Peter Pin | Migration of Memory II

Country of origin: United States
Project location: United States
Program: Magnum Foundation Fellowship
Year: 2011


In early November, 2011 Pete Pin, EF Fellow, spoke to Joyce Wong, a licensed clinical social worker, and Ousara Sophuok, a Cambodian family health worker who immigrated as a refugee from Cambodia in 1986. Joyce and Ousara work together at Montefiore Hospitalin the Bronx, New York where they provide mental health services to the Cambodian and Vietnamese Bronx community.

PETE PIN: Can you describe the clinic and the work you do here in the Bronx?

JOYCE WONG: We have been providing out-patient mental health services for the last twenty years as part of a collaboration between the Department of Psychiatry and Family Medicine. We are part of an urban medical center but we actually modeled our program after the Harvard Program in Refugee Trauma who were pioneers in the identification and treatment of torture and mass violence. With the program, mental health care is integrated in a community healthcare setting as a truly collaborative model of care.

Cambodian refugees were resettled in the Bronx in the mid-1980's and came to our clinic for healthcare. However, physicians were not equipped to deal with a lot of the medical and psychiatric problems the patients presented. Not only were medical problems associated with lack of access to medical care—as many refugees were living and languishing in refugee camps between five to ten years—but many patients suffered from psychiatric trauma from the Khmer Rouge Regime (1975-1979).

In the mid 1980's, we partnered with the departments of psychiatry and family medicine at Montefiore and developed a collaboration with a small mental health program to attempt to address some of these problems. At that time non-governmental organizations, especially abroad, addressed the problems of food, clothes and shelter for persons who had undergone mass violence, trauma and natural disaster. But the NGOs did not usually address their mental health needs. My colleagues at Harvard were one of the first to conduct scientific research studies when Cambodian refugees were living in refugee camps in Thailand, and found that high levels of depression existed within the refugee camps. When the refugees were resettled here in the Bronx , the focus on the mental health care needs of refugees was very progressive for that time. It was a holistic approach. This was over twenty years ago.

But how do you present mental health to someone who does not have a western frame of reference or worldview? A lot of the work in the first years was getting to know the community and going out to the community because you're not going to expect someone to come to your door even if they are living across the street from your clinic. We established a motto of "Eat, Work and Play": eating with the community, working with the community, and playing with the community. It meant attending weddings we were invited to, attending important religious holidays at the local Buddhist temple, conducting home visits to get a sense of the social issues that the people in the community were facing, walking up and down Fordham Road in the Bronx.

PIN: Were there things unique about the Cambodian community in regards to their trauma and their history that compounded the difficulty of providing services and hindered their ability as individuals and a community to assimilate and to make that transition from the camps to America?

WONG: It was very difficult for Cambodians because during the genocide between one to three million people were killed from a population of seven million. Much of the educated population of Cambodia was killed. Many of the surviving Cambodians that were able to flee and escape to refugee camps were rice farmers who didn't have high levels of literacy in their own language or education. In contrast, many other immigrant groups came from countries where there was a solid infrastructure, where there's a high level of educational attainment, and this really influences their experiences when they come to the United States. It affects their ability to navigate in their new home country and what opportunities are available to them on a day to day. The refugees that came to the Bronx from Cambodia were already a disenfranchised community and further marginalized because they were resettled in a physically and economically distressed community. To compound this, not being able to read and write, not having access to resources because of the language was a barrier on all levels: education, work, and health.

PIN: Sarah can you discuss your work in the community and how you became involved in the clinic? It's important to stress to readers that you are yourself a member of the Bronx Cambodian refugee community, that you immigrated here under the exact circumstances as the people you have been providing services to.

OUSARA SOPHUOK: Joyce Wong had mentioned that during the war a lot of educated individuals were killed and the majority of our patients, especially the ones that came for care at our clinic, didn't have a lot of formal education, including myself. During the war I didn't have a lot of education, I only finished a few years in school. I escaped to a refugee camp where I studied English for six months. When I arrived to New York there was a temple three blocks from this clinic I went to regularly. That's how the community got together. I arrived 1986 and I went to the temple where they had a Cambodian women's program where I studied English.

One day there was a person from Adelphi University who was recruiting people for training in human services and a job program. They wanted us to go for field placement. At that time I didn't know what I wanted so I said, "I want to work on something that relates to the community and I can help people" although I could not even help myself at that point. It was what I wanted to do, so they said "Ok you can do your field placement at the temple." When I was doing my field placement my English was not great and I was so nervous to be doing the work. Then I looked at the people that were going to the ESL class at the temple, and I realized I knew more English than them because I studied it in the refugee camp. I said to myself, "These community members need more help than I do." That's what gave me a lot of courage to go to school. I went to the training for six months and at the time when I graduated from the program they were looking to hire someone to work in the mental health clinic for Cambodian and Vietnamese refugees at Montefiore.

I grew up in a family that served the community, which is where my desire to help others comes from. My father used to be a Buddhist monk in the Bronx temple and we went to the temple all the time. We prayed and ate together there so I really knew the community before I started working here. Like Joyce had mentioned, we had to eat and play so I went to the temple and I recruited people. I explained to them what I was doing and the services we had here. The people trusted me because my father was the monk in the temple and people trusted him.

PIN: When you approached people to talk about the services here, how did you phrase it, how did you talk to people? You obviously played a very pivotal role in the outreach.

SOPHUOK: At that time it was very difficult to translate from English to Khmer. The word psychiatrist, psychiatry or mental health literally translates to "crazy." It's a very strong word so I used the word "emotional health." Instead of physical health I said emotional health and I explained to them that we have the clinic here and the doctor will take care of your physical health and we will take care of your emotional health. You have to educate the people that emotional and physical is the same, that they're very connected to each other. This is critical because we went through a lot of trauma during the war.

At first, it was difficult for people to understand. Traditionally we didn't talk about mental health and our feelings; we always suppressed this during the war. You didn't say anything during the war, you kept everything inside to survive; you acted as if you were dumb. There's a Cambodian word a ting mong meaning a scarecrow on the farm. We called ourselves a ting mong because we acted as if we didn't know anything. We hid our intelligence to survive.

WONG: The Khmer Rouge had a slogan: "To destroy you is no loss, to keep you is no gain." If you're constantly told that you're not of any value and disposable, something happens to your psyche which has ramifications for survival at that time but also psychological consequences in the future.

PIN: Is this something that you see manifesting itself decades after?

WONG: It was a coping mechanism during the war for survival, but as you said it had repercussions for the future. The a ting mong mentality became so ingrained during the genocide and the refugee years, that even after immigrating to the U.S. many Cambodians continued to wear that cloak. If you don't bring the trauma into consciousness, then it continues to manifest itself and weigh on you every day.

PIN: You carry the weight of that with you. For me I think that's very critical, the residual affects of trauma; that's something the academic and resettlement community doesn't widely recognize. There hasn't been a lot of work on residual trauma, and this perspective is brand new in regards to the need to provide holistic, culturally sensitive mental health services to refugees that takes into account their unique circumstances.

SOPHUOK: We had to get people to understand that the clinic was a very safe place to talk about our emotional health. I had to convince them that if they said something wrong here they were not going to get killed and that here in the clinic we take care of their emotional needs. And then the people started to open their minds a little bit and began to trust us. After a few years, the program expanded by word of mouth, the doctors, and self referrals.

PIN: Please describe the community within the first year or two here in the Bronx, how their experiences were, even your experience, during that transition in the first several years of resettlement?

SOPHUOK: It was very difficult even for myself. I encountered a lot of difficulties even though I spoke a little bit of English. It was very scary to go outside and it was very difficult to go somewhere because of the culture shock. The culture was different. The living situation was different. The first years were difficult because we couldn't go anywhere. We were like children learning how to walk step by step. We learned how to walk block by block. At that time we could only go to the temple and a Cambodian store that opened in the community. So people were not able to take the train or bus to travel outside of the neighborhood. We were both scared to get lost and confined. I'm of course talking about myself—that I felt confined—but I know that other people felt confined too. Imagine the older Cambodians who didn't speak English. The first year was very difficult. Even now there are a lot of Cambodians who are ill and remain confined.

PIN: Yes. A lot of people don't realize this. When I talk outside the Cambodian community the usual response is "that's just the immigrant story," that it's the normal transition for immigrants when they resettle. As if all these issues can be generalized for all immigrants. However, obviously there are very unique circumstances that are endogenous to the Cambodian community as a result of the specific historical circumstances of their displacement and the resultant demographic outcomes as a result of the genocide.

WONG: Exactly. And refugees are disproportionately affected because of the multiple past trauma events of undergoing a war and genocide. The average number of trauma events a Cambodian refugee has undergone is 16. From torture, starvation, separation of family and friends, witnessing of killing, rape, and slave labor. So it's not just acculturation, but the refugee's past traumas and the resulting possible psychiatric distress and disability. Furthermore, these refugees were situated in economically distressed communities.

PIN: Please talk about the outreach in terms of strategies you talked about; eat, work and play?

WONG: Like our colleagues at Harvard, our approaches were a little unconventional and off-the-beaten path in trying to recruit and present ourselves in a way that community members would trust us. That really meant getting out there in the community and talking to people. Advocating for social changes, injustices. Challenging slum landlords in housing court, accessing social services, creating art programs that community members could participate in to beautify there community. The best forums usually are established places or places of faith, which play a very large role in community members' lives. As Sarah said we often visited the temple on major holidays, made home visits, and attended weddings, funerals, religious ceremonies. We have always had a big component of also providing social services to meet the psychosocial needs of the community. We've had the privilege of being here for twenty years so we have followed people through the lifecycle; many of the patients grew up with us. We have been there through their marriages, through having children, through having teenage children, pregnancies, domestic violence, alcoholism, poverty, discrimination, deportation, etc. We really have run through the gamut in regards to problems and scenarios that community members have faced.

But one thing I think was pivotal for us during our time here is the realization that although mental health is very important, it's important to stress economic and social sustainability. That comes from building community and empowering it through self-determination. So our approach has always been holistic. It was crucial when we partnered with the Committee Against Anti-Asian Violence in the Bronx, a grassroot organization in New York in the mid 1990's. I just felt that at some point maybe six years after we started providing services, doors were closing on our community members. I didn't feel they were progressing socially or economically; not because they didn't want to but because of lack of investment of the US government and other institutions. So we partnered with The Committee Against Anti-Asian Violencethrough their youth leadership development project to organize and advocate for economic, social and health justice on behalf of the refugee community. We began to organize the community around other issues such as welfare rights, education rights, immigration rights, language rights, and accessing comprehensive healthcare. Witnessing the community mobilizing themselves and taking action was a highlight of my career. It was liberating to actually see the community developing consciousness and building its confidence.

If you ask me, as you've said before "how is it different?" I would say old models of recovery aren't really effective anymore, and the humanistic/holistic approach to recovery is crucial. I really do feel hopeful with our community. I've seen that people really can recover from mass trauma and violence and can live very productive lives and can begin to trust other people again.

PIN: How have your patients progressed over this life cycle?

WONG: It's a reality that some things may never really go away. Patients and community members still suffer from major depression; they still suffer from post-traumatic stress disorder. It doesn't go away. But even if you have these psychiatric conditions, you can learn how to cope and live a fulfilling rich life. That's huge. And that gives me hope. Our patients can still enjoy life, can still have positive healthy relationships with other people; you don't have to be so isolated. I tell them they are not experiencing these things because of bad karma but because they underwent genocide and that it's a normal reaction to terrible horrific events. I think it's very reassuring and relieving for suffering people.

PIN: Sarah, can you elaborate on that?

SOPHUOK: I just want to add a point—about patients learning to cope, and learning the result of the war was no fault of their own. For some patients with severe psychiatric problems, the process was very slow. We had to work very hard. We encourage them to do things that relieve them of suffering such as exercising, walking daily, socializing at the Buddhist temple, engaging in meaningful activities, being of service to others.

WONG: This patient Sarah is referring to goes to the gym two to three times a week. This was somebody who was completely homebound and confined when we started treating her 15 years ago. She was paralyzed with her story and with her pain. So she's still limited in many ways but now she feels she has some control over the quality of her life and pain. She can do things for herself: she can lead a more productive life. For us, progress doesn't always translate into a job. And although we feel work is a great value, being productive could also mean going to the park three times a week to meet your friends, or going to the temple on a daily basis. All of these activities are of great value and have a lot of healing qualities.

PIN: Again, that's one of the issues: the old models of treatment are limited to the idea of providing English instruction and jobs.

WONG: Yes, it's short-term thinking and a residual form of social welfare.

PIN: Yes, and what's great about this is the fact that you have been providing services for over twenty years and it remains an ongoing process. You have acknowledged the reality that severe trauma does not magically go away.

WONG: Yes, it doesn't go away but the way they see their lives, and the way they live their lives can still change. They are survivors, not victims anymore.

PIN: There's a generation of Cambodians who immigrated here as teenagers or children, who came here when they were 14 or 15 and started high school here in the Bronx, or like myself were born in refugee camps but were raised in the inner-city; their experiences are very different because of their age. For the young Cambodians I met in the Bronx—and I think this goes across the board for all Cambodian diaspora communities in America—they have experienced their own unique forms of trauma inherited from their parents and compounded by the social ills of the inner-city.

When we started this interview, I played an audio clip of a teen I photographed in the Bronx who was speaking about her experience in regards to her parent's trauma. You can hear a hint of trauma in her voice. For me it's very profound how trauma can be passed on generationally. This is something I see in my own life. Have you treated people like this?

WONG: Yes, definitely. Within the last year there was a young Cambodian woman in her thirties and she was severely tortured during the Khmer Rouge.

This particular woman is a single mother with a seven-year-old daughter. She is one of the more traumatized and depressed patients that I have seen in a long time. It was just so clear how her depression and post-traumatic stress was affecting her relationship with her daughter. The little girl was taking care of her mother. Her mother was usually very depressed, very angry, and not able to parent her daughter in a consistent way. When I would ask, "Are you able to cook for your daughter or spend time with your daughter" she would respond, "No, I buy Chinese food or my daughter cooks her own meals." Her daughter was going to sleep after eleven o'clock because her mother was not able to set boundaries and limits. The daughter was put in the role of an adult and that clearly affected the mother's ability to be a parent.

Most of our patients are on psychotropic medication because it decreases their flashbacks, depressive and anxiety symptoms. This has helped her. Once her symptoms were relieved a bit, we were able to start talking about the importance of creating a secure and loving attachment with her daughter. When you're that depressed it's difficult to have an understanding of how your mental health problems can or are affecting your child and make the necessary changes.

PIN: What is your assessment of the community now? You've told me that you feel very hopeful, can you elaborate on that?

SOPHUOK: I feel very hopeful because our patients have received services and medication to help relieve them of their symptoms from trauma. They can now participate in community organizations like the Committee Against Anti Asian Violence and Mekong. With community organizational support, plus the temple our clinic that makes me very hopeful for the future. But still we need more. We do not have enough services for our community, which limits our progress but we have been actively working on Mekong.

WONG: I just feel hopeful to hear Cambodian youth say, "We want to be in charge of our community, we want to promote culture and dignity and we want to heal our community." This makes me feel very hopeful. With these ideas we began to envision Mekong an emerging organization in New York City that will serve Southeast Asians by trying to improve the quality of life through community organizing, promoting arts, culture, language, and social services. It is a holistic approach to community organizing. Since last year we have been working with CAAAV to transition the Youth Leadership Project into an independent organization after a community needs assessment of Southeast Asians was conducted by emerging local leadership. On March 29, 2012 we will officially launch Mekong and that is something to celebrate and embrace. I would like to think that I've contributed a little grain of sand that creates hope and power.