Wednesday, September 29, 2010

Cambodian woman's mental illness, family members' murders in Seattle linked to trauma of the past

From the Seattle Times:

Like thousands of her countrymen, Saroeun Phan (pictured) fled Cambodia's genocide in the late 1970s, hiking through the jungle for days before reaching Thailand.

She left behind the horror of Pol Pot's Khmer Rouge, which exterminated as many as 3 million people through execution, torture and starvation, forcing many into labor camps.

Local mental-health providers, citing privacy laws, could not talk about Phan, who killed three family members and wounded her daughter on Sept. 23 in her West Seattle home before committing suicide.

But they say the events Phan and thousands of other refugees experienced in Cambodia still haunt them and can exacerbate underlying mental-health problems. And because of a stigma many feel toward mental illness, refugees like Phan often have difficulties seeking help or sticking with treatment.

Family members said Phan, 60, had struggled with depression and schizophrenia for years. They were unsure whether she'd been taking her medication in the past few months.

"I don't think anybody can really appreciate the horror that was Cambodia," said Dr. Carey Jackson, medical director of the international clinic at Harborview Medical Center. Studies showed the average Cambodian refugee family experienced seven traumatic events — more than twice as many as other Southeast Asian refugees — including torture, rape, watching the torture or rape of a loved one, imprisonment and warfare, he said.

"They frequently don't talk about it," said Jackson, an internist. "There's nothing there they're particularly proud of, so they don't pass it on to their kids. They sublimate it; they push it down ...

"They are literally haunted people."

Phan's family members recalled how she would become agitated and fearful, reacting to the sound of gunfire in a video game, thinking someone was trying to kill her.

She was mugged recently on Beacon Hill and became fearful of going out alone, said her husband, Chhoey Sok. She took a self-defense class and learned to shoot a gun, he said.

Researchers say Cambodian women in particular are at greater risk for developing serious mental-health problems.

"It is reality for many of our community members who have to relive that traumatic situation," said Yoon Joo Han, director of the behavioral health program at Asian Counseling and Referral Service.

For some Cambodians, the Asian counseling center may use nontraditional techniques such as acupuncture or enlisting a shaman, she said. The challenge is made more difficult by the stigma many Southeast Asian refugees feel about mental illness. That, coupled with schizophrenia's very nature, "makes it very hard for our clients to take medication," Han said.

Some of that reluctance is based on history, she said. Many have come from cultures where, in the past, "if you have mental illness, you were taken involuntarily and locked up forever, with no treatment and no rights."

It's more difficult for people from Southeast Asian cultures, she said, to see mental illness in the same way they see physical illness — as something that, if treated, can get better.

"That understanding of mental health needs to happen in our community," she said. "Unless people gain insight to their status and need for the medication, it's always hard to convince people to take medication."

For older people, there's also a certain amount of pride, said Sopha Danh at the White Center Community Development Association. "They think they should be wiser than to have such problems," she said.

Phan had received some type of care at Harborview Medical Center, but she hadn't been seen there for about seven years. The family last week was unable to share any details about her recent treatment.

Mental-health providers also said modern life is difficult for Cambodian elders, even without diagnosed mental illness. While older people are respected in traditional Cambodian culture for their wisdom, older refugees who resettle often find themselves lost in their new life.

The farming skills they once mastered — reading the wind and weather — aren't helpful in a new and foreign urban environment.

"All the things that they knew were useless here," Han said. "The family is broken down. It is very, very difficult."

Here, many refugees also face financial hardships that make it difficult to get treatment or medication. Mental-health providers said all services are squeezed by budget cuts and the many people seeking treatment.

When an illness causes a patient to begin skipping medication and other help, intensive follow-up is needed, said Jackson, of Harborview Medical Center.

"Those services are eroding," he said. "It's harder in the community to get both primary care and mental-health services for the chronically mentally ill. There are a limited number of providers and limited numbers of resources for managing issues of language and culture."