Baksbat (broken courage): the development and validation of the inventory to measure baksbat, a Cambodian trauma-based cultural syndrome of distress

Why local concepts matter: Using cultural expressions of distress to explore the construct validity of research instruments to measure mental health problems among Congolese women in Nyarugusu refugee camp

There is considerable variation in the presentation of mental health problems across cultural contexts. Most screening and assessment tools do not capture local idioms and culturally specific presentations of distress, thus introducing measurement error and overlooking meaningful variation in mental health. Before applying screening and assessment tools in a particular context, a qualitative exploration of locally salient idioms and expression of distress can help assess whether existing measures are appropriate in a specific context as well as what adaptations may improve their construct validity. We aimed to employ a mixed-methods approach to describe and measure cultural concepts of distress among female Congolese survivors of intimate partner violence in Nyarugusu refugee camp, Tanzania. This sequential study used data from 55 qualitative (free-listing and in-depth) interviews followed by 311 quantitative interviews that included assessments of symptoms of common mental disorder to explore whether the symptom constellations were consistent across these methodologies. Results from thematic analysis of qualitative data and exploratory factor analysis of quantitative data converged on three concepts of distress: huzuni (deep sadness), msongo wa mawazo (stress, too many thoughts), and hofu (fear). The psychometric properties of these constructs were comparable to those of the three original common mental disorders measured by the quantitative symptom assessment tools-anxiety, depression, and post-traumatic stress disorder-adding weight to the appropriateness of using these tools in this specific setting. This mixed-methods approach presents an innovative additional method for assessing the local "cultural fit" of globally used tools for measuring mental health in cross-cultural research.

Key expressions of trauma-related distress in Cambodian children: A step toward culturally sensitive trauma assessment and intervention

More than half of all children in Cambodia experience direct abuse and over 70% experience other traumatic events, which significantly increase their risks for a range of physical and mental health problems. Additionally, Cambodian children face longstanding sociopolitical, intergenerational, and cultural factors that compound the impact of other trauma. As a result, rates of posttraumatic stress symptoms among Cambodian youth are high. However, care providers often rely on Western-based nosology that does not account for culturally specific expressions of trauma. A greater understanding of culturally-salient expressions of distress can help inform diagnostic assessment accuracy and treatment effectiveness and monitoring. The current study utilized a qualitative design to interview 30 Cambodian caregivers of children with trauma experiences and 30 Cambodian children (ages 10-13 years) with trauma experiences to identify key local expressions of trauma. Findings reveal certain PTSD symptoms and culturally-specific frequent and severe trauma-related problems for Cambodian children and domains of functioning impacted by trauma. Certain symptoms seem particularly important to evaluate in this group, such as anger, physical complaints (e.g., headache and palpitations), and cognitive-focused complaints (in particular, "thinking too much"). All caregivers and children reported physical health as impacted by trauma-related problems, highlighting a particularly salient domain of functioning for this population. Expressions of distress explored in the current study are discussed in the context of assessment and intervention development to inform diagnostic and clinical efforts for those working with trauma-exposed Cambodian children.

Local clinician perspectives on cause, impact, and treatment of key expressions of distress in Cambodian children

Child trauma and posttraumatic stress in Cambodia is highly prevalent, perpetuated within a postwar sociocultural context. The examination of locally meaningful expressions of distress is needed to provide culturally sensitive assessment and treatment of trauma-affected Cambodian children. The acceptable, feasible, and sustainable incorporation of expressions of distress into assessment and intervention development relies on key mental health professionals operating in Cambodia, who can provide invaluable perspectives on child trauma experiences in this particular sociocultural context. In this study, qualitative interviews were conducted with 15 Cambodian mental health professionals (MHPs) who work directly with trauma-affected Cambodian children. MHPs were presented with seven key posttraumatic problems derived from previous qualitative interviews with Cambodian children and caregivers, and discussed 1) the causes of these problems, 2) the impact of the problem on the child or those around them, 3) the current treatment for the problem in Cambodia, and 4) recommended treatment. MHPs provided unique insights and perspectives of trauma-affected children in the Cambodian context regarding key target problems, including palpitations, difficulties in school, headache, and thinking too much, and highlighted future directions for assessment and intervention. Recommendations are discussed in regard to programming design and organizational training development to promote culturally salient, feasible, and sustainable mental health service provision in Cambodia.

Causal beliefs regarding schizophrenia and help-seeking behaviors among patients with schizophrenia and family caregivers attending psychiatric clinics in Cambodia

Schizophrenia often follows a chronic or recurrent course, placing an immense burden on patients and their families. Mental health services in Cambodia are still highly limited, thus there is a major treatment gap. It is common that people consult traditional healers (Kru Khmer) and monks. In this culture, people who receive psychiatric medical treatment are expected to exhibit higher mental health literacy, but little is known about this factor. In this study, we interviewed 59 patients with schizophrenia and 59 family caregivers attending psychiatric clinics in Cambodia. Through qualitative analysis using a thematic analysis approach, we extracted eight themes of causal beliefs regarding schizophrenia: (1) spiritual beliefs, (2) cultural symptoms, (3) physical problems, (4) heredity, (5) substance abuse, (6) traumatic events, (7) stress in human relationships or in one's social environment, and (8) socioeconomic position. We found that "thinking too much" (kit chroeun) and "worrying too much" (prouy / barom chroeun), cultural idioms of distress, were recognized as causal factors of schizophrenia by both parents and family caregivers. Some participants were aware of the possible causal factors in light of the latest psychiatry findings, such as genetic factors and childhood trauma. Our data show that causal beliefs are not a decisive factor in shortening the duration of untreated psychosis (DUP). In Cambodia, where the treatment for schizophrenia is pluralistic, we suggest that it is crucial to embed the meaning of psychiatric treatment into local meaning worlds for better help-seeking behaviors.

Exposure to Starvation: Associations with HbA1c, Anthropometrics, and Trauma Symptoms Four Decades Later Among Cambodians Resettled in the USA

BACKGROUND

Epidemiological data suggest that populations exposed to starvation show increased incidence of type 2 diabetes but these studies are limited by lack of person-level data. Cambodians resettled in the USA survived severe malnutrition during distinct historical eras. We examined the relationship of individual exposure to starvation with current HbA1c, anthropometrics, and trauma symptoms among Cambodian Americans.

METHODS

Participants were excluded for extant diabetes but all had elevated risk factors for type 2 diabetes and depression. Participants identified images on a 5-point scale that best depicted their body size during four distinct periods: before 1970 (peacetime), 1970-1975 (USA bombing campaign, widespread hunger), 1975-1979 (Pol Pot regime, mass starvation), and "now" (2016-2019, resettled in the USA). They reported trauma symptoms and provided anthropometrics and a blood sample.

RESULTS

The n = 189 participants were mean = 55 years old and had glycosylated hemoglobin (HbA1c) mean = 5.5%. Self-reported body size showed excellent validity by strong correlations between body thinness "now" and objectively measured waist circumference (r =  -0.35), weight (r =  -0.50), and body mass index (r =  -0.50). Whereas there was some variability, modal self-reported body size started as normal during peacetime, became thinner during the USA bombing campaign, became emaciated during the Pol Pot regime, and rebounded to normal/slightly heavy "now." Body size during Pol Pot showed the strongest associations with long-term outcomes; thinner body size (greater starvation) was associated with higher trauma symptoms and higher HbA1c even after controlling for age, current waist circumference, and current body mass index.

CONCLUSION

Greater degree of starvation was associated with higher HbA1c and trauma symptoms four decades later.

Transgenerational Trauma and Mental Health Needs among Armenian Genocide Descendants

The trauma of a genocide can be transmitted to subsequent generations though familial mental health, sociopolitical trauma, and cultural narratives, thereby impacting mental health and well-being. Understanding specific mechanisms that are unique to each ethnic group impacted by genocide illuminates cultural, sociopolitical, and individual factors related to the transmission. For the Armenian community, the unresolved historical loss of the Armenian Genocide of 1915, with the threat of acculturation for such a large diasporic population, a continued denial by the perpetrators, as well as subsequent generations’ refugee experiences, may further exasperate the impact of transgenerational trauma from the genocide. This literature review explores the mental health needs of Armenian youth in the current sociopolitical context and provides implications for how schools and communities may use this knowledge to inform supports that center Armenian community healing. Future directions for research are also discussed.

Social disconnection and metabolic syndrome score among Cambodian Americans with depression

AIMS

Migrants experience social disconnection and also have high risk for metabolic syndrome (MetS). This study explored associations of social alienation, social isolation, and social support with MetS among Cambodian Americans.

METHODS

We conducted secondary data analysis on baseline assessments from a diabetes prevention trial for Cambodian Americans with depression and high risk for diabetes. Participants were aged 35-75, Cambodian or Cambodian-American, Khmer speaking, lived in Cambodia during the Pol Pot regime, lived in the northeastern U.S. at the time of study, endorsed elevated risk factors for diabetes and met criteria for depression by medication for depression and/or elevated depressive symptoms. They completed surveys and provided anthropometric and blood pressure measurements and fasting blood samples.

RESULTS

In multiple linear regressions, greater social alienation was associated with increased risk for MetS. The social alienation-MetS association was stronger in men than women. Associations were not better accounted for by crude indicators of social isolation such as marital status, living alone, and number of people in the household. Social support was not associated with MetS and did not buffer the deleterious association between social alienation and MetS.

CONCLUSIONS

Decreasing social alienation may mitigate risk for MetS among migrant populations.

Quality of life and its social determinants for patients with schizophrenia and family caregivers in Cambodia

Due to inadequate human and financial resource support, the development of mental health services in Cambodia has been undertaken by various non-governmental organizations (NGOs). Schizophrenia is the most common functional psychotic disorder, causing severe and chronic symptoms, and the programs provided by the NGOs should have enhanced the quality of life (QoL) of patients and their caregivers; however, epidemiological research, which is a driving force behind the recognition of mental health as a global public health concern, is lacking for schizophrenia in Cambodia. This study therefore aimed to create QoL evaluation questionnaires available in Khmer (the Cambodian language) for patients with schizophrenia and family caregivers, and to identify the social determinants and predictors of their QoL. This cross-sectional study recruited 59 patients and 59 caregivers attending three clinics operated by two NGOs: the Transcultural Psychosocial Organization (TPO) Cambodia and the Supporters for Mental Health (SUMH) Cambodia. We conducted linguistic validation of the Schizophrenia Quality of Life Questionnaire 18-item version (S-QoL 18) and the Schizophrenia Caregiver Questionnaire (SCQ), then analyzed correlations between the QoL dimensions and socio-demographic factors. The main findings of this study were as follows: 1) the newly created Khmer versions of S-QoL 18 and SCQ are relatively good psychometric tools that are suitable for research to identify patients’ and caregivers’ needs to improve their QoL; and 2) engaging in paid work or being of the post-Khmer Rouge generation results in higher QoL for patients, but having low household economic status or being affected by chronic disease leads to lower QoL for family caregivers. These findings are useful for enabling community mental health professionals and aid organizations to create programs to lessen the patient and caregiver burden in Cambodia. Further research is necessary to develop practical projects that will improve patients’ and caregivers’ QoL in various clinical settings in Cambodia.

Global Mental Health and Idioms of Distress: The Paradox of Culture-Sensitive Pathologization of Distress in Cambodia

Efforts to provide culturally appropriate global mental health interventions have included attention to local idioms of distress. This article critically examines the potential gap between lay ethnopsychological understandings of the Cambodian idiom of baksbat (broken courage) on the one hand and clinical conceptualizations of the idiom as a potential indicator of posttraumatic stress disorder. Ethnographic semi-structured interviews with trauma survivors reveal resistance to current clinical translations and hybrid Euro-Western and Khmer treatment interventions. While the notion of idioms of distress is intended to draw attention to everyday non-pathologizing forms of discourse, the creation of hybrid assessment and treatment constructs linking idioms to trauma-related pathology may obscure the pragmatic communicative functions of the idiom, making them subordinate to an existing model of psychiatric disorder and pathologizing everyday modes of coping. Participants' narratives highlight self-perceived connections between stressors that determine the trajectory and outcome of distress and shared cultural worldviews that together uniquely shape their meaning. These observations point to the dilemmas of linking idioms of distress with co-morbid illness constructs in ways that may pathologize normal emotional responses. Results have implications for efforts to develop effective models of post-conflict trauma care in global mental health.

Network models can help focus research on the role of culture and context in psychopathology, but don't discount latent variable models

Borsboom et al. correctly note that the use of latent variable models in cross-cultural research has resulted in a futile search for universal, biological causes of psychopathology; however, this is not an inevitable outcome of such models. While network analytic approaches require further development, network models have the potential to better elucidate the role of cultural and contextual variables related to psychopathology.

Cultural expressions of depression and the development of the Indonesian Depression Checklist

Depression may manifest differently across cultural settings, suggesting the value of an assessment tool that is sensitive enough to capture these variations. The study reported in this article aimed to develop a depression screening tool for Indonesians derived from ethnographic interviews with 20 people who had been diagnosed as having depression by clinical psychologists at primary health centers. The tool, which we have termed the Indonesian Depression Checklist (IDC), consists of 40 items. The tool was administered to 125 people assessed to have depression by 40 clinical psychologists in primary health centers. The data were analyzed with Confirmatory Factor Analysis (CFA) (IBM SPSS AMOS Software). CFA identified a five-factor hierarchical model ( χ ² = 168.157, p = .091; CFI = .963; TLI = .957; RMSEA = .036). A 19-item inventory of the IDC, with five factors - Physical Symptoms, Affect, Cognition, Social Engagement and Religiosity - was identified. There was a strong correlation between the total score of the IDC and total score of the Center for Epidemiological Studies-Depression scale (revised version CES-D), a standard tool for assessing symptoms of depression. The IDC accommodates culturally distinctive aspects of depression among Indonesians that are not included in the CES-D.

Conceptualizing Culturally Infused Engagement and Its Measurement for Ethnic Minority and Immigrant Children and Families

Despite the central role culture plays in racial and ethnic disparities in mental health among ethnic minority and immigrant children and families, existing measures of engagement in mental health services have failed to integrate culturally specific factors that shape these families' engagement with mental health services. To illustrate this gap, the authors systematically review 119 existing instruments that measure the multi-dimensional and developmental process of engagement for ethnic minority and immigrant children and families. The review is anchored in a new integrated conceptualization of engagement, the culturally infused engagement model. The review assesses culturally relevant cognitive, attitudinal, and behavioral mechanisms of engagement from the stages of problem recognition and help seeking to treatment participation that can help illuminate the gaps. Existing measures examined four central domains pertinent to the process of engagement for ethnic minority and immigrant children and families: (a) expressions of mental distress and illness, (b) causal explanations of mental distress and illness, (c) beliefs about mental distress and illness, and (d) beliefs and experiences of seeking help. The findings highlight the variety of tools that are used to measure behavioral and attitudinal dimensions of engagement, showing the limitations of their application for ethnic minority and immigrant children and families. The review proposes directions for promising research methodologies to help intervention scientists and clinicians improve engagement and service delivery and reduce disparities among ethnic minority and immigrant children and families at large, and recommends practical applications for training, program planning, and policymaking.

Mass fainting in garment factories in Cambodia

This paper reports an ethnographic study of mass fainting among garment factory workers in Cambodia. Research was undertaken in 2010-2015 in 48 factories in Phnom Penh and 8 provinces. Data were collected in Khmer using nonprobability sampling. In participant observation with monks, factory managers, health workers, and affected women, cultural understandings were explored. One or more episodes of mass fainting occurred at 34 factories, of which 9 were triggered by spirit possession. Informants viewed the causes in the domains of ill-health/toxins and supernatural activities. These included "haunting" ghosts at factory sites in the wake of Khmer Rouge atrocities or recent fatal accidents and retaliating guardian spirits at sites violated by foreign owners. Prefigurative dreams, industrial accidents, or possession of a coworker heralded the episodes. Workers witnessing a coworker fainting felt afraid and fainted. When taken to clinics, some showed signs of continued spirit influence. Afterwards, monks performed ritual ceremonies to appease spirits, extinguish bonds with ghosts, and prevent recurrence. Decoded through its cultural motifs of fear and protest, contagion, forebodings, the bloody Khmer Rouge legacy, and trespass, mass fainting in Cambodia becomes less enigmatic.

Testimony Therapy With Ritual: A Pilot Randomized Controlled Trial

Testimony therapy can provide low-cost, brief, simple, and culturally adaptable psychosocial services in low-income countries (Agger, Raghuvanshi, Khan, Polatin, & Laursen, 2009). Nonetheless, there have been no well-controlled studies of testimony therapy. We report the analyses of a randomized controlled trial designed to assess the effectiveness of testimony therapy plus a culturally adapted ceremony in reducing mental health symptoms among Khmer Rouge torture survivors from across Cambodia. Using multilevel modeling, we compared symptoms of posttraumatic stress disorder, anxiety, and depression between a treatment (n = 45) and a control group (n = 43) at baseline, 3 months, and 6 months. We found that testimony therapy plus ceremony significantly reduced symptoms of posttraumatic stress disorder (d = 0.49), anxiety (d = 0.44), and depression (d = 0.53).

Calming the mind: Healing after mass atrocity in Cambodia

After catastrophic events in which people's survival has been threatened, as happened during the Khmer Rouge regime in Cambodia 1975-1979, some continue to suffer from painful mental symptoms. Surveys carried out in Cambodia based on Western diagnostic categories have found a high prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in the population. This study explored Cambodian approaches to healing trauma, examining the ways in which Cambodians appeal to elements of Buddhism in their efforts to calm their minds, situating this mode of coping in the context of broader Khmer Buddhist practice and understandings. Western psychology may have much to learn from local, contextualised methods of dealing with the aftermath of trauma, including Khmer understandings of distress and approaches to relief. Methods of assessment and treatment of distress cannot be transposed wholesale from one cultural setting to another but require considerable cultural adaptation. This kind of cultural interchange may give rise to innovative, hybrid discourses and methods that may have much to offer in the support of victims of organised violence.