clinical relevance of grief and mourning among cambodian refugees

Sm. Sci. Med. Vol. 25, No. 7, pp. 765-112. 1987 Printed in Great Britain. All rights reserved

0277-9536/87 $3.00 + 0.00 Copyright 0 1987 Pergamon Journals Ltd

CLINICAL RELEVANCE OF GRIEF AND MOURNING AMONG CAMBODIAN REFUGEES

JAMES K. BOEHNLEIN

Robert Wood Johnson Foundation Clinical Scholars Program, 2L NEB School of Medicine, University of Pennsylvania, Philadelphia, PA 19104-6094, U.S.A.

Abstract-From 1975 to 1979, one to two million Cambodians were executed or died of disease and starvation during the rule of the Pol Pot government. In the aftermath of that catastrophe, many survivors have developed symptoms of post-traumatic stress disorder. There is some evidence that the intrusive symptoms of this disorder, such as nightmares, sleep disorders, and startle reactions, can be treated with medication. But other psychosocial problems that are similar to those found in chronic grief, such as avoidance behavior, shame, and decreased involvement with other individuals, are more resistive to treatment. On a cross-cultural level, the interpretations of, or meanings given to, specific symptoms by the patient may be influenced by culturally-specific religious beliefs, rituals, and social traditions. For the clinician, these cultural factors have relevance not only for engaging the patient in treatment, but also in the planning of specific therapeutic interventions.

Key words<ambodia, refugees, grief, trauma

There was a lady who wept because she had so many misfortunes. She poured out her misery to Buddha who told her that these miseries would go away if she would obtain a seed from a house that had never known sorrow. The next week Buddha found her singing happily. When the Enlightened One asked if she found the Seed of Happiness, the old woman replied, “No, Blessed One. I went to every house seeking it and found no house that had not known sorrow. Everywhere I went I saw troubles much worse than my own, and from these I learned that I do not have it bad at all.”

Cambodian folk tale [I].

During the years 1975-1979, millions of Cambodians experienced multiple traumas in prisons and com- munes during the Pol Pot regime, including torture, the witnessing of executions of family members and friends, starvation, and disease. After the genocidal government was overthrown by a Vietnamese in- vasion in 1979, waves of refugees escaped to Thai- land, where they often spent difficult years awaiting resettlement in a new host country. However, even after resettling in secure and stable countries- 104,000 in the United States; 30,000 in France; 11,000 in Australia; 9,000 in Canada [2]-they have continued to face other challenges such as poverty, adjustment to new societies, and a reconstitution of their own traditional culture [3,4]. This adjustment has been made even more difficult for many individuals by disturbing and often incapacitating symptoms of depression and post-traumatic stress disorder (PTSD) [5, 61.

For these Cambodian refugees, the traumas of the last ten years have involved a continuing series of losses: human, material and symbolic. Many individuals have lost their spouses, children or parents, along with lifetime savings and possessions. Others have lost their means of livelihood, previous social status or social role. In addition, all Cambodian refugees have literally lost their homeland and many

aspects of their rich and centuries-old cultural traditions.

In this paper, I will initially discuss general aspects of grief and mourning after a loss, with specific relation to the Cambodian experience, including a review of the ethnographic, medical anthropology and psychiatry literature pertaining to this topic. I will then consider the clinical relevance of these concepts in the diagnosis and treatment of PTSD in Cambodian refugees, as there are great similarities between the clinical presentations of PTSD and that of chronic grief. However, the psychological challenges which Cambodians face are additionally difficult because of the disruption of traditional cognitive structures of meaning and orientation over the past ten years. The following questions are relevant to the clinical management of these patients and will be addressed through discussion and an extended case presentation:

1. What are cross-cultural factors which may affect the patient’s and the clinician’s understanding of loss and trauma?

2. How do social traditions and religious beliefs affect the patient’s subjective experience of specific PTSD symptoms such as nightmares, hopelessness, and shame? In turn, how can various therapeutic interventions effectively address these cultural factors?

The clinical material is drawn from my work with Cambodian refugees over the past several years in academic medical centers and community agencies and illustrates the cross-cultural issues which chal- lenge the clinician working with these individuals. The ideas explored in this paper are an attempt to integrate anthropological, sociological and psychiatric concepts in a specific cultural matrix. From a social science perspective, the clinician is essentially a participant-observer who identifies relevant cultural factors which influence the individual’s

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766 JAMES K. BOEHNLEIN

interaction with his or her environment; general cultural norms serve as an important background for the assessment of both the patient’s subjective distress and observed behavior [7].

BACKGROUND-RELIGION AND RITUAL MOURNING IN CAMBODIA

The basis of belief and an explanation for suflering: Buddhism and folk religion.

Because the complex existential questions centered around loss and meaning are some of the major challenges for those individuals suffering from PTSD, it is imperative that the clinician understand the religious background of his or her patients. The bereaved person does not have to be religious in a formal sense; however, how the person was socialized to reconcile the pain of loss is important [8]. Further- more, the assessment of patients from this perspective takes into account the impact of philosophy, values and social attitudes upon disease [9].

All religions help their followers to cope with suffering in two major ways: 1, by offering an explanation for suffering; and 2, by providing techniques by which suffering may be avoided or diminished [lo]. Furthermore, religious symbols, beliefs, myths and rites enable individuals and groups to deal with the ultimate conditions of existence which are experienced by members of every society [ll]. The use of ritual attempts to reinforce central cultural beliefs which re-establish the concept that there is some order in the universe [12-141. From the standpoint of the individual as part of a social unit, religion also serves as a source of conceptions of the world, the self, and the relations between them [15].

For Cambodians, what mafie the roles of both Buddhism and folk religion in allowing them to deal with grief, loss and the events of the Pol Pot era? Even though an 85% majority are solidly and de- voutly Buddhist [1], the majority religion is inter- twined with a folk religion that is of considerable significance and which is based on belief in a variety of animistic, ancestral, guardian, ghostly or demon- like spirits; it has its own rituals and specialists [16].

Buddhist rituals that occur at events that symbolize significant life transitions such as birth and death have been at the center of Cambodian village life for centuries. The Sinhalese form of Theravada Bud- dhism appeared in Cambodia during the thirteenth century, coming from Burma and Thailand [16]. In Buddhist beliefs,

life is basically unhappy and this sorrow is caused by desire. Desire means hungering after anything, be it wealth, food or ambition. The sorrow of life can be overcome only by crushing the desire. Further- more, although the true Theravadist reveres Buddha as an ideal he would like to emulate, he has no god to whom he can pray for help or moral guidance. Man, he believes, controls his own destiny by the power of his will. Life does not end with death, and the soul is reborn through reincarnation; the cycle of life is repeated endlessly until he becomes enlightened

PI. An eight-fold path by which desire can be crushed

includes the correct understanding of the sources of unhappiness, correct intent for specific actions,

honest speech, good conduct, the choice of a noble vocation, honest effort, alertness and concentration [17]. However, as Spiro notes,

the most that the average person can hope for in any one rebirth is the gradual reduction of suffering by the gradual reduction of desire. The origin of suffering does not explain the cause of personal existential suffering. Illness, loss and death are attributed by Buddhism to the working out of one’s karma, which consists of the consequences of the good and evil deeds committed in all one’s previous existences; suffering, therefore, is the karmic consequence of one’s past sins and one cannot escape or alleviate present suffering. One can only hope for a better existence in the next rebirth by performing numerous acts of merit [lo].

These meritorious deeds are often centered around the Buddhist temple which, as a religious and social center, serves to integrate the community by means of shared norms and rituals and reinforces social ties [16]. A brief clinical case specifically illustrates this point.

A 45year-old widow had been treated over a period of one year for symptoms of FTSD and major depression. Although the physiological symptoms of insomnia, anorexia, startle reactions and psycho- motor retardation had responded to antidepressant medication, other symptoms such as social withdrawal and decreased interest in previously enjoyed activities were more refractive to treatment. During one particularly revealing followup session, the patient stated that the only thing which continued to give her hope in the future, despite the execution of her husband and two adult children by Pol Pot forces, was her weekly visits to the local Buddhist pagoda. During these visits she was able to pray, give offerings to Buddha, and socialize with other Cambodian women.

In addition, elements of Brahmanism are still evident in religious and secular ritual, particularly in life cycle ceremonies [18], including ritual aspects of fortune-telling and the use of protective magic and amulets. The older Brahmanic practice of attempting to assure a superior rebirth by proper religious devotion just before death, has also been maintained; holy thoughts at death serve to prevent rebirth in an inferior state [ 171.

However, for many individuals, pain and suffering in the present life cannot often be relieved solely by an orientation to a more promising future life. As Eisenbruch [ 191 describes, the suffering individual cannot be content with a philosophical explanation, but seeks to act on the immediate environment to feel that he or she has some control over it; in fact, in Buddhist societies, animistic and spiritualistic cult healers exist alongside of traditional Buddhist healers. Furthermore, folk religion can give reasons for and means of coping with the incidental problems of an individual’s present existence [16]. It is not unusual for a Cambodian to offer rice to a neak ta, or spirit, at a tiny homemade shrine after making devotions to Buddha at the pagoda [l].

Since Buddhist doctrine teaches that personal misfortune is inevitable, many Cambodians seek comfort and explanation for unhappiness in supernatural beliefs; this reliance on alternate religious concepts has permitted Cambodians to withstand numerous

Clinical relevance of grief and mourning among Cambodian refugees 167

ordeals over the centuries [20]. Furthermore, as Spiro [lo] notes, supernaturalism can be a more emo- tionally satisfying alternative to Buddhism, which ultimately places responsibility for suffering exclu- sively on the sufferer, but precludes any possibility of coping with it; in Buddhism, there is no escape from one’s karma. For example, in the realm of folk religious belief, the sufferer can be entirely blameless for personal misfortune by being a victim of supernatural events, or in other cases only minimally responsible by having mistakenly offended a neck ta; in both cases, suffering can be alleviated by appropri- ate rituals.

Ebihara [ 16, p. 4251 specifically describes the various elements of Cambodian folk religion related to supernaturalism, death and funeral rituals:

Neak ta-literally translated as ‘ancestral person’. Harmless if given proper respect, but will bring illness if ignored. Inhabit the natural environment such as trees, rice paddies or streams.

Kmauit-translated as ‘corpse’. Several types of ghosts which can appear in human or animal form. Some are spirits of dead persons, especially those who have committed suicide or have been murdered. They are especially frightening and many Cam- bodians refuse to talk about them.

Meba-ancestral spirits (not of specific ascendants but ancestors in general) who watch over living members of the family. They receive offerings of food at life cycle ceremonies.

Cambue cue-ghosts of deceased members of the family. Cause illness when ignored or angered at misdeeds of descendants.

Certain persons acquire distinct competence as mediators with these spirits:

Achaa-these individuals officiate at various life cycle rituals. Achaa yoki preside over funerals, guid- ing participants through their ceremonial roles. When death is imminent, uacha and/or Buddhist monks are called to the family home to recite Bud-

dhist prayers. After death, the corpse is bathed (with water blessed by monks) by the aacha and the deceased’s children, and then dressed in white clothing.

Cremation, rather than burial, is reinforced by the belief that evil spirits are especially prone to arise from slowly decaying cadavers [17].

The role of rituai in individual and collective mourning

The rituals that enable individuals or groups to deal with loss and death very often entail elements of both majority and folk religions, along with secular culture. Rosenblatt et al. [21], in their review of cross-cultural mourning practices, note that in societies throughout the world death is followed by passage ceremonies both for the deceased who are removed to the symbolic world of the dead, and also for the immediate survivors who are removed from their status and roles lost when the death occured. This enables the survivors to gradually come to a realization that life must go on for them and encour- ages them to reintegrate into the rest of society which did not suffer the loss directly. Group mourning parallels and can facilitate the personal mourning process, and can also solidify the group through the communication of shared grief [22].’ The process of grief and mourning is greatly facilitated by the inher-

ent continunity of meaning which is developed over generations in the rituals of any given culture. Ortner [23] notes that these rituals do not begin with the eternal truths, but arrive at them; they begin with some cultural problem and then work various oper- ations upon it, arriving at a newly meaningful solu- tion.

The emotional tenor of mourning rituals can vary greatly from culture to culture. In Cambodia, funerals have not traditionally been occasions for the demonstration of grief because of the Buddhist belief in reincarnation [20]. It has been noted that:

During the cremation, traditional and popular music is played over the loudspeaker. Guests are served food and liquor. There is no air of mandatory gloom. The immediate family and close kin do feel a grief that is manifested by periodic tears and sad remi- niscences about the deceased. But the sorrow of death is, of course, tempered by the thought that the deceased will pass into another, and hopefully better, reincarnation. Relatives and friends look through the ashes for remnants of bone and teeth that are collected and washed with coconut milk and per- fume. These fragments will eventually be placed in an urn that is kept either at home or placed at a temple [16, pp. 505-5061.

Ebihara additionally notes that symbols of rebirth such as rice (which is also used in birth rituals), are used in Cambodian funeral rites. Evidence of a symbolic reincarnation is additionally seen in other Cambodian customs which follow major loss or trauma. A ritual name change is often provided for someone who has experienced a traumatic event; thus, past actions or events can be ascribed to that prior individual [24].

The following sections now will explore the appli- cation of this ethnographic background to clinical psychiatry.

THE CROSS-CULTURAL CLINICAL ASSESSMENT OF GRIEF AND F’TSD

Whereas grief is

the sorrow, mental distress, sadness and suffering caused by the death of a loved one, mourning is the culturally defined acts that are performed when a death occurs in a community; of course, grief behavior can be modified by the specific culture and mourning itself may be influenced by the biology and psychology of grief [21].

Pollock [25] notes that a number of previous writers such as Darwin, Bowlby, and Lindemann have described similar biological symptoms of grief in widely divergent human populations and primates. Early motor behavior such as hand wringing and aimless pacing give way to sorrow, despair, fatigue and exhaustion when the grieving individual realizes that the loss is irrevocable. Furthermore, Bowlby [26] contends that separation is the primal experience in the formation of anxiety and that other sources of anxiety, including the expectation of death, are im- bued with emotional significance by equation with separation anxiety. Yalom [27] extends those ideas, stating that the most fundamental human anxiety issues from the threat of loss of one’s self; individuals fear the loss of a significant other because that loss symbolizes a threat to one’s own survival.


It should be kept in mind that the ritual mourning of the loss of family members, friends and homeland has often not been possible for many refugees. Dur- ing the Pol Pot era, the majority of Buddhist monks were executed by Khmer Rouge forces because they represented a strong tie to traditional beliefs that was not to be tolerated in the formation of a new society; the performance of traditional mourning rituals was punishable by death. Moreover, it may be especially difficult for many Cambodians to reconcile the especially violent deaths of relatives and friends that occurred during the four years of genocide because, as Spiro [lo] notes, in folk beliefs it may be impossible for a person to have a good reincarnation if his or her mind is filled with evil thoughts as the result of a violent death.

There are striking clinical similarities between the symptoms of chronic, unresolved grief and those of PTSD. Insomnia, preoccupation with thoughts of the deceased, vivid and disturbing dreams, unpredictable periods of anger, chronic anxiety, survivor guilt, numbing of emotions and withdrawal from others are present in both of these conditions. Moreover, the grieving individual’s frequent misinterpretation of certain events or signs as indicating that the deceased is still alive, which sometimes occurs in chronic grief, is also very similar to the phenomena of flashbacks and startle reactions in PTSD. The person may re-experience the traumatic event as the result of hearing a loud noise or through the process of reading about or witnessing violence.

Another clinically important parallel can be drawn between the dreaming that occurs in chronic grief and the recurrent, disturbing, and often delayed nightmares that one often sees-in PTSD. Pollock [25] describes a patient of Freud’s who experienced a repetitive dream about his father who had died after a long illness. The dream occurred months after the father’s death and, in the dream, the father was alive again and the patient talked to him in the same manner as before the death. In patients with PTSD, one sees repetitive dreams which also entail the working through of experienced loss. Dynamically, this may be due to a strong desire to reassert control over a previously uncontrollable traumatic event or to cancel out the reality of that event.

Case presentation

The following case report illustrates the clinical significance of religious belief, ritual, and perceived self-image in the phenomenology of mourning and PTSD. Additionally, it clearly illustrates how illness is so profoundly shaped by cultural factors governing the perception and explanation of personal experience [28]. This acquisition of a culturally relevant system of meaning to explain subjective inner experience contributes to,what Kleinman has described as the patient’s symbolic reality [29]. This patient’s personal symbolic reality is specifically influenced by her Buddhist beliefs, along with her social role as eldest daughter in the family, and is mirrored in her eloquent discussions of her experiences, dreams, and feelings.

A 45year-old widow was referred for psychiatric evaluation because of anorexia and slow, yet steady,

weight loss. She had numerous symptoms of major depression, but also admitted to a number of subjectively disturbing symptoms of PTSD such as nightmares and intrusive thoughts of her war experiences, numbing of emotional feeling for loved ones, and startle reactions accompanying loud noises or knocks at the door. She shares a house with her 30-year-old sister and Il-year-old son. During the evaluation session and initial two months of treatment, she was very reluctant to discuss family history or anything about her previous life in Cambodia.

With antidepressant medication, there was sub- stantial improvement in her nightmares and startle reactions, yet she remained chronically depressed, with a pervasive feeling of helplessness and hopelessness. Parenthetically it should be noted that, throughout the course of treatment, the patient was very resistant to any significant increases in medication dosage due to anticholinergic side effects (such as dry mouth and orthostatic hypotension). A number of standard antidepressant medications (e.g. imipramine, desipramine, doxepin) were sequentially introduced at specific points during treatment, yet adequate dosage levels (above 75-IOOmg per day) could not be reached due to the patient’s extreme sensitivity to side effects. Ultimately, alprazolam (a benzodiazepine with both antidepressant and anti- anxiety properties) was used and was well tolerated at therapeutic doses of 2.0-2.5 mg per day.

Three months after the start of treatment, she had an exacerbation of symptoms (particularly nightmares) associated with an impending reduction in family welfare payments due to her son’s turning 18 years old and also associated with receipt of a letter from a 40-year-old sister who had recently become seriously ill in a Thai refugee camp. Nightmare themes, as before, centered around the violent deaths of many family members who had perished during the Pal Pot years.

During that session she spontaneously related an excruciating tale of an experience during the Pol Pot era which had haunted her for many years in her nightmares and daily thoughts. In her presence, her father had committed suicide with an overdose of medication because of his fear of the impending discovery, by Khmer Rouge forces, of his former position as a military officer in the Lon No1 govem- ment (the regime overthrown by the Khmer Rouge); this discovery would have meant certain death. The patient engaged in a physical struggle with her father in an attempt to extract the medication from him, but was too weak to do so because of prolonged starvation and malnutrition. She described her failure and helplessness at not being able to prevent his suicide. She felt like crying constantly after his death, but refrained, as any sign of teais would be a sign of weakness to Pol Pot forces and subsequently would have led to her own execution. She went on to describe her great concern that her father’s body had not been cremated, but instead had been buried in a mass grave; there was a brief covert family ceremony marking his death. In attempting to come to terms with her father’s death, she remained concerned that the manner of his death (suicide) and the lack of cremation may have eternally affected his reincarnation.

It is likely that the reactivation of this woman’s unresolved grief represented her response to three more possible losses: (1) the loss of her older sister through illness and death, (2) the impending loss of her only son due to his increasing independence, and (3) the loss of her younger sister through marriage


(she had recently begun a serious relationship and was considering getting married). During the treatment of this woman over a 15month period a number of recurrent themes [30] were addressed:

Her personal responsibility in the death of her father. The retroactive assertion of personal control and responsibility after a traumatic event is an attempt to overcome chronic feelings of helplessness and powerlessness [31]. Yet, the survivor’s willingness to accept the reality of helplessness under previous extraordinary circumstances and exonerate them- selves from guilt remains one of the key tasks in recovery [32]. For this woman, this sense of personal responsibility may have been additionally enhanced by her social role as eldest daughter in the family.

These issues were successfully dealt with by gently encouraging the patient to absolve herself of responsibility, both for her father’s suicide (she had nothing to do with his former military role nor with the vendettas of the Pol Pot regime) and for her own physical weakness (she was not responsible for her previous malnourished state caused by starvation and disease).

Her continued obsession with the past, which included a chronic self-image as a weak and powerless individual. This image was countered, with some success, during the course of treatment by continually pointing out to her that she must possess greater personal strength than she presently acknowledges. This strength of character has allowed her to survive extraordinary trauma in Cambodia and immense challenges encountered during acculturation to a new country. In has been very important for her to hear that her symptoms are not a sign of weakness, but are shared by many other individuals who have experienced extraordinary events beyond their control. This reassurance has also contributed to a reduced sense of personal shame, as many of the symptoms of PTSD are often interpreted by Cambodian patients as a sign of ‘going crazy’, particularly in a culture with an intense stigma of mental illness.

The patient’s reliance on a prior self-image as a weak and ineffective daughter was also dealt with in family therapy with her younger sister and son. The culturally valued roles of nurturant mother and wise older sister were continually highlighted, rather than concentrating on her weaknesses. Although the family’s respect and love for deceased’ ancestors was acknowledged in therapy, they were additionally receptive to therapeutic interventions which placed great emphasis on current family cooperative relationships which were so important to their individual and group survival.

Religious considerations and views of personal fate. The patient’s religious beliefs had a significant influence upon her views of her father’s ultimate fate in his next life, along with her own feelings of personal responsibility in not being able to prevent his suicide. These factors, in turn, influenced her clinical symptoms and ongoing depression. As the eldest child, she had felt responsible for ensuring that Buddhist burial ceremonies for her deceased father were adhered to as closely as possible. Although this was, in fact, impossible due to the dictates of the Khmer Rouge, she continued to be haunted by her perceived lack of responsibility in that area.

Along with ongoing psychiatric treatment which included antidepressant medication and the ex- ploration of these recurrent themes in psychotherapy, the patient was encouraged to participate in local Cambodian anniversary festivals and Buddhist ceremonies. It was hoped that these latter interventions would facilitate some reduction in her doubts about whether or not she had adequately followed religious precepts.

After one year of treatment which featured a fluctuating clinical course, her condition became sta- bilized, allowing her to increase contact with other individuals, including friends and relatives. This clinical improvement was also evident in her reports of a series of dreams in which her father, now safe and content in his next life, had suggested certain folk remedies, including changes in diet and the manipu- lation of the hot-cold imbalance in her body, which would help to alleviate her chronic symptoms. She, in fact, described her improvement as being due to these suggestions, the knowledge that her father was alive and happy, and her growing realization of the love that surviving family members had for her.

A discussion of cultural determinants of meaning in treatment-theoretical considerations

Individuals who suffer a series of traumatic experiences are faced with the task of explaining to them- selves or to others why the seemingly meaningless events occurred. This can be even more difficult when the events are perceived as being caused by human beings (especially one’s own countrymen) rather than by the forces of nature or a god.

As noted previously, meaning in cultures is primar- ily influenced by religious traditions and by social and secular values; therefore, what constitutes meaning in any society will be highly culturally determined. In reference to Cambodian patients, the religious belief systems, both traditional and folk, may theoretically either foster the resolution of grief and a reconstitution of meaning after trauma, or they may just as easily contribute to more difficulties for the individual. For example, devout Buddhism may be protective for individuals dealing with survivor guilt to the extent that bad karma is the result of deeds in a past life and not related to anything that the person has done in the present life. Also, a belief in a more favorable reincarnation may allow the person to maintain hope if he or she is able to survive the trials of this life. On the other hand, Steinberg [20] has noted that Cambodians believe that permanent separation from the homeland may adversely affect one’s reincarnation. This, of course, has important impli- cations in the resolution of chronic grief caused by separation from one’s native country. In addition, the fact that Buddhist tradition also holds that an individual totally controls his or her own destiny without the moral assistance of divine providence [20] does not allow devout believers to place responsibility for meaningless traumatic events upon a deity, despite prayer and noble deeds which attempt to procure divine intercession; the responsibility lies totally with mankind or with oneself.

Folk beliefs do allow some escape from that responsibility by placing blame for evil on the supernatural but, like Buddhism, this belief system can also


be a double-edged sword. As noted previously in the discussion of Cambodian funeral rituals, proper respect for the dead through the performance of traditional rites prevents evil from being promulgated by spirits at some future time. However, as seen in the previous clinical case, during the Pol Pot era people who were executed or died of disease or famine were often buried in mass graves without funerals or cremation. For Cambodian refugees who adhere strongly to folk beliefs, the fact that these rituals were not performed may further contribute to chronic grief and some clinical symptoms of PTSD by, in their understanding, causing nightmares or intrusive thoughts created by the spirits of deceased relatives. However, these fears can also be reduced by the use of folk healing practices. For example, it has been noted that within the Cambodian community there exists the concept of suteh aram or ‘moral sickness’ which only affects refugees and is caused by extreme isolation and loneliness:

“sadness” or “thinking too much” could make one sick, leading to weight loss, talking to oneself, or uncontrolled crying. Small children are protected from this type of illness by binding a small lock of their hair with black thread when something especially sad happens, such as death. This custom is believed to prevent children from dreaming about the absent friend or relative and this protects them from melancholy and sickness [33, pp. 94951.

when many sociocultural anchors within a specific culture are in great disarray. The therapeutic relationship can serve as an intial catalyst for the patient’s attempt to build a renewed sense of trust and meaning in life. The security and acceptance that the patient feels with a therapist who is attempting to accurately understand him or her can provide what Bowlby [34] has called a ‘secure base’ that would allow the patient to begin exploring a new world and interacting with others once again. Yalom [27] feels that the therapist’s most important tool is his or her own person and that the therapist guides the patient towards engagement with other people by first re- lating authentically to the patient. Haley [35], in her discussion of the therapeutic relationship with those who have experienced traumatic situations, notes that it is essential that the therapist be a ‘real person’ rather than a transference figure; until the time in therapy that the patient reveals atrocities, he or she has been the only judge of personal culpability or responsibility during the traumatic experience.

One also sees patients wearing amulets or string tied around the wrist to keep away evil and encourage healing. Patients come to treatment with skin marks of traditional healing techniques, such as coining and cupping, which attempt to heal headaches and other somatic symptoms. Cupping, which leaves a bruise on the forehead secondary to suction frorri a glass cup, is used to draw out the evil forces which are causing the specific symptom. Coining, which leaves behind streaks on the trunk and limbs, entails scratching the surface of ‘the skin with the edge of a coin in an attempt to release harmful ‘winds’ from the body. These healing techniques are performed by elderly family members or by traditional healers (kru); the latter can also cure illness through the use of herbal medicines or through the exorcism of malevolent spirits.

This latter point is particularly well illustrated in the case discussed previously, in which the patient’s personal sense of responsibility both for her father’s suicide and for the performance of a culturally appro- priate funeral ritual had never been seriously ques- tioned by anyone but herself. To adequately address sensitive issues, while at the same time protecting the patient’s self-esteem, the therapist can use gentle questioning to reveal and clarify areas of conflict [36]. This specific approach to the cross-cultural treatment of PTSD is especially important in working with Asian patients, as a sense of shame for particular actions can be such an important variable in one’s view of self in relationship to others and society.

The therapeutic relationship

It is conceivable that many of the post-traumatic symptoms that are observed in a variety of different ethnic groups represent a universal human response to the cognitive disruption of a sense of order and meaning, which comes from a stable system of culturally specific beliefs and values. Individuals experience great cognitive dissonance between what they observe and experience in reality and what they previously believed were stable, secure and predictable relationships, not only with other individuals, but with the supernatural and the metaphysical.

Another subjectively disturbing symptom of PTSD which was illustrated in the case discussion, a chronic feeling of detachment and estrangement from other individuals, also has cultural determinants. In Cam- bodian culture, one’s world view and sense of self is profoundly influenced not only by age and sex- specific roles in the nuclear family, but also by the cosmologies of Buddhism and folk religion; these factors, in essence, can make up the very core of self-identity. An individual whose religious and family ties have been extinguished or radically altered as a result of the events of the Pol Pot years may no longer possess a stable internalized sense of self. Therefore, the clinician must assist the patient in slowly rebuilding his or her connections to the altered cultural foundations in life which contribute to self- identity and meaning. This therapeutic approach includes not only using psychotherapy and medication in individual treatment, but also incorporating family therapy and encouraging participation in traditional Buddhist life cycle ceremonies.

One of the greatest tasks for patients with PTSD, after they have attempted to place their traumatic experiences in some context of meaning, is to find some reason for continuing with their life. The con- tinuance of a life which has meaning requires some . .

And, by offering support and encouragement in dealing with the challenges of day-to-day life and acculturation to a new country, the clinican can assist the patient in recovering some degree of control over his or her environment. The observations of Frank1 [37] in his work with World War II concentration camp survivors also have great utility in this context. He noted that it was important to encourage survivors to realize that their lives still had meaning and degree of engagement with the environment and with

other individuals. This can be especially difficult the future was still expecting something from them.


In the long-term management of these patients, it

is particularly important that the clinician anticipate any changes in the structure of treatment, such as changes in health care personnel who are directly involved with the individual, in order to adequately prepare the patient for transitions. Although this is important in the medical care of any patient or family, it is particularly significant in the care of these refugees who have experienced so many losses and who have had very little security or stability over the past ten years. The loss of their primary health care provider or case worker can contribute to the reactivation of symptoms which were previously under control.

The optimal clinical care of refugee patients with PTSD also presents the Western therapist with a number of challenges to his or her self-perception as a health professional. Although it is important that the professional communicate the wisdom and confidence that is very much expected by Asian patients, he or she must also create an atmosphere of nurturance and warmth. The clinician can be asser- tive and confident in the recommendation of Western approaches to the treatment of symptoms, yet must also communicate a sense that he or she understands the patient’s own belief system in regards to the etiology and treatment of illness. The fact that patients may consult traditional healers and monks, at the same time that they are consulting the Western professional, should not be viewed as unusual or undesirable.

A final consideration is that the clinician who treats PTSD patients often must be prepared to enter into a long-term therapeutic relationship, due to the often chronic nature of the disorder. This requires an ability to tolerate stories of great human pain and cruelty, an ability to modulate one’s own emotional response, and also a willingness to seek supervision from other clinicians and social scientists who are experienced in cross-cultural medicine.

CONCLUSIONS

In the foregoing discussion, I have explored grief and mourning in the context of traditional Cam- bodian belief systems and have attempted to show the relevance of those concepts to the understanding of the phenomenology of PTSD in Cambodian refugees. As I have described, there are a number of similarities between the symptoms of chronic grief and PTSD, and on a cross-cultural level the interpretations of, or meanings given to, specific symptoms by the patient may be influenced by culturally specific religious beliefs, rituals and social traditions.

For the therapist, these issues have relevance not only for engaging the patient in treatment, but also in the planning of specific therapeutic interventions. The ability of healers to be effective with these patients within their own cultural system is dependent upon the healers being seen by individuals and the Cambodian community as effective, worthy of respect, and as providing a secure, safe and predictable environment for the healing precess.

For therapists working with a cultural group, such as Cambodians, that is both acculturating and col-

lectively recovering from trauma, success is also dependent upon bridging the symbolic systems in cultural beliefs and healing rituals that exist both in the acculturating group and the majority society. The Western therapist need not attempt to become a traditional healer in order to be sensitive to the social and spiritual, along with the medical and psychiatric, needs of patients. Although it is necessary for therapists to understand the cross-cultural dynamics of grief, along with the physiological and psychological symptoms of PTSD, in the specific clinical populations he or she is working with, a recognition of the often subtle disruption of sociocultural systems of thought and action is equally important. This is an ongoing process of discovery and synthesis whereby the therapist strives for an optimal and efficacious fit between psychiatry’s biopsychosocial model and an often different sociocultural model of human cog- nition and behavior.

Acknowledgements-The author wishes to thank Renee C. Fox, Ph.D., for her suggestions during earlier revisions of this paper, Amy Laub for her editorial assistance, the staff of the Nationalities Service Center and the Veterans Administration for their support of this project.

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