Proposal for Support Group Therapy
and Direct Service Approach
for Cambodian Elderly with Depression


by Sompia Paigne
Master of Social Work
California State University at Long Beach

INTRODUCTION

This proposal for support group therapy and direct service approach is designed for the Cambodian elderly who has been diagnosed with depression and is in need of support in terms of acculturation and full utilization of the resources that are available in the community. This support group therapy was further extended to meet the direct service approach in order to meet the cultural and social service needs of the group. These extended services may include serving food during group therapy and networking them with community resources. The following content of this paper will further discuss in detail the general component and structure of support group therapy as it applies to Cambodian refugee elderly.

PURPOSE OF GROUP THERAPY AND DIRECT SERVICE APPROACH

The purpose of the proposed group therapy and direct service approach for Cambodian refugee elderly is: (a) to provide culturally sensitive support group therapy in terms of mental care for depression, (b) to help them to better acculturate in their community (Long Beach, California), and (c) to provide them with a sense of freedom and access to basic needs. Services may include transportation, filling out forms for social service purposes, translation, helping with their family members' problems/concerns, and helping them to network with community resources.

THE CAMBODIAN EXPERIENCE

Cambodian refugees suffered and survived the atrocities of the Cambodian holocaust under the communist Pol Pot's Khmer Rouge regime in the mid '70s. Hundreds of thousands of civilians were subjected to work in labor camps while other civilians died from execution, starvation, or disease (Chueng, 1993). The following paragraph graphically highlights some of their grueling experiences during the Cambodian genocide.

Torture, rape, knifing or axing, beatings to the head, beatings to other parts of the body, near drowning, near suffocation with a plastic bag, murder of a family member or friend, combat situation, forced evacuation under dangerous conditions, shelling or grenade attack, imprisonment, brainwashing, being lost or kidnapped, forced labor, forced marriage, extortion or robbery by armed bandits, lack of food or water, lack of shelter, and ill-health without access to medical care, and witnessing murder of a stranger, torture, rape, knifing or axing, beatings to any parts of the body, suicide attempt, near drowning, and near suffocation with a plastic bag. (Mollica, McInnes, Poole, & Tor, 1998)
During the 1980's, Cambodian refugees experienced the further difficulties of adjusting to their new life in the United States. They are psychologically burdened by their traumatic past while at the same time experiencing the stress and demands of acculturation in their new homeland.
      A research study found Cambodians to be the least educated, most physically ill, and most depressed group among all Southeast Asian refugees who arrived in the U.S. (Meinhardt, Tom, Tse, & Yu, 1994). Another study suggested that stress is a post-emigration factor among Southeast Asian refugees, created by learning a new language, seeking employment, establishing social supports, and redefining roles (Nicholson, 1977). Due to the severity and duration of stressors, many developed the risk of serious mental health problems (Kinzie, Fredrickson, Ben, Fleck, Karls, 1984) such as depression, anxiety, and post-traumatic stress disorder (PTSD).
      Among Southeast Asian refugees, Cambodians show much higher rates for depression (80%), anxiety (88%), and PTSD (86%) (Carslon & Rosser-Hogan, 1993). Kinzie and Fleck (1987) also suggested that Cambodians are the most traumatized and are at the greatest risk for future mental health problems among Southeast Asian refugees in the U.S.
      In addition to health problems, many Cambodians experience financial difficulty which may impact their physical well-being (Rambaut, 1985). Bach (1979) reported that among Indochinese refugees, Cambodians have the lowest rate of employment. Additionally, Uba & Chung (1991) strongly suggested that pre-migration stresses effect quality of life and results in unemployment, low income, and poor health. Even after many years as residents in the U.S., many refugees are still suffering from significant mental distress and yet do not seek mental health treatment (Carlson & Rosser-Hogan, 1993). Gong-Guy and colleagues (1991) reported that mental health services that are available in the U.S. rarely offer services in the refugees' native language. The mental health services serving these refugees are geared towards helping them to gain employment and to establish financial sufficiency (Carlson & Rosser-Hogan, 1993). Overall, the service lacks psychological treatment and health professional staff who are culturally and linguistically competent in terms of treatment for the Cambodian population.

RECRUITMENT, SELECTION, LOCATION, GROUP COMPOSITION, LENGTH OF PROGRAM

The support group therapy will be held in the Asian Pacific Mental Health program in Long Beach, California. This program is a subdivision of the Los Angeles County, Department of Mental Health and its goal is to serve Asians and Pacific Islanders with mental health problems. Since most of the program's clients are Cambodian refugees, access to recruitment is an advantage for the therapist. Most Cambodian elderly clients do not read and write in Khmer or English, so a brief verbal face-to-face solicitation is necessary to recruit clients for group therapy. Additionally, all case managers, supervisors, therapists, and psychiatrists should know about the existence of this support group therapy for depressed individuals in the program. A staff meeting may be necessary to inform all staff members about the support group and to encourage them to recruit prospective clients by briefly informing their clients (who are diagnosed with depression) of the purpose of support group therapy and direct service approach and whom to contact if a client is interested in joining the group.
      The size of the support group should be limited to fifteen members. Members will be given the flexibility of joining and leaving the group at anytime they please. There are no specific rules and regulations for this group. Specific rules and regulations applied to the group may be considered to be culturally offensive to most Cambodian elderly and possibly elicit feelings of past traumatic experiences during the war. Under the Khmer Rouge, they had to adhere to strict regulations, violation of which resulted in harsh punishment or execution. Most likely, they were forced to witness the executions of other victims who did not abide by the rules.
      The composition of the group is homogeneous in terms of clients' diagnosis with depression. This group is also an open membership group serving both male and female Cambodian elderly who are age 50 and over. The length of the support group should be ongoing until there is a significant drop-out rate. Finally, the selection criteria should include clients who are diagnosed with depression and have issues with acculturation or have problems with attaining their basic needs/resources.

TYPE OF GROUP, GOALS, OBJECTIVES, TIME FRAME, TECHNIQUES, STRUCTURE/FORMAT

The type of group therapy for the Cambodian elderly will be based on the support group model. Tolseland (1990) suggested that support groups help older persons to cope with stressful situations and with transitions in their lives.
      According to Tolseland (1990), the goals of the support group is to help members cope with stressful life events and to provide social support and social contacts with one another. Members may also help each other to attain a goal. The focus of the group is to share the concerns of each member. The concerns of the Cambodian elderly may range from difficulty in filling out forms and maintaining social services benefits to dealing with the loss of family members during the genocide. Also, depending upon the nature of their concerns or issues, other focuses may include positive reinforcement, self-disclosure, empathy, self-care, mutual affirmation, and support network.
      The objectives of the support group include learning to help support each member regarding any concern or issue and learning how to express their emotions and feelings pertaining to their concerns, needs, or issues.
      The techniques of this group therapy are many and it will cover aspects that are culturally sensitive for group members. The techniques may be different than the westernized version, but it will be tailored in order to meet the cultural needs of the Cambodian elderly and to acquire trust and respect from the clients. This may include room setting, providing food, type of therapist, and other cultural practices that will be incorporated into this group therapy process.
      The support group therapy will be held weekly on Friday at 10:30 a.m. through 12:00 p.m. A Cambodian (Khmer) therapist is necessary to facilitate this group due to the language and cultural needs of the clients. Often a mental health setting and health providers may seem intimidating to the group, therefore a non-intimidating environment is important for clients to feel safe. The room for group therapy should be private and clients should be seated in chairs that are arranged in a circle. The therapist should also provide a table in the center of the circle for serving tea, fruit, and sweets that should be available to them at any time. Providing food for the Cambodian elderly is considered to be a cultural practice demonstrating respect for the elderly. Food, especially tea, is also considered to have medicinal properties and it is proper to serve it just in case a member feels uncomfortable or has a headache.
      The therapist should facilitate the group by greeting members and introducing himself/herself. Self-disclosure is necessary at this point in order to gain a sense of trust and mutual respect from the group. An example of self-disclosure may include telling the group the therapist's place of birth and family history (such as parents' name and occupation). The therapist will then ask each member to introduce himself/herself in the same manner and facilitate conversation. This is similar to the technique called "Platica" or "friendly conversation," which is one of the strategies recommended for facilitating communication with Hispanic Americans (Valle, 1980). This socialization process is necessary for the Cambodian elderly to feel comfortable and stay connected with one another while fostering respect and mutual support among each other.
      After the socialization process (the therapist should know when to end socialization and begin the next process without offending the group), the therapist should inform group members the purpose of support group therapy with direct service approach, role of the therapist, and clients' rights and confidentiality. Since most Cambodian elderly had not experienced group therapy before nor have a basic knowledge of group therapy, the therapist should encourage clients to ask questions relating to group therapy at anytime, during or after group therapy. After this group agenda is completed, the therapist should ask the group whether there are any questions or concerns they have regarding the practice of support group therapy and direct service approach.
      The second session should apply the technique of support group therapy and direct service approach while maintaining the ambiance of a safe environment. In other words, providing food and a safe, comfortable environment should be a regular practice. Based on the first session, the therapist should proceed with the group therapy process by initiating members to share their experience, concerns, and thoughts about their lives in the U.S. It has been observed that most Cambodian elderly do not consider depression a mental impairment or illness, but that it may arise from living situations and conditions such as family disruption and medical illness. It is hoped that this group therapy process will allow them to express their emotions, concerns, and needs without feeling shame or loss of dignity as a Cambodian elderly.
      New group members should be introduced to the group in the same manner as the first session; however, educating and informing them about support group therapy and direct service approach, confidentiality, and role of therapist should be conducted privately with the therapist before they join the group. The format and structure mentioned above after the first session should be conducted weekly in order to gain a sense of group cohesion.
      With regard to direct service approach, the therapist should plan activities and social gathering outside the facility about once per month. Some of the outside activities should include educating group members about transportation services or other resources that are available to them in the community. The therapist may also have to conduct a tour to give members a hands-on experience in order to develop a better sense of acculturation among group members.
      Both support group therapy and direct service approach will ultimately help the Cambodian elderly to build a sense of trust for the therapist and will help them to effectively express their emotions and needs during group therapy.

ISSUES TO ADDRESS FOR THE CAMBODIAN ELDERLY

The Cambodian elderly have various issues to contend with as refugees in their new homeland. These issues include their attitude toward mental health and its under-utilization, language and cultural barrier, and the lack of resource network with the social services in the community.
      Among Southeast Asians, there is a strong stigma attached to mental illness (Westermeyer,Vang, & Neider, 1983a). Laderman and Esterik (1988) suggested that this association is related to physical manifestation of uncontrolled emotions that are considered to be pathological and humiliating. For many Cambodians, mental illness is perceived as being in the state of "madness" requiring long-term placement in a psychiatric institution (Kleinman, 1977).
      Carlson and Rosser-Hogan (1993) reported that the Cambodian population shows a high rate of depression, anxiety, and post-traumatic stress disorder. Cambodians perceive mental health problems as indicative of "madness," "craziness," or sometimes possession by implacable spirits (Tseng, 1975). Tseng further argued that as a result, many are conditioned to think and worry about their problems in a somatic way.
      Cambodian patients often minimized their traumatic past and associated symptoms due to guilt and shame (Kinzie, Boehnlein, Leung, Moore, Riley, & Smith, 1990). Kinzie et al. (1990) further reported that they also tend to associate life events and phenomena with "animistic" or "supernaturalistic beliefs," therefore the western concept of a doctor or care provider being able to treat their emotional symptoms is regarded as strange and foreign to them.
      In addition to the risk factors of depression, the Cambodian elderly are vulnerable to cultural conflicts between their rural, low socioeconomic background and their isolated foreign status in the U.S. They not only must adjust to the western culture, but they must cope with their psychiatric impairments and problems with cultural barriers.
      In sum, the important issues to address here is the population's mental health attitudes and their reluctance to use mental health care facilities as well as social services agencies, which can help them to acculturate better in their community in terms of financial support and other social service needs. The results of the under-utilization of mental/medical health and social services may pose as high risk factors with regard to the population's poor health and high mortality rate. One limitation of the proposed support group therapy and direct service approach is that it may not be as effective as one might wish due to the population's attitudes about western therapy and other related issues of cultural conflict.

EVALUATION AND OUTCOME

There is no outcome measurement tool that is appropriate for this support group among the Cambodian elderly nor will there be a tool created to measure the group's outcome for this proposed support group and direct service approach. The reason for no measurement tool is the high illiteracy rate (both in their native language and English) among the Cambodian elderly since most are former farmers with little opportunity for a formal education. Another concern of the therapist with regard to measurement tools is the clients' possible feelings of intimidation and fear of not responding "correctly" to the measurement tool.
      An alternative way to evaluate the progress and success of each member is to conduct a group interview in the same room as the group therapy setting. The therapist should facilitate this by first informing and educating members of the process of evaluation and progress, and then have each member discuss how they feel about their own progress and what they like or dislike about group therapy. This evaluation task should be conducted every three months, and the therapist should use the results to further tailor group therapy to meet the standards of cultural sensitivity and help members progress with acculturation skills and therapeutic ways to cope with their depression.


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