luck” (riesey).

Some patients gave an explanation of total-reliving nightmares that did not involve the wandering-soul theory, simply attributing the nightmare to a weakened mind that predisposed to recall of past events. Often, though, even reliving dreams were attributed to the wandering-soul theory: that a Khmer Rouge, evil ghost, or a sorcerer forced one’s soul to go to the place where a Pol Pot trauma occurred to reenacted the traumatic even in the hope of causing fright to the point of death, so that one’s soul might become its (the evil ghost’s) slave.

In explaining how nightmares occurred, some patients gave an explanation of how they might be attacked in their dreams by Khmer Rouge soldiers who had harmed them during the Pol Pot period: (1) the perpetrator is still alive, and while sleeping, his or her soul leaves the body and goes to meet the dreamer’s soul; (2) the perpetrator (or victim) has died and is now a khmaoch, most likely, a beysaach or “horrible-death khmaoch,” which attacks one’s soul; or (3) the perpetrator, who is still alive, uses magic, perhaps with the aid of a sorcerer, to attack the dreamer’s soul, to command a khmaoch to attack the dreamer’s soul and to create an illusion of reliving the past event.

According to the surveyed patients, the rate of soul-wandering-caused dreams, and whether the wandering soul will be attacked by some maleficent force, depends on a number of variables. Many Cambodians stated that weakness and current psychological distress cause the soul to wander from the body during sleep, producing higher rates of dreams and nightmares, and that weakness caused the thoughts to wander during waking hours, the mind to recall past events during sleep and the soul to wander during sleep and so produce many dreams. The person’s soul can be easily attacked and greatly harmed by various beings when it wanders during dreaming if the person is “weak” (khsaoy) or has low riesey (good luck)—a sort of magical protecting force, resulting from the conjunction of the stars and planets—or if the person has high bad luck (kruah), which is inversely related to riesey.⁹

Types of Assaulting Beings in Nightmares

Most patients worried that, as the soul wandered out in the world, it might be attacked by any of various types of beings: by a yea, a giant-sized supernatural being with fangs; by an aap,¹⁰ a flying creature that only has a head from which intestines hang down; or by a khmaoch. The most common assaulting being in a nightmare was a khmaoch, a term that means a “corpse” or “the spirit of a dead person.” According to Cambodian belief (based on Buddhist concepts), a person who leads a virtuous life may be reborn into human form again soon after dying; a person who commits heinous acts is reborn as an animal, as an insect, maggot or worm or as a khmaoch that wanders the earth, a type of khmaoch called a preet. See Table 2 for a description of the various types of khmaoch, whose temperament ranges from mild to the malicious. [For further discussion of the khmaoch and supernatural beings of the Cambodian cosmology, see Ebihara (1968) or D. Hinton et al. (2005b)].

Table 2 Types of khmaoch (ghosts of the dead)

A khmaoch may take any form it wishes: that of a person, of a mouse, of a grisly figure with protruding eyes, bloody face and crooked fingers. The more evil a khmaoch, the more likely it wishes to do one harm by frightening one to death. The khmaoch must use up its “demerit” by living as a khmaoch, which involves suffering in various ways before it can be reborn, such as by eating and smelling horrible substances,¹¹ an action called “eating demerit” (sii baab). If a living person performs a merit-making ceremony, this also serves as a food for the khmaoch to which it is directed and decreases the khmaoch’s demerit.

Study V: Types of Dreams According to the Local Interpretive System and Those Dreams’ Metaphoric Meanings and Trauma Associations

We interviewed 100 patients who had nightmares to determine their ideas about the types of nightmares. Since we were interested in the affective power of dreams, how nightmares give rise to dysphoric affect and worsened PTSD, we asked the patients about the metaphoric meaning of and trauma associations to those nightmare subtypes.

Parsing the nightmares of the patients in terms of the patient-provided explanations, there were nine major subtypes, with some of the nightmares blending several of these elements. In Table 3, we list the nine types of nightmares, the patient explanation of the nightmare’s cause and the dangers it is thought to indicate. Some further explanation is needed of dreams involving dead relatives or friends.

Table 3 The nightmare types, causes and perceived dangerousness according to the Khmer system of dream interpretation (oneirocriticism)

Among Cambodian refugees, a group who lost so many relatives (and friends) during the Pol Pot period, the trauma subjectivity often revolves around concerns about rebirth, around worry about whether those friends and relatives have been reborn.¹² These rebirth concerns may be related to “survival guilt” (Hyer et al. 1990), a much discussed topic in the Western trauma literature; but “survival guilt” and rebirth concerns—that is, worry about the deceased’s spiritual status, with all the related beliefs and rituals—represent two very different trauma ontologies.¹³

When a Cambodian meets a dead relative or friend in a nightmare, he or she will usually interpret it as meaning that he or she should perform merit-making Buddhist rituals for that person: by offering clothes or food to monks at a local temple or by performing meditation and sending the earned merit to the relative.¹⁴ This merit making for the deceased—especially relatives—to assure rapid and auspicious rebirth is a major preoccupation for Cambodians. One of the most important yearly rituals, “phoechum boen,”¹⁵ specifically aims to make merit for deceased relatives. Nightmares about dead relatives tend to increase as phoechum boen approaches. Often patients perform elaborate merit-making ceremonies in a deceased relative’s native village in Cambodia; this raises the deceased’s spiritual status and facilitates the deceased’s rebirth.

The meaning and affective power of several of the dream types listed in Table 3 result in part from related metaphors. The interpretation of “falling dreams” partially emerges from language idioms. The idea of “falling” evokes the idea of “falling riesey” (riesey choh: riesey, meaning “good luck”; choh, “going down”). In Cambodian, the phrase “fall into a pit” (into an ânluang) means “to be in a miserable situation,” with the word for “pit” (ânluang) meaning both a hole in the ground and a depression in a body of water.

Metaphors increase the emotional salience of drowning and fire dreams. In the Cambodian language, “to try and swim over a ‘depression’ (ânluang) in a body of water” (hael chlâng ânluang) means “to try and escape from a miserable situation.” Often Cambodians refer to having passed through a sort of negative event as “having swam through it,” as in the common statement, “I swam through the Khmer Rouge period.” The idea of drowning evokes asphyxia metaphors, as “out of breath” (hât), a common idiom to describe feeling overwhelmed by current difficulties. That “fire” dreams are so feared emerges in part from the fact that multiple Cambodian idioms configure anger, misfortune and problems as a “fire” and that, in the Cambodian ethnopsychology, the ideal state is one of coolness and moistness, which suggests happiness, vigor and mental control.

The affective power of the various “dream types” is further increased by related trauma associations. There are trauma associations with chasing- and asphyxia-type dreams, as discussed above. Additionally, falling dreams often have trauma associations. In several cases, the patient had accidentally fallen into corpse-filled holes in the Pol Pot period, when out at night stealing food, when running to escape battles during the Vietnamese invasion in 1979, and when trying to escape from Cambodia. In the Pol Pot period, bodies were often buried in a shallow grave, so if one stepped on that spot, the foot often would sink down into the pit. Not uncommonly, the pits contained a hundred or more bodies; sometimes they were not covered, but rather filled up with water. In addition, before and during the Pol Pot period, many patients almost drowned upon stepping into a deep depression when walking in shallow water, depressions that Cambodians refer to as “pits” (ânluang). (Most Cambodians are unable to swim, so that drowning commonly occurs in this way.)

Dreams in which the sorcery-sent objects are worms may evoke memories of the bloated and maggot-infested corpses that were a common sight in the Pol Pot period. Fire may recall the civil war period (1970–1975), when there was massive bombing throughout the country, not uncommonly with napalm, and when there were constant battles and frequent bombardments with ordinance. It may also recall the Vietnamese invasion (1979), when similar events occurred, or it may recall house fires that occurred in the United Sates, which are not uncommon in the tenements of poor urban areas of Lowell where Cambodians primarily live. Dreams involving deceased friends and relatives may recall their deaths, as well as that of other friends and relatives. Such dreams may also, through the abstract theme of death, recall other deaths observed during the Khmer Rouge period—as in the many who died of starvation, the numerous anonymous corpses.

Study VI: Nightmares as an Indicator of Bodily and Spiritual Vulnerability

We also interviewed 100 consecutive patients with nightmares to determine what they considered to be the nightmare’s meaning with respect to bodily and physical vulnerability. We asked what the patient thought the nightmare meant about his or her physical and spiritual strength and then specifically asked about certain fears. For the results, see Fig. 5.

Fig. 5

Nightmare-caused fears of physical and spiritual vulnerability among patients who had a nightmare in the previous month (N = 100)

As indicated in Fig. 5, fears were prominent, and nightmares caused patients to worry about physical and spiritual vulnerability. Many patients considered a nightmare to indicate that they would have physical and other types of problems over the coming weeks. As gauged by the responses of patients, this seemed to be especially true of certain dreams: those in which the “soul” was beckoned to go to another locale or dreams in which the soul became lost in the forest. Cambodians fear having “soul-loss illness” (cumngeu luah proleung). When the soul is not firmly secured in the body, there is a feeling of bodily lightness, of hollowness and a predisposition to startle, to dreaming, to tinnitus, to the soul wandering far from the body.¹⁶ The fright caused by encountering the khmaoch not only weakens the body, but also may dislodge the soul, and “soul loss” may cause a prolonged illness, insanity or even death.

Most patients thought that the nightmares indicated a weakened body¹⁷ and that this bodily weakness would lead to potentially fatal illness episodes, such as “khyâl attacks,” bouts of “inner hotness” and “heart weakness,” not only immediately upon awakening but also in the following days; they thought that the nightmare indicated a weakened spiritual status that predisposed to car accidents, financial failures, family disputes, disputes with friends and those at work and attacks by khmaoch (as in during sleep). The very fact of having nightmares was a stigmata of physical and spiritual weakness. The nightmare, by causing fright, was also thought to weaken the body—fear enervates. Physical and spiritual weakness also was thought to cause the soul to wander and to be easily dislodged from the body.

Study VII: Treatments and Ritual Actions Undertaken as a Result of Having a Nightmare

We interviewed 100 patients with nightmares in the previous month about the following: the treatments and rituals that were undertaken in the previous month, and in the previous 12 months, as a result of having a nightmare and why these were performed. The treatments and rituals are reported in Table 4, along with the percentage of patients performing them in the last month and year. Table 4 also reports the supposed effect of the treatments and rituals on the layers of concentric ontological security.¹⁸ See Figs. 1 and 2 for a description of these various layers and their location in space.

Table 4 Rituals and self-treatments performed as a result of having a nightmare, percentage of patients performing the rituals and self-treatments in the last month and year and effects of the rituals and self-treatments on concentric ontological security, as assessed among patients having at least one nightmare in the previous month (N = 100)

The treatments and ritual actions undertaken as a result of a nightmare aimed to create and strengthen protective layers and to extrude maleficent forces and spirits. Often the patients described the purpose of ritual actions—chanting, meditating, wearing a waist talisman or wearing a sanctified string at the wrist, obtained during the holy water ceremony—as “creating a holy perimeter” (poat seymaa), that is, a special defensive perimeter.¹⁹ Some treatments and ritual actions were performed just after awakening from a nightmare, others every night before sleeping to prevent further nightmares and others just once, to treat the negative effects of the nightmare and to prevent having further nightmares.

Immediately upon awakening from a nightmare, certain actions were very commonly undertaken. To treat the panic symptoms experienced upon awakening, symptoms usually considered to be the result of a “khyâl attack” or “inner hotness,” many patients “coined” and “cupped,” treatments that aim to restore the normal flow of khyâl and blood and to remove khyâl and “steam” from the body. Upon awakening from a nightmare, not uncommonly patients invoked protective powers, such as the Buddha and ancestors, and they frequently performed boenhchii, a ritual that aims to rid the body of the maleficent forces that have intruded into the body during the nightmare and to remove bad luck (kruah).²⁰

In many cases, the patient considered the nightmare to have a transparent meaning, indicating the need to perform certain types of ritual action. A nightmare in which someone asked the “soul” to go somewhere was considered a serious assault dream, a dream that dislocates the soul and indicates the need to undertake immediate treatment, such as receiving the holy water ceremony to build up the defensive forces and secure the soul in the body. A nightmare of a deceased relative or friend was thought to reveal that that person was still not reborn, still wandered the earth in a forlorn state, and that one should make merit for, and send offerings to, the deceased person—most commonly, by presenting a food donation at the morning liturgy at the temple (which makes merit for, and sends food to, the deceased) and by giving a food offering to the deceased at the Buddhist altar within the home (which sends the food to the deceased). Even if the dream had a rather clear cultural interpretation, patients often consulted friends, older people in the family, a monk or, in some cases, a traditional healer.

Upon being extremely frightened by a nightmare, many patients asked a monk to do a divination of their riesey status (moel riesey). A person’s riesey is thought to vary yearly. To examine riesey status, monks use one of two methods (as do other traditional healers), both based on the birth date: adding and subtracting numbers to arrive at a luck level number or determining which of 12 images on a wheel-like form (with the images positioned between “spokes”) indicates the luck status. In the worst case, indicating the patient to be in great danger, the monk determines the luck status to be represented by a certain image: that of a man’s decapitated body, a symbol called “the bad luck cuts off the head” (kruah kâmbât kâ). If these divination methods reveal the patient to have high riesey (or, put another way, low kruah), no ceremony is needed; if the patient has a middle level of riesey, the holy water ceremony will most likely be suggested; and if the patient has a low level of riesey, an elaborate ritual must be performed, called “removing bad luck” (rumdâh kruah), which also raises “good luck” (riesey)—for bad luck and good luck are opposite ways of describing the same concept.

After having a nightmare, two of the most commonly performed rituals are the holy water ritual and the presentation of food at the morning liturgy (on the food-donation liturgy, see Table 4). In the holy water anointing ceremony (sraoch tdeuk moeun), the monk chants passages—often those describing the virtues of the Buddha—from the Buddhist holy texts, while holding a lit candle above the water, the wax dripping down, and then inserts the lit end into the water container; this immersion symbolizes the extinguishing of all ill-causing heat and transfers Buddha and dharma power into the water. Next the monk uses a baton-shaped object to anoint the patient with holy water, while giving blessing; then the monk ties a string to the wrist of the patient to secure the soul in the body and to provide protective power.

As the monk ties the wrist, he calls the soul and gives blessing. A typical blessing would be as follows: “May the soul stay in the body, may no khmaoch bother you, may you be free of nightmares, may your ‘good luck’ [riesey] increase, may no ‘bad luck’ [kruah] come near you.” The slaathou and baaysii (see below for a description of these ritual objects) are often present during the ceremony. The monk will usually give the patient a container of the holy water to take home; the patient will keep this on the home altar. Some of the water will be applied to the face, some sprinkled around the house.

The water anointing ceremony serves to raise good luck and to wash away bad luck, presumably erasing the negative effects of the nightmare and preventing its recurrence. The wrist talisman will be worn for weeks, even months; this wrist talisman creates a sacred perimeter and ties the soul to the body. The ceremony is also thought to increase bodily energy and to refresh; after this ceremony, the patient will often say that he or she felt “clear in the face, clear in the mouth” (sroelah muk sroelah moat). Nightmares usually decrease after the “water anointing” ceremony.

One ritual, the activation of the “birth kruu,” requires further explanation and, also, illustrates the importance of the idea of power layering within Khmer culture and thought. A “birth kruu” is a spiritual force representing one particular ancestor (often called “a former mother,” or mdaay daoem) or all ancestors. This protective force is invoked at ceremonies honoring ancestors such as New Year’s festivities. If someone is born completely wrapped in a placenta, or with the placenta forming a sash across the body or with the umbilical cord in loops around either the head or the neck,²¹ this indicates that a very powerful and special “birth kruu” protects the newborn, bestowing special powers: possessing healing power or having skin that resists penetration by knives and bullets.

At the birth of the baby, a ceremony honoring the birth kruu should be conducted, a ritual for which a slaathoa is made, an object that afterward will be kept on the family’s home altar. As an adult, the person who has a special “birth kruu” should do the following on Buddhist holy days: take down the slaathoa from the altar, light the incense sticks that are inserted into it and give it offerings. On the monthly Buddhist holy day that falls on a full moon, some consider it important to light the central candle of the slaathoa. If a Cambodian who has a birth kruu has a nightmare, this may be attributed to having neglected giving offerings to the special “birth kruu,” decreasing protective powers and allowing attack by a khmaoch.²² Even if a person was not born with the special placenta and umbilical coverings, the occurrence of frequent nightmares may be attributed to failing to honor the “birth kruu.” A ceremony will be held in which a slaathoa features prominently, and afterward, the person should keep the slaathoa at the house altar or even place it at the head of the bed. On Buddhist holy days, the person should perform the ceremonies honoring the birth kruu (which were described above), ceremonies that involve the slaathoa.²³

In many of the rituals that aim to restore the body and defend against nightmares, the slaathoa and baaysey are used: in the holy water anointing ceremony, birth kruu ceremonies, soul-calling ceremonies, elaborate rituals to rid the body of kruah. These two objects can be used in any ceremony and are thought to have an amplificative effect on the power and effectiveness of any ritual. The slaathoa and baaysey are comprised of multiple concentric layers (for further description, see Hinton and Hinton 2009): the slaathoeu has a coconut as its base, on which concentric rows of objects are placed, as in a concentric circle of candles, then areca nuts and, next, incense sticks; and the baaysey is made from banana leaves, which are placed in multiple concentric layers. We hypothesize that these two ritual objects are a representation of the ideal self, of concentric ontological security; that each acts as an ideal-self object, as a representation, an invocation, of the desired state—of the concentric mandala form, a form idealized at the level of psychology, social structure, spiritual state and political system (Tambiah 1976, 1985).

Nightmare Cases

Below we describe several cases to illustrate the variety of nightmare experiences among the Cambodian refugee population. It should be noted that, in almost all cases, the patients considered the symptoms that occurred upon awakening as episodes of “khyâl,” “soul loss” or “inner hotness,” and implemented multiple treatments, most commonly coining, often asking spouses and children to perform those techniques. In many cases, the patient did boenhchii to rid the body of bad influence and lit incense at the altar to ask for protection from the Buddha and other powers. But in the case descriptions we focus on the dream content, the flashbacks experienced upon awakening, the relationship of the dream content to past traumas and the patient’s interpretation of the dream as some kind of assault. The cases were elicited during medication visits with the first author (D.H.).

Diep: A Nightmare as a Slight Variant of a Traumatic Event

Diep, a 48-year-old male, lived with his wife and his 12-year-old son. Before the Khmer Rouge period, he worked as a rice farmer. On the day of his medication appointment Diep arrived looking distressed. When asked why, he related the following nightmare. People grabbed his “soul” (proleung), then carried it; next, they suddenly threw it into a body of water; his proleung gasped for air, unable to swim. (As mentioned above, a Cambodian refers to the dream protagonist as his or her soul—the proleung; in general, the dream is considered to be the experiences of the wandering “soul.”) Diep awoke from this nightmare in a terrified state and recalled the following trauma.

One day three Khmer Rouge showed up at Diep’s house and accused him of stealing rice. They grabbed him and led him outside. He felt sure he would be killed. The soldiers took him to a bridge over a river and threw him in. Like many rural Cambodians, Diep could not swim. Though he started to sink, he managed to grab onto a branch and pull himself to safety.

Diep had a flashback of this event upon awakening that lasted five minutes, and palpitations for 30 min. He worried that he was weak, causing his soul (proleung) to wander to Cambodia, resulting in the nightmare, and that the nightmare had weakened him, predisposing to spirit assault and serious illness, like “khyâl attacks” and “inner hotness.” He worried that his soul had wandered to Cambodia and that a khmaoch, or some of his Khmer Rouge tormentors, had tried to harm his “soul.” He couldn’t sleep again that night.

Bun: A Chasing Nightmare and Condensation

This 44-year-old woman, mother of three teenage daughters, had a recurrent nightmare. In it, Bun’s soul was chased by men wielding knives and guns; some men were running, others were in carts. Dogs also chased her soul. In addition, Bun had sleep paralysis twice a week. During these episodes a dog would approach her, position itself next to her face and bare its teeth menacingly. She found herself unable to move, paralyzed for about two minutes. This terrified her.

Upon awakening from the nightmare, Bun had flashbacks of being forced to do slave labor during the Pol Pot period, particularly of when she carried dirt to make a dam and of when she had to run away from Khmer Rouge during the Vietnamese invasion. She also recalled one time when she was rice farming and about eight people were escorted past her and shot nearby; she heard the sounds of their begging for mercy, interspersed with the sound of gunshots, and saw each person collapse to the ground after being shot in the head.

Perplexed by the prominence of the dog imagery, D.H. asked Bun whether she had any bad memories involving dogs. Bun replied that one night during the Pol Pot period she heard the growling of dogs coming from under the house. Like most rural dwellings in Cambodia, the house was set about 15 feet above the ground, supported by several wooden posts; she looked through the space between the floorboards and saw three dogs dragging the corpse of a grown man. The dogs proceeded to consume the corpse over the next hour or two. D.H. asked whether she feared that the dog in her sleep paralysis, and in the nightmare, was the khmaoch of the man whose corpse the dogs had eaten. (Khmaoch can change into the form of an animal.) She said “yes,” and that it might also be the khmaoch of those she saw killed during the Khmer Rouge period.

As another related trauma, most of her relatives were killed because they were former soldiers, and she just barely escaped that fate. One day Bun heard from a friend that the Khmer Rouge in the village had learned that her relatives were former soldiers, so she had to flee from the area. Some local Khmer Rouge followed her, but she escaped.

In Bun’s case, her nightmare is a composite of several trauma memories: (1) the dog event, (2) running from Khmer Rouge during the Vietnamese invasion, and (3) running away from Khmer Rouge once they had learned the history of her extended family.

A week after her medication visit, Bun consulted a monk and told him of the nightmare. He asked for her birth date and determined her “good luck” status, that is, her riesey. He said she had low riesey and must have the “removing kruah” ceremony performed, that the dog represented the kruah that was threatening to harm her. After the elaborate ceremony, aiming to remove kruah and raise riesey, the patient had a great decrease in nightmares.

Thong: A Chasing-Type Nightmare

In a recurrent dream, Thong’s soul was chased by a big black shape grasping a knife. In some nightmares, the shape caught her soul and tried to stab it with the knife. Sometimes the shape succeeded, drawing blood.

Thong sought counsel from a monk, who explained that the nightmare resulted from “thinking too much” (keut charaoen), which made her weak, and that weakness caused her soul to wander during sleep and to be prone to khmaoch assault. The monk performed the holy water ceremony, saying that it should cause her to sleep well and not to be bothered by any khmaoch. The ceremony was somewhat helpful, but she remained fearful that the nightmare would return.

Thong had been struck in the head with the butt of a gun by Khmer Rouge; the blow was punishment for supposed laziness in her work habits while transplanting rice. She fainted, bleeding, into the rice field; she awoke in the morning, covered with leaches. The chasing dream made her have flashbacks of the event. After recounting the flashback, Thong showed D.H. the scar on her head from the blow.

Sarina: A Chasing-Type Nightmare That Triggers Flashbacks

Sarina, a 42-year-old woman, had six children. One day she came to her medical appointment looking worse than usual, complaining of multiple somatic symptoms. She attributed this worsening to a nightmare. In the nightmare, her soul was chased by a boy and a girl, both of whom had a knife, and they were trying to stab her soul.

Upon awakening, Sarina had flashbacks of three people being eviscerated as punishments for misdeeds they had committed in the Pol Pot period. And she recalled a time here in the United States when her husband beat her, even though she was pregnant: he knocked her down to the ground, causing her head to hit a radiator, and then kicked and slugged her.

Having the nightmare made Sarina fear low riesey and being weak. She sought advice at the local temple. The monk there made calculations and determined that her riesey was indeed low. He gave her a talisman to wear around her waist to “create a protective barrier” (poat seymaa), increase her riesey and prevent khmaoch attack.

Soeun: A Nightmare Causing Fear of “Soul Loss”

Soeun, a 55-year-old male, lived with his sister and her family. He had four children, all living with his former wife. He had chronic PTSD but had been relatively asymptomatic, though chronically anxious.

The week before coming to see D.H. for a medication appointment, the patient had a nightmare. Since then he had not slept well and had a great worsening of symptoms. This included the return of flashbacks and orthostatic panic. Flashbacks of Pol Pot events occurred every morning upon standing and feeling dizzy; he would sit back down and have a panic attack lasting 15 min, with dizziness, palpitations and fear of death. After the nightmare, he felt light in the body (sraal khnong khluan), as if his soul were no longer secured to his body. He felt weak.

Soeun told D.H. that he had these symptoms because his “soul was called” (hav tow). He then related his dream. His “soul” was in his sister’s house and heard a knock at the door. His soul went and opened the door and looked out, but there was no one there. Soeun awoke, frightened, and had palpitations for about five minutes, finally calming himself.

Soeun consulted several older people (elders are considered to have special knowledge of customs and spiritual matters), who told him that if, in a dream, someone knocks at the door, it means that one’s soul is being called by a khmaoch or other force. If the soul responds verbally, it will be taken. This is called the “khmaoch takes your soul” (khmaoch yook proleung). D.H. asked Soeun what would happen if one’s soul were “taken” in this way. Soeun said that one would become ill, perhaps die. To recover, one would have to do a ceremony to “remove bad luck” (rumdâh kruah) and have the soul called back to the body (hav proleung). He said that having a “soul calling” dream meant that one had low riesey (riesey da) and that, if one had low riesey, a khmaoch might take one’s soul.

Soeun worried that this was his situation and that he had low “good luck.” After this nightmare, he had slept poorly, fearing the being would return and try to take his soul. In the next few days, he was planning to go to the temple to undergo the water anointing ceremony, which would include the monk’s tying a string around his wrist to secure his soul in the body. (As described above, the holy water ceremony almost always includes the monk’s calling the person’s soul to the body and securing it with a string tied around the wrist; the wrist string also forms a protective barrier.)

Soeun stated that strange things had been occurring since his father’s death a few months earlier. His father had died in the very house in which Soeun was living. Just after the death, Soeun’s older sister was possessed by the father’s soul. Through her, the father had asked that incense be lit for him at the family altar. A month later, Soeun’s mother had a dream in which her dead husband invited her to go to a beautiful place. And Soeun asserted that if her soul had gone with her husband in the dream, she would have died.

Soeun was afraid that it might have been his father who had called his soul. He suspected that his father missed his family too much, and so had not been reborn into another life. The family planned to do a merit making for the father to help him be reborn, and with the hope that the merit would also protect the family. In addition, Soeun was afraid that his former wife might have hired a sorcerer to harm him, and that the sorcerer might have used a khmaoch to attack him in his sleep.

The nightmare had trauma resonances. In the Pol Pot time, Khmer Rouge customarily would knock on his hut door at 4 a.m. to get him to go and do slave labor; if he did not get up quickly, they threatened him. Twice Khmer Rouge knocked on the door and took him to “study,” meaning that they arrested him for a day and lectured him about poor work habits. Both times he thought they were going to kill him.

The patient returned 3 weeks later for another medication visit. After his last medication visit, Soeun had gone to see a monk at the temple. He told the monk about the nightmare and how it caused him to be upset, confused and dizzy, made him feel as if he “couldn’t figure out any problems” (smook smaanh, keut meun choenh). The monk suggested performing the holy water anointing ceremony. The monk chanted for about 15 min to make the holy water; he then poured the sacralized water over Soeun’s head and body, tied a protective string around his wrist and called his soul. The ceremony made Soeun feel “clear in the face, clear in the mouth” (sroelah muk sroelah moat). He said the water anointing ceremony “removed kruah, raised riesey,” made it so no assault could be perpetrated against him, and he explained that the chanting chased away khmaoch. The monk also suggested that Soeun light candles and incense at his altar before going to sleep and ask the Buddha, his ancestors and all powers for protection. Since going to the temple, Soeun has had no nightmares and has felt well.

Chorn: Nightmares, Survival Guilt and Fear of Soul Loss

Despite pharmacological treatment and therapy, and improvement, Chorn still had severe PTSD. She arrived at her medical appointment with D.H., who asked how she had been. Chorn replied that she had been ill (chheu), and when D.H. asked her the reason for being ill, she denied knowing it. D.H. then queried whether Chorn had had any nightmares. Chorn related that she had had several nightmares and that, in her opinion, the nightmares had made her fall ill.

Three weeks prior, in a nightmare, Chorn had seen a close friend who had been killed in the Khmer Rouge time. One night during the Pol Pot period, the friend, who was starving, snuck out of her hut at night to steal food. She was caught and arrested by the Khmer Rouge, and taken to be killed. In her dream, Chorn’s soul went to a rice field in Cambodia and met her friend. The friend asked Chorn’s soul whether she wanted to go with her. Chorn’s soul told her friend that she couldn’t, that she needed to return home.

Chorn believed that her friend was calling her soul in this dream and that her friend had not yet been reborn; her soul was still wandering the earth, because she had died a horrible death and had been transformed into a vengeful khmaoch. Chorn said that just talking about the dream made her hair stand on end (preu soembol) and caused her to have palpitations. After the nightmare, Chorn felt out of energy (âh dai âh choeng) and had more bodily pain, a soreness she tried to treat by sleeping with a hot-water bottle; also, she had been unable to sleep and frequently felt dizzy.

One week later, that is, 2 weeks before her current medication appointment, Chorn had the same nightmare. And 1 week after that, in a dream, an older woman came to her and asked for food. At first the patient refused. The woman left, and Chorn’s soul ran after her and gave her a bowl of rice and one of curry. Then Chorn’s soul washed the dishes. Chorn stated that if she had not given the woman food, Chorn herself would have become very ill. By giving the woman food, Chorn had made merit. She explained that the woman was a person who had died, but who had no relatives to make merit for her; she needed someone to make merit for her so that she might be reborn into another incarnation.

Chorn consulted with her elders about these dreams. They said Chorn should do a merit making for the woman and for her friend. So the previous week (i.e., a week before her medication appointment), Chorn performed a merit making for them. To do so, she took food to the monks and offered the merit to them. Chorn also gave offerings at her private altar: a food dish, bananas and hard liquor. As she lit incense and candles, she offered the food to her friend, and to the old woman, and asked the Buddha, all deities and her relatives for protection. Chorn asked that the friend and the woman be reborn to another life. Despite the merit making, Chorn still worried that the fright of the dream had dislodged her soul somewhat (yook proleung boentoec), weakening her and causing her to be more prone to khmaoch attack.

D.H., looking at Chorn’s right wrist, noticed a string tied around it and inquired as to why it was there. Chorn explained that, 3 months earlier, she had had a dream in which someone called her soul away. Afterward, she called her own soul (kov proleung) back to her body (yook proleung weunh) and had her husband tie her wrist to secure it.

Roeun: Nightmares, Sleep Paralysis and Survival Guilt

Roeun, a 48-year-old woman, was a new patient and still had severe PTSD. When she worried about current problems, such as financial problems and the acting-out behavior of her children (e.g., skipping school), she experienced flashbacks—especially of abuse perpetrated by her husband. The flashbacks occurred twice a week and usually lasted for about 10 min. Often these nightmares involved the abuse perpetrated by a former husband. In 1987, this former husband had beat her frequently. She married another man in 1998 who often drank and, when drunk, would hit her and her children. On several occasions he grabbed Roeun’s hair and banged her head into the wall.

At her current medication visit, Roeun reported a very upsetting nightmare in which 10 Khmer Rouge grabbed her soul and tied its arms behind its back. As they prepared to shoot her soul, she begged for mercy. Roeun awoke, terrified, and thought about the following memory.

During the Khmer Rouge period, one day Roeun had snuck out to collect mushrooms in the rice fields, an infraction punishable by arrest and execution. While foraging for mushrooms, she saw 10 men lined up, each with his hands tied behind his back. Khmer Rouge soldiers proceeded to shoot each of them in the head and then in the body. She ran away, terrified.

Rouen explained that, because the 10 people she had witnessed being killed died a so-called “horrible death” (taai haong), they were necessarily transformed into vengeful and cruel khmaoch. She believed that these vengeful khmaoch caused her wandering soul to endure the dream events, taking the form of the 10 Khmer Rouge, hoping to frighten her to the point of death. Also, Roeun had sleep paralysis, in which she saw a being come upon her. She was unable to move and felt as if she would be unable to breath. Roeun thought this was one of those she saw killed, transformed into a enraged khmaoch.

Upon awakening from the flashback or sleep paralysis, Roeun had flashbacks of various traumas, including the witnessed execution and the abuse perpetrated by previous husbands. She had palpitations, dizziness and other symptoms. Roeun feared these symptoms were a “khyâl attack” that might cause death. She called her children to “coin” her to treat the “khyâl attack.” She asked her children to improve their behavior. She told them that if their behavior caused her to worry too much, this would weaken her to the point that she might die.

Discussion

As shown by our studies, nightmares form a key aspect of the trauma ontology of Cambodian refugees. First, almost all PTSD patients had experienced nightmares in the previous month, and the nightmares caused great distress—panic attacks, flashbacks upon awakening, difficulty returning to sleep. Second, nightmares were given an elaborate cultural interpretation, and that interpretation—along with trauma associations—caused distress and worsened PTSD, as depicted in the “nightmare-PTSD model” (see Fig. 3). And finally, patients often considered nightmares to indicate impaired concentric ontological security (Figs. 1 and 2), so they engaged in activities aiming to diagnosis the supposed defects in the layers of defense, and to restore and activate those layers.

Each of the 15 zones of ontological security constitutes a potential self-object, with the actions performed to fortify and maintain these zones forming key self-processes (Hollan 2004), serving as key ways of constructing identity, an identity built in an attempt to tap sources of power and protection. These “techniques of the self” (Foucault 1986, 1988, 2005) aim to maintain health, to increase spiritual strength and to maintain the integrity of concentric layers of protection; in this sense, many Cambodian “techniques of the self” are “security techniques.” An elaborate oneirocritism indicates whether “techniques of the self” need to be performed. In many of the techniques of the self that aim to maintain security, the slaathoa and baaysey are present, and these ritual objects seemingly symbolize the ideal state, a multitude of radiating orbs of power, of concentric layers of protection, a mandala form.

In the Cambodian context, dreams and related rituals form a key aspect of the self of the traumatized individual, of “self-constitution” (Ewing 2003), and are key sources of the self (Taylor 1989). Such a self extends beyond the skin or surrounding clothing, constituting what might be called “the extended self” (see also Connor 1982; Mageo 2003b), which is a power-layer self. The self is a “congeries of identities” (Mageo 2003b, p. 10), and these identities continually shift, as one and then another is conjured to mind, as one and then another act is performed. There is the “I-that-prays-at-the-altar,” the “I-that-is-a-merit-maker,” the “I-that-had-the-monk-tie-this-string-to-the-wrist,” the “I-that-has-tattoos,” the “I-that-has-a-birth-teacher.” The many “I’s” are so many scenes in which the “I” is present and that are recalled to mind: “me at the water anointing ceremony,” “my soul being chased in a dream by a Khmer Rouge,” “me that has low riesey.” In this sense, the “I” is multiple, and often nested (e.g., scenes related to riesey), and it consists of the many self-related scenes that are brought to mind. This is the “security I,” an “I’ that is multiple, constituted by a multiplicity of self-related scenes, a certain security-oriented identity, a mandala self.

For Cambodians, nightmares represent part of the hermeneutics of self, of the hermeneutics of ontological security. Ontological security requires a high bodily energy level, high “good luck” levels, low “bad luck” levels, ancestor protection and house spirit benevolence. For an American, a nightmare may temporarily cause a fear of the trauma recurring; for a Cambodian, the nightmare indicates compromised ontological security, a defect in one’s protective barriers. In the Cambodian context, the nightmare results in multiple cultural practices being initiated that aim to increase protective spheres, layers of needed protection. One’s well-being is fragile; it depends on a secure soul, bodily energy, ancestors, gods, riesey. One carries a certain level of “bad luck” (kruah) and demerit; one must try to increase riesey and merit. To be safe, the soul should be firmly secured in the body; the body should be strong, not weak; the mind should have auspicious, merit-making thoughts, as in recalling to mind the Buddha’s qualities; the emotional state should be a positive, merit-making emotion, such as radiating “loving kindness” to all beings. For Cambodians, the world is full of dangerous forces: those who died a bad death, particularly those one saw killed in the Pol Pot period, are enraged and in a vengeful state; khmaoch that enjoy frightening the living, aiming to kill; friends and relatives who have not been reincarnated and remain on this level of reality, missing you to the point that they may kill you to have a companion. The nightmare and its related “techniques of the self” keep these core beliefs vividly real and affectively salient. The meaning of the nightmare can only be understood in the context of this cosmology and model of personhood, and their related practices.

Among Cambodian refugees, trauma results in nightmares and sleep paralysis, in the production of poor sleep and palpitations and somatic symptoms; these sleep-related phenomena and symptoms create a sense of a depleted, concentric ontological security, a fear of soul loss, of attack by khmaoch, of having low riesey and much kruah. The layered self seems highly vulnerable. Here, there is a reflexive process, whereby the self is assessed for breaches. The question is not, “Who am I?” but, instead, “How intact are my security spheres?” These security-related ontological spheres are part of the extended self. Cambodians conduct constant risk assessment, have a risk consciousness and, so, constantly assess these ontological zones. The patient does a risk assessment by surveying these protective layers, asking him- or herself the following questions about dreams and what predisposes to bad dreams, to nightmares: Have I had dreams, nightmares, sleep paralysis or other symptoms that would suggest that one of these spheres is not intact? If so, where does the breach in ontological security lie? Have I felt light, as if no soul is in my body? Have I been frightened or weak, causing my soul to be easily dislodged? Have I slept poorly, making me weak? Has my luck been bad recently? Might I have high “bad luck” or low “good luck”? Have I had time to conduct merit makings? Have I made offerings to the house spirits, to my ancestors, to my “birth kruu” and to the local deities?

As shown by this article, patients often find nightmares to be deeply upsetting. Often a patient will be doing fairly well until having a nightmare, such as one in which the “soul” encounters a dead relative or is asked by some being to go away with it. This may well cause the patient to have increased anxiety and panic attacks during the following days, even weeks, but the patient may only tell the clinician, “I have been ill” (chheu). Such a patient may come to the clinic with circles on the forehead from “cupping” or linear marks on the arms from “coining” (as described above, these are the traditional methods to treat khyâl attacks and “inner hotness,” common local presentations of anxiety states), and when asked the reason for being “ill,” the patient will simply reply, “I have had a khyâl attack,” or “I have had ‘inner hotness,’ a fever.” Even when asked the reason for the worsening, the patient may again simply mention khyâl and fever. Further questioning may well reveal that the night before the worsening, the patient had a nightmare, producing fears of low physical and spiritual strength and evoking trauma memories. This combination of self-perceived vulnerability and trauma memories often leads to great worsening.

How does self-perceived vulnerability lead to worsening? The psychological literature suggests that self-perceived vulnerability greatly influences the likelihood of panic and PTSD (Gregor et al. 2005; Schmidt et al. 2003). It does so by creating vicious cycles of worsening. Let us examine how this occurs in the Cambodian case with nightmares. A nightmare results in a sense of vulnerability, of impaired concentric ontological security, as described above. This creates a state of anxiety, a feeling of imminent assault. This anxiety alone may produce symptoms like palpitations and cold extremities. Then the patient will consider these somatic symptoms as further evidence of being “weak” and vulnerable, and the somatic symptoms may cause the patient to fear having an episode of khyâl or of inner hotness, to fear a dangerous rising within the body of khyâl, steam and blood. Fear of bodily dysfunction, of having an episode of rising khyâl, stream or blood, will increase anxiety. Increased anxiety will produce more trauma recall, hypervigilance and nightmares. Additionally, having another nightmare, along with having more trauma recall and being anxiously hypervigilant, will perpetuate the vicious cycles of worsening.

The current study suggests how nightmares, and their impact, should be assessed among Cambodian refugees and traumatized refugees in general. One should determine the nightmare frequency, whether there are flashbacks upon awakening, the symptoms upon awakening, the numbers of hours needed to fall asleep again and the nightmare content and meaning. The clinician should determine the patient’s trauma associations with the nightmare’s content, the patient’s understanding of the nightmare and what the patient has done as a result of the nightmare. The clinician should examine the patient’s “techniques of self” that establish ontological security—what might also be called “security operations,” the creation of “protective devices” (Giddens 1984, p. 125)—and how the patient feels about his or her state of ontological security. In addition, given the close relationship between nightmares and sleep paralysis, the latter should also be assessed—as in its frequency, whether a figure is seen approaching the body, whether the approaching figure is considered to be an attacking being. Often sleep paralysis and nightmares co-occur, the one worsening the other. And if a patient presents with a worsening of anxiety, or if some local anxiety-related syndrome increases in severity (e.g., khyâl attacks among Cambodian refugees), the clinician should determine the role of nightmares in that worsening. For example, in the case of Cambodian refugees, if a patient complains of increased severity of “khyâl attacks” or of inner hotness, the treater should ask whether the “khyâl attack” episodes began or worsened after a nightmare.

As part of the treatment of nightmares in a certain setting, one must assess multiple dimensions, multiple aspects, such as trauma associations and the meaning of nightmares according to the local dream interpretive system. In this way, a “nightmare-PTSD model” for that cultural group can be constructed, as in Fig. 3, for the Cambodian population, that can be used to guide treatment. In the case of Cambodian refugees, any of the processes identified in Fig. 3 can be targeted to decrease nightmares and PTSD: exploring trauma associations, decreasing catastrophic cognitions about the somatic symptoms experienced upon awakening, decreasing fear of supernatural assault, increasing the patient’s sense of ontological security.

Promoting a sense of ontological security, decreasing the fear of supernatural assault and decreasing the gloomy sense of being in a dire state of inauspiciousness, of dark bad luck, are crucial treatment goals when treating Cambodian refugees with nightmares. If, for example, the patient worries about having “low bodily” energy and poor health, these fears need to be reviewed and assuaged. The prescribing of medicine can be framed in a way that increases the sense of ontological security. The prescriber (or therapist) can discuss how the medicine increases bodily energy—directly, by increasing a sense of energy, and indirectly, by increasing sleep and appetite and decreasing startle and reactivity. The clinician should provide an alternate explanation of nightmares: that such nightmares are a direct effect of trauma, that the nightmares do not represent a supernatural assault and that the dream content relates to memories of trauma. Afterward, one might joke that the medicine will protect against assault by a khmaoch, that the taste of the medicine is repulsive to the khmaoch, thereby creating a protective layer. Or one might teasingly assert that the medicine “creates a holy perimeter” (poat seymaa). One should encourage the patient to utilize culturally sanctioned methods to increase ontological security, to activate the spheres of ontological security: doing “merit making” at the temple, for example, by offering food to the monks; making merit for the khmaoch that the nightmare supposedly involves; practicing “loving kindness” (psaai meetaa) to increase merit, to increase riesey and to make surrounding khmaoch less aggressive; requesting a holy water anointing ceremony from the monks, which includes calling the soul, tying in the soul with a wrist talisman and empowering the body with a wrist talisman; making food offerings to the ancestors at the home altar or at the temple; and meditating.

As the current article has shown, to investigate a nightmare in comparative perspective, the local conception of person (Carrithers et al. 1985; Connor 1982; de Munck 2000; Shweder and Bourne 1982) and ontological security needs to be determined. If a nightmare is construed as an attack on the self in a particular society, then an adequate explanation of nightmare must explicate the nature of the self and its protective layers—as well as the nature of the attacking forces, the local cosmology, the local ethnopsychology, the local ethnophysiology and the techniques used to restore a sense of ontological security. Many dreams act as selfscape dreams, indicating the “state of the self”; what the dreams say about the state of the self, its interpersonal relationships, the dreamer’s state of self-esteem, the self’s state of security, requires an understanding of the local conception of the self—for example, a car as a key symbol of the self in suburban Southern California (Hollan 2003), the buffalo in Toraja society (Hollan 2003), the mandala self, and its field of resonances in Cambodian culture—and the local system of oneicriticism.

Each dream will undergo a process of “subjectification” (Hollan 1989) by which it becomes a part of the particular person’s experience and life trajectory, a process through which dream meaning is negotiated and determined—through consultation with family members, friends, elders and ritual experts, and through ritual action. The interpersonal and personal meaning of dreams, the effect of these meanings on self-esteem and the field of action, is contested and shifting. What is the dream a representation of? What does it indicate should be done? Does it represent the self or others? Does the dream mean that I am in danger? From what? From whom? The answer to these questions will depend on the system of oneirocriticism and what aspect of the oneirocriticism is invoked.

As indicated by this article, when studying nightmares, one must determine the role of nightmares in “risk assessment” [or “risk profiling” (Giddens 1984, 1991)], and whether that ontological security assessment results in the employment of “techniques of ontological security,” that is, activities aiming to reduce the degree of being at risk. Among Cambodian refugees, dream interpretation is a key method of “ontological security assessment,” and its indicated practices form key “ontological security techniques,” form what might be called “ontological security processes” (a type of “self-process”). These are not only sources of self-identity, but also sources of ontological security and ontological threat (Giddens 1984, 1991)—which are culturally informed. And Giddens’s claim that Western modernity is uniquely characterized as a “risk society,” in which “risk assessment” and “risk profiling” create a feeling of constant threat beyond that seen in other groups and other time periods, would not seem to be accurate; clearly, other groups, such as Khmer refugees, would seem likewise to constantly perform risk profiling—but in different terms and ways. These issues are extremely important in the cross-cultural study of anxiety and trauma ontology.

More generally, we would suggest that trauma and its effects in other cultures might be examined from the perspective of ontological security, with security here meant in a broad sense: physical (e.g., threat of actual physical assault), financial (e.g., ability to obtain adequate food and housing), bodily (i.e., physical health, both in the biomedical sense and in the local sense, that is, according to the local ethnophysiology) and spiritual (e.g., threat of attack by supernatural forces). This will allow a more experience-near description of trauma’s effects in particular contexts, and this type of local knowledge will give insights into how to facilitate recovery from trauma. In this article, we have investigated the nightmares of Cambodian refugees and found worries about bodily security (e.g., about a disordered ethnophysiology) and supernatural security (e.g., about supernatural assault) to be extremely important in its phenomenology. No doubt other types of security concerns also play a role in nightmare meaning and generation in the Cambodian context, as when concerns about housing and finances produce anxiety, and that anxiety increases nightmares and PTSD, thereby starting and worsening some of the vicious cycles described above.