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Psychosocial Adjustment of Cambodian Refugee Women: Implications for Mental Health Counseling.

This paper examines the psychosocial adjustment issues encountered by Cambodian refugee women. A discussion on premigration and postmigration challenges is presented as well as a discussion on how premigration trauma experiences impact postmigration adjustment. Implications for multicultural counseling are discussed and recommendations for mental health counselors are presented.

There are more than 26 million refugees worldwide (United Nations, 1995) with over 80% of the adult refugee population being women (Refugee Women in Development, 1990). The United States is one of the Western countries that has refugee resettlement policies and receives large numbers of refugees from different countries. Approximately 3,000 immigrants and refugees arrive daily (Aponte & Crouch, 2000), resulting in almost 10% of the U.S. population being refugees (Balian, 1997).

In 1980, the United Nations High Commissioner for Refugees designated refugee women as a high-risk group for developing serious psychological problems due to their premigration war experiences of rape and sexual violence (Refugee Women in Development, 1990). In the resettlement country refugee women not only have to cope with their premigration traumas, but also they encounter significant challenges in postmigration adjustment. Refugee women play a crucial role in the lives of family members; what affects the women directly impacts their families. With continuing wars, conflicts, and natural disasters, it is clear that the United States will maintain a major role in refugee resettlement. It is, therefore, critical that mental health professionals become aware and understand the unique experiences of this group, so they can be effective in assisting refugee women and their families towards successful adjustment.

Although the article focuses on Cambodian refugee women, all refugee women tend to experience similar challenges given their gender and status as refugees. The article begins with a brief discussion of the premigration history and trauma of Cambodian refugee women, followed by a presentation of the postmigration challenges, including an examination of psychological distress and help-seeking behavior. Finally, implications and recommendation for culturally responsive mental health counseling are discussed.

PREMIGRATION HISTORY AND TRAUMA

Since the United States left Vietnam in 1975, more than 1.5 million Southeast Asian refugees (e.g., Vietnamese, Cambodians, Laotians, and Hmong) have sought refuge in the United States (Chung, Bemak, & Okazaki, 1997). Almost half (44%) of this population are women (U.S. Committee for Refugees, 1988). Similar to other refugee women, Southeast Asian refugee women have been categorized as a high-risk group for developing serious mental health problems due to their premigration traumatic experiences (Cole, Espin, & Rothblum, 1992; Mollica & Lavelle, 1988; Rumbaut, 1990). These traumatic experiences occurred during three periods of premigration: the war and genocide, the escape process, and the refugee camp experience (Mollica & Lavelle, 1988). Many refugee women experienced multiple traumas including physical and psychological torture.

Cambodian women specifically have been found to be at greater risk for developing serious mental health problems due to their experiences during the Pol Pot Khmer Rouge government (Mollica, Lavelle, & Khoun, 1985). Pol Pot was a dictator who orchestrated mass violence, atrocities, and genocide on the Cambodian people during his regime (1975-1979). It is estimated that 1 to 3 million of Cambodia's 7 million died from either execution, starvation, or illness, resulting in the virtual extermination of Cambodian people and culture (Kinzie & Leung, 1989; White, 1982). Those who survived the executions were placed into labor camps and collective farms and forced to work 18 to 20 hours each day while living on only one-half cup of watery rice per day (Szymusiak, 1986). Almost two thirds of Cambodians had at least one close relative who died (U.S. General Accounting Office, 1990), one third were political prisoners, and one third suffered assaults (Lee & Lu, 1989). Since the aim of the Khmer Rouge was to eliminate bourgeois Cambodians and Western influence, Buddhist monks and other religious and political leaders, intellectuals, and those educated were targeted to die. Books and eyeglasses were destroyed because they symbolized Western culture and education and families were separated due to the fear that family bonds could undermine the loyalty to the Khmer Rogue. Children were conscripted into armies of children (Nidorf, 1985) and oftentimes returned to their villages to spy on their families for the Khmer Rouge. Neighbors also spied on each other in order to save their own lives, cultivating mistrust (Rozee & Van Boemel, 1989). Sanctioned by the Khmer Rogue a national police of young boys was formed and given rifles with authorization to bury people alive for disobedience or questioning their authority. They also brutalized young children and beat people on the head (where Cambodians believe the soul resides), which in Cambodian culture is a cultural taboo, since children are not supposed to touch elders (Rozee & Van Boemel, 1989).

In 1979 and 1980, with the collapse of the Pol Pot Khmer Rouge regime, hundreds of thousands of Cambodians sought asylum in refugee camps in Thailand. It has been well-documented that the refugee camps in Thailand were inadequate to house the Cambodian refugees, with reports of unsanitary conditions, malnutrition, diseases, lack of physical safety, lawlessness, violence, the lack of effective law enforcement and internal security, over-crowding, poverty, and shortage of water and firewood (Mollica & Jalbert, 1989).

The trauma Cambodians suffered has been widespread and especially affected Cambodian women. For example, in one study, 95% of the Cambodian women reported that they have been sexually abused or raped (Mollica, 1986). Cambodian women reported nearly nine times more trauma than other Southeast Asian refugee groups (Mollica et al., 1985). Three specific subgroups of Cambodian refugee women have been identified as high risk: (a) those who have been raped or sexually abused; (b) those who are widowed, and (c) those who have lost their children. As a response to the severity of the premigration traumatic experiences, some older Cambodian women have displayed nonorganic or psychosomatic blindness (Van Boemel & Rozee, 1992). The degree of subjective visual impairment has been found to be significantly related to the number of years the women were interned in the camps and also the degree and level of traumatic events they witnessed (Van Boemel & Rozee, 1992). A explanation that typifies the experience of many Cambodian women is illustrated in the following statement: "I started crying hard for a long time ... later when I finally stopped crying I could not see" (Van Boemel, & Rozee, 1992).

It has been found that Cambodian refugees in the United States display a dummy personality called Tiing Moong (Mollica & Jalbert, 1989). Tiing Moong was a technique employed by Cambodians to survive during the Pol Pot regime, whereby individuals acted as if they were deaf, dumb, foolish, confused, or stupid, and learned to obey orders obediently without asking questions or complaining. Any appearance of intelligence or emotions could quickly lead to torture or execution. Thus continuing to act like a Tiing Moong and being afraid to speak up or show feelings is a survival technique to avoid death or punishment and remains with many Cambodians even while in the United States (Mollica & Jalbert, 1989).

Given the genocide that occurred in Cambodia, it is not surprising to find both clinical (those who accessed mainstream mental health services) and community samples of Cambodian refugee women who reported the experience of multiple traumatic premigration events, including the loss of a spouse, children, and siblings (Chung & Bemak, in press-a; Mollica et al., 1985). For example, in a community sample of 300 Cambodian refugee women, 22% reported death of a spouse and 53% reported loss or death of other family members (Chung & Bemak, in press-a). Furthermore, the experience of multiple traumatic events was a significant predictor of psychological distress and affected Cambodian women's psychosocial adjustment in the United States (Chung & Bemak, in press-a). Therefore, an examination of premigration and postmigration variables and their interaction is important to develop effective prevention and intervention programs and provide effective mental health counseling for this population.

POSTMIGRATION ADJUSTMENT ISSUES

Employment

Resettlement may prove to be challenging for many Cambodian women. Due to high rates of spousal death, Cambodian women must cope with being the primary caretaker of their families and sole provider for the household (Chung & Okazaki, 1991). A high percentage of Cambodian refugee women had no formal education and poor English language skills, which is significant since low levels of English proficiency was found to be a significant predictor of psychological distress for this group (Chung & Bemak, in press-a). English proficiency is not only a prerequisite for gainful employment but also a necessity in assessing community resources. Due to the lack of education and English language skills, Cambodian women may have jobs that demand long hours with little pay or part-time jobs that make it difficult to support a family.

Given the lack of education and English language proficiency, it is therefore not surprising to find a high percentage of Cambodian women, who have been in the United States for almost 4 years, are fully dependent on welfare (Chung & Bemak, 1996). This presents a psychological risk given the findings that if they received welfare at any point in their lives, there is a greater likelihood of psychological distress even after ending their welfare dependency. An explanation for this may be a cultural response to avoid the loss of face and shame (Chung & Bemak, 1996).

Social Support

Resettlement in a foreign country may also mean the loss of community support. The customary support system that includes extended family, community leaders, and spiritual leaders may be unavailable in the resettlement country (Uba, 1994). The resettlement policy for this group in the United States was to disperse them throughout the country, adding to feelings of isolation (Uba, 1994). In addition, Cambodian women were frequently the heads of households, with demanding work schedules that inhibited time for participation in social activities (Mollica et al., 1985). Social isolation was further exacerbated by cultural taboos about dating and rejection by peers due to a perception that women who are widowed, separated, and divorced are a threat to one's husband (Mollica et al., 1985). Subsequently, family losses and economic responsibilities--coupled with community rejection, cultural isolation, and alienation--may place Cambodian women in an extremely difficult emotional situation with little or no social support.

Survivor's Guilt

Refugee women may also be experiencing survivor's guilt during resettlement. Many may be haunted by the guilt of successfully escaping from their home country, while leaving family, relatives, and friends behind in a potentially dangerous situation (Bemak & Chung, 2000; Brown, 1982; Lin, Masuda, & Tazuma, 1982). The lack of information about those who have been left behind frequently adds to the already existing guilt (Chung, Bemak, & Okazaki, 1997) resulting in some refugee women experiencing nostalgia, depression, anxiety, and frustration (Bemak & Chung, 2000) that interferes with successful adjustment. Compounding survivor's guilt was the decision to leave their country. For example, in one study 22% of Cambodian women reported the loss of their spouse; therefore, many of them made the decision to leave Cambodian (Chung & Bemak, in press-a). It has been found that those who made the decision to leave Cambodian were more likely to experience psychological distress, which may relate to feelings of guilt about subjecting their families in the United States to financial hardship, especially for those who are fully dependent on welfare, as well as concerns about family and friends left behind (Chung & Bemak, in press-a).

Acculturative Stress

Relevant to the Cambodian refugee woman is. the concept of acculturative stress, a unique type of distress that involves adjusting to a foreign culture and possibly changing identity, values, behaviors, cognitions, attitudes, and affect (Berry, 1990; Berry & Anis, 1974; Liebkind, 1996; Miranda & Matheny, 2000). Research has suggested that acculturative stress combines the ameliorating effects of environmental, familial, demographic, and other factors (Miranda & Matheny, 2000). Liebkind (1996) postulated that for refugees, acculturative stress is influenced by multiple factors that comprised sociodemographic characteristics, premigration experiences, the social and political context of the resettlement society, and postmigration acculturation experiences (Liebkind, 1996). Miranda and Matheny (2000) argued that acculturative stress models are limited, given the focus is on external factors, and suggest that internal psychological resources such as coping strategies be included.

Psychological Distress and Symptom Expression

Cambodian refugee women reported higher levels of psychological distress compared to their male counterparts and other Southeast Asian groups (e.g. Chung & Bemak, in press-a; Mollica & Lavelle, 1988). Findings have also shown that Cambodian women, similar to other Asian groups, expressed distress in a culturally sanctioned manner (Chung & Kagawa-Singer, 1995), manifesting distress in a pattern of symptoms more consistent with their cultural nosology rather than Western clinical categories. Thus, Cambodian women express distress in clusters of symptoms that resemble neurasthenia that originated as a Western diagnosis in 1869, and was in and out of fashion for the past 100 years (Abbey & Garfinkel, 1991). It was finally deleted from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R, 1987), due to ambiguity as well as its overlap with other psychoneurotic disorders (Abbey & Garfinkel, 1991; Young, 1989), but remains a common psychiatric diagnosis in Asian countries (Cheung, 1989; Murakata, 1989). Neurasthenia consists of both somatic and psychological manifestations of distress and describes a complex set of symptoms that are compatible with the holistic concept of health and illness basic to the traditional Asian medical paradigm in which psychological and somatic factors coexist in a mind/body complementarily. Since mental illness among Asians is highly stigmatized and viewed as a genetic defect (Cheung, 1989), the concept of neurasthenia offers useful ambiguity, which allows for implicit and discrete admission of a variety of less socially acceptable symptoms and still allows for saving face (Cheung, 1989). Therefore, neurasthenia is considered to fit a culturally sanctioned Asian idiom of distress (Kleinman, 1986).

Help-Seeking Behavior

Given the high degree of traumatic experiences and the reported levels of psychological distress by Cambodian women, it is not surprising that one study reported that 88% of this population have utilized Western mainstream mental health services (Chung & Lin, 1994). The high utilization of Western medicine in the United States is a dramatic shift in the pattern of help-seeking behavior, changing from a utilization of traditional medicine in Cambodia to a far more pronounced usage of mainstream services in the United States This reduction in the use of indigenous healing methods in the United States may be a due to the unavailability of traditional methods, since many Cambodian traditional care providers, including monks, were killed during the Pol Pot regime, leaving no alternative but Western medicine.

Although the findings do point towards this dramatic increase in the utilization of Western health care services, traditional methods of health care continue to be important in the resettlement country and are sought as the preferred method of treatment. This is evident in Cambodian women who displayed a greater usage of traditional medicine as compared to their male counterparts (Chung & Lin, 1994). It is important to note that generally Cambodians reported utilization of a dual health care system of both traditional and Western practices in the United States (Chung & Lin, 1994). A partial explanation for this may be related to the women's reported lower levels of education and literacy in their own language (Khmer) and English as compared to their male counterparts. These same variables were found to predict whether individuals used traditional versus Western treatment methods (Higginbotham, Trevino, & Ray, 1990).

IMPLICATIONS FOR COUNSELING

Knowledge of and familiarity with the multicultural counseling competencies (Sue et al., 1998) are essential prerequisites for counselors working with refugee clients. The multicultural competencies provide counselors with the first steps in being effective with this population. The Multi-Level Model (MLM) of psychotherapy developed by Bemak, Chung, and Pedersen (in press) is a model specifically designed for counseling refugee populations. The MLM therefore is used as a framework to discuss recommendations for culturally sensitive counseling with this population.

The model involves four interrelated levels: psycho-education, culturally sensitive psychotherapy, cultural empowerment, and traditional healing methodologies. The levels can be implemented either independently or concurrently. Level I, psycho-education, emphasizes the education of refugee clients about the Western counseling process. Given Cambodian refugee women's unfamiliarity with counseling, education about Western mental health practices, techniques and expectations is critical to acquaint them with the counseling process and avoid premature termination of counseling. This may range from explaining the intake interview, time boundaries for sessions, confidentiality, the role of the counselor, types of questions that will be asked, and expectations for both counselor and client. Psycho-education is especially important to establish trust, given premigration experiences that cultivated mistrust, skepticism, and suspicion of people in authority (Bemak et al., in press) and is important to infuse as an ongoing process as needed in the counseling relationship.

Level II, psychotherapy, incorporates practices in Western counseling with that of individual, group, and family counseling in a culturally responsive manner. The model emphasizes the use of group and family since most refugees are from collectivistic cultures, and therefore, group and family counseling is more in line with their cultural value system. To establish credibility and to understand the client's worldview, it is critical that counselors are aware, understand, and accept the influence of cultural on the conceptualization of mental health, patterns of symptom presentation (Chung & Kagawa-Singer, 1995), help-seeking behavior, treatment expectations, and outcomes (Chung & Lin, 1994). Therefore, counselors must be aware of the cultural biases inherent in the Western diagnostic tools such as the DSM-IV (1994; Chung & Kagawa-Singer, 1995; Fabrega, 1989; Kirmayer, 1989; Kleinman, Eisenberg, & Good, 1978; Mezzich, Fabrega, & Kleinman, 1992). To be culturally responsive as counselors, it is critical to work cooperatively with community leaders who can educate the counselor about cultural norms and values as well as act as a cultural broker and liaison for the client and the wider community. For example, Cambodian refugee women community leaders could educate the counselor about displaying culturally appropriate empathy (Chung & Bemak, in pressb), interpreting cultural conceptualizations and reactions to mental illness, or culturally based attitudes associated with rape (Mollica & Son, 1989). Group counseling interventions may be particularly helpful given the high percentage of Cambodian refugee women who lost a spouse or close family member and the lack of social support in the United States, especially given studies that have demonstrated the efficacy of support groups in assisting refugee women in their psychosocial functioning (Mollica et al., 1985).

In addition, culturally sensitive treatment methods with refugees must take into account Post Traumatic Stress Disorder (PTSD; Draguns, 1996, Friedman & Marsella, 1996; Kinzie & Fleck, 1987). Similar to Holocaust survivors, the technique of reconstructing and helping victims of PTSD relive their traumatic experiences may not be a useful and beneficial technique for Cambodian refugees, due to this group's extreme inhumanity experiences that may have tapped the limits of human ability to 'undergo this technique (Draguns, 1996; Kinzie, 1987). Eight universal components of effective intervention specific to refugees diagnosed with PTSD have been identified (see Kinzie and Fleck, 1987) that help clients integrate the premigration trauma into postmigration adjustment.

Level III, cultural empowerment, involves providing clients with information and resources that enable them to master the new culture and gain a sense of cultural empowerment. During this level the counselor assumes a role as an advocate for the refugee client, moving beyond traditional roles and assisting clients with pressing immediate concerns such as housing, employment, and transportation (Chung & Okazaki, 1991) as well as issues such as discrimination and family reunification. For example, since English as a second language (ESL) is important for Cambodian refugee women in attaining gainful employment, providing information for Cambodian refugee women regarding ESL classes and helping them make contact with agencies or schools that offer classes would be invaluable in the counseling process. In addition, counselors may assist the Cambodian women accessing community resources and opportunities, helping them to develop cultural and self-empowerment that is essential for successful adjustment (Bemak et al., in press).

Level IV of the MLM emphasizes integrating Western and traditional healing methodologies. It is crucial that counselors understand and accept that refugee clients may seek and prefer traditional healing methodologies (Chung & Lin, 1994) as compared to Western counseling practices. Therefore, counselors are encouraged to work collaboratively with traditional healers, which has been established in the literature as an important alliance (e.g., Chan, 1987; Draguns, 1997; Hiegel, 1994). This may require counselors to identify traditional healers within the Cambodian community and form therapeutic alliances, thus providing an integration of conventional Western counseling interventions and traditional healing. The resultant partnership provides validation for cultural healing perspectives through the use of traditional healers within the Cambodian community, while simultaneously utilizing Western counseling methods that may be highly beneficial. This requires the counselor to be flexible, open, and culturally sensitive (Bemak et al., in press).

In summary, counselors must to be aware, understand, acknowledge, and accept the cultural, psychosocial, political, and historical issues surrounding the Cambodian refugee women's' experience to provide effective counseling. It is important to take into account that the experiences of Cambodian women and other refugee women are not solely a woman's problem, but are issues that affect the entire social fabric of the Cambodian community. Women play a crucial role in the lives of their families and communities so that when there are shifts in gender roles and responsibilities, the entire structure of family and community life becomes disrupted and the psychological well-being of family is effected. It is therefore important for counselors to maintain heightened awareness of their work within a collectivistic society and respond to unique challenges of both pre- and postmigration factors that contribute to the psychological well-being of Cambodian refugee women.

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Rita Chi-Ying Chung, Ph.D., is an associate professor in the Counseling and Development Program, Graduate School of Education, George Mason University. Correspondence should be addressed to Rita Chi-Ying Chung, Counseling and Development Program, Graduate School of Education, MSN4B3, George Mason University, Fairfax, VA 22030-4444. Email: rchung@gmu.edu.
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Date:Apr 1, 2001
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