The stress of dislocation shows on the face of this Cambodian refugee, who has resettled in Madison, Wis.
Both photos © David Tenenbaum.
Traditional Cambodian dancers (photographed in Washington, DC, in 1991), are trying to salvage a culture wracked by bombing, genocide and civil war.
In your mind, or in your body?
We're always reluctant to coin jargon, but some of these promising tools could be called "community therapy."
The issue of adapting the therapy to the culture is never more pressing than when dealing with Cambodian refugees. While the term "ethnic cleansing" became notorious during the Serbian campaign in Bosnia, the Khmer Rouge in Cambodia referred to their reign of terror (between 1975 and 1979) as a "return to the year zero." While the Serbs in Bosnia and Kosovo selected victims based on ethnicity, the Khmer Rouge focused on class, exterminating anyone deemed educated or bourgeois (including those who wore eyeglasses). An estimated 1 to 2 million Cambodians perished before the Vietnamese invaded and expelled the Khmer Rouge in 1979.
Most of the refugees who fled Cambodia during and after "Pol Pot time" spent years in crowded refugee camps before gaining asylum in the United States or elsewhere.
Although they have suffered the torture of seeing loved ones killed and the pain of dislocation, the Cambodians have no concept of mental illness. They do, however, complain of bodily illnesses that psychologists attribute to their horrific experiences (see "Stay Alive.... " in the bibliography).
Can psychotherapy, a product of the West, be adapted to help people with non-Western world views? Perhaps. In different forms in different places, new therapies are being invented to take advantage of the parts of the refugee society that still function. Instead of paying attention to the bad, they focus on the good. Instead of forcing refugees to fit the existing mental-health system, they try to adapt the system to the culture.
Thinking broadly
Instead of relying solely on traditional mental-health processes, Garms favors a community approach based, like Cambodian society itself, on Buddhism. In Cambodia, life centers on the temple and its monk. Lacking a temple, refugees spent more than a decade in Wisconsin with no place for traditional ceremonies. Then, in 1997, Wisconsin's Cambodian community converted a farmhouse into a temple and found a Cambodian Buddhist monk to live there. The temple has become a center of community life, particularly for older, more traumatized refugees. As in the old country, those who cannot cope in the larger society can seek refuge at the temple.
Roger Garms, a Madison, Wis., psychologist who had previously worked with American GI's with post-traumatic stress disorder, says many Cambodian refugees represent classic cases of PTSD. At night, their sleep is punctuated by nightmares. During the day, tiny events -- even scenes on television -- can revive the trauma of Pol Pot time. Many victims are quick to anger; their problems with memory and getting along with people prevent them from working.
Experts in surviving torture
Munczek finds the individual focus of Western mental-health treatment misbegotten. "It's not a psychiatric or merely mental problem. The problem has a social origin, and has to be dealt with on multiple levels. You can't just treat the individual. You have to deal with the society" and try to "reestablish a sense of community in people who have lost it."
Rather than urging refugees to visit mental-health clinics, Munczek, a clinical psychologist at Columbia Presbyterian Center, favors meetings at churches or community centers that "incorporate a mental health component, but do not focus on mental health."
A second tactic is to work through natural community leaders or healers. "We educate these people about the psychological and psychosocial impacts of dislocation, multiple losses, shocks and trauma, how it affects communication with family and the ability to work."
Similarly, the Center for Victims of Torture in Minneapolis is educating leaders of Somali and Bosnian refugees about the effects of torture and displacement. "They are in a position to make referrals to resources for people who want to know how to get help," observes social worker Evelyn Lennon.
The effort to exploit existing strengths is simply good social work, she says. "It's accepted social work practice to look at the strengths that are in the community. You don't have to teach them our way. We don't have all the answers."
Community therapy also seems to be helping Latin Americans scarred by years of totalitarianism. New York psychologist Debora Munczek gained experience with the effects of torture while helping families of the "disappeared" in her native Argentina in the 1970s. (These people, often labor or political activists, were abducted, killed and secretly buried by government-sponsored death squads.)
Coffee Klatsch
CAFES is an appropriate acronym, Weine indicates. "If you walked in, you'd see a bunch of people sitting around, drinking Bosnian coffee and eating pastries." The event is pitched not as a therapy session but as a chance to connect with other Bosnian families and learn to survive in the United States. "The family is the center of Bosnian life," says Weine, who has devoted six years to research, therapy and advocacy for Bosnian refugees. "Bosnians say, 'If you want to understand Bosnia, you have to understand the family.'"
The new tack avoids the need to "invite Bosnians to identify themselves as sick or distressed," Weine adds. "We say, 'Come because you are a family, because you have this experience, come because you are Bosnian.'" Guided by trained Bosnian facilitators, the discussions range from dealing with social service agencies to dealing with memories. "What do you do with these memories" of massacres, rape, burning villages, and concentration camps, Weine asks? "Do you want to keep quiet about them or talk about them all the time?"
The research into CAFES' effectiveness is not yet complete, but Weine suggests that mental-health workers need to think about foregoing the clinic and searching for ways to help traumatized refugees rebuild their societies. "Our job as professionals is to identify and maximize these processes in ways that are acceptable to the community and culture."
Can we cure these traumas?
In Chicago, psychiatrist Stevan Weine has taken psychotherapy out of the clinic by organizing Coffees and Family Education and Support (CAFES). The goal is to reach the majority of Bosnian refugees who suffer PTSD and depression, but don't attend clinics -- even free ones staffed by Bosnian mental health workers.
