By Katherine Kam
WebMD Health News
Reviewed by Arefa Cassoobhoy, MD, MPH
Feb. 19, 2015 -- Kim Morn's face is angular and weathered, his eyes pensive. At 68, he relives in his nightmares the terror of Khmer Rouge soldiers taking Cambodians away to be executed.
Morn was a young husband, only 28, when soldiers under dictator Pol Pot forced him and his wife into a mass exodus in 1975 that drove Cambodia's entire population into work camps. The couple were split apart and sent to separate sites.
Morn labored for more than 10 hours each day, carrying baskets of dirt to build dams. Soldiers beat and prodded him to move faster, although his tall frame had weakened from a starvation diet of rice gruel. He willed himself to keep working to stay alive during almost 4 years in captivity. All around him, the Khmer Rouge staged a constant stream of executions.
Morn and other refugees who resettled in the United States outlived an estimated 2 million Cambodians who perished in the Khmer Rouge killing fields. After Morn reunited with his wife in a Thai refugee camp, the two came to the U.S. in 1985 and resettled in San Jose, CA.
The torrent of nightmares has slowed over the years. But, says Morn: "I still struggle with feeling angry."
A Profound Challenge
Doctors diagnosed Morn with depression and post-traumatic stress disorder (PTSD). But the term PTSD might be too limiting to capture the trauma, says Daryn Reicherter, MD. He's a psychiatrist at Gardner Family Care Corporation, a behavioral health care clinic in San Jose where Morn receives treatment. Reicherter has also worked with patients through the Center for Survivors of Torture, which is also in the city.
"Cambodians are basically very similar to Holocaust survivors. They've been through a completely traumatic experience that was pretty hopeless, very violent, very graphic, where they witnessed murders and were physically tortured, raped, beaten," Reicherter says.
A 2005 study of 586 Cambodian refugees in Long Beach, CA, showed that 62% had PTSD. About 51% of the refugees had depression. Many had both.
"Even though it's been more than 30 years... they're still re-experiencing their trauma," says Yeon S. Lee, LCSW, a social worker who supervises Cambodian mental health services at Gardner. "It interferes with their life functioning. A lot of people suffer flashbacks and hear voices. They have nightmares, sometimes of people chasing them." Some endure insomnia or panic attacks.
Often, dwelling on upsetting thoughts -- an expression of anxiety -- plagues Cambodians with present-day stressors, she says. "They tend to worry about the same things over and over again.".
Chuoi Ho, 55, labored for 6 months in a Khmer Rouge camp when he was 16. His father and brother died. He escaped to South Vietnam, resettled in San Jose, and married a Cambodian woman. They raised a daughter, now 28. He struggles with nightmares, PTSD, and "a lot of depression," he says.
Ho, a small man with a gray goatee, worked at an electronics company assembling computer parts, but was laid off. He hasn't found a new job. "I became more depressed because of the financial situation," he says.
These survivors often need extensive mental health care, but cultural misunderstandings can thwart proper treatment. Few Western-trained psychiatrists understand Cambodians' experiences, Reicherter says.
Frustrated by that void, he's made several trips to Cambodia to understand cultural concepts of mental illness and effective treatments.
He discovered a gulf between Cambodian and Western beliefs.
"Some of the Cambodians have strong beliefs that are culturally appropriate -- a belief that ghosts visit them or that they interact with loved ones or other people that they lost in the killing fields," Reicherter says. But talking to ghosts might sound unusual or psychotic to Westerners, he says.
Such cultural differences have spawned serious problems. When the Gardner clinic hired Reicherter a decade ago, many patients who talked of seeing ghosts were mistakenly prescribed drugs for schizophrenia, often by doctors outside of the clinic. "That's pretty alarming," he says. "Those medicines are not without risk."
Since the clinic employs several Cambodian counselors and translators, Reicherter used their language and cultural expertise to get to the roots of patients' misdiagnoses.
Cultural insight helps to decipher other complaints as well. Like many people with mental illness, Cambodians often describe emotional distress in physical terms, Lee says, in part because of the stigma about mental health. "Rather than saying that 'I'm feeling anxious, nervous, depressed,' they'll say, 'I have stomach aches, I have body pain.' They're talking about their physical health issues before they talk about their mood or emotion."
The Next Generation
Another problem: Survivors often keep silent about life under the Khmer Rouge. They fear upsetting their children and grandchildren with talk of the past, says Theanvy Kuoch, LPC. She's the executive director of Khmer Health Advocates in West Hartford, CT. Or, survivors may have been terrorized into silence, Kuoch says. "The people who lived under the Khmer Rouge understood 100% that you must not talk at all. If you talk, you die. In order for you to survive, you must not talk at all."
When survivors don't talk, the trauma can overwhelm them and potentially deprive their children of nurturing, she says.
Kuoch was a refugee who lost 19 relatives to starvation and abuse in Cambodia. After training in cross-cultural family therapy in the U.S., she began working with Cambodian survivors of torture and persecution.
She practices "contextual family therapy," an approach that considers the individual, but aims to benefit all family members. "Cambodian families have very close ties," she says. "When you see Cambodians, you're not only seeing one member of the family, you're seeing the whole family. It's really a 'whole family' problem."
Culturally Sensitive Mental Health Care
Within Lee's program, Morn and Ho undergo treatment that blends Western and Asian practices. Both men take antidepressants and receive counseling with a professional counselor and fellow survivor who lost her three young children in Cambodia. Once a week, the two men attend a mindfulness meditation group and lecture led by a Buddhist monk. Theravada Buddhism is the main religion of Cambodia.
In that country, monks play a huge role in mental health, Lee says. "They're very influential people. They're considered a teacher, social leader, and spiritual leader. They can help people to change behavior and manage emotion and feeling."
In line with Buddhist practice, the monk guides them in training their minds to tolerate strong emotions and to let thoughts pass without judgment.
As Morn says, "The monk helps me to find a way to have peace of mind, to calm down."
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