The Journal of General Psychology, 118(3),215-225
The Relationship Between Trauma and Financial and Physical Well-Being Among Cambodians in the United States LAURA UBA Department of Psychology and Department of Anthropology California State University,Northridge RITA CHI-YING CHUNG National Research Center on Asian American Mental Health University of California at Lm Angeles
ABSTRACT. This study focused on the relationship between trauma and financial and physical well-being of Cambodian refugees in the United Sates. Trauma was defined by three variables: whether or not trauma had been experiencedin Cambodia, the number of traumas experienced, and the number of years spent in refugee camps. It was hypothesized that these trauma variables would predict financial and physical health among Cambodians in the United States. A discriminant analysis showed significant relationships between the trauma variables and current employment status, and multiple regression analyses showed that trauma predicted income and physical health. CAMBODIAN REFUGEES generally immigrated to the United States after 1978 in response to the Vietnamese invasion of Cambodia, Khmer Rouge atrocities, and guerilla warfare in Cambodia. Before arriving in the United States, these refugees were exposed to a number of traumatic events that occurred during the war, the escape, and in the refugee camps. They were separated from family members, many of whom died in labor camps or were This study was supported by the National Research Center on Asian American Mental Health [NIMH #ROI MH443311 and the Medical Research Council of New Zealand Fellowship. The authors wish to thank Asian Community Mental Health Services in Oakland, California. Requestsfor reprints should be sent to Laura Uba, Department of Psychology, California State University, Northridge, 181I1 Nordhoff St. -PSYC,Northridge, CA 91330. 215
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The Journal of General Psychology
murdered. They witnessed atrocities and were forced to commit them, sometimes on their own families. Many refugees were victims of guerilla warfare, starvation, rape, and assault. After often harrowing escapes from their homeland, they were forced to live for months or years in overcrowded, unsanitary refugee camps while waiting to be resettled. These traumas did not leave the refugees unscathed (Nicassio & Pate, 1984). Yet when studying the effects of the traumas, researchers have focused on a relatively narrow range of effects: Historically, those studying trauma among Southeast Asian refugees have focused on the psychiatric effects of trauma (Beiser, ’hmer, & Ganesan, 1989; Hussain, 1984; Kinzie, Sack, Angell, Manson, & Rath, 1986; Lin, 1986; Rumbaut, 1985; Van Deusen, 1982). As Hussain (1984) noted, the effects of trauma may have wider implications, but little is known about the effects of trauma on nonpsychiatric forms of wellbeing. Our study examines some of the wider implications of the effects of trauma on Cambodian refugees. We proposed that the effects of traumatic experiences are not restricted to clinical psychological problems but may also extend to and be manifested in other areas of life in a nonclinical population. Rather than investigating the effects of trauma on clinical psychological dysfunction, our study examines whether there is a relationship between the Cambodian refugees’ traumatic experiences and two other areas of their wellbeing, namely, their current financial status and physical health. These aspects of well-being are examined because we believe that they are important determinants of self-sufficiency and well-being. Moreover, the refugees have financial problems (Rumbaut, 1985) and health problems (Rumbaut, 1985; Van Deusen, 1982). In this study, we examined whether traumatic experiences may be one factor that underlies these problems. We hypothesized that past traumatic experiences would predict current financial status, our reasoning being that time and effort spent coping with traumatic experiences would detract from the refugees’ ability to focus on financial advancement. Evidence (Lin, Tazuma, & Masuda, 1979; Westermeyer, Callies, & Neider, 1990) that psychological functioning is relevant to financial status among Southeast Asian refugees supports this expectation. Furthermore, Bach (1979) found that the rate of employment for Indochinese refugees in the United States was similar to that of the general population, yet the Cambodian employment rate is especially low. It should be noted that Cambodian refugees generally experienced more trauma than other Southeast Asian refugees (Rumbaut, in press). We also hypothesized that prior traumatic experiences would predict current physical health because traumas can entail physical abuse that could have lasting effects on health, or traumas may be manifested as psychosomatic disorders.
Method Subjects This study is based on a nonclinical, random sample of 590 Cambodians and is a secondary analysis of the California Southeast Asian Mental Health Needs Assessment study conducted by Asian Community Mental Health Services in Oakland, California (Gong-Guy, 1987). The respondents ranged in age from 18 to 68, with a mean of 36 years. Males were 49.2% (n = 290) and females were 50.8% (n = 300) of the sample. Table 1 summarizes additional sample characteristics. The sample appears to be representative of Cambodians in the United States. For example, annual family income averages ranged from $8,118 to $11,698. This seems to reflect the 1980 Census (General Accounting Office, 1990) figures, which showed a median family income of $8,712 for Cambodians. As our sample did, the 1980 Census showed slightly more females than males among U.S. Cambodians. Procedure Sampling. We used multicluster sampling in various counties in California. Our colleagues with a knowledge of Cambodian residential patterns helped with the initial selection of neighborhoods and apartment houses. We asked every nth household within a cluster for permission to interview. The refusal rate was less than 1%. Training interviewers. Standardized interviews were conducted in Khmer. Each interviewer completed a minimum of 6 hours of training that included
TABLE 1 Summary of Sample’s Characteristics Characteristics
%
Employment status Working Unemployed Homemaker Students Other (disabled, retired, etc.) Experienced trauma
18 34 3 19 26 43
Nore. Mean numbers of years subjects spent in refugee camps and in the United States were 3.20 and 4.70.respectively.
2 18
The Journal of General Psychology
practice with interviewing techniques and a thorough word-by-word review of the questionnaire to clarify any misunderstandings. To ensure that interview training was consistent from site to site, training in each location adhered closely to an interviewer training manual based on Rumbaut’s (1985) Indochinese Health Adaptation Research Project. Each interviewer was given a copy of this manual. Among the issues covered in the manual were sampling procedures, the importance of confidentiality, and the importance of adhering to the established protocol. Questionnaire. The questions addressed issues that included history of traumas, current psychological functioning, current financial status, and current physical health, as well as demographic information. To ensure that interviewers understood the nature of each question, their interpretations were cross-checked with oral back-translations of the standardized English interview. Each interview lasted at least 1 hour. Measures. To assess whether the experience of trauma was related to financial status and physical health, traumatic experiences were defined by three variables: (a) Given a dichotomy of 0 (no) and 1 (yes), respondents were asked whether they had experienced trauma in Cambodia that continued to affect them. (To ensure that the respondents understood what was meant by “trauma,” they were given examples of traumas such as separation or loss of family members, imprisonment, and torture.) (b) Respondents were asked the number of traumas experienced; and (c) Respondents were asked the number of years they had spent in refugee camps because other research (Beiser, lhrner, & Ganesan, 1989) has indicated that the refugee camps often presented traumatic experiences. The Health Opinion Survey (Leighton, Harding, Mecklin, MacMillan, & Leighton, 1963) was used to measure psychological functioning. Four factors were identified using principal components analysis with a varimax rotation. Each item loaded .30 or above on each factor. The psychosocial dysfunction factor, consisting of 11 items (alpha coefficient = .95), addressed such issues as the degree to which nervousness or worry had physically affected the respondents, caused problems with their family life or social activities, and impeded their ability to work. Respondents answered on a 5-point scale from never (1) to all the rime ( 5 ) . The general psychopathology factor (alpha = .81) included 8 items addressing issues such as how often respondents had unwelcome or strange thoughts that frightened them, thought people were following them or plotting against them, became upset and irritable with those around them, had feelings of unreality, and saw or heard things that other people did not. Responses were rated on a 5-point scale from never (1) to all the rime ( 5 ) .
Uba & Chung
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The anxiety factor consisted of 15 items (alpha = .89), such as how often respondents’ hands trembled, whether their hands or feet felt damp and clammy, and whether they had experienced strong heartbeats, sleep problem, nightmares, cold sweats, upset stomach, or loss of appetite. Respondents noted their answers on a 3-point scale from never (1) to ofen (3). The depression factor, consisting of 11 items (alpha = .85), included questions such as how often respondents wondered whether anythmg was worthwhile, had crying spells or felt like crying, did not enjoy doing things, felt alone and helpless, felt that life was hopeless, felt that people did not care what happened to them, or had trouble sleeping. The depression factor was based on responses measured on a 3-point scale from never (1) to ofen (3). To measure financial status, respondents were asked (a) whether they were currently employed or unemployed, on strike, or laid off, and (b) their current annual family income. Because variance in family income could be a function of the number of family members employed, the respondents were also asked how many family members had jobs. On a 5-point scale from excellent (1) to very bud ( 5 ) respondents described their physical health during the last 12 months. Demographic information was also obtained for age and gender with 0) male and 1) female. ?kro statistical techniques were used to examine the relationships between traumatic experiences and financial and health status: a discriminant analysis for the relationship between traumatic experiences and employment status, because the latter is a nominal variable, and multiple regression for all other instances because they involved continuous variables.
Results Trauma was defined in terms of whether or not trauma had been experienced that still affected the respondents, the number of traumas experienced, and the number of years spent in refugee camps. Correlations for whether trauma had been experienced with number of traumas and number of years in refugee camps were .84, p < .001, and .lo, p < .002,respectively. The correlation for number of traumas with number of years in refugee camps was .07, p < .03. Both, whether trauma had been experienced that still disturbed the respondent and the number of traumas experienced, were included in the model despite their high correlation because the tolerance levels indicated that the two measures were not redundant and thus not multicollinear. Hypothesis 1: Past traumatic experiences will predict current financial status. To test the first hypothesis, a discriminant analysis of the trauma variables and employment status was conducted. Inasmuch as the aforementioned research literature has suggested a relationshipbetween traumatic experiences and psychological functioning, the four measures of psychological functioning were included as control variables, as were age and gender. The discrim-
220
The Journal of General Psychology
inant analysis (n = 293; Wilks's lambda = .744;p = .OOO) showed significant relationships between the trauma variables and employment status, thus supporting the first hypothesis. The results of this analysis are presented in Table 2. The relationships between employment status and each individual trauma variable taken separately were in the expected direction: Respondents who had experienced a trauma that still disturbed them, had experienced more traumas, or spent more years in refugee camps were more likely to be unemployed, All the controlling variables were also significant. Multiple regression analysis was performed on the trauma variables and income, controlling for the number of family members employed, age, gender, and the four psychological functioning measures. The correlation between employment status and income was not very high (r = .175);therefore, employment status was also used as a controlling factor. The results of this analysis are presented in Table 3. The multiple regression analysis also supported the first hypothesis: The overall model was significant, r2 = .233; F(11,570) = 1 5 . 4 3 ; ~= .OOO. The most significant trauma predictors were whether or not trauma had been experienced that still disturbed the respondents, and the number of traumas experienced. Unexpectedly, the respondents who had experienced trauma that continued to disturb them were more likely to have a higher income. However, the experience of many traumas predicted lower incomes. Of the variables controlled for, the most important predictors were the number of family members employed and age. TABLE 2 Relationship Between 'lkauma and Employment Status Characteristics Whether trauma experienced Number of traumas Number of years in refugee camp Age Gender General psychopathology Psychosocial dysfunction Anxiety Depression
Rb
F
.28 .26
.33
.so
7.99** 6.53** 24.62***
.56 .30
.69 .29 .40 .71 .7 1 .62
47.15*** 8.23**
SCDa
.lo
- .07
- .10 .36 .I8 .02
15.69***
50.83*** 49.69*** 38.24***
Standardized canonical discriminant function coefficients. Correlations between discriminating variables and canonical discriminant functions. * p = .05. ** p = .01. *** p = .001.
UbaBrChung
221
TABLE 3 Relationship Between 'kauma and Income Characteristics Whether trauma experienced Number of traumas Number of years in refugee camp Employment status Number of family members employed Age Gender General psychopathology Psychosocial dysfunction Anxiety Depression
P
Pl'
.21 -.13 - .06
- .07 - .06
- .03
- .03
.42
- .08 - .04 .03 .07 - .08 - .07
.12
.42
- .M - .04 - .02 .04
- .05 - .04
t
3.12**
- 1.96* - 1.58
- .83 11.39*** - 1.98* - .96 .54 1.01 - 1.30 - 1.02
Partial correlation. * p = .05. * * p = .01. ***p = .001.
Hypothesis2: Experiencing traumas will predict current physical health. To test the second hypothesis, a multiple regression analysis was performed on the trauma variables and current physical health, controlling for income, gender, and age. Table 4 displays the results of this analysis, which supported the second hypothesis. The overall model was significant: f l = S12; F(10, 556) = 5 7 . 1 9 ; ~= .OOO. The number of traumas experienced was the most important of the trauma predictors. Respondents who had experienced more traumas tended to be in worse health. The significant controlling variables were age, gender, psychosocial dysfunction, and anxiety. Our findings suggest that it is sometimes important to differentiate between whether or not trauma was experienced and the number of traumas experienced: The number of traumas experienced may be a significant predictor, whereas whether or not trauma has been experienced is not. To illustrate this point, the number of traumas experienced predicted the respondent's current health but whether or not trauma had been experienced did not.
Discussion In a discriminant analysis, significant relationships were found between the trauma variables and employment status. A multiple regression analysis showed the trauma variables predicted income. In light of the fact that psy-
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The Journal of General Psychology
TABLE 4 Relationship Between 'hauma and Physical Health
Characteristics Whether trauma experienced Number of traumas Number of years in refugee camp Income Age Gender General psychopathology Psychosocial dysfunction Anxiety Depression
P
Pr"
- .08
- .04
.ll .06
.06 .06
- .05
- .05
.19 .07 - .01 .I7 .39 .06
.17 .07
- .oo
.10 .24 .03
t
- 1.48 2.13* 1.91 - 1.78
5.78***
2.22* -.15 3.41*** 8.16*** .99
.Partialcorrelation. *p = .05. * * p = .01. * * * p = ,001.
chological functioning was controlled for in both analyses, it appears that the refugees' traumatic experiences may have affected their financial status independently of the effects of psychopathology: Coping with a traumatic history is distinct from coping with the psychological dysfunction that may arise from the traumatic history, and coping with a traumatic history may in itself affect financial achievement. A multiple regression analysis supported our hypothesis concerning the relationship between traumatic experiences and physical well-being. It may be that traumatic experiences affected the respondents' current health because many of the traumas the Cambodians experienced included physical hardships, such as torture or labor camps, that caused lasting physical ills. Poor health care in refugee camps may have compounded health problems (Liem, 1980). Another possibility is that the Cambodians are somatizing their traumas (Lin, 1986; Owan, 1985). Unexpectedly, we found that respondents who experienced traumas that continue to disturb them are more likely to have higher incomes. Possibly, having experienced a trauma caused the refugees to recognize the degree to which their vulnerability (e.g., the inability to keep the family together, afford transportation, or obtain food) was rooted in a lack of financial resources and consequently they worked harder than those who had not experienced such trauma so that they would have money in the future. Another possibility is that those who experienced trauma feel guilty that they survived and feel they owe it to their families to become successful or to sublimate their guilt-driven anxiety into economic striving. Or, those who experienced trauma may be trying to recapture self-esteem that was damaged during the traumatic expe-
UbaBiChung
223
riences by becoming financially self-sufficient. However, a number of traumas may have pushed the refugees beyond a coping threshold and had the opposite effect. Surprisingly, the number of years the Cambodians spent in refugee camps did not predict income or health. It may be that, as Beiser, ' lh e r , and Ganesan (1989) suggest, the traumas of the refugee camps recede with time. The results, although significant, did not reveal high beta scores for individual trauma variables. Obviously, other variables also affect financial and health status. The Southeast Asians continue to be bombarded by life changes (Masuda, Lm, & Tazuma, 1980) and new challenges, such as learning English, becoming accustomed to American ways, developing skills that are appropriate to the American economy, and coping with cultural conflicts and racism. Our study does highlight, however, that the traumatic experiences in Asia continue to affect the current financial and health status of Cambodians in the United States even though the Cambodians in the sample had lived in the United States for an average of almost 5 years. Others (Lin,1986; Lin, Masuda, & Tazuma, 1980) have noted that traumatic experiences may have a delayed and recurrent effect on psychological functioning. Our findings suggest that traumatic experiences may also have such an effect on the Cambodian refugees' financial and physical health. Furthermore, the effects of traumatic experiences are not limited to clinical populations. Over 40% of this random, nonclinical sample of Cambodians experienced traumas and the results of ow study suggest that their premigration traumas still d e c t the quality of their lives. That the sample of Cambodians in our study was entirely from California is one of its limitations. However, the sample was from a variety of counties and seemed to reflect census demographics. Another limitation of our study is that because some Southeast Asians earn money illegally, the respondents may or may not have been honest about their current income. .In addition, there was no objective measure of traumatic experiences, which might or might not have been phenomenologically valid, and no examination by a physician that could be used as an additional measure of current health. It could be argued that those with lower income or poorer health for some reason consciously remember more traumas than those with higher incomes or those who describe their health as better, but such an interpretation is not likely in this case. If respondents accounted for their low income or poor health by saying they remember more traumas, one would expect them to report that they experienced traumas that continue to disturb them. The results of our study indicate otherwise, however. Furthermore, it is inappropriate to posit that those Cambodian refugees who are currently unemployed, have low incomes, or are unhealthy voluntarily subjected themselves to more trauma; the traumatic experiences were thrust upon them (Beiser, 'lher, & Ganesan,
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1989). Thus, the results of our study suggest that traumatic experiences are among the causes of unemployment, low income, and poor health in US. Cambodian refugees.
REFERENCES Bach, R. L. ( 1979). Employment characteristics of Indochinese refugees. Washington, DC: U.S.Department of Labor. Beiser, M., 'hmer, R. J., & Ganesan, S. (1989). Catastrophic stress and factors affecting its consequences among Southeast Asian refugees. Social Science Medicine, 26, 183-195. General Accounting Office. (1990). Asian Americans: A status report. (Contract No. HRD-90-36FS). Washington, DC: United States General Accounting Office. Gong-Guy, E. (1987). California Southeast Asian mental health needs assessment. Oakland: Asian Community Mental Health Services. Hussain, M. F. (1984). Race related illness in Vietnamese refugees. International Journal of Social Psychiatry, 30, 153-156. Kinzie, J. D., Sack, W., Angell, R., Manson. S., & Rath, B. (1986). The psychiatric effects of massive trauma on Cambodian children. I. The children. Journal of the American Academy of Child Psychiatry, 25, 370-376. Leighton, D. C., Harding, J. S., Mecklin, D. B., MacMillan. A., & Leighton. A. H. (1963). The character of danger. New York: Basic Books. Liem, N. D. (1980). The resettlement of Vietnamese refugees. Journal of AsianPacijic & World Perspectives, 4 , 39-50. Lin, K. M. (1986). Psychopathology and social disruption in refugees. In C. L. Williams & J. Westermeyer (Eds.), Refugee mental health in resettlement countries. (pp. 61-73). Washington, DC: Hemisphere Publishing. Lin, K., Masuda, M., & Tazuma, L. (1980). Adaptational problems of Vietnamese: 1975-1978. Paper presented at the Second Pacific Congress of Psychiatry, Manila, Philippines. Lin, K., Tazuma, L., & Masuda, M. (1979). Adaptation problems of Vietnamese refugees: Health and mental health status. Archives of General Psychiatry, 36, 955-96 1 . Masuda, M., Lin, K., & Tazuma, L. (1980). Adaptational problems of Viemamese refugees. Archives of General Psychiatry, 37, 447-450. Nicassio, P. M. & Pate, J. K. (1984). An analysis of problems of resettlement of the Indochinese refugees in the United States. Social Psychiatry, 19, 135-141. Owan, T. (1985). Southeast Asian mental health: Transition from treatment to prevention-a new direction. In T.C. Owan (Ed.), Southeast Asian mental health: Treatment,prevention, services, training, and research. pp. 141-168 Washington, DC: National Institute of Mental Health. Rumbaut, R. G. (1985). Mental health and the refugee experience: A comparative study of Southeast Asian refugees. In T. C. Owan (Ed.), Sourheast Asian mental health: Treatment, prevention, services, training, and research. pp. 433-486. Washington, DC: National Institute of Mental Health. Rumbaut, R. G.(in press). The agony of exile: A study of the migration and adaptation of Indochinese refugee adults and children. In F. Ahearn & J. Garrison (Eds.), Refugee children: Theory, research, and practice. Baltimore: Johns Hopkins University Press.
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Van Deusen, J. M. (1982). HealWmental health studies of Indochinese refugees: A critical overview. Medical Anthropology, 6, 23 1-252. Westermeyer, J., Callies, A., & Neider, J. (1990). Welfare status and psychosocial adjustment among 100 b o n g refugees. Journal of Nervous and Mental Disease. 178, 300-306.
Received October 9, I990
The Relationship Between Trauma and Financial and Physical Well-Being Among Cambodians in the United States LAURA UBA Department of Psychology and Department of Anthropology California State University,Northridge RITA CHI-YING CHUNG National Research Center on Asian American Mental Health University of California at Lm Angeles
ABSTRACT. This study focused on the relationship between trauma and financial and physical well-being of Cambodian refugees in the United Sates. Trauma was defined by three variables: whether or not trauma had been experiencedin Cambodia, the number of traumas experienced, and the number of years spent in refugee camps. It was hypothesized that these trauma variables would predict financial and physical health among Cambodians in the United States. A discriminant analysis showed significant relationships between the trauma variables and current employment status, and multiple regression analyses showed that trauma predicted income and physical health. CAMBODIAN REFUGEES generally immigrated to the United States after 1978 in response to the Vietnamese invasion of Cambodia, Khmer Rouge atrocities, and guerilla warfare in Cambodia. Before arriving in the United States, these refugees were exposed to a number of traumatic events that occurred during the war, the escape, and in the refugee camps. They were separated from family members, many of whom died in labor camps or were This study was supported by the National Research Center on Asian American Mental Health [NIMH #ROI MH443311 and the Medical Research Council of New Zealand Fellowship. The authors wish to thank Asian Community Mental Health Services in Oakland, California. Requestsfor reprints should be sent to Laura Uba, Department of Psychology, California State University, Northridge, 181I1 Nordhoff St. -PSYC,Northridge, CA 91330. 215
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The Journal of General Psychology
murdered. They witnessed atrocities and were forced to commit them, sometimes on their own families. Many refugees were victims of guerilla warfare, starvation, rape, and assault. After often harrowing escapes from their homeland, they were forced to live for months or years in overcrowded, unsanitary refugee camps while waiting to be resettled. These traumas did not leave the refugees unscathed (Nicassio & Pate, 1984). Yet when studying the effects of the traumas, researchers have focused on a relatively narrow range of effects: Historically, those studying trauma among Southeast Asian refugees have focused on the psychiatric effects of trauma (Beiser, ’hmer, & Ganesan, 1989; Hussain, 1984; Kinzie, Sack, Angell, Manson, & Rath, 1986; Lin, 1986; Rumbaut, 1985; Van Deusen, 1982). As Hussain (1984) noted, the effects of trauma may have wider implications, but little is known about the effects of trauma on nonpsychiatric forms of wellbeing. Our study examines some of the wider implications of the effects of trauma on Cambodian refugees. We proposed that the effects of traumatic experiences are not restricted to clinical psychological problems but may also extend to and be manifested in other areas of life in a nonclinical population. Rather than investigating the effects of trauma on clinical psychological dysfunction, our study examines whether there is a relationship between the Cambodian refugees’ traumatic experiences and two other areas of their wellbeing, namely, their current financial status and physical health. These aspects of well-being are examined because we believe that they are important determinants of self-sufficiency and well-being. Moreover, the refugees have financial problems (Rumbaut, 1985) and health problems (Rumbaut, 1985; Van Deusen, 1982). In this study, we examined whether traumatic experiences may be one factor that underlies these problems. We hypothesized that past traumatic experiences would predict current financial status, our reasoning being that time and effort spent coping with traumatic experiences would detract from the refugees’ ability to focus on financial advancement. Evidence (Lin, Tazuma, & Masuda, 1979; Westermeyer, Callies, & Neider, 1990) that psychological functioning is relevant to financial status among Southeast Asian refugees supports this expectation. Furthermore, Bach (1979) found that the rate of employment for Indochinese refugees in the United States was similar to that of the general population, yet the Cambodian employment rate is especially low. It should be noted that Cambodian refugees generally experienced more trauma than other Southeast Asian refugees (Rumbaut, in press). We also hypothesized that prior traumatic experiences would predict current physical health because traumas can entail physical abuse that could have lasting effects on health, or traumas may be manifested as psychosomatic disorders.
Method Subjects This study is based on a nonclinical, random sample of 590 Cambodians and is a secondary analysis of the California Southeast Asian Mental Health Needs Assessment study conducted by Asian Community Mental Health Services in Oakland, California (Gong-Guy, 1987). The respondents ranged in age from 18 to 68, with a mean of 36 years. Males were 49.2% (n = 290) and females were 50.8% (n = 300) of the sample. Table 1 summarizes additional sample characteristics. The sample appears to be representative of Cambodians in the United States. For example, annual family income averages ranged from $8,118 to $11,698. This seems to reflect the 1980 Census (General Accounting Office, 1990) figures, which showed a median family income of $8,712 for Cambodians. As our sample did, the 1980 Census showed slightly more females than males among U.S. Cambodians. Procedure Sampling. We used multicluster sampling in various counties in California. Our colleagues with a knowledge of Cambodian residential patterns helped with the initial selection of neighborhoods and apartment houses. We asked every nth household within a cluster for permission to interview. The refusal rate was less than 1%. Training interviewers. Standardized interviews were conducted in Khmer. Each interviewer completed a minimum of 6 hours of training that included
TABLE 1 Summary of Sample’s Characteristics Characteristics
%
Employment status Working Unemployed Homemaker Students Other (disabled, retired, etc.) Experienced trauma
18 34 3 19 26 43
Nore. Mean numbers of years subjects spent in refugee camps and in the United States were 3.20 and 4.70.respectively.
2 18
The Journal of General Psychology
practice with interviewing techniques and a thorough word-by-word review of the questionnaire to clarify any misunderstandings. To ensure that interview training was consistent from site to site, training in each location adhered closely to an interviewer training manual based on Rumbaut’s (1985) Indochinese Health Adaptation Research Project. Each interviewer was given a copy of this manual. Among the issues covered in the manual were sampling procedures, the importance of confidentiality, and the importance of adhering to the established protocol. Questionnaire. The questions addressed issues that included history of traumas, current psychological functioning, current financial status, and current physical health, as well as demographic information. To ensure that interviewers understood the nature of each question, their interpretations were cross-checked with oral back-translations of the standardized English interview. Each interview lasted at least 1 hour. Measures. To assess whether the experience of trauma was related to financial status and physical health, traumatic experiences were defined by three variables: (a) Given a dichotomy of 0 (no) and 1 (yes), respondents were asked whether they had experienced trauma in Cambodia that continued to affect them. (To ensure that the respondents understood what was meant by “trauma,” they were given examples of traumas such as separation or loss of family members, imprisonment, and torture.) (b) Respondents were asked the number of traumas experienced; and (c) Respondents were asked the number of years they had spent in refugee camps because other research (Beiser, lhrner, & Ganesan, 1989) has indicated that the refugee camps often presented traumatic experiences. The Health Opinion Survey (Leighton, Harding, Mecklin, MacMillan, & Leighton, 1963) was used to measure psychological functioning. Four factors were identified using principal components analysis with a varimax rotation. Each item loaded .30 or above on each factor. The psychosocial dysfunction factor, consisting of 11 items (alpha coefficient = .95), addressed such issues as the degree to which nervousness or worry had physically affected the respondents, caused problems with their family life or social activities, and impeded their ability to work. Respondents answered on a 5-point scale from never (1) to all the rime ( 5 ) . The general psychopathology factor (alpha = .81) included 8 items addressing issues such as how often respondents had unwelcome or strange thoughts that frightened them, thought people were following them or plotting against them, became upset and irritable with those around them, had feelings of unreality, and saw or heard things that other people did not. Responses were rated on a 5-point scale from never (1) to all the rime ( 5 ) .
Uba & Chung
219
The anxiety factor consisted of 15 items (alpha = .89), such as how often respondents’ hands trembled, whether their hands or feet felt damp and clammy, and whether they had experienced strong heartbeats, sleep problem, nightmares, cold sweats, upset stomach, or loss of appetite. Respondents noted their answers on a 3-point scale from never (1) to ofen (3). The depression factor, consisting of 11 items (alpha = .85), included questions such as how often respondents wondered whether anythmg was worthwhile, had crying spells or felt like crying, did not enjoy doing things, felt alone and helpless, felt that life was hopeless, felt that people did not care what happened to them, or had trouble sleeping. The depression factor was based on responses measured on a 3-point scale from never (1) to ofen (3). To measure financial status, respondents were asked (a) whether they were currently employed or unemployed, on strike, or laid off, and (b) their current annual family income. Because variance in family income could be a function of the number of family members employed, the respondents were also asked how many family members had jobs. On a 5-point scale from excellent (1) to very bud ( 5 ) respondents described their physical health during the last 12 months. Demographic information was also obtained for age and gender with 0) male and 1) female. ?kro statistical techniques were used to examine the relationships between traumatic experiences and financial and health status: a discriminant analysis for the relationship between traumatic experiences and employment status, because the latter is a nominal variable, and multiple regression for all other instances because they involved continuous variables.
Results Trauma was defined in terms of whether or not trauma had been experienced that still affected the respondents, the number of traumas experienced, and the number of years spent in refugee camps. Correlations for whether trauma had been experienced with number of traumas and number of years in refugee camps were .84, p < .001, and .lo, p < .002,respectively. The correlation for number of traumas with number of years in refugee camps was .07, p < .03. Both, whether trauma had been experienced that still disturbed the respondent and the number of traumas experienced, were included in the model despite their high correlation because the tolerance levels indicated that the two measures were not redundant and thus not multicollinear. Hypothesis 1: Past traumatic experiences will predict current financial status. To test the first hypothesis, a discriminant analysis of the trauma variables and employment status was conducted. Inasmuch as the aforementioned research literature has suggested a relationshipbetween traumatic experiences and psychological functioning, the four measures of psychological functioning were included as control variables, as were age and gender. The discrim-
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The Journal of General Psychology
inant analysis (n = 293; Wilks's lambda = .744;p = .OOO) showed significant relationships between the trauma variables and employment status, thus supporting the first hypothesis. The results of this analysis are presented in Table 2. The relationships between employment status and each individual trauma variable taken separately were in the expected direction: Respondents who had experienced a trauma that still disturbed them, had experienced more traumas, or spent more years in refugee camps were more likely to be unemployed, All the controlling variables were also significant. Multiple regression analysis was performed on the trauma variables and income, controlling for the number of family members employed, age, gender, and the four psychological functioning measures. The correlation between employment status and income was not very high (r = .175);therefore, employment status was also used as a controlling factor. The results of this analysis are presented in Table 3. The multiple regression analysis also supported the first hypothesis: The overall model was significant, r2 = .233; F(11,570) = 1 5 . 4 3 ; ~= .OOO. The most significant trauma predictors were whether or not trauma had been experienced that still disturbed the respondents, and the number of traumas experienced. Unexpectedly, the respondents who had experienced trauma that continued to disturb them were more likely to have a higher income. However, the experience of many traumas predicted lower incomes. Of the variables controlled for, the most important predictors were the number of family members employed and age. TABLE 2 Relationship Between 'lkauma and Employment Status Characteristics Whether trauma experienced Number of traumas Number of years in refugee camp Age Gender General psychopathology Psychosocial dysfunction Anxiety Depression
Rb
F
.28 .26
.33
.so
7.99** 6.53** 24.62***
.56 .30
.69 .29 .40 .71 .7 1 .62
47.15*** 8.23**
SCDa
.lo
- .07
- .10 .36 .I8 .02
15.69***
50.83*** 49.69*** 38.24***
Standardized canonical discriminant function coefficients. Correlations between discriminating variables and canonical discriminant functions. * p = .05. ** p = .01. *** p = .001.
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TABLE 3 Relationship Between 'kauma and Income Characteristics Whether trauma experienced Number of traumas Number of years in refugee camp Employment status Number of family members employed Age Gender General psychopathology Psychosocial dysfunction Anxiety Depression
P
Pl'
.21 -.13 - .06
- .07 - .06
- .03
- .03
.42
- .08 - .04 .03 .07 - .08 - .07
.12
.42
- .M - .04 - .02 .04
- .05 - .04
t
3.12**
- 1.96* - 1.58
- .83 11.39*** - 1.98* - .96 .54 1.01 - 1.30 - 1.02
Partial correlation. * p = .05. * * p = .01. ***p = .001.
Hypothesis2: Experiencing traumas will predict current physical health. To test the second hypothesis, a multiple regression analysis was performed on the trauma variables and current physical health, controlling for income, gender, and age. Table 4 displays the results of this analysis, which supported the second hypothesis. The overall model was significant: f l = S12; F(10, 556) = 5 7 . 1 9 ; ~= .OOO. The number of traumas experienced was the most important of the trauma predictors. Respondents who had experienced more traumas tended to be in worse health. The significant controlling variables were age, gender, psychosocial dysfunction, and anxiety. Our findings suggest that it is sometimes important to differentiate between whether or not trauma was experienced and the number of traumas experienced: The number of traumas experienced may be a significant predictor, whereas whether or not trauma has been experienced is not. To illustrate this point, the number of traumas experienced predicted the respondent's current health but whether or not trauma had been experienced did not.
Discussion In a discriminant analysis, significant relationships were found between the trauma variables and employment status. A multiple regression analysis showed the trauma variables predicted income. In light of the fact that psy-
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TABLE 4 Relationship Between 'hauma and Physical Health
Characteristics Whether trauma experienced Number of traumas Number of years in refugee camp Income Age Gender General psychopathology Psychosocial dysfunction Anxiety Depression
P
Pr"
- .08
- .04
.ll .06
.06 .06
- .05
- .05
.19 .07 - .01 .I7 .39 .06
.17 .07
- .oo
.10 .24 .03
t
- 1.48 2.13* 1.91 - 1.78
5.78***
2.22* -.15 3.41*** 8.16*** .99
.Partialcorrelation. *p = .05. * * p = .01. * * * p = ,001.
chological functioning was controlled for in both analyses, it appears that the refugees' traumatic experiences may have affected their financial status independently of the effects of psychopathology: Coping with a traumatic history is distinct from coping with the psychological dysfunction that may arise from the traumatic history, and coping with a traumatic history may in itself affect financial achievement. A multiple regression analysis supported our hypothesis concerning the relationship between traumatic experiences and physical well-being. It may be that traumatic experiences affected the respondents' current health because many of the traumas the Cambodians experienced included physical hardships, such as torture or labor camps, that caused lasting physical ills. Poor health care in refugee camps may have compounded health problems (Liem, 1980). Another possibility is that the Cambodians are somatizing their traumas (Lin, 1986; Owan, 1985). Unexpectedly, we found that respondents who experienced traumas that continue to disturb them are more likely to have higher incomes. Possibly, having experienced a trauma caused the refugees to recognize the degree to which their vulnerability (e.g., the inability to keep the family together, afford transportation, or obtain food) was rooted in a lack of financial resources and consequently they worked harder than those who had not experienced such trauma so that they would have money in the future. Another possibility is that those who experienced trauma feel guilty that they survived and feel they owe it to their families to become successful or to sublimate their guilt-driven anxiety into economic striving. Or, those who experienced trauma may be trying to recapture self-esteem that was damaged during the traumatic expe-
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riences by becoming financially self-sufficient. However, a number of traumas may have pushed the refugees beyond a coping threshold and had the opposite effect. Surprisingly, the number of years the Cambodians spent in refugee camps did not predict income or health. It may be that, as Beiser, ' lh e r , and Ganesan (1989) suggest, the traumas of the refugee camps recede with time. The results, although significant, did not reveal high beta scores for individual trauma variables. Obviously, other variables also affect financial and health status. The Southeast Asians continue to be bombarded by life changes (Masuda, Lm, & Tazuma, 1980) and new challenges, such as learning English, becoming accustomed to American ways, developing skills that are appropriate to the American economy, and coping with cultural conflicts and racism. Our study does highlight, however, that the traumatic experiences in Asia continue to affect the current financial and health status of Cambodians in the United States even though the Cambodians in the sample had lived in the United States for an average of almost 5 years. Others (Lin,1986; Lin, Masuda, & Tazuma, 1980) have noted that traumatic experiences may have a delayed and recurrent effect on psychological functioning. Our findings suggest that traumatic experiences may also have such an effect on the Cambodian refugees' financial and physical health. Furthermore, the effects of traumatic experiences are not limited to clinical populations. Over 40% of this random, nonclinical sample of Cambodians experienced traumas and the results of ow study suggest that their premigration traumas still d e c t the quality of their lives. That the sample of Cambodians in our study was entirely from California is one of its limitations. However, the sample was from a variety of counties and seemed to reflect census demographics. Another limitation of our study is that because some Southeast Asians earn money illegally, the respondents may or may not have been honest about their current income. .In addition, there was no objective measure of traumatic experiences, which might or might not have been phenomenologically valid, and no examination by a physician that could be used as an additional measure of current health. It could be argued that those with lower income or poorer health for some reason consciously remember more traumas than those with higher incomes or those who describe their health as better, but such an interpretation is not likely in this case. If respondents accounted for their low income or poor health by saying they remember more traumas, one would expect them to report that they experienced traumas that continue to disturb them. The results of our study indicate otherwise, however. Furthermore, it is inappropriate to posit that those Cambodian refugees who are currently unemployed, have low incomes, or are unhealthy voluntarily subjected themselves to more trauma; the traumatic experiences were thrust upon them (Beiser, 'lher, & Ganesan,
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The Journal of General Psychology
1989). Thus, the results of our study suggest that traumatic experiences are among the causes of unemployment, low income, and poor health in US. Cambodian refugees.
REFERENCES Bach, R. L. ( 1979). Employment characteristics of Indochinese refugees. Washington, DC: U.S.Department of Labor. Beiser, M., 'hmer, R. J., & Ganesan, S. (1989). Catastrophic stress and factors affecting its consequences among Southeast Asian refugees. Social Science Medicine, 26, 183-195. General Accounting Office. (1990). Asian Americans: A status report. (Contract No. HRD-90-36FS). Washington, DC: United States General Accounting Office. Gong-Guy, E. (1987). California Southeast Asian mental health needs assessment. Oakland: Asian Community Mental Health Services. Hussain, M. F. (1984). Race related illness in Vietnamese refugees. International Journal of Social Psychiatry, 30, 153-156. Kinzie, J. D., Sack, W., Angell, R., Manson. S., & Rath, B. (1986). The psychiatric effects of massive trauma on Cambodian children. I. The children. Journal of the American Academy of Child Psychiatry, 25, 370-376. Leighton, D. C., Harding, J. S., Mecklin, D. B., MacMillan. A., & Leighton. A. H. (1963). The character of danger. New York: Basic Books. Liem, N. D. (1980). The resettlement of Vietnamese refugees. Journal of AsianPacijic & World Perspectives, 4 , 39-50. Lin, K. M. (1986). Psychopathology and social disruption in refugees. In C. L. Williams & J. Westermeyer (Eds.), Refugee mental health in resettlement countries. (pp. 61-73). Washington, DC: Hemisphere Publishing. Lin, K., Masuda, M., & Tazuma, L. (1980). Adaptational problems of Vietnamese: 1975-1978. Paper presented at the Second Pacific Congress of Psychiatry, Manila, Philippines. Lin, K., Tazuma, L., & Masuda, M. (1979). Adaptation problems of Vietnamese refugees: Health and mental health status. Archives of General Psychiatry, 36, 955-96 1 . Masuda, M., Lin, K., & Tazuma, L. (1980). Adaptational problems of Viemamese refugees. Archives of General Psychiatry, 37, 447-450. Nicassio, P. M. & Pate, J. K. (1984). An analysis of problems of resettlement of the Indochinese refugees in the United States. Social Psychiatry, 19, 135-141. Owan, T. (1985). Southeast Asian mental health: Transition from treatment to prevention-a new direction. In T.C. Owan (Ed.), Southeast Asian mental health: Treatment,prevention, services, training, and research. pp. 141-168 Washington, DC: National Institute of Mental Health. Rumbaut, R. G. (1985). Mental health and the refugee experience: A comparative study of Southeast Asian refugees. In T. C. Owan (Ed.), Sourheast Asian mental health: Treatment, prevention, services, training, and research. pp. 433-486. Washington, DC: National Institute of Mental Health. Rumbaut, R. G.(in press). The agony of exile: A study of the migration and adaptation of Indochinese refugee adults and children. In F. Ahearn & J. Garrison (Eds.), Refugee children: Theory, research, and practice. Baltimore: Johns Hopkins University Press.
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Van Deusen, J. M. (1982). HealWmental health studies of Indochinese refugees: A critical overview. Medical Anthropology, 6, 23 1-252. Westermeyer, J., Callies, A., & Neider, J. (1990). Welfare status and psychosocial adjustment among 100 b o n g refugees. Journal of Nervous and Mental Disease. 178, 300-306.
Received October 9, I990
