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Normal Grief and Complicated Bereavement Among Traumatized Cambodian Refugees: Cultural Context and the Central Role of Dreams of the Dead

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Abstract

This article profiles bereavement among traumatized Cambodian refugees and explores the validity of a model of how grief and post-traumatic stress disorder (PTSD) interact in this group to form a unique bereavement ontology, a model in which dreams of the dead play a crucial role. Several studies were conducted at a psychiatric clinic treating Cambodian refugees who survived the Pol Pot genocide. Key findings included that Pol Pot deaths were made even more deeply disturbing owing to cultural ideas about “bad death” and the consequences of not performing mortuary rites; that pained recall of the dead in the last month was common (76 % of patients) and usually caused great emotional and somatic distress; that severity of pained recall of the dead was strongly associated with PTSD severity (r = .62); that pained recall was very often triggered by dreaming about the dead, usually of someone who died in the Pol Pot period; and that Cambodians have a complex system of interpretation of dreams of the deceased that frequently causes those dreams to give rise to great distress. Cases are provided that further illustrate the centrality of dreams of the dead in the Cambodian experiencing of grief and PTSD. The article shows that not assessing dreams and concerns about the spiritual status of the deceased in the evaluation of bereavement results in “category truncation,” i.e., a lack of content validity, a form of category fallacy.

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Notes

  1. Some use the term “bereavement” to refer to the state of having lost someone and the term “grief” to indicate the reaction to the loss.

  2. See too the following DSM-V website: http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=577

  3. To provide context for loss numbers, totaling together living and deceased relatives, participants had a mean of 5.0 siblings (SD = 2.3) and 4.8 children (SD = 2.5).

  4. Immediate cremation of those who had a “bad death” was thought to produce a dangerous “heat”—heat is considered to be an inauspicious element—that might bring illness and hardship to all in the surrounding area.

  5. Such deaths are referred to as inauspicious, and there is a suggestion of demerit. Not being reborn may also be attributed to “inauspiciousness,” a system of explanation that parallels closely the “demerit” explanatory frame.

  6. For example, one patient’s husband suddenly died at a young age owing to hypertension, and it upset her that even after 2 months he had not visited her in dream; consequently, she would go to sleep holding his photograph, hoping for such a dream. Clearly then, dreams can also help the bereavement process, creating a transitional period of farewell.

  7. For example, merit-making can be done through the gift-bestowal ritual (bangsoekool), which sends merit, food, and various objects to the deceased (see Table 2 for a description of the gift-bestowal ritual, or bangsoekool).

  8. In fact, key rituals and events begin at the moment of death. Ideally, when a relative passes away, one should be present, which is called “being on time for the last breath” (tdoeun danghaeum), and some patients feel quite badly if they miss this moment. Not only ritual but also mental state affects rebirth: it is believed that upon dying one should be feeling happy and peaceful and be thinking auspicious thoughts in order to facilitate rebirth.

  9. Some of the dead become “Preta,” who are greatly suffering beings: they have very thin necks and extremely narrow esophagi that make eating extremely difficult and they have very large stomachs that indicate the degree of hunger. It is thought that Preta can more easily eat the special rice offered at the holiday.

  10. In another common merit-making activity, laypersons place money and rice into monk bowls that have been positioned in a line on a table.

  11. Upon making this prayer, the celebrant presses the hands together to make the typical greeting and prayer gesture in which the hands are cupped together to mimic the shape of a lotus bud; next the celebrant raises the cupped hands so that the tips of the index fingers reach the forehead.

  12. There is a cultural mandate to make merit for all deceased relatives, but it is strongest for a child towards a parent because of the expectation that children show gratitude to parents by performing merit-making actions.

  13. The shaving of all hair is considered a sacrifice that is merit-making because it entails giving up a possession of pride and baldness makes one resemble a monk.

  14. Food given to the dead is referred to by the special term “samnaeng.” This differs from the word used to describe food eaten by people, which is “meuhoup.” This linguistic system creates the sense of another realm. Amplifying this sense of separate realms, the Cambodian language has multiple terms to refer to the process of eating depending on the status of the eater: for animals, “sii”; for children or lower classes of persons, “nyam”; for higher status persons, “pisaa”; for monks, “tdeutduel tdieun”; and for ghosts, “phsaep phsaoy.” Also, the word for “eat” for ghosts is very closely related to the word for “smoke,” which is “phsaeng,” ghosts are thought to eat the food carried to them through the smoke of candles and incense.

  15. Some patients consider wearing white to be auspicious, but not this patient.

  16. The patient also still had monthly dreams of when she had been tortured, namely, being hit, having her nails pulled out, being caressed when she was tied up, and being threatened with rape.

  17. Moreover, sometimes the relative was seen being taken away or being killed, so that this memory may be invoked upon thinking nostalgically of the deceased.

  18. Eisenbruch (1991) includes “social loss” in the definition of his term “cultural bereavement,” but it would seem that social loss represents a different category. Concern about the loss of cultural traditions or access to traditional foods might be more accurately called “cultural loss” or “cultural nostalgia,” with the term “bereavement” best applied to the effect of the death of family and friends and the term “social loss” indicating a broader category that includes both separation by death and separation by living far apart.

  19. Kleinman (1998) discusses the concept of sociosomatics, how social distress moves into the body. Here there is a local theory of how bereavement distress moves into the body.

  20. The current study also casts some doubt on the cross-cultural validity of one of the bereavement criterion: avoiding thoughts of the deceased. Cambodians place great emphasis on thinking about the deceased, such as when doing the “recalling-with-gratitude” ritual, when making food offerings at the home altar, or when asking that the deceased be reborn. These are private memorialization rituals that involve invoking the deceased and evoking their image and presence. Cambodians believe that the deceased may still maintain a relationship with the living. In Western groups with complicated bereavement, complicated bereavement is strongly marked by avoidance of prior shared activities, people, and reminders of the loss. Thus, in certain cultural contexts, approach rather than avoidance may be more emphasized in bereavement. Even in Western, English-speaking populations, approach behaviors may be emphasized in bereavement, such as being drawn to reminders of the deceased (Simon, et al. 2011).

  21. In a particular cultural group, the clinician needs to determine whether dreams of the deceased occur more often near the time of major holidays and if so whether the living perform certain activities for the deceased during that time or the deceased visit the living. In such cultural contexts, nostalgic recall of the dead may be much more acute, or even limited to, those periods around major holidays. Such dreams are considered deeply upsetting because of what they indicate about the spiritual state of the deceased, and bereavement may well extend throughout the year in the absence of further dreams of the deceased during the year.

  22. In bereavement, culturally specific processes of somatization include metaphor-guided somatization: coldness in the body evoking a sense of loss of human connection.

  23. As indicated above, in many Cambodian idioms “cooling” is often considered therapeutic. But there are phrases representing human contact and close human connection as “warmth” (kokdaw), with cold extremities often occurring during thinking of the deceased, as documented in the study. Hence, coining warms the limbs to counter the actual physical coldness of vasoconstriction and creates a sense of bodily warmth to counter the metaphoric sense of coldness.

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Hinton, D.E., Peou, S., Joshi, S. et al. Normal Grief and Complicated Bereavement Among Traumatized Cambodian Refugees: Cultural Context and the Central Role of Dreams of the Dead. Cult Med Psychiatry 37, 427–464 (2013). https://doi.org/10.1007/s11013-013-9324-0

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