"Everybody suffers": Karen refugee women's experiences and ...
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"Everybody suffers": Karen refugee women's experiences and conceptualisations of wellbeing and distress Author: Watkins, Paula Grace Publication Date: 2012 DOI: https://doi.org/10.26190/unsworks/15635 License: https://creativecommons.org/licenses/by-nc-nd/3.0/au/ Link to license to see what you are allowed to do with this resource. Downloaded from http://hdl.handle.net/1959.4/52081 in https:// unsworks.unsw.edu.au on 2022-07-06
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"Everybody suffers": Karen refugee women's experiences andconceptualisations of wellbeing and distress
Author:Watkins, Paula Grace
Publication Date:2012
DOI:https://doi.org/10.26190/unsworks/15635
License:https://creativecommons.org/licenses/by-nc-nd/3.0/au/Link to license to see what you are allowed to do with this resource.
Downloaded from http://hdl.handle.net/1959.4/52081 in https://unsworks.unsw.edu.au on 2022-07-06
“Everybody Suffers”:
Karen Refugee Women’s Experiences and Conceptualisations of
Wellbeing and Distress
Paula Grace Watkins
A thesis submitted in fulfilment
of the requirements for the
Degree of Doctor of Philosophy
School of Public Health and Community Medicine
University of New South Wales
Sydney Australia
October 2012
ii
iii
Originality Statement
I hereby declare that this submission is my own work and to the best of my knowledge
it contains no materials previously published or written by another person, or substantial
proportions of material which have been accepted for the award of any other degree or
diploma at UNSW or any other educational institution, except where due
acknowledgement is made in the thesis. Any contribution made to the research by
others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in
the thesis. I also declare that the intellectual content of this thesis is the product of my
own work, except to the extent that assistance from others in the project’s design and
conception or in style, presentation and linguistic expression is acknowledged.
Signed …………………………………………
Date ……………………………………………
iv
Copyright Statement
I hereby grant the University of New South Wales or its agents the right to archive and
to make available my thesis or dissertation in whole or part in the University libraries in
all forms of media, now or here after known, subject to the provisions of the Copyright
Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to
use in future works (such as articles or books) all or part of this thesis or dissertation.
I also authorise University Microfilms to use the 350 word abstract of my thesis in
Dissertation Abstract International (this is applicable to doctoral theses only).
I have either used no substantial portions of copyright material in my thesis or I have
obtained permission to use copyright material; where permission has not been granted I
have applied/will apply for a partial restriction of the digital copy of my thesis or
dissertation.
Signed …………………………………………
Date ………………………………… …………
Authenticity Statement
I certify that the Library deposit digital copy is a direct equivalent of the final officially
approved version of my thesis. No emendation of content has occurred and if there are
any minor variations in formatting, they are the result of the conversion to digital
format.
Signed …………………………………………
Date ……………………………………………
v
Dedication
Here we live in a country that is peaceful, we don’t have to worry for anything
at all. But we worry for those left behind. We wonder how they live. We
wonder what they eat. (Mëh Luh)
This thesis is dedicated to “those left behind”, to those who struggle(d) for peace in
Burma, and to the participants and Karen community in Sydney who shared their
stories, lives and knowledge with me.
vi
Why do we tend to think in dichotomies? What is the primal factor that makes
us prefer black or white to grey, ecstatic sin or salvation to mundane daily
indecision, fervent conviction or denial to reasoned uncertainty, friend or
enemy to neutrality? Whatever it is, it often drives people to hatred and warfare
in the interpersonal and political spheres, as well as to intellectual confusion in
medicine, philosophy, and science. This love of simply splitting into extreme
groups tends to lead us to think not only in dichotomies, but also in false
dichotomies. (Andreasen, 1995, p. 963)
vii
Acknowledgements
A strong and supportive team stands behind this doctoral thesis.
I am deeply grateful to both of my supervisors, Dr Husna Razee and Associate
Professor Juliet Richters, for their expertise and astute intellectual guidance, patience
and continual encouragement. Thank you for encouraging me to be curious and
confident.
Professional editor, Dr G. A Plum, provided copyediting and proofreading services,
according to the guidelines laid out in the university-endorsed national guidelines, “The
editing of research theses by professional editors”. I wish to thank him for his technical
expertise and help.
I wish to also mention the considerable support and encouragement from other members
of the School of Public Health and Community Medicine. Special thanks to Associate
Professor Jan Ritchie, Dr Bibiana Chan and Dr Catherine Bateman Steel – thank you for
your time and valuable feedback.
To the Karen community in Sydney – ta blu doh ma. Thank you for your warmth,
generosity, trust and patience.
To my family, thank you for your love, for your tolerance in accepting my fascinations
and pursuits, and for your grace in understanding what is important to me.
To James, who witnessed all manner of joys and anxieties in the creation of this thesis.
Who watched me get stuck and unstuck and who all the while remained unwavering in
his belief in me and in my work. Thank you for your immeasurable support. Thank you
for your love.
viii
Publications
Publications arising from this thesis
Watkins, P., Razee, H., and Richters, J. (In press, accepted 14 March, 2012). “I’m
telling you … the language barrier is the most, the biggest challenge”: Barriers to
education among Karen refugee women in Australia. Australian Journal of Education.
Conference presentations arising from this thesis
Watkins, P. G., Razee, H., and Worth, H. (2009). Psychosocial distress and wellbeing
amongst Karen refugee women. Paper presented at the School of Public Health and
Community Medicine Postgraduate Research Student Conference, 23 November, 2009.
Sydney, Australia.
Watkins, P. G., Razee, H., and Worth, H. (2010). Ethnographic methods in cross-
cultural mental health research with refugee communities. Paper presented at the XXth
Congress of the International Association for Cross-Cultural Psychology, 7–10 July,
2010. Melbourne, Australia.
Watkins, P. G., Razee, H., and Richters, J. (2010). Researching sensitive topics:
Reflexivity, ethics and a feminist perspective. Paper presented at the School of Public
Health and Community Medicine Postgraduate Research Student Conference, 22
October, 2010. Sydney, Australia.
Watkins, P. G., Razee, H., and Richters, J. (2011). ‘Feeling useless’: Listening to
refugee women. Paper presented at the International Society of Critical Health
Psychology 7th Biennial Conference, 18–20 April, 2011. Adelaide, Australia.
Watkins, P. G., Zu, D., Razee, H., and Richters, J. (2011). So you want to be useful.
Paper presented at the 2011 Refugee Conference, 14–17 June, 2011. Sydney, Australia.
ix
Table of Contents
Originality Statement.................................................................................................... iii
Copyright Statement ...................................................................................................... iv
Authenticity Statement .................................................................................................. iv
Dedication ..................................................................................................................... v
Acknowledgements ........................................................................................................ vii
Publications ................................................................................................................. viii
Table of Contents ........................................................................................................... ix
List of Figures ............................................................................................................ xviii
List of Images ............................................................................................................ xviii
List of Tables ............................................................................................................. xviii
Abstract .................................................................................................................. xix
List of Acronyms .......................................................................................................... xxi
Glossary of Karen Terms ........................................................................................... xxii
Chapter 1 Introduction ................................................................................................... 1
1.1 Background .......................................................................................................... 1
1.2 Aims of the study and research questions ............................................................ 3
1.3 Significance of the study ...................................................................................... 4
1.4 Locating the researcher ........................................................................................ 4
1.4.1 Development of topic and perspective .......................................................... 5
1.4.2 Educational and professional background .................................................... 5
1.4.3 Personal background ..................................................................................... 6
1.5 Thesis structure .................................................................................................... 6
Chapter 2 The Mental Wellbeing of Refugees .............................................................. 8
2.1 Introduction .......................................................................................................... 8
2.2 Refugees ............................................................................................................... 8
2.2.1 Current crises and solutions .......................................................................... 9
2.3 War and the psyche ............................................................................................ 11
2.4 Refugee mental health ........................................................................................ 12
2.4.1 The dominant discourse: trauma-focused psychiatric epidemiology .......... 13
2.4.2 The dominant debates: cross-cultural construct validity and category
fallacies ...................................................................................................... 19
2.4.3 Intervention issues: practical, clinical and ethical challenges ..................... 26
x
2.4.4 Developments and directions for research: the emic-etic evolution ........... 30
2.5 Addressing the gaps ........................................................................................... 35
Chapter 3 Setting the Scene: Burma and the Karen ................................................. 37
3.1 Introduction ........................................................................................................ 37
3.1.1 Burma, Burman, Burmese and Myanmar: a note on terms and usage ........ 37
3.2 Burma: an overview ........................................................................................... 37
3.2.1 Politics and power ....................................................................................... 40
3.2.2 Human rights abuses and life under the regime .......................................... 43
3.2.3 Religion and culture in Burma .................................................................... 46
3.3 Karen .................................................................................................................. 48
3.3.1 Language ..................................................................................................... 49
3.3.2 Karen culture ............................................................................................... 50
3.3.3 Karen religion ............................................................................................. 51
3.3.4 Karen traditional medicine .......................................................................... 52
3.4 The Thailand-Burma border ............................................................................... 53
3.4.1 Hosts and providers ..................................................................................... 55
3.4.2 Life in camps ............................................................................................... 57
3.4.3 Access to resettlement ................................................................................. 61
Chapter 4 The Local Context: Refugee Resettlement in Australia .......................... 62
4.1 Introduction ........................................................................................................ 62
4.2 Australia’s current refugee program .................................................................. 63
4.2.1 Onshore component .................................................................................... 63
4.2.2 Offshore component .................................................................................... 64
4.3 Initial resettlement services for refugees............................................................ 65
4.3.1 Pre-departure ............................................................................................... 65
4.3.2 Post-arrival: the humanitarian settlement services program ....................... 67
4.4 Ongoing settlement services .............................................................................. 69
4.5 The local scene ................................................................................................... 72
Chapter 5 Methodology ................................................................................................ 74
5.1 Introduction ........................................................................................................ 74
5.2 A critical realist approach .................................................................................. 72
5.2.1 Explanation and justification of a qualitative realist approach ................... 74
5.3 Theoretical perspectives ..................................................................................... 78
5.3.1 Ethnography ................................................................................................ 79
xi
5.3.2 Feminist perspective.................................................................................... 81
5.3.3 Grounded theory.......................................................................................... 84
5.4 Summary ............................................................................................................ 85
Chapter 6 Method ......................................................................................................... 86
6.1 Introduction ........................................................................................................ 86
6.2 Selecting participants ......................................................................................... 86
6.2.1 Karen women .............................................................................................. 87
6.2.2 Key informants ............................................................................................ 87
6.2.3 Saturation .................................................................................................... 87
6.3 Participant observation ....................................................................................... 88
6.4 Interviews ........................................................................................................... 88
6.4.1 In-depth interviews ..................................................................................... 88
6.4.2 Group interviews ......................................................................................... 89
6.4.3 Recording, interpreting and transcribing interviews ................................... 91
6.5 Ethics .................................................................................................................. 92
6.6 Data analysis ...................................................................................................... 93
6.7 Rigour ................................................................................................................. 95
6.7.1 Criterion 1: Clarification, justification or theoretical rigour ....................... 96
6.7.2 Criterion 2: Procedural and methodological rigour .................................... 96
6.7.3 Criterion 3: Representativeness .................................................................. 96
6.7.4 Criterion 4: Interpretative rigour ................................................................. 97
6.7.5 Criterion 5: Reflexivity and evaluative rigour ............................................ 98
6.7.6 Criterion 6: Transferability ......................................................................... 98
6.8 Logistics and limits .......................................................................................... 100
6.9 Conclusion ....................................................................................................... 100
Chapter 7 The Ethnographic Journey: A Researcher’s Reflections ...................... 101
7.1 Introduction ...................................................................................................... 101
7.2 Identifying and entering the community .......................................................... 101
7.3 Identifying and working with a bilingual research assistant ............................ 103
7.4 Informal participant observation encounters .................................................... 106
7.5 Formal interview encounters ............................................................................ 109
7.5.1 Formal encounters with groups ................................................................. 113
7.6 Transcribing speech and presenting quotations ............................................... 117
7.7 Ethics ................................................................................................................ 118
xii
7.7.1 Maintaining confidentiality and anonymity .............................................. 120
7.8 The analytic journey ......................................................................................... 120
7.9 The reflexive journey ....................................................................................... 123
7.9.1 Memo-writing ........................................................................................... 123
7.9.2 Learning patience and being honest .......................................................... 125
7.9.3 Distance and the “other” ........................................................................... 125
7.9.4 Representation and voice .......................................................................... 127
7.9.5 “Conversations with Karen”: positively using researcher power and the
reflexive journey ...................................................................................... 129
7.10 Ending the study ............................................................................................. 130
Chapter 8 “Starting at zero”: Women’s Problems and the Sources of Distress ... 131
8.1 Introduction ...................................................................................................... 131
8.2 “The biggest barrier”: language and communication....................................... 131
8.2.1 Barriers to language education .................................................................. 132
8.2.2 Barriers to communication ........................................................................ 134
8.3 “Everything is new”: lack of environmental mastery ...................................... 135
8.3.1 Mastering space: fear of freedom .............................................................. 136
8.3.2 (Un)employment ....................................................................................... 138
8.3.3 Financial hardship ..................................................................................... 141
8.3.4 Housing ..................................................................................................... 143
8.3.5 Transport ................................................................................................... 145
8.3.6 Health ........................................................................................................ 146
8.3.7 Parenting ................................................................................................... 146
8.4 “Power struggles”: gender role changes and women’s wellbeing ................... 150
8.4.1 “Too much responsibility”: increasing pressures on women .................... 151
8.4.2 “Not enough responsibility”: men’s experience of gender role changes .. 152
8.4.3 Domestic violence ..................................................................................... 153
8.4.4 Witches and bitches: single women negotiating gender ........................... 156
8.5 War, culture and daily stressors: women’s problems in context ...................... 159
8.6 Summary and reflections.................................................................................. 161
Chapter 9 A Suffering Heart-mind: Conceptualising, Experiencing and
Explaining Distress ................................................................................ 165
9.1 Introduction ...................................................................................................... 165
9.2 A suffering heart-mind: women’s idioms of distress ....................................... 165
xiii
9.2.1 Thinking too much: hso k’moe dha ........................................................... 165
9.2.2 A suffering heart-mind: tha… ................................................................... 166
9.2.3 Sickness of the heart-mind: tha dha hsar .................................................. 167
9.2.4 Madness: dha blu ...................................................................................... 168
9.3 Causes of distress ............................................................................................. 168
9.3.1 Daily stressors ........................................................................................... 169
9.3.2 Persecution and forced migration: loss and traumatic war stressors ......... 170
9.3.3 Biology and inherited vulnerability .......................................................... 172
9.3.4 Supernatural .............................................................................................. 173
9.4 Experiencing and expressing distress............................................................... 173
9.4.1 Aching heads and aching bodies: somatic complaints .............................. 173
9.4.2 “I have a problem”: social complaints and social expressions ................. 175
9.4.3 “I am useless”: expressing failure and frustration..................................... 177
9.4.4 “I remember”: remembering suffering ...................................................... 179
9.4.5 “I want to die by crying”: severe distress .................................................. 181
9.4.6 Feeling fierce: tha dha hsar and anger ...................................................... 182
9.4.7 “Eating grass”: manifestations of madness (dha blu) ............................... 185
9.5 Summary and reflections.................................................................................. 185
9.5.1 Trajectory of distress ................................................................................. 185
9.5.2 Similarities and differences ....................................................................... 187
9.5.3 The ubiquity of uselessness ....................................................................... 188
9.5.4 The importance of anger ........................................................................... 190
9.5.5 Balancing ethnopsychiatries...................................................................... 190
Chapter 10 We All Suffer. We All Cope: Managing Emotional Distress .............. 193
10.1 Introduction ..................................................................................................... 193
10.2 Self-control ..................................................................................................... 193
10.2.1 Thought control: “think about your thinking” ......................................... 193
10.2.2 Distraction: “think about something else” ............................................... 194
10.2.3 Acceptance: “you have to accept reality” ................................................ 195
10.2.4 Contextualising a controlled self ............................................................. 196
10.3 Collective self ................................................................................................. 200
10.3.1 The collective self and communal suffering: accepting and normalising
suffering ................................................................................................... 200
10.3.2 The collective self and communal support: “we support one another” ... 203
xiv
10.3.3 “Sharing and caring”: helping others to help oneself .............................. 206
10.4 Religious coping ............................................................................................. 209
10.4.1 “Through God’s strength” ....................................................................... 209
10.4.2 Religious community ............................................................................... 210
10.5 Professional support: coping and service providers ........................................ 212
10.5.1 Doctors ..................................................................................................... 213
10.5.2 Australian service providers .................................................................... 214
10.6 Summary and reflections ................................................................................ 215
10.6.1 Emotional and practical support .............................................................. 217
10.6.2 Shared experiences .................................................................................. 218
10.6.3 Acceptance and normalisation ................................................................. 219
Chapter 11 Bridging Idioms: Karen Women’s Explanatory Models of Western
Psychiatric Constructs ........................................................................... 222
11.1 Introduction ..................................................................................................... 222
11.2 Vignettes and explanatory models .................................................................. 222
11.3 Vignette A / Aunty A: DSM-IV Major Depressive Disorder ......................... 222
11.4 Vignette B / Aunty B: DSM-IV Panic Disorder ............................................. 227
11.5 Vignette C / Aunty C: DSM-IV Posttraumatic Stress Disorder ..................... 230
11.6 Summary ......................................................................................................... 233
11.6.1 Social model ............................................................................................ 233
11.6.2 Psychological model ................................................................................ 235
11.6.3 Biological model ...................................................................................... 237
11.6.4 Course, severity and impact ..................................................................... 238
11.6.5 Explanatory models and treatment .......................................................... 238
11.7 Reflections ...................................................................................................... 239
11.7.1 The ordinariness of suffering ................................................................... 241
11.7.2 Talking about trauma ............................................................................... 243
11.7.3 Illuminating diversity ............................................................................... 244
Chapter 12 Invisible Clients and Invisible Problems: Experiences and Perceptions
of Settlement Services ............................................................................ 246
12.1 Introduction ..................................................................................................... 246
12.2 Positive perceptions ........................................................................................ 246
12.2.1 “Here it’s the best” ................................................................................... 246
12.2.2 Community connection ............................................................................ 247
xv
12.3 Learning about limitations .............................................................................. 247
12.4 Case management and orientation support ..................................................... 248
12.5 Communication issues .................................................................................... 248
12.5.1 Not Korean, not Burmese ........................................................................ 249
12.5.2 (Mis)trust and ethnic tension ................................................................... 250
12.5.3 Interpreter availability .............................................................................. 251
12.6 Lack of bilingual, bicultural and female service providers ............................. 252
12.7 Barriers to English language education .......................................................... 253
12.7.1 Access barriers ......................................................................................... 253
12.7.2 Classroom and teaching barriers .............................................................. 254
12.8 Face value: limited perceptions of Karen women’s needs .............................. 257
12.9 Elder and service provider burnout … “the profacticals” ............................... 259
12.10Lack of awareness, understanding and cohesion between service providers . 261
12.11Summary ......................................................................................................... 262
Chapter 13 “It’s good … but it’s not very effective”: Experiences and Perceptions
of Health and Mental Health Service Provisions ................................ 264
13.1 Introduction ..................................................................................................... 264
13.2 “Extra special” care from GPs ........................................................................ 264
13.3 Primary health and healthcare services ........................................................... 265
13.3.1 Encountering healthcare and illness ........................................................ 265
13.3.2 Mismatched expectations ......................................................................... 265
13.3.3 “They should be fine”: communication barriers and GPs ....................... 269
13.4 Mental health services: cultural differences and paradigm clashes ................ 272
13.5 Reflections ...................................................................................................... 280
Chapter 14 Implications for Practice and Future Research ................................... 283
14.1 Introduction ..................................................................................................... 283
14.2 Implications and recommendations for generalist HSS service providers ..... 283
14.2.1 Case management and resettlement orientation ....................................... 283
14.2.2 Non-Karen speaking service providers .................................................... 284
14.2.3 Adult Migrant English Program .............................................................. 285
14.2.4 Poverty and housing ................................................................................. 286
14.2.5 Employment support services .................................................................. 287
14.2.6 Parenting .................................................................................................. 287
14.3 Implications and recommendations for mental health service providers ........ 287
xvi
14.3.1 Prioritise (a) prevention over treatment and (b) issues that are of concern
to the community ..................................................................................... 288
14.3.2 Build individual and community capacity and self-efficacy ................... 288
14.3.3 Work with existing community strengths and integrate interventions into
existing support networks ........................................................................ 289
14.3.4 Engage communities in critical reflection ............................................... 289
14.3.5 Address gender and work with women .................................................... 290
14.3.6 Enhance staff cultural competency training ............................................. 290
14.3.7 Improve access to bilingual, bicultural and gender-matched healthcare
staff .......................................................................................................... 291
14.3.8 Evaluate intervention and service provider efficacy ................................ 291
14.3.9 Utilise practice-based evidence ............................................................... 292
14.3.10Design culturally congruent mental health interventions ........................ 292
14.4 Implications and recommendations for future research .................................. 294
14.4.1 Use explanatory models to further explore mental health topics with
refugee women ......................................................................................... 294
14.4.2 Work sensitively with refugee communities and strive to access emic
perspectives .............................................................................................. 295
14.4.3 Investigate the roles and challenges of refugee community leaders ........ 295
14.4.4 Explore notions of power(lessness), use(lessness), dependency and
identity ..................................................................................................... 295
14.4.5 Investigate the strengths, limitations and pathways of emic coping
strategies .................................................................................................. 296
14.4.6 Explore pathways and patterns of refugee adjustment to resettlement
overtime ................................................................................................... 299
Chapter 15 Conclusions .............................................................................................. 300
15.1 Introduction ..................................................................................................... 300
15.2 Women’s conceptualisations of distress and the transferability of Western
theories ............................................................................................................ 300
15.3 Risk, resiliency and wellbeing in social, cultural and political context .......... 303
15.4 Coping: the commonsense, complex and contradictory ................................. 308
15.5 Paradigm clashes and practical problems ....................................................... 310
15.6 Final reflections .............................................................................................. 311
References ................................................................................................................. 314
xvii
Appendices ................................................................................................................. 386
Appendix A: DSM-IV criteria .................................................................................. 387
Appendix B: Interview guide for Karen key informants .......................................... 391
Appendix C: Interview guide for service providers .................................................. 393
Appendix D: Interview guide for Karen women....................................................... 397
Appendix E: Participant information and consent form (English version only) ....... 403
Appendix F: Group interview guide ......................................................................... 408
Appendix G: Conversations with Karen: art exhibition ............................................ 414
xviii
List of Figures
Figure 1: Map of Burma illustrating ethnic minority areas including Karen State ..... 39
Figure 2: Map of internally displaced people and refugee camps along Thailand-
Burma border ............................................................................................... 55
Figure 3: Four-point participant observer continuum ................................................ 106
Figure 4: Trajectory of distress .................................................................................. 186
Figure 5: Trajectory of distress .................................................................................. 233
Figure 6: Karen social, cultural and political context and associated negative
psychosocial sequela .................................................................................. 306
List of Images
Image 1: Complete storyboard regarding employment difficulties........................... 116
Image 2: Storyboard panel depicting women’s isolation .......................................... 116
Image 3: Storyboard panel depicting Karen women’s difficulties assisting their
children with homework ............................................................................ 117
Image 4: Cross-stitch depicting quotation from interview with participant Mr W. .. 129
Image 5: Karen women’s visual depiction of the emotional impact of
(un)employment and interactions with Job Services Australia .................. 140
Image 6: Picture of a salad – used by women to make an analogy between
nutritional value and the value inherent in women .................................... 178
List of Tables
Table 1: Local service providers relevant to this study .............................................. 73
Table 2: Karen women’s trajectory of idioms of distress with causes and
descriptions ................................................................................................ 192
xix
Abstract
Studies of refugee mental health have largely focused on epidemiological assessments
of posttraumatic stress disorder and other diagnoses using Western-derived assessment
measures. However, research has increasingly highlighted the role of culture in shaping
refugee mental wellbeing and suggests that local idioms of distress may be more salient
to refugee populations than Western-derived constructs of psychopathology.
The central aim of the study was to explore experiences and perceptions of suffering
and distress amongst Karen refugee women in Sydney, Australia. The Karen, an ethnic
group from Burma, have been gravely affected by decades of conflict and human rights
abuses in their homeland yet there is a dearth of information concerning their
psychosocial needs.
Informed by a critical realist theoretical paradigm, the research was guided by
ethnographic, feminist and grounded theory methodological traditions. Data was drawn
from over 200 hours of ethnographic observations and 67 interviews with Karen women
and key informants between 2009 and 2011. Data analysis was based on principles of
grounded theory.
The findings revealed important relationships between pre-migration cultural context,
persecutory experiences (including but not limited to trauma), post-migration
psychosocial stressors and current experiences of emotional distress. Women’s daily
social and material stressors, such as interacting with service providers, were central to
their distress. They conceptualised their experiences of suffering and trauma within
cultural frameworks and idioms of distress, which often differed from the Western
psychiatric models. Karen women primarily coped through traditional community and
religious networks. Language was a key barrier to seeking support from Australian
service providers. Women’s timidity and communication patterns, stemming from the
interplay of cultural, gendered and pre-migration experiences, were further barriers.
The study contributes to an empirical understanding of Karen refugee women’s
experiences and conceptualisations of mental wellbeing. It enhances existing knowledge
and developments in cross-cultural mental health and adds a new dimension by
demonstrating how pre-migration culture, refugee-specific migration experiences, post-
migration difficulties and wellbeing were linked through the interconnected issues of
xx
power(lessness), use(fulness) and identity. The findings have implications for service
provision and suggest that Western mental health practitioners should reflexively
explore prevailing discourses concerning traumatic suffering and healing.
xxi
List of Acronyms
AMEP Adult Migrant English Program
CBT Cognitive behavioural therapy
DIAC Department of Immigration and Citizenship
DSM Diagnostic and Statistical Manual of Mental Disorders
EM Explanatory model
FAAST Forum of Australian Services for Survivors of Torture and Trauma
GDP Gross domestic product
GP General practitioner
HSS Humanitarian Settlement Services
ICD-10 International Classification of Diseases-10
NAATI Australian National Accreditation Authority for Translators and
Interpreters Limited
PTSD Posttraumatic stress disorder
STARTTS Service for the Treatment and Rehabilitation of Torture and Trauma
Survivors
TIS Translating and Interpreting Service
UN United Nations
UNHCR United Nations High Commissioner for Refugees
xxii
Glossary of Karen Terms
Dha blu Mad
Hso k’moe dha Thinking too much
Tha Heart
Heart-mind
Tha ba do Hurt
Tha ba yo Worry
Tha da mu Upset
Tha dhar hsar Sickness of the heart
Sickness of the heart-mind
1
Chapter 1
Introduction
We start at zero and go – one, two, three, four. (Key informant – Mr O)
“Starting at zero” is a useful phrase to situate the experiences of Karen refugee women
who, after fleeing persecution in Burma, begin their life anew in Australia. This
ethnographic study explores Karen women’s experiences and conceptualisations of
emotional distress and wellbeing, and addresses concerns and issues that have been
raised in the literature relating to the application of Western psychiatric frameworks for
refugee mental health.
1.1 Background
For the past 25 years, mental health researchers have documented the devastating
effects of political violence and forced migration on the wellbeing of affected
populations (Porter & Haslam, 2005). The majority of these studies have focused on
epidemiological assessments of posttraumatic stress disorder (PTSD) and major
depressive disorder using Western-derived assessment measures and have consistently
reported elevated rates of these and other psychiatric disorders (Hollifield, 2005;
Hollifield et al., 2002; Miller, Kulkarni, & Kushner, 2006).
However, psychiatric scholarship of refugee populations has increasingly come under
intense criticism from both ideological (Summerfield, 1999) and methodological
(Hollifield, 2005; Hollifield et al., 2002) perspectives. Despite the plethora of
epidemiological studies, the findings and implications have been difficult to interpret
due to methodological problems and cultural differences in conceptualisations of
wellbeing, suffering and healing. Critics have argued that research to date has been too
narrow in its nearly exclusive reliance on a biomedical, epidemiological and trauma-
focused approach (Bracken, Giller, & Summerfield, 1995; Ingleby, 2010; Miller,
Kulkarni, et al., 2006). It has been argued that such an approach to understanding and
addressing human suffering and wellbeing represents an ethnocentric imposition of an
“etic” or outsider’s (in this case Western) epistemology on predominantly non-Western
populations and assumes the universal salience of psychiatric constructs (Summerfield,
2002). Critics such as Miller, Kulkarni, et al. (2006) and others (de Jong & Komproe,
2
2002; Pupavac, 2004; Wilson, 2007) have also argued that the dominant trauma-focused
discourse has resulted in culturally inappropriate and unsustainable rehabilitation
services that do not address issues of relevance to the experiences and interpretations of
refugee communities.
In recent years some researchers have begun to utilise more qualitative ethnographic
methods to identify the range, depth and meaning of mental health responses amongst
refugees (Djuretic, Crawford, & Weaver, 2007; Hubbard & Pearson, 2004; Miller,
Kulkarni, et al., 2006; Phan, Steel, & Silove, 2004). These qualitative studies have
allowed for an identification of emic or insider’s beliefs, local syndromes and idioms of
distress, as well as an understanding of strengths, forms of resilience and patterns of
help-seeking behaviour.
The ethnographically informed research to date has demonstrated that local idioms of
distress may be more salient to indigenous populations than constructs of
psychopathology identified by Western-derived diagnostic systems. Mental health
practitioners have demonstrated how these studies have the potential to assist with the
development and evaluation of psychosocial and mental health interventions that are
both clinically effective and contextually appropriate (Hubbard & Pearson, 2004).
Moreover, many of the qualitative approaches to refugee mental health research also
give voice to the refugee experience and allow for the rich texture of human life,
suffering and meaning to be heard and appreciated (Mollica, 2001).
Increasingly, rather than seen as being in opposition, ethnographic and epidemiological
approaches to refugee mental health research have been viewed as mutually supportive
(Bass, Bolton, & Murray, 2007; de Jong & Van Ommeren, 2002; Eisenbruch, de Jong,
& van de Put, 2004; Patel, 2001). From these approaches a consensus has emerged
identifying ethnographic investigations as a necessary first step towards developing
accurate, as well as culturally and contextually appropriate, bio-psychosocial
understandings of refugee communities (Petevi, Revel, & Jacobs, 2001).
There have been a variety of creative and effective solutions from researchers
committed to understanding the emic perspectives of refugee communities (Bolton &
Tang, 2002, 2004; Miller, Omidian, et al., 2006; Phan et al., 2004). However, there have
also been some consistent limitations in research to date as well as unexplored and
3
potentially useful methodologies. Limitations include an insufficient exploration and
acknowledgement of the broader sociopolitical issues affecting refugee communities, a
failure to utilise qualitative (especially ethnographic) methods as a means to explore
local explanatory models of mental illness and a paucity of information concerning
utilisation of relevant services (Summerfield, 2001), combined with a failure to report
on and involve a range of relevant service providers in order to guide policy-relevant
research. This study was undertaken to address these knowledge gaps, explore Karen
women’s emic perspectives about distress and to understand the circumstances affecting
their psychosocial wellbeing from multiple perspectives. Thus, this study provides
empirical information about Karen refugee women, a refugee population whose
wellbeing had not been explored.
The Karen people are an ethnic minority population from Burma. Following a military
coup in 1962 around 3.5 million citizens in Burma have been displaced (Refugees
International, 2010) by violence, persecution and human rights abuses including torture
and extrajudicial murder, forced labour and sexual violence against women (United
Nations General Assembly, 2010a). Since 2005 approximately 90,000 refugees from
Burma have been resettled around the world and around 10,000 now reside in Australia
(Department of Immigration and Citizenship, 2011c; International Organization for
Migration, 2011b). Karen refugees represent the largest ethnic minority community of
refugees from Burma in Sydney, where this study was undertaken (M. Salgado,
Department of Immigration and Citizenship, personal communication, 25 November,
2009).
1.2 Aims of the study and research questions
The aims of this thesis are to (a) explore Karen refugee women’s experiences and
perceptions of suffering and distress, (b) analyse the women’s major psychosocial needs
within the Australian context, and (c) frame recommendations for action by community
organisations and services. The following questions guided this study:
1. How do Karen refugee women conceptualise emotional distress?
2. What issues affect Karen women’s wellbeing?
3. How do Karen women cope with emotional distress?
4
4. What are the explanatory models (beliefs regarding illness) provided by Karen
women concerning the Western psychiatric constructs of posttraumatic stress
disorder, depression and anxiety?
5. How are some of the current services provided for Karen refugee women
perceived and how might they be improved?
1.3 Significance of the study
Progress in improving the psychosocial wellbeing of refugee populations in Australia
depends on culturally accurate understandings and assessments of the problems that
need to be addressed (Kleinman, 1977, 1999; Miller & Rasco, 2004). However, there is
a dearth of knowledge regarding the experiences, needs and perceptions of the growing
population of Karen refugees from Burma in Australia. In the absence of information
about the psychosocial needs of this population there is no firm basis on which to
design programs and assess program effectiveness. This study will address this gap in
the literature and provide information to inform service providers and policy makers.
This study draws on and advances contemporary approaches to refugee mental health
research. It contributes to research and knowledge through demonstrating an approach
that integrates the experiences and perceptions of both refugee community members and
relevant service providers. The framework and methodology employed aims to gather
detailed descriptions of mental health-related needs as experienced by Karen refugee
women as well as other knowledgeable persons, such as community leaders and service
providers. Furthermore, this study employs a unique approach to utilising the
explanatory model framework from medical anthropology to understand Karen
women’s perceptions of Western psychiatric constructs. This approach allows for the
integration of emic and etic perspectives, which is essential for the development of
epidemiology studies as well as for the effective delivery of health services. The
findings will be critically discussed in relation to aspects of dominant discourses about
refugee mental health and current approaches to service provision.
1.4 Locating the researcher
This study is situated in a naturalistic, qualitative approach to research. In this tradition
researchers seek to enhance the transparency and rigour of their research through the
process of reflexivity in which they clarify how their personal beliefs, values and
5
experiences impact on the intention, implementation and interpretation of their research
(Abreu, 2001; Blignault & Ritchie, 2009; Denzin & Lincoln, 2005; Ritchie, 2001). This
section explores my personal values and prior experiences contributing to the
development of this thesis topic so as to bring about a “thoughtful, conscious self-
awareness” (Finlay, 2002, p. 532) and facilitate greater transparency of my research. A
reflexive account of the research journey is presented in Chapter 7.
1.4.1 Development of topic and perspective
Ideas for this research began to form in the winter of 2008 when I spent several months
at a locally run refugee hospital on the Thailand-Burma border assisting staff with
mental health program planning. During my time there I listened to the concerns of
local counselling staff, and observed the serious challenges they faced as they tried to
implement Western-style trauma counselling en masse to a population unfamiliar with
the concept and unwilling or unable to avail themselves of the service. The local staff
were part of a project implemented and coordinated by a Western mental health
professional who had not obtained any ethical approval and was advocating the use of
what was at the time a highly contested form of psychotherapy. The intervention, eye-
movement desensitisation therapy, had no supportive evidence regarding its use in non-
Western post-conflict settings. Moreover, a United Nations (UN) evaluation report
(Melville & Faye, 2003) argued that the technique was “not appropriate” (p. 7) in such
contexts, following field research with survivors of armed conflict in Indonesia. My
interest in undertaking research was generated by my commitment to an ethic of care
and the pressing need to understand and address the emotional experiences and needs of
refugees from a cross-cultural perspective.
1.4.2 Educational and professional background
I bring to this research perspectives and experiences from my training and work as a
clinical psychologist in New Zealand and abroad. I graduated from a firmly positivist-
oriented psychology department at the University of Otago, New Zealand, where I was
trained within the scientist-practitioner model. I completed my clinical psychology
degree and embarked on a quantitative investigation of cognitive deficits related to
schizophrenia for my master’s thesis. I was also interested in cultures and world
religions and during my undergraduate years took numerous classes through the
6
Religious Studies department. I became especially interested in South East Asia and
was fascinated by how cultural and religious concepts related to the experience of
mental wellbeing and the treatment of mental illness. After completing my clinical
training in 2005 I worked in a variety of contexts including hospitals, prisons and
private practice. In more recent years I worked with humanitarian organisations in
Cambodia and, as mentioned, on the Thailand-Burma border.
1.4.3 Personal background
Unlike many of the Karen women in this study I was fortunate to spend my childhood
in a country that enjoyed a time of peace. I was born to a middle class family in New
Zealand and spent my childhood busily engaged in educational, family-oriented, and
recreational pursuits. I was aware of mental illness from a young age through the
challenges of schizophrenia faced by members of my family and decided to study for a
career in mental healthcare.
Whilst working as a clinical psychologist in New Zealand I became involved in an
organisation assisting women and child survivors of human trafficking in Cambodia. I
left my job in New Zealand and travelled to South East Asia when an opportunity arose
to assist their team with developing ways to evaluate the outcome of their treatment
program and improve their procedures for reporting to donors. During my time in Asia I
travelled to the Thailand-Burma border and thus began my interest in working with
refugees from Burma.
My values and background have shaped the construction of this research project and I
acknowledge that other researchers, working from different perspectives, would define
and construct this project in different ways. I have reviewed my personal values and
prior experiences so as to make them a conscious element in designing, analysing and
presenting the research findings.
1.5 Thesis structure
This introductory chapter has provided a brief background to the study and introduced
the aims and research questions. The following second chapter critically explores the
field of refugee mental health and discusses the various conceptual issues and debates
that have shaped research to date. It concludes by locating this study within
7
contemporary refugee mental health literature. Chapter 3 focuses upon the background
of Karen refugee women and explores the geographic, cultural, social and political
characteristics of Burma and the Karen. An overview of the local (Australian) context is
provided in Chapter 4 where the resettlement services available to refugee entrants are
described. In Chapters 5 and 6 the research methodology and methods are detailed,
followed by an exploration of how the ethnographic journey unfolded in Chapter 7.
Chapters 8 to 13 present the research findings. These chapters loosely correspond to
each of the research questions. Each presents the relevant data and explores the findings
in relation to the literature. Chapter 14 addresses implications for resettlement service
providers and health practitioners respectively and provides recommendations for future
research. Lastly, Chapter 15 concludes the thesis, reflecting on the major findings and
implications in relation to both theory and academic discourse as well as service
provision.
8
Chapter 2
The Mental Wellbeing of Refugees
2.1 Introduction
This chapter explores the history of mental health research with refugee populations. It
begins with a sketch of the refugee phenomenon, outlining the definition of a refugee
and briefly describing the current refugee crisis. Historical conceptualisations of war-
related emotional suffering are explored briefly in Section 2.3, providing a context for
understanding contemporary approaches. Section 2.4 explores in detail the predominant
psychiatric trauma-focused approach guiding refugee mental health research and
practice, noting the key findings and contributions of this tradition. The historical
context in which the study of trauma came to be prioritised will be examined, as will the
limitations of the framework. More recent trends in approaches and methodologies will
be discussed including the contribution of medical anthropology frameworks. Finally,
areas that have received comparatively little attention will be highlighted in Section 2.5
and their significance for this study noted.
2.2 Refugees
Armed conflict and forced migration have been ubiquitous features of human history.
However, changes in 20th century conflicts have had a dramatic effect on global
migration as refugees from Third World conflicts are increasingly resettling into asylum
countries (Ingleby, 2010; Silove, 2004). Indeed, in the 50 years since the two world
wars, more people than ever have been displaced by conflict (D. Pedersen, 2002; Zwi &
Ugalde, 1989).
The present day United Nations High Commissioner for Refugees (UNHCR) was
established in 1950 and in 1951 the Convention relating to the Status of Refugees
(hereafter referred to as the Convention) was ratified. The following definition of a
refugee is set forth in Article 1 of the Convention (modified in 1967 by Article 1 of the
Protocol relating to the Status of Refugees, hereafter referred to as the Protocol)
(UNHCR, 2011b):
[Any person who] owing to well-founded fear of being persecuted for reasons of
race, religion, nationality, membership of a particular social group or political
9
opinion, is outside the country of his nationality and is unable or, owing to such
fear, is unwilling to avail himself of the protection of that country; or who, not
having a nationality and being outside the country of his former habitual
residence as a result of such events, is unable or, owing to such fear, is unwilling
to return to it. (p. 16)
Following the formation of the UNHCR and the advent of the Convention, refugees and
asylum seekers during the 1950s to mid-1970s were received with relative warmth in
host nations where they typically enjoyed full access to citizenship. Alarmingly, since
the early 1980s there as been a backlash in attitudes towards displaced people. As the
global refugee crisis has continued to grow steadily and significantly, public opinion,
political rhetoric and policy have simultaneously deteriorated. The contemporary
attitude of the international community is one of fatigue and frustration towards the
global refugee situation. Today, many nations are increasingly denying access to asylum
seekers, forcibly detaining applicants without providing adequate assessment of their
claims and enforcing repatriation policies (Silove, 2003). The increased “warehousing”
of millions of refugees in camps, sometimes for decades, is another saddening trend
(Ingleby, 2010).
2.2.1 Current crises and solutions
There are currently 15.4 million refugees and 27.5 internally displaced people
(International Organization for Migration, 2011a). The latter are essentially refugees
who have not crossed an internationally recognised state border (International
Organization for Migration, 2011a). In 2010, the top five refugee source countries were
Afghanistan (2,887,100), Iraq (1,785,200), Somalia (678,300), Democratic Republic of
Congo (455,900) and Burma (405,700) (UNHCR, 2010a).
Most refugees first cross international borders close to their country of origin and into
some of the poorest countries in the world where around 30% subsist in camps and the
rest live in urban slums or rural areas (UNHCR, 2010a). In recent decades an increasing
number of refugee situations have become protracted. The UNHCR defines protracted
circumstances as those in which 25,000 or more refugees remain in a situation that has
continued for five years or more without signs of resolution (UNHCR, 2004). There are
currently 5.5 million refugees living in such situations.
10
Today the UNHCR (2004) uses three strategies or “durable solutions” (p. I/1) in
response to the forced migration of refugees: repatriation, integration and resettlement.
Of these solutions, the UNHCR considers voluntary repatriation (return to country of
nationality) to be the most favoured but often finds it unachievable due to ongoing
conflict and safety concerns. Opportunities for legal local integration into the first
country of asylum (often countries neighbouring the refugees’ homeland) are also
limited. The third and final solution of resettlement is the UNHCR’s least favoured
option (UNHCR, 2004). It is also unavailable to most refugees and only 1% are
processed and submitted for resettlement as the demand for resettlement greatly exceeds
places made available by host countries (UNHCR, 2010b). In 2009, the UNHCR
submitted over 128,000 refugees; of those, 84,000 were accepted. When family
members are included this number rises to 112,400. Most were resettled in the United
States of America (79,000), followed by Canada (12,500) and Australia (11,000).
Smaller numbers were resettled across 16 other countries (UNHCR, 2010d).
Resettlement is often expensive and generally involves major culture change for
refugees. Its success depends heavily on the policies and services put in place by host
nations for language classes, education, interpreter services, vocational training and
employment.
The UHHCR has also developed policy and programs specific to the needs of refugee
women and girls. Female refugees are recognised to be “less likely [than men and boys]
… to have access to even the most fundamental of their rights. These include their right
to food, healthcare, shelter, nationality and documentation” (UNHCR, 2008, p. 6). In
addition, women are at risk of gender-based violence and are often restricted from
participating in education and decision-making. The protection concerns of women and
girls are addressed through the Women At Risk criteria and program. With respect to
resettlement, this program aims to identify women in particularly vulnerable situations
and fast-track their resettlement.
The impacts of mass conflicts and forced migrations are boundless. They affect
environments, economies, societies and of course individuals. Not surprisingly, the
health impact of violence for individuals is immense. Most obviously, armed conflict
causes direct violence which leads to increased mortality rates and physical injury
(Toole, 2003; Toole & Waldman, 1988) and since the 1980s civilian deaths have
increased to account for around 90% of all war-related deaths (M. G. Marshall & Gurr,
11
2003; D. Pedersen, 2002). The broader physical health impacts of war-related structural
violence such as poverty, malnutrition and disease are also well documented (Reed &
Keely, 2001; Toole & Waldman, 1990). These issues are particularly pertinent today
when an increasing number of conflicts are protracted and force civilian populations
into prolonged displacement and extended confinement in refugee camps. This thesis is
concerned with the mental health effects of armed conflict and forced displacement on
refugees.
2.3 War and the psyche
Psychiatric literature began to document the psychological consequences of conflict
during the American Civil War when soldiers who complained of aches located in the
left side of the chest and a weak heartbeat were diagnosed with “Da Costa’s syndrome”.
British soldiers in the Boer Wars were diagnosed with “debility syndrome”
characterised by joint pain and muscle weakness. During the First World War, British
and American soldiers were diagnosed according to four categories of “war neurosis”:
shell shock (literally shock to the physical and mental body following exposure to high
explosives), hysteria (loss of control over one’s motor, sensory or perceptual functions),
neurasthenia (nervous exhaustion following exposure to repeated stressors), and
disordered action of the heart (also known as Da Costa’s syndrome; characterised by
symptoms of cardiac sensations with no organic cause) (Watters, 2010; Young, 1995).
Interest in the field of post-conflict mental health grew substantially following the
return of American soldiers from the Vietnam War and research with this population
heavily influenced the development of a new diagnostic construct PTSD, which was
entered into the third edition of the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM) in 1980 (Steel, Frommer, & Silove,
2004; Summerfield, 2001). The social, political and cultural atmosphere contributing to
the emergence of this disorder and the conceptual origins of the diagnosis have been
subject to much criticism (Scott, 1990; Summerfield, 2001; Yehuda & McFarlane,
1995) and much has been made of the connection between Vietnam War veterans and
the development of PTSD (see Section 2.4.2).
Today DSM-IV (American Psychiatric Association, 2000) retains PTSD as an anxiety
disorder characterised by significant impairment or distress due to symptoms of (a) re-
12
experiencing a traumatic event (e.g., through nightmares or flashbacks), (b) avoidance
of stimuli associated with a traumatic event and numbing of affect, and (c) persistent
increased arousal (e.g., hypervigilance or irritability). The diagnosis of acute stress
disorder is used for a similar syndrome lasting less than 30 days (the full diagnostic
criteria for these constructs can be found in Appendix A). In addition to DSM-IV, the
International Classification of Diseases-10 (ICD-10) (World Health Organisation, 1992)
diagnostic system also provides criteria for the diagnosis of PTSD. However, the DSM-
IV criteria for PTSD and other psychiatric disorders are the most commonly utilised in
refugee mental health (McFarlane, 2004) and will generally be the system referred to
throughout this thesis. As we will see, a trauma-focused framework guided by the
DSM-IV diagnosis of PTSD has radically dominated the focus of war and refugee
mental health researchers and practitioners since the field began in earnest in the 1980s.
2.4 Refugee mental health
Throughout its relatively short history, the field of refugee mental health research and
practice has been remarkably productive despite being exceptionally polarised in its
approach. At its extremes it has been governed by two approaches (Silove, 2010). The
first and dominant, known as the etic approach, is characterised by epidemiological
studies documenting the prevalence rates of psychiatric disorders among refugees. This
approach assumes that the psychiatric diagnoses of Western-derived nosologies
(represented by DSM-IV or ICD-10) are universal disorders and can therefore be
legitimately and usefully applied to non-Western cultures. Advocates of a cultural
relativist or emic perspective, strongly influenced by anthropological frameworks,
contest the validity of Western conceptualisations of mental illness for non-Western
populations. Embedded within this ongoing debate is the contested issue regarding the
relevance of a psychological trauma perspective and, more precisely, the
appropriateness of extending the Western nosological category of PTSD to non-Western
refugee populations.
The terms etic and emic are widely used in refugee mental health literature. Though first
used in linguistics (Pike, 1954), these words were adopted by anthropologists who used
them to distinguish between concepts and frameworks held by a cultural group under
study (emic) and those of an observer (etic) (Harris, 1976). In the case of refugee mental
health literature, the emic perspective reflects the beliefs held by refugee communities
13
themselves whereas the etic orientation represents that of Western psychiatry or
psychology (Weiss et al., 1992).
It is only in the last decade that a greater number of published articles in the field have
moved beyond heated oscillating debate and polarised etic versus emic opinions
towards a more balanced and integrated acknowledgement of the importance and
relevance of both frameworks to understanding and addressing refugee mental health
issues. Yet, a trauma-oriented framework has continued to shape the research agenda
and a “problematic gap” (Miller, Kulkarni, et al., 2006, p. 409) has emerged between
research and practice in which research findings seldom provide information relevant to
the needs of refugee populations and those who work with them. Understanding the
evolution of academic attention to refugee mental health is an important starting point
and leads naturally to a consideration of the contemporary challenges and opportunities
facing today’s researchers.
2.4.1 The dominant discourse: trauma-focused psychiatric epidemiology
It was not until the 1980s that the field of civilian and refugee mental health gained its
current momentum and contemporary focus on trauma (Ingleby, 2010; Miller, Kulkarni,
et al., 2006). Prior to this time, medical interventions, humanitarian efforts and research
with refugee populations had largely focused on their basic physical needs. There had
been sporadic clinical descriptions of psychic pathology, neurotic illnesses and
psychoses experienced by World War II refugees (Brill & Beebe, 1955; Eitinger, 1959;
Kardiner, 1947; H. B. M. Murphy, 1955), concentration camp survivors (Eitinger, 1961;
Krystal, 1968; Niederland, 1964) and survivors of the Hiroshima nuclear bomb attack
(Lifton, 1967), but no trauma framework as seen today had been applied. Indeed,
according to Ingleby (2010), the word “trauma” was not mentioned in published articles
on refugees between 1968 and 1977.
The present and prevailing focus on trauma in refugee mental health resulted from two
coinciding events in the 1980s. The first was the advent of PTSD in psychiatric
nosology. The second was the international focus on and proliferation of humanitarian
interventions drawn to the plight of refugees from South East Asia. Some of the first
modern refugee mental health studies emerged from collaborations between mental
health researchers and humanitarian relief organisations assisting Cambodian survivors
14
of the Khmer Rouge in South East Asia where researchers (Mollica et al., 1992; Mollica
et al., 1990) set to developing questionnaires to assess rates of PTSD symptoms.
Within two decades of its appearance in DSM, the clinical concept of PTSD was being
rapidly researched, expanded and applied in a wide range of ethnic groups, cultures and
regions where it had not previously been diagnosed or even heard of, including Sierra
Leone (S. H. Fox & Tang, 2000), Central America (Michultka, Blanchard, & Kalous,
1998), Bosnia (Weine, Vojvoda, et al., 1998), Burma (Allden et al., 1996) and Tibet
(Holtz, 1998). Today, published material concerning refugee mental health exceeds
1000 documents (Miller & Rasco, 2004), with most empirical studies focusing on PTSD
and other psychiatric sequelae (most notably other anxiety disorders and depression) of
refugee trauma.
Key findings
Epidemiology studies of refugee mental health have yielded important findings, firstly
in reporting prevalence rates of psychiatric disorders and secondly in demonstrating
several consistent risk and protective factors affecting the wellbeing of refugee
communities. This latter contribution came later in the progression of the field after
early studies had already provided evidence of a dose-dependent relationship between
exposure to traumatic experiences and PTSD symptoms (Mollica, McInnes, Pham, et
al., 1998; Mollica, McInnes, Pool, & Tor, 1998). Researchers soon moved beyond
exploring simple linear relationships between traumatic events and psychopathology
and began to address additional variables contributing to wellbeing and distress. In line
with non-refugee literature, findings began to clearly indicate that vulnerability and
resilience for mental illness (including PTSD) was influenced by complex and
interacting variables including genes, early developmental environment (Bagot et al.,
2007), cultural and social context (Lemelson, Kirmayer, & Barad, 2007), and previous
life experience with stress and trauma (Brewin, Andrews, & Valentine, 2000). It is now
widely accepted that a matrix of pre- and post-migratory factors across physiological,
social, existential, political and experiential domains affect vulnerability and resilience
for refugee populations (Mollica, Cui, McInnes, & Massagli, 2002; Porter & Haslam,
2005; Shrestha et al., 1998; J. P. Wilson & Drozdek, 2007).
15
More recent advancements in refugee mental health have emerged from behavioural
neuroscience studies of fear, anxiety and trauma. As recently discussed by Bremner
(2007), dozens of neuroimaging studies demonstrate decreased hippocampal volume
associated with impaired short-term memory in PTSD patients in comparison to both
non-traumatised controls as well as non-PTSD trauma survivors. These findings are
supported by research with refugee populations (Sabioncello et al., 2000) demonstrating
marked abnormalities in the hypothalamic-pituitary-thyroid axis of East German
refugees (Bauer, Priebe, Kurten, Klaus-Jurgen, & Baumgartner, 1994) and stress
hormone irregularities amongst displaced Croatian women with PTSD (Sondergaard &
Theorell, 2003).
With regards to prevalence rates, epidemiology studies have routinely demonstrated the
presence of symptoms of PTSD, depression and other psychiatric diagnoses amongst
refugees in both clinical and community samples and across a range of cultures. A
review of interview-based prevalence studies of mental disorder amongst community-
based refugees resettled in Western countries reported prevalence rates of 9% for PTSD
and 5% for depression with high levels of comorbidity (Fazel, Wheeler, & Danesh,
2005). However, a wide variation in prevalence rates (e.g., 3% – 86% for PTSD and 3%
– 80% for depression) within and between refugee populations has been noted (Fazel et
al., 2005; Hollifield et al., 2002) and findings across populations are often difficult to
interpret. These inconsistencies may be explained by differences between the
populations studied (e.g., cultural background, war-related experiences and degree of
persecution), research methodology factors (e.g., random processes, non-equivalent
measures and translation issues), as well as problems of low validity of the constructs
measured (Bhui & Bhugra, 2002; D. Murphy, Ndegwa, Kanani, Rojas-Jaimes, &
Webster, 2002; Van Ommeren, 2003). Indeed, epidemiological studies of refugee
mental health are notoriously difficult to undertake. Researchers face enormous
methodological barriers and, increasingly, harsh criticism regarding the validity,
relevance and ethics of their approach. Today these criticisms remain highly pertinent
and, as will be in seen in the following sections, have begun to shape the progression of
the field.
16
Methodological limitations and criticisms
As noted, psychiatric epidemiology studies of refugee mental health are a challenging
venture and further attention needs to be given to sampling methods, validity and
reliability. The variety of measures employed makes it difficult to interpret findings
across studies and populations. Measures used include symptom checklists, most
commonly the Harvard Trauma Questionnaire, the Hopkins Symptoms Checklist and
the Impact of Events Scale (Aptekar & Giel, 2002; Ketzer & Crescenzi, 2002;
McFarlane, 2004; Modvig & Jaranson, 2004), semi-structured interviews and structured
clinical interviews (Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997).
Concerningly, different measures lead to widely differing prevalence rates. For
example, the PTSD prevalence rates reported by studies using structured clinical
interviews are 411% higher than those using other measures (Hollifield, 2005). A
further and fairly consistent criticism of epidemiological research to date is that due to
the use of symptom checklists, findings are often based on symptom identification
rather than on full psychiatric diagnosis (de Jong, Komproe, & Van Ommeren, 2003;
Eisenbruch et al., 2004).
Many measures and studies are also plagued by translation and interpretation issues.
Some checklists and questionnaires are back-translated and piloted, and an
understanding of terms is reached through community consultation (Bolton &
Betancourt, 2004), but this is not always the case (Hollifield et al., 2002). Some studies
create community-specific checklists and seek to use a wording that reflects emic
conceptualisations (Miller, Omidian, et al., 2006), but again many do not (Hollifield et
al., 2002). Clinical interviews may be conducted by mental health professionals acting
with or without interpreters. In other cases the interviewer may be a trained local – often
a fellow refugee. The implications of these variations are significant. The PTSD
prevalence rate is 288% higher when studies use interpreters rather than interviewers
who share the participants’ language (Hollifield, 2005). When symptoms are identified
on the basis of back-translated and piloted instruments utilised by interviewers who
speak the local language, the measures are often still not formally validated for use with
the local population (Bolton & Betancourt, 2004). These factors are likely to contribute
to the inconsistent and varied findings that plague the now large body of literature
relating to refugee mental health.
17
There is also debate about how well PTSD measures can assess the multiple effects of
torture (Silove, 1999) and the “polytrauma” (Hollifield et al., 2002, p. 618) experienced
by refugees who do not simply suffer from isolated, appalling events but rather from
chronic dreadful situations (Ingleby, 2010). Measures of PTSD are generally designed
to assess symptoms after an isolated traumatic event (Watters, 2010) which, in
developed Western nations, is a conceivable situation. However, the experience of
isolated trauma is likely to be uncommon for refugees, many of whom continue to
endure unsafe, unsanitary and unstable environments. Studies with refugees often fail to
conceptualise psychological responses within this contextual framework and report
prevalence rates of PTSD symptoms amongst populations whose daily experiences are
not necessarily “post” traumatic.
The field also lacks longitudinal studies and desperately needs them. It is debatable
whether rates of PTSD in refugee populations are enduring or transient, as studies have
repeatedly demonstrated that the majority of civilians forcibly displaced by war do not
suffer long-term psychiatric impairment (de Jong & Komproe, 2002; Silove, 1999,
2010). The symptoms critical to the PTSD diagnosis (e.g., re-experiencing, avoidance
and arousal) are considered to be normal, evolutionarily adaptive and biologically
hardwired psychobiological responses to extremely threatening experiences (Lemelson
et al., 2007; Rau & Fanselow, 2007; Silove, 2007; Yehuda, 2003a, 2003b). For
example, remembering or re-experiencing the traumatic event can help an individual
learn from a situation and improve their ability to respond in future. Avoiding stimuli
and situations associated with the trauma, and generalising one’s learning to other
contexts, is also likely to reduce the chance of encountering such a threat again. Finally,
increased arousal (e.g., hypervigilance), the third and last symptom category associated
with PTSD, increases one’s likelihood of detecting a threat before it is too late.
Analgesic response to threat may also account for the “numbing” symptoms in the
PTSD criteria (Bouton & Waddell, 2007). Indeed, abnormality could perhaps be marked
by the absence of these symptoms (Modvig et al., 2000; Yehuda, 2003b).
This situation poses a serious problem for the interpretation of data, as elevated rates of
PTSD symptoms in such populations may simply demonstrate an expected short-term
adaptive increase in stress response. Silove (2007) suggests that immediate post-conflict
PTSD symptoms might be more accurately conceptualised as “survival overdrive state
(SOS)” (p. 249) which might better explain why the full list of PTSD symptoms have
18
been consistently observed in trauma survivors in the immediate aftermath of their
traumatic experience (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992; Shalev, 2007).
A number of recent reviews and meta-analyses have confirmed that whilst careful etic
epidemiological research has improved knowledge of refugee mental health, notorious
problems persist including a lack of attention to cross-cultural and contextual (e.g.,
sociopolitical) issues. Most critics do not question the importance of understanding the
traumatic impact of war-related violence. However, there is a growing recognition that a
considerable amount of the variance in reported distress with war-affected communities
is related not to violence experienced in the past but to cultural and contextual factors,
and to the ongoing stressors in people’s day-to-day lives (Blight, Ekblad, Lindencrona,
& Shahnavaz, 2009; Silove, 1999).
Meta-analytic data shows that residing in a country at war is associated with increased
risk for psychopathology independent of direct exposure to war events or experiencing
displacement (Porter & Haslam, 2001). Moreover, displaced persons exhibit greater
mental health distress than non-displaced persons who have also experienced direct
exposure to war. These and other findings (Miller & Rasmussen, 2010) suggest that
factors specific to the post-migratory refugee experience impact on mental health,
additional to the effects of having been exposed to war trauma (Keyes, 2000). In an
analysis of data totalling 67,294 subjects, social conditions after displacement (e.g., type
of accommodation and economic opportunities) were found to be the strongest
moderators of mental health outcomes (Porter & Haslam, 2005). Better psychological
outcomes were associated with private and permanent accommodation, less restricted
economic opportunity and resolution or stabilisation of initiating conflict.
Methodological limitations of trauma-focused refugee mental health research were
made evident in Hollifield and colleague’s (2002) landmark review of the literature. The
review highlighted cross-cultural construct validity concerns, a hotly contested issue
surrounding the validity of applying Western psychiatric diagnoses to non-Western war-
affected populations (Eisenbruch et al., 2004; Miller, Kulkarni, et al., 2006). The
problem of validity stems from a conceptual issue and it is one that deserves thorough
exploration. The issue amounts to the concern that measures of mental illness constructs
such as PTSD across societies can yield misleading results since the meaning of
symptoms may differ across societies and settings.
19
According to Miller, Kulkarni, et al. (2006), refugee mental health research presents an
extensive history of examining diagnostic categories without first establishing the
construct validity of those concepts. When Hollifield and colleagues (2002) reviewed
the range of instruments used to measure the mental health of refugees following trauma
they found that about 90% of the instruments used either did not test reliability or
lacked appropriate construct validity for use in the population of focus. A sample of 183
published studies using 125 different instruments showed that only 12 were developed
specifically for use in refugee populations (and only 22% of the studies utilised these 12
instruments) and another 8 were adapted for use with the population of focus. It has
been argued that this issue represents the most serious flaw in refugee mental health
literature, with critics claiming that sufficient reliability or other improved research
methods “cannot redeem” (Summerfield, 2007, p. 362) a study that lacks cross-cultural
construct validity.
2.4.2 The dominant debates: cross-cultural construct validity and category
fallacies
The cross-cultural validity debate has lingered as one of the most heated in the field of
refugee mental health (Miller, Kulkarni, et al., 2006; D. Pedersen, 2002; Summerfield,
2002). These concerns had previously been raised by medical anthropologists
(Eisenbruch, 1983; Kirmayer, 1989; Kleinman, 1977) but in relation to refugee mental
health, their critiques have only begun to gain sufficient impetus in the past decade. At
the heart of the issue is Kleinman’s (1987) warning against the temptation to assume the
universality of a psychiatric syndrome simply because it can be demonstrated in
different contexts. He termed this error a “category fallacy” which he described as:
the reification of a nosological category developed for a particular cultural group
that is then applied to members of another culture for whom it lacks coherence
and its validity has not been established. (p. 452)
Those who question the presumed universality and cultural relevance of PTSD as a
response to traumatic stress with war-affected populations have drawn attention to
culture-specific responses to war, persecution and forced displacement (D. E. Hinton &
Otto, 2006; Marsella, 1994; Marsella, Friedman, Gerrity, & Scurfield, 1996). They
argue that these experiences and expressions of emotional or mental distress are very
20
unlikely to be identified if the salience of PTSD (or other psychiatric diagnoses) is
assumed a priori and only symptoms fitting the diagnostic profile are assessed. Indeed,
Kleinman (1977) argued that much of Western cross-cultural psychiatric research was
not truly cross-cultural because “by definition it will find what is universal and
systematically miss what does not fit its tight parameters” (p. 4).
Although symptoms of PTSD and depression may be found in a given refugee
population, we cannot assume that the diagnosis has the same meaning or salience as it
does to Western mental health professionals. The presence of PTSD symptoms may
actually tell us little about the degree to which their behaviour is considered normative
or deviant in the local context. Nor can we presume to know how traumatic stress is
understood and experienced. For example, Liberians believe that trauma and chronic
stress can cause Open Mole – a state of suffering defined by a soft spot on top of the
skull and accompanied by additional symptoms including fatigue, somatic aches and
pains, nightmares and social withdrawal (Abramowitz, 2010). Afghans readily identify
symptoms of PTSD but are more likely to understand war-related suffering in terms of
jigar khun, an indigenous idiom of distress that shares some symptomatic overlap with
PTSD, yet is also distinct from it (Miller, Omidian, et al., 2006). Among Latinos, a
trauma survivor is more likely to suffer from ataque de nervios (attack of nerves) than
symptoms comprising the PTSD profile, though again some features of the two
constructs overlap (Lewis-Fernandez et al., 2010). Traumatised Cambodian refugees
report suffering from khyal attacks, a complex cultural syndrome related to
ethnophysiological beliefs in the concept of “wind flow” (D. E. Hinton, Pich, Marques,
Nickerson, & Pollack, 2010, p. 245).
These findings suggest that we can interpret little from an affirmative answer to the
question of whether a refugee experiences symptoms comprising the PTSD diagnosis.
For example, we do not know how the PTSD symptom of nightmares is experienced
and understood from, say, the perspective of a Sudanese woman who witnessed the
violent death of her brother and was unable to bury his body. Her nightmares may be
interpreted within a cultural context in which it is believed that the spirits of deceased
family cannot rest until burial rituals are observed, and her difficulties could be resolved
by the performance of certain rites by a local traditional healer or spiritual guide. That
her symptoms overlapped with PTSD does not negate the reality that her experience
21
was perhaps better conceptualised, and resolved, through indigenous or emic
approaches.
The unquestioned assumption that Western psychiatric diagnoses were applicable to
non-Western refugee populations came under attack shortly after the early cross-cultural
mental health studies of Cambodian refugees (Mollica, Wyshak, & Lavelle, 1987;
Mollica et al., 1990) were published. Not surprisingly, it was medical anthropologists
who were amongst the first to call for researchers to examine the cultural assumptions
underlying the diagnosis of PTSD. They appealed for a tentative approach to the use of
this Western ontology with non-Western refugees (Bracken et al., 1995; Eisenbruch et
al., 2004; Eisenbruch & Handelman, 1989; Gaines, 1992; Handelman & Yeo, 1996;
Higginbotham & Marsella, 1988; Weiss, 1997). These critics argued that assumptions
and claims of the universality of PTSD were, at best, prematurely unwarranted
examples of empiricist epistemology (Bracken et al., 1995; Summerfield, 2008) and, at
worst, examples of Western ethnocentric imperialism (Bracken et al., 1995; Eisenbruch,
1992; Summerfield, 2007).
Western epistemology
Western academically acquired knowledge cannot be separated from its cultural
base even though it presents itself as our natural way of looking at the world.
(Lutz, 1985, p. 65)
Critics argued that psychiatric explanations and the DSM concept of discrete psychiatric
disorders reflect a set of contemporary assumptions that are likely to differ greatly from
the accounts of psychological phenomena in other cultures and cannot be presumed to
have high diagnostic validity across settings (Kleinman, 1980). Anthropologists have
demonstrated that illness and distress are interpreted, experienced and expressed in
different ways across cultural settings and argued that Western psychiatry “is but one
among many ethnopsychiatries” (Summerfield, 2008, p. 993). Ethnopsychiatries differ
in their beliefs about the aetiology of emotional or mental illness and the healing
practices employed. They are also entwined with a populations’ conceptualisations of
self and identity, time, mind and memory, as well as moral authority and religious or
spiritual belief systems (Andary, Stolk, & Klimidis, 2003).
22
Several culture-bound notions have been identified as underlying Western psychiatric
approaches to mental illness. Primary amongst them is Western individualism, which
assumes that the individual is the appropriate unit of analysis in relation to mental
disorder (Karasz, 2005; Markus & Kitayama, 1991). In contrast, for the majority of the
world’s cultures, a collective ontology prevails; dependency and interdependency are
emphasised over individuality; and frameworks for mental health incorporate a more
holistic range of physical, spiritual, supernatural, moral and social domains
(Constantine, Myers, Kindaichi, & Moore, 2004; de Jong, 2004; Drozdek, 2007;
Eisenbruch, 1983; Karasz, 2005; Summerfield, 2008; Wing, 1998). Young (1995)
convincingly argues that the concept of PTSD requires acceptance of several other
uniquely Western notions, particularly those related to the idea of self, mind and
memory, and the belief that a traumatic event can result in some sort of lasting
psychological wound.
Western culture’s medicalised explanation for emotional or mental suffering (Horwitz,
2010) is also at odds with the ontological beliefs of other cultures. During the last
century, Western bureaucracies have increasingly shifted towards a medicalisation of
human experience based on models that assume states of mental illness exist in nature
independently of our definitions of them (Horwitz, 2010; Watters, 2010). Inherent in
this shift has been an intolerance towards suffering. Kleinman (1995) addresses this in
his book Writing at the Margin: Discourse between Anthropology and Medicine:
The idea in the DSM is that suffering can not and should not be endured. It
should be brought to an end. This is central to the ideology of America: there is
nothing that needs to be endured. Even memories can be “worked through”. (p.
180)
However, throughout history, world religions have provided followers with other
models for understanding their pain and suffering (Almedom & Summerfield, 2004),
including the suffering associated with war and persecution. For most non-Western
cultures today, human suffering continues to be explained as a defining characteristic of
the human condition and a vital aspect of one’s existential plight (Boehnlein, 2007).
An extension of the medicalisation of life is the perception that culture is an arbitrary
phenomenon superimposed on a universally uniform biological reality (Lewis-
23
Fernandez & Kleinman, 1994; Vance, 1991). Contemporary Western psychiatry, as
reflected in DSM-IV, largely conceptualises mental disorders as discrete entities of
organic or biological origin. However, evidence for this is lacking. Few psychiatric
constructs boast convincing evidence of biological causation or even a biological
marker, as is common for most physical illnesses and diseases (Schwartz & Corcoran,
2010). Indeed, despite the supposed universality and organic origin of many Western
psychiatric constructs, history has seen dozens of constructs come and go from
inclusion in diagnostic publications in line with social and cultural trends (Summerfield,
2008, 2010; Watters, 2010). It has been argued that “with the exception of the clearly
defined organic disorders, almost all presently used [psychiatric] diagnostic categories
are, at best, provisional” (Silove, 2010, p. 36).
Nor does the conceptualisation of mental illnesses as discrete entities receive unanimous
support within psychiatry and psychology. In fact, in preparation for the introduction of
DSM-V (due for release in 2013) there has been a resurgence of interest, controversy
and debate around the suggestion that mental health and illness are better
conceptualised as dimensional continua of affect and function rather than in terms of
discrete disease states (Bonanno & Mancini, 2012; Giles & Matthews, 2012; Horwitz,
2010). In relation to PTSD, this argument is supported by several lines of evidence
suggestive of a “biological continuum” (Konner, 2007, p. 315; Summerfield, 2010)
comprising PTSD, other anxiety disorders and mood disorders.
Picking apart PTSD: hegemony, trauma and the medicalisation of war
Amongst the critiques against the cross-cultural application of Western psychiatric
nosological constructs with refugees, much has been made of the sociopolitical context
surrounding the diagnosis of PTSD. In The Harmony of Illusions: Inventing Post-
Traumatic Stress Disorder, ethnographer Allan Young (1995) traces the development of
the diagnosis and argues:
The disorder is not timeless, nor does it possess an intrinsic unity. Rather, it is
glued together by the practices, technologies, and narratives with which it is
diagnosed, studied, treated, and represented and by the various interests,
institutions, and moral arguments that mobilized these efforts and resources. (p.
5)
24
Outspoken critic Summerfield (2001) has similarly claimed that:
A central assumption behind psychiatric diagnosis is that a disease has an
objective existence in the world … however, the story of PTSD is a telling
example of the role of society and politics in the process of invention rather than
of discovery (p. 95).
Such critiques are not universally supported and several authors believe that the
conceptual origins of the diagnosis are traceable through historic psychiatric literature
(Turnbull, 1998; van der Kolk & van der Hart, 1989; Wakefield, 2001; J. P. Wilson,
1994). Nonetheless, most accounts of the conceptual development of modern PTSD
recognise the influence of the post-Vietnam War era. According to Watters (2010), the
diagnosis was originally called “Post-Vietnam Syndrome”, an idea that originated out of
meetings held by the Vietnam Veterans Against the War and attended by anti-war
psychoanalyst Dr Chaim Shatan.
Several authors (Scott, 1990; Watters, 2010; Young, 1995) have suggested that the idea
behind post-Vietnam syndrome was not to create a diagnosis but rather to call attention
to the unique situation experienced by Vietnam veterans who felt “deceived, used and
betrayed” (Watters, 2010, p. 115) by the US government, military and society. In 1975,
Dr Shatan approached the then Chairperson of the DSM-III taskforce advocating the
inclusion of Post-Vietnam Syndrome. A DSM-III working group was assigned to
explore the concept which, during the course of research and development, was
variously renamed “Post-Combat Disorder” and “Catastrophic Stress Disorder” (Young,
1995). Psychiatrists in the working group soon linked the same set of symptoms to other
patient populations (e.g., burn victims) and by 1980, when DSM-III was first published,
the diagnosis of PTSD had been developed and extended far beyond the Vietnam
veterans’ and Dr Shatan’s original suggestion.
The inclusion of PTSD was one of many changes heralded by the publication of DSM-
III (American Psychiatric Association, 1980) which marked “a revolutionary turn in
American psychiatry” (Young, 1995, p. 100). Prior to this time there was no
standardised neo-Kraepelinian nosology in psychiatry. Neo-Kraepelinian psychiatrists
identified with the nosological perspective of the German psychiatrist Emil Kraepelin
(1856–1926) who assumed a non-arbitrary division between sanity and mental illness,
25
and argued that research would eventually demonstrate the biological origins of discrete
psychiatric disorders (Klerman, 1978). In part the DSM-III developers were pressured
to create a standardised system in order to meet the needs of government and insurance
companies whose support for psychiatry was waning (Young, 1995). However, the
taskforce was also comprised of researchers who endorsed biological explanations for
psychiatric constructs.
According to Summerfield (1999), the inclusion of PTSD into DSM-III was intended to
stimulate further research. However, he argues that the result was a near-paralysis of
inductive research into human reactions to traumatic experiences, and the advent of an
era of PTSD epidemiology research. Indeed, as we have seen, since the 1980s the
construct of PTSD has been rapidly applied to refugee populations with an often
unquestioned assumption of its scientific validity, universality and cultural relevance.
Quickly viewed as a matter of scientific technology, there was money to be made both
in research and in the development of treatments for PTSD. On the international stage,
the construct quickly became a political currency in humanitarian aid situations where
the diagnosis became, and remains, a part of regulation governing the status of migrants
fleeing violence (Drozdek, 2007). Descriptions of PTSD as a “hidden epidemic”
(Almedom & Summerfield, 2004, p. 383; Silove, 2007) and the most important public
health problem in recently war-torn countries reflect the informational sources affecting
the decision-making of donor organisations and governments involved in humanitarian
crisis intervention (Gozdziak, 2004). In 1995, the then editor-in-chief of the American
Journal of Psychiatry observed: “it is rare to find a psychiatric diagnosis that anyone
likes to have, but PTSD seems to be one of them” (Andreasen, 1995, p. 964).
In this manner it could be argued that PTSD came to life through a self-perpetuating
cycle of promotion. Several authors (Bracken, 2001; Pupavac, 2004; Summerfield,
1999) have further interpreted the rapid growth and promulgation of PTSD through the
lens of political sociology and attributed its rise to other postmodern cultural
developments including the secularisation of society, demise of traditional value
systems and subsequent loss of meaning. Alongside these changes were developments
and challenges in the field of humanitarian intervention. Pupavac (2004) describes the
politicisation and vehement criticism facing humanitarian organisations in the 1990s
26
and argues that the rise in PTSD, and more broadly refugee mental health, resulted from
the wider “crisis of purpose” (p. 497) in humanitarianism.
Notwithstanding the important points that critics have made, it should be noted that
refugee populations have benefited from trauma-focused research to date. Firstly,
through the interest associated with PTSD, the plight of refugee communities has
obtained public, professional and political recognition (Bala, 2010). Secondly, many
refugees who do experience debilitating mental health difficulties have been able to
access mental healthcare.
2.4.3 Intervention issues: practical, clinical and ethical challenges
Beyond conceptual arguments about the evidence and ethics of approaching refugee
mental health through the lens of Western psychiatry, critics have noted additional
practical limitations and expressed concern that trauma-focused research has often
failed to provide the sort of useful information that could support the development of
culturally appropriate and empirically sound mental health interventions.
From as early as the 1980s, humanitarian organisations, researchers and mental health
practitioners rapidly devised and implemented trauma-focused treatments in the
immediate aftermath of conflict and displacement. Today this practice remains common
(Watters, 2010) yet there is limited evidence for the efficacy of psychotherapy with
refugee populations (Aroche & Coello, 2004; Drozdek & Wilson, 2004; Nicholl &
Thompson, 2004; Nickerson, Bryant, Silove, & Steel, 2011; J. P. Wilson & Drozdek,
2007). Critics have argued that a medicalised trauma-focused model of refugee mental
health has had the effect of spawning “a self-sustaining and self-serving trauma
counseling industry” (Silove, 2007, p. 242) in the absence of supportive empirical
evidence.
It is beyond the scope of this thesis to detail the variety of psychotherapies implemented
in refugee communities. The terms counselling, trauma counselling, psychotherapy and
psychological support are used by a multitude of authors in a variety of ways and these
labels often tell us little of what the intervention actually involved. Different forms of
cognitive behavioural therapies (CBT), most often involving exposure therapy, appear
to be the most commonly applied psychotherapy with refugees (Murray, Schweitzer, &
Davidson, 2010; Nicholl & Thompson, 2004; Nickerson et al., 2011; Palic & Elklit,
27
2011). This is in large part due to the trauma focus of refugee mental health literature
and the fact that CBT is the most widely studied and accepted intervention for PTSD
amongst Western populations (Bisson & Andrew, 2007; Foa, Keane, & Friedman,
2000; Foa, Rothbaum, Riggs, & Murdock, 1991). Other psychotherapies commonly
utilised in refugee studies include narrative and testimony approaches (De Haene,
Grietens, & Verschueren, 2010; McPherson, 2012; Weine, Kulenovic, Pavkovic, &
Gibbons, 1998), eye-movement desentisitation (Oras, de Ezpeleta, & Ahmad, 2004), as
well as music and art therapy (Orth, Doorschodt, Verburgt, & Drozdek, 2004;
Wertheim-Cahen, van Dijk, Schouten, Roozen, & Drozdek, 2004). Despite their
differences, most trauma psychotherapies tend to be guided by the notion of “working
through” the traumatic event (Ingleby, 2010, p. 7).
The limited evidence base for interventions may be partly explained by methodological
problems including the diversity of psychotherapies. However, the efficacy of
treatments is also limited because the needs, experiences and healing approaches of
refugee populations do not always align with the orientation of Western-derived trauma-
focused interventions.
It has been argued that psychiatric (and particularly trauma-focused) approaches to
understanding and addressing human suffering and wellbeing have resulted in
rehabilitation services for refugees that (a) pathologise refugee reactions, deny
resilience and encourage a culture of passivity and victimhood (Pupavac, 2004), (b)
overlook individual and community strengths and resources (Horwitz, 2010; Rousseau
& Measham, 2007; J. P. Wilson & Drozdek, 2007), (c) lack a cultural basis in refugee
communities, (d) fail to accommodate the range of experiences and expressions of
suffering, and (e) are underutilised and unsustainable because they do not address issues
that are relevant to the experiences and interpretations of the community (de Jong &
Komproe, 2002; Miller, Kulkarni, et al., 2006).
This situation has led critics to question the ethics of trauma-oriented interventions and
point to evidence that they may be ineffective, unwarrranted and impractical (Silove,
2007; Silove, Steel, & Bauman, 2007). Worse still, trauma interventions can be
patronising, offensive, stigmatising (Boehnlein et al., 2004; Ekblad & Jaranson, 2004;
D. Pedersen, 2002) and even harmful (Kenardy, 2000; Mayou, Ehlers, & Hobbs, 2000;
Raphael & Wilson, 2000; Rose, Bisson, Churchill, & Wessely, 2009). In light of these
28
concerns it is imperative that future research explore refugees’ perceptions of service
provisions. The current study addresses this in relation to Karen refugee women.
In the past refugee populations have seldom been consulted before mental health
epidemiology studies and intervention projects are undertaken (D. Murphy et al., 2002).
Communities have generally not been asked about their needs and priorities, nor their
opinions about having their mental health framed and published in psychiatric discourse
and literature (Summerfield, 2002). Moreover, there is little evidence that these
populations are actually seeking to have access to Western psychiatric concepts and
treatments over their own traditional systems (Summerfield, 1999). Not surprisingly,
this lack of community consultation can easily result in research that does not address
the priorities of the community.
Critics also argue that the trauma-focused discourse (and industry) of refugee mental
health imposes a sort of professional imperialism in assuming that refugees (a) might
harbour hidden problems, (b) need help (from professionals), (c) are in denial if they do
not agree with outsiders’ observations about their hidden problems (Ingleby, 2010), and
(d) require Western psychiatric methods over their own healing systems. Despite
evidence that coping patterns vary across ethnic groups (Bhui, King, Dein, &
O’Connor, 2008), studies of refugees’ mental wellbeing often fail to recognise or
adequately explore emic approaches to coping with trauma and emotional distress. This
situation can lead to a gross misinterpretation of culturally (and perhaps universally)
normative patterns of behaviour and the undermining of traditional systems.
Critics have deplored Western health professionals for their “misguided image of war
and its aftermath … far removed from the actual experience of non-Westernised
societies” (Summerfield, 2002, p. 1105). They argue that the PTSD discourse amounts
to the medicalisation, sanitisation and “psychologising” (Pupavac, 2004, p. 491) of “the
misery and horror of war” (Summerfield, 2001, p. 96). This argument was put forward
in one of the earliest criticisms of psychiatry’s trauma-focused discourse on refugee
mental health; in 1988 Higginbotham and Marsella argued:
Investing authority in biomedical reasoning about human problem eliminates
explanations of disorder at levels of psychologic, political and economic
29
functioning. Consequently, problems with origins in poverty, discrimination,
role conflict and so forth are treated medically. (p. 559)
Several authors have called for recognition of the way in which war and forced
migration affect the “social fabric” (Summerfield, 2000, p. 418) of refugee communities
(Miller & Rasco, 2004). Concepts such as “collective trauma” (Somasundaram, 2010;
Somasundaram & Jamunanantha, 2002) and “cultural bereavement” (Eisenbruch, 1992)
have been offered as alternative frameworks from which to appreciate the material,
social and spiritual losses that accompany forced migration.
Psychosocial interventions have also often been promoted as a means of addressing the
broader contextual factors affecting the mental health outcomes of refugees. In contrast
to most psychotherapies, which typically focus on the individual or perhaps the family
unit, psychosocial or ecological interventions emphasise the connection between the
individual and their larger social environment. Accordingly, in addition to providing
support for psychological distress, psychosocial interventions also attempt to give
attention to the cultural, socioeconomic and sociopolitical factors affecting
psychological wellbeing (Ekblad & Jaranson, 2004). Given the cultural orientation of
these approaches, their planning and implementation typically involves more
community consultation and generally includes the use of indigenous healing strategies.
Psychosocial interventions aim to foster people’s inherent coping ability and are guided
by the notion that, given adequate social support, most refugees will cope with the loss
and trauma they have endured.
There are many versions of psychosocial interventions. According to the Psychosocial
Working Group (2003), an intervention is considered psychosocial if it promotes
“human capacity or the social ecology of a community or contribute[s] to people’s
efforts to re-establish culture and values in some way” (p. 3). Given the broad focus of
the psychosocial framework it is difficult to know what is meant when authors refer to
using psychosocial interventions. It is also difficult to measure the efficacy of such
programs (Hubbard & Miller, 2004). Unfortunately little is known about the feasibility
and outcomes of psychosocial interventions in terms of mental wellbeing. It is unclear
whether the needs of the most mentally unwell are met through this approach (Silove,
2010).
30
2.4.4 Developments and directions for research: the emic-etic evolution
The muddled situation fostered by polarised opinions about how to approach refugee
mental health could have deleterious consequences as it risks confusing planners and
funding agencies, as well as humanitarian and mental health staff (Rousseau &
Measham, 2007; Silove, 2007). It also risks harming those it aims to help when
ineffective and impertinent interventions are used.
Fortunately, the past decade has witnessed innovative solutions to the challenges and in
response to calls to “move on from head-counts and surveys demonstrating more
prevalence figures and associations” (Patel, 2000, p. 746). Increasing numbers of
researchers have implemented research that is inclusive of and sensitive to the local
needs of the community, and sought to provide useful information for practitioners and
policy makers. Such calls are of course not new. Decades earlier, medical
anthropologist (and psychiatrist) Arthur Kleinman (1977) had heralded the beginning of
the “new cross-cultural psychiatry” (p. 5) in response to the “seriously distorting
influence” (p. 9) of the dominant approach to transcultural psychiatry. He envisaged
that the new cross-cultural psychiatry would integrate anthropological and psychiatric
research.
Kleinman was perhaps premature in announcing significant change to the dominant
discourse for psychiatry in general, and particularly in relation to refugee mental health.
However, from the mid-1970s onwards we did see the development of several
influential emic-oriented frameworks in anthropology and medical anthropology
(Weiss, 2001). In the past decade several research teams have extended the framework
of refugee mental health research to include ethnographic and other emic-oriented (e.g.,
qualitative) methodologies (Bolton, 2001; Bolton, Wilk, & Ndogoni, 2004; Eisenbruch
et al., 2004; Hubbard & Pearson, 2004; Miller, Omidian, et al., 2006; Mollica, 2001;
Patel, Abas, Broadhead, Todd, & Reeler, 2001; Phan et al., 2004; Silove & Bryant,
2006). These studies have allowed for an identification of local syndromes and idioms
of distress, and an understanding of strengths, forms of resilience and patterns of help-
seeking behaviour.
Ethnographic and epidemiological approaches to refugee mental health are now widely
viewed as mutually supportive approaches (Hollifield, 2005; Hollifield et al., 2002;
Silove & Bryant, 2006) and creative mixed-method solutions have emerged (Bass,
31
Bolton, & Murray, 2007; Bolton et al., 2007; de Jong, 2002; Eisenbruch et al., 2004;
Patel, 2001). It is now accepted that ethnographic explorations of community
psychosocial concerns and beliefs about mental wellbeing are a necessary first step if
we are to address the needs of refugee communities (Bass et al., 2007; Keyes, 2000;
Marsella, Friedman, Gerrity, & Scurfield, 1996; Miller, Kulkarni, et al., 2006; Petevi,
Revel, & Jacobs, 2001; Silove & Bryant, 2006; Summerfield, 2008).
Researchers have been particularly interested in documenting refugees’ idioms of
distress which, according to the DSM-IV, should form part of clinicians’ “cultural
formulation” (American Psychiatric Association, 2000, p. 897) of patients from non-
Western cultures. Anthropologist Mark Nichter (1981) is credited with first theorising
this conceptual framework and coining the term “idiom of distress”, explaining:
In any given culture, a variety of ways exist to express distress. Expressive
modes are culturally constituted in the sense that they initiate particular types of
interaction and are associated with culturally pervasive values, norms,
generative themes, and health concerns. (p. 379)
Subsequently, in refugee mental health literature, idioms of distress have been variously
described and defined as “popular categories of mental and emotional suffering”
(Lewis-Fernandez et al., 2010, p. 220), and “those particular ways in which members of
sociocultural groups convey affliction” (D. E. Hinton & Lewis-Fernandez, 2010b, p.
210). In an Appendix, the DSM-IV (American Psychiatric Association, 2000) provides
a guide which encourages clinicians to note non-Western patients’ “idioms of distress”
(p. 897) including:
… the meaning and perceived severity of the individual’s symptoms in relation
to the norms of the cultural reference group, any local illness category used …
and the perceived causes or explanatory models that the individual and the
reference group use to explain the illness. (pp. 897–898)
Amongst the suggested emic-oriented frameworks and methods for exploring refugees’
idioms of distress, Kleinman’s (1980) explanatory model (EM) conceptual framework
has been especially influential. The EM framework provides a method for researchers to
explore emic beliefs about illness and healthcare. Kleinman first described EMs as
“notions about an episode of sickness and its treatment” (p. 105) formed by the various
32
cultural experiences, expectations and symptoms that are associated with a particular
illness. The original model aimed to tap respondents’ understanding or perception of (a)
what to call their illness based on their experience or dominant complaints, (b) the cause
of the illness, (c) the timeline or anticipated course of the illness, (d) the consequences
of having the illness as well as the perceived controllability of these factors, and (e)
appropriate and effective treatments (Bhui, Rudell, & Priebe, 2006).
Although Kleinman (1980) was careful to distinguish between general illness beliefs
(which he termed health ideology) and EMs (which he considered related to a specific
episode of illness), this distinction has not been upheld in subsequent research. The EM
framework has been expanded and frequently applied to explore illness beliefs in the
absence of a current specified disease or illness, particularly in the field of mental health
research (Dejman, Ekblad, Forouzan, Baradaran-Eftekhari, & Malekafzali, 2008; Patel,
Ferrao Simbine, Soares, Weiss, & Wheeler, 2007; Williams & Healy, 2001; Ying,
1990). Others have developed Kleinman’s original ideas into instruments to elicit EMs
(Lloyd et al., 1998; Weiss, 1997). These measures aim to tap collective and individual
cultural beliefs, knowledge and explanations about illness and distress.
Mental health researchers have frequently explored EMs in relation to depression
(Aidoo & Harpham, 2001; Dejman et al., 2008; Okello & Ekblad, 2006; Patel, Pereira,
& Mann, 1998; Raguram, Weiss, Keval, & Channabasavanna, 2001; Sulaiman, Bhugra,
& de Silva, 2001; Ying, 1990), although a range of psychiatric constructs have been
studied including schizophrenia (McCabe & Priebe, 2004) and somatisation
(Henningson, Jakobsen, Schiltenwolf, & Weiss, 2005). Findings indicate that patients’
causal EMs are strong predictors of impairment and short-term prognosis (Bhui et al.,
2006). For example, poor prognosis is associated with EMs emphasising biological
causes amongst patients with somatoform disorders (Henningson et al., 2005). These
and other findings indicate that EMs may complement other clinical evaluations for
understanding illness prognoses (Bann et al., 2004).
Cross-cultural EMs of mental illness have been investigated in both clinical and non-
clinical populations through the use of vignettes depicting etic mental illness constructs
(Dejman et al., 2008; Okello & Ekblad, 2006; Patel et al., 2007; Sulaiman et al., 2001;
Wig et al., 1980; Ying, 1990). Culturally grounded vignettes may assist with group
interviews regarding sensitive topics and have also been used to validate information
33
obtained from in-depth interviews (A. Bailey, 2008). Findings from studies using
vignettes have been used to select mental health service priorities according to
prevalence, perceived harmful consequences, community concern and availability of
appropriate treatments (Wig et al., 1980). While elements of the EM framework have
been used in refugee research, these studies have generally been limited to exploring
refugee communities’ casual understandings of mental illness (Eisenbruch, 1990;
Eisenbruch & Handelman, 1989; Handelman & Yeo, 1996). Moreover, the literature
review failed to identify any refugee EM studies using vignettes to explore emic (local)
conceptualisations of etic (Western) psychiatric constructs.
Despite recent advances, several other limitations of qualitative studies of refugee
mental distress remain. Like their predecessors, these studies have often retained an
individualised focus on psychological experience and given insufficient attention to the
broader sociopolitical issues affecting the community. Few have used qualitative
(especially ethnographic) methods to explore local EMs of mental illness. Moreover,
most research still “uses Western categories and looks for what are believed to be local
permutations, but assumes that Western categories and nosologies are universally
applicable” (de Jong & Komproe, 2002; Gaines, 1992, p. 4). Research beginning from
this premise risks overlooking important emic perspectives in the search for the
universal.
A further limitation of the restricted biomedical, epidemiological and trauma-focused
orientation to refugee mental health has been a failure to draw across disciplines and
engage potentially useful sociological theories and frameworks. For example, the
sociological frameworks developed by the late French anthropologist, sociologist and
philosopher Pierre Bourdieu (1977) could provide a powerful basis for understanding
the experience and psychosocial consequences of persecution, forced migration and
refugee resettlement. Through the concept of habitus Bourdieu sought to explain how
the social world is internalised and embodied in the dispositions of individual actors.
These dispositions include gendered, class and culture-based mannerisms, behaviours,
habits, beliefs and feelings (Jenkins, 2002) and are embodied in individuals and as a
collective characteristic of a particular social group. The power of the notion of habitus
lies in the way in which certain behaviours or beliefs become an automatic part of social
structure operating below a level of conscious rationale. Despite the shift toward
34
psychosocial explanations and interventions of refugee mental health, to my knowledge,
Bourdieu’s work has not been used specifically used in studies to date.
Few studies have focused on women’s specific emotional experiences and needs,
despite the challenges they face during war and forced migration. Research indicates
that refugee women are more likely to experience depression and PTSD than men
(Schubert & Punamaki, 2011) but this phenomenon is poorly understood. A recent
review found resettled refugee and immigrant women were also around 30% more
likely to suffer from postnatal depression (C. H. Collins, Zimmerman & Howard, 2011)
than non-immigrant women though here again, the studies contributing the review
suffered from methodological flaws common to studies of refugee mental health.
Indeed, the most recent review of questionnaires for measuring the health of refugee
women described those used as “suboptimal” (Gagnon & Tuck, 2004, p. 141).
During all phases of the refugee journey women are at high risk of gender-based
violence, exploitation and discrimination (Kaplan & Webster, 2003; Pittaway &
Bartolomei, 2001; Ryan, Doonley, & Benson, 2008; Zwi & Alvarez-Castillo, 2003).
Commonly, women and children are also the first to flee as men remain and fight
(Drumm, Pittman, & Perry, 2001). Pre-migration gendered experiences such as access
to education impact on women’s resettlement and affect their wellbeing (Deacon &
Sullivan, 2009). Resettled refugee women also often take on new social and family roles
as a result of forced migration and their experiences of these shifting responsibilities
require further exploration (Yakushko & Espin, 2010).
Ethnographic studies have also often overlooked the opportunity to explore refugees’
perspectives about mental health and psychosocial service provisions. A related gap
concerns the absence of emic-oriented refugee studies that take a broader focus and
include the perspectives of staff at service providers. This information is important in
order to fully understand the context surrounding the implementation of mental health
interventions and usefully guide policy-relevant research. Finally, many of the
ethnographic studies have been undertaken in refugee camps where individuals and
communities are likely to have some (albeit compromised) access to their traditional
ways of life and customs. However, as cultural beliefs and customs are not fossilised
entities, it is important to understand how cultural factors relate to the health and
wellbeing of resettled communities who are likely to be much farther removed from
35
traditional ways of life. Future ethnographic psychosocial assessments of refugee
communities must address resettled populations and the service providers who work
with them – both of whom face the challenge of adapting to each others’ foreign
language and culture.
2.5 Addressing the gaps
This chapter has outlined several limitations and gaps in refugee mental health literature
that this study aims to address. These include:
A lack of studies exploring refugees’ emic perspectives of mental or emotional
wellbeing and distress, and approaches to coping.
Insufficient attention to refugees’ EMs of mental illness as well as an absence of
studies using vignettes to explore refugees’ conceptualisations of Western
psychiatric constructs.
Inadequate consideration of gender and the gender-based challenges of refugee
women.
Insufficient attention to refugees’ perspectives about mental health service
provisions combined with an absence of studies that include the perspectives of
refugee service providers.
These gaps in mental health literature are particularly evident in relation to refugees
from Burma and, more specifically, the Karen ethnic group. Refugees from Burma
represent one of the UNHCR’s largest resettlement populations (UNHCR, 2010a).
However, only three published studies (Allden et al., 1996; Lopes Cardozo, Talley,
Burton, & Crawford, 2004; Schweitzer, Brough, Vromans, & Asic-Kobe, 2011) have
specifically explored the mental health of this population. All reported prevalence rates
of depression (ranging between 36% and 42%) and PTSD (ranging between 4.6% and
23%), which were measured according to psychometric questionnaires. Two of the
studies (Allden et al., 1996; Lopes Cardozo et al., 2004) used interview methods to
adapt the measures and identify “culturally dependent” (Allden et al., 1996, p. 1562)
symptoms and coping strategies. The most recent study (Schweitzer et al., 2011) also
examined the contribution of pre- and post-migration stressors to wellbeing amongst
Burmese refugees in Australia. However, none of the studies specifically explored emic
conceptualisations of wellbeing and distress or investigated participants’ EMs.
36
Moreover, the literature review failed to identify any studies focusing on the mental
health of Karen refugees or Karen refugee women. This study will address these gaps.
37
Chapter 3
Setting the Scene: Burma and the Karen
3.1 Introduction
This chapter sets the scene for understanding the pre-migration lives of Karen refugee
women from Burma. It describes the relevant sociopolitical history of Burma, detailing
the contemporary human rights abuse situation and the effects of oppression on the
national culture and psyche. The rich cultural tapestry of the people of Burma will be
explored, giving emphasis to the Karen. Finally this chapter attempts to depict refugee
camp life where thousands of Karen (and other) refugees from Burma have lived since
the early 1980s. An understanding of camp conditions and culture is highly relevant to
this thesis as most refugees from Burma who arrive in Australia have spent several
years, and in most cases a decade or more, living in this setting.
3.1.1 Burma, Burman, Burmese and Myanmar: a note on terms and usage
In 1989 the Burmese military junta changed the official name of the country to the
Union of Myanmar (currently the Republic of the Union of Myanmar). This thesis
adopts the position of the Australian Government, who do not recognise this name
change and continue to use the name Burma (Department of Foreign Affairs and Trade,
2011). The Burman people, or “Bamah” (Steinberg, 2010) are the dominant ethnic
group in Burma today and are differentiated in language and culture from the many
other ethnic minority groups including the Karen, Shan, Mon and Chin. Like Steinberg
(2010) and Fink (2009), this thesis uses the term Burman to refer to members of the
largest ethnic group and the term Burmese when referring to (a) the language spoken by
the dominant Burmans, and (b) all citizens of the country. However, I acknowledge that
some people from Burma reject this latter use of the term Burmese and do not like its
association with the dominant Burmans.
3.2 Burma: an overview
In approximately 2500 BC the Mon people of Central Asia are thought to have settled
throughout the lower parts of South East Asia and modern-day Burma, followed by the
Tibeto-Burmans to whom modern Burmans trace their early ancestry. Today Burma’s
total population is an estimated 54 million, of which approximately 70% are ethnic
38
Burman. There are an estimated 130 different ethnic minority communities within seven
ethnic states (Kachin, Karen, Karenni, Shan, Chin, Mon and Arakan) which make up
60% of the territory (Ekeh & Smith, 2007), as shown in Figure 1. These states are
acknowledged in Burma’s 1947 constitution which allows traditional local leaders to
manage the day-to-day affairs in ethnic regions while the central state government
maintains absolute sovereignty over the nation. In reality, however, the “regulatory
authority [of the central state government] is neither uniform, coherent, unified, nor
unchallenged” (Callahan, 2007, p. 6). Whilst there is no reliable census data on the
ethnic minority communities, the UN and human rights organisations estimate the
largest ethnic minorities are Shan (9%) and Karen (7%). The official national language
is Burmese, but most of the ethnic minority groups speak their own languages, and
many do not speak Burmese (United Kingdom Home Office, 2009).
Burma is rich in natural resources, especially timber (particularly teak), arable land,
marine fisheries and gas, but is currently one of the poorest countries in Asia and
around 30% of the population live below poverty (Department of Immigration and
Citizenship, 2011d; Department of Foreign Affairs and Trade, 2011; Central
Intelligence Agency, 2010). On the 2010 UN Human Development Index (a measure of
wellbeing), Burma ranked a low 132nd out of 169 countries (United Nations
Development Programme, 2010). The financial system is underdeveloped, plagued by
corruption and a large black market economy, and spending is skewed towards the
military (Department of Foreign Affairs and Trade, 2011). Burma is also the world’s
second largest producer of illicit opium (Central Intelligence Agency, 2010) and
methamphetamine production is increasing (Steinberg, 2010).
39
Figure 1: Map of Burma illustrating ethnic minority areas including Karen State.
Adapted from Karen Human Rights Group website (Karen Human Rights
Group, 2005.)
40
3.2.1 Politics and power
Burma was ruled under a monarchical system until 1886 when, after a series of Anglo-
Burmese wars, Britain gained control of the country. For many years the British
administered Burma as a province of India and complete colonisation lasted for 62 years
until Burma gained independence from Britain in 1948. The nation’s independence
hero, General Aung San, was expected to have led an interim government but was
assassinated some months before independence was granted. In 1948, Prime Minister U
Nu took power and established a new constitution based on a democratically elected
parliament. The nation was in a volatile situation and intense civil war soon erupted as
the government was challenged by various communist organisations as well as ethnic
minority groups (M. Smith, 1994). In 1962 the government was overthrown by a
military coup led by General Ne Win and life rapidly changed for the citizens of Burma.
Political opposition was banned, strict censorship laws were implemented and the
“Burmese Way to Socialism” began. The country plunged into a devastating economic
and social crisis.
In the decades since, the military has violently suppressed anti-government activities,
most famously opening fire and killing around 3,000 peaceful protestors during a mass
demonstration on 8 August 1988 (known as the 8888 Uprising) (Department of Foreign
Affairs and Trade, 2011). Thousands of democracy activists fled to the jungle and
neighbouring countries. Another military coup erupted the following month. General Ne
Win stepped down and the military, calling itself the State Law and Order Restoration
Council, again assumed power.
In 1990, the military junta held democratic elections in which Aung San Suu Kyi’s
(daughter of General Aung San) party, the National League for Democracy, won an
overwhelming 392 of the 485 parliamentary seats. The State Law and Order Restoration
Council refused to validate the results and soon arrested Aung San Suu Kyi, her party
members and other democracy supporters. Whilst under house arrest, Aung San Suu
Kyi was awarded the 1991 Nobel Peace Prize.
In recent years poverty and bloodshed have continued to plague the nation. In August
2007 the junta withdrew fuel subsidies, prompting a 500% fuel price increase, and an
increase in rice prices by 50% in four months. The situation prompted pro-democracy
demonstrations in September 2007. The military government again violently suppressed
41
the protests with gunfire. The nation suffered another crisis on 2 May, 2008 when
Cyclone Nargis struck the south of Burma, killing an estimated 140,000 people and
affecting a further 2.4 million (Department of Foreign Affairs and Trade, 2011). The
military government was slow to respond whilst also initially blocking international
assistance, prompting international condemnation. In the aftermath of the cyclone, on
10 and 28 May, 2008, the government also pushed forward with national referendums
for a new constitution. The regime announced its 92.48% win; “a figure no independent
observers believed was valid” (United States Department of State, 2010, para. 1).
On 7 November, 2010, Burma held its first elections in two decades. However, the
international community (United Nations General Assembly, 2010a), including the
Australian Government, later declared the elections “fundamentally flawed … and
patently unfair” (Department of Foreign Affairs and Trade, 2011, para. 17). Many
democrats chose not to participate in the election due to unfair election laws; people
also contested the final poll in which the regime’s party (the Union Solidarity and
Development Party) won 76% of seats overall, and Thein Sein became President.
According to the Human Rights Watch (2011), the situation in Burma has not
significantly improved since the 2010 elections.
On 13 November, 2010, Aung San Suu Kyi was released from house arrest. She has
remained a prominent international and local figure and was among 43 of her party
members elected to parliament in the April 2012 by-elections. The elections were part
of General Then Sein’s wave of political and economic reforms, which seek to gain
international legitimacy for Burma and overcome Western economic sanctions.
However, the military-backed party continues to effectively hold around 80% of seats in
parliament and the current constitution bars Aung San Suu Kyi from ascending to
presidency because she married a foreigner (“Burma’s NLD”, 2012).
The Yugoslavia of Asia: ethnic politics in Burma
In common with many other post-colonial societies around the world, such as
Indonesia, Burma is a somewhat artificial entity with which many of the ethnic
minorities, in particular, have great trouble identifying … As a consequence, in
what is sometimes called the “Yugoslavia of Asia”, there is the ever-present
danger of explosive political disintegration. (Philp & Mercer, 1999, p. 27)
42
Ethnic divergence and tensions have a long history in Burma (Steinberg, 2010).
However, such divisions were intensified and strategically exploited under British rule
(Fink, 2009; Steinberg, 2010). Ethnic minorities, particularly the Karen, aligned with
British forces and faith (Christianity), and many were rewarded with access to higher
education and employment status during colonial rule (Suu Kyi, 2010). During World
War II, the Karen continued to support British forces while the Burmans aligned,
temporarily, with the Japanese. Atrocities were committed on both sides and ethnic
tensions worsened (Neiman, Soh, & Sutan, 2008).
During independence negotiations some ethnic groups petitioned the British for their
own land and nation. The Karen established the Karen National Union and advocated
for a Karen nation, Kawthoolei, independent from Burma (Karen National Union,
2011). They were, however, unsuccessful in achieving their political aims. The post-
independence Burmese Government also declined requests for ethnic group autonomy.
General Ne Win and the military junta attempted to transform the multiethnic Burma
into a homogenised state through the “widespread and systematic persecution of ethnic
minority peoples” (Philp & Mercer, 1999, p. 44) and through imposing restrictions on
the use of minority languages and dress (Bisht & Bankoti, 2004). As a result, many of
the ethnic minority groups formed armed resistance movements (including the Kachin
Independence Army, the United Wa State Army, the Shan State Army, the Karen
National Liberation Army, the Karenni Army, and the Shan State National Army) and
civil war erupted again throughout the country (Kalnin, 2010).
Following General Ne Win’s seizure of power in 1962, things changed rapidly for
ethnic minority groups including the Karen. The junta implemented a policy known as
the “Four Cuts”, which aimed to cut food, funds, intelligence and recruits to the ethnic
armies. The Four Cuts campaign wreaked havoc for villagers as the military initiated
“forced relocations of entire communities … destruction of crops … and a shoot-on-
sight policy after curfew hours” (Rajah, 2002, p. 532; M. Smith, 1994). Many ethnic
minority groups fled to remote areas and zones controlled by ethnic armies where they
could continue to practise their cultural traditions and speak their indigenous
language(s).
The Karen National Union was particularly successful in protecting the cultural identity
and wellbeing of their ethnic population and established Karen schools, hospitals and
43
administrative departments. However, after several devastating military attacks in recent
decades, the now weakened Karen army has lost much of their territory and
infrastructure and today operates from remote and mobile bases on the Thailand-Burma
border (M. Pedersen, 2008) in what has become the “longest rebellion in modern world
history” (Steinberg, 2010, p. 12).
Today widespread human rights abuses perpetrated by the military continue to affect
ethnic minority (and Burman) populations leading to massive displacement and greater
civil unrest. Despite sporadic peace negotiations and temporary cease-fires, persecution
and fighting has continued. Ethnic minority communities continue to be displaced
(Thailand Burma Border Consortium, 2010a) and new waves of refugees fled Burma in
the wake of the contested 2010 election results (UNHCR, 2011a). Today Burma could
still be described as a “social volcano” (Philp & Mercer, 1999, p. 24).
3.2.2 Human rights abuses and life under the regime
The international community has continued to express concern for human rights in
Burma where “the denial of economic, social and cultural rights” affect the majority of
the population (United Nations General Assembly, 2010a, p. 18). A recent United States
Department of State (2009) human rights report on Burma documented dozens of
human rights abuses including extrajudicial killings, torture, rape, disappearances,
recruitment of child soldiers, trafficking of women and girls and forced labour.
Arbitrary arrests, detentions and disappearances are also common and widespread fear
affects family and social networks as family and friends may be detained in place of
missing activists (Fink, 2009). Citizens have little hope for justice as the judiciary is not
independent of the military government. The junta has denied UN allegations that there
“are a number of human rights abuses in Myanmar that could constitute crimes against
humanity” (United Nations General Assembly, 2010b, p. 15).
Life under the regime is characterised by mistrust, uncertainty and fear as people seek to
go about their daily life without drawing unwanted attention from the military
intelligence unit who regularly conduct surveillance operations on the general public.
According to Skidmore (2003), roadside signboards declaring “Observance of discipline
leads to safety” (p. 8), “Anyone who is riotous, destructive and unruly is our enemy” (p.
10) and “Crush all destructive elements” (p. 13) are one of many forms of political
44
propaganda and social control. The military government severely restricts freedom of
speech and press and the activities of citizens are closely monitored, including the use
of all two-way electronic communication devices. Ownership of unregistered
telephones, fax machines and computer modems warrants imprisonment (Selth, 2010).
Less than 0.2% of the population use the internet, and their usage is heavily censored
(United States Department of State, 2010). Virtually all organisations must be
registered. The government officially prohibits unauthorised outdoor assembly of more
than five persons, though this is only sporadically enforced. Censorship and propaganda
prohibit free speech and “freedom of thought” (Suu Kyi, 2010, p. 203). As we will see
later in this thesis, the damaging impact of this chronic climate of fear and silence can
deeply affect refugees long after they escape persecution.
Rural village life under the regime is also extremely difficult as the military demand
labour, food and money from villagers. Livestock and crops are confiscated or
destroyed and citizens are subject to violence, arrest, torture, execution and rape.
Village populations are forcibly displaced for economic development (Bisht & Bankoti,
2004). Villages are also often simply burned to the ground as part of the Four Cuts
policy, destruction that has been corroborated by satellite imagery (United Nations
General Assembly, 2010a). As a result of the persecution and destruction, communities
flee (without adequate supplies) into the jungle, into areas littered with landmines, and
in some cases, eventually towards Burma’s borders. The United States Department of
State’s (2009) Human Rights Report on Burma has also referred to unverified reports of
“deaths and injuries caused by security forces using civilians to clear landmines,
particularly in Karen State” (para. 92).
All Karen groups and other ethnic minority communities have been subject to
persecution in Burma. Many minority communities continue to claim that a policy of
“Burmanization” (Steinberg, 2010, p. 126) is manifest and underpins many of the
human rights abuses perpetrated against them. Their armed ethnic armies continue to
fight “for autonomy, equality, and the right to maintain their own languages and
cultures” (M. Pedersen, 2008, p. 54). However, it is important to mention that, like the
military junta, the Karen National Liberation Army and other ethnic armies have been
noted to perpetrate human rights abuses, including the use of child soldiers (M. Smith,
1994).
45
In recent years the international community has gradually increased pressure for action
against Burma’s military government. Approximately thirteen countries support UN
calls for a commission of inquiry but these efforts have been blocked by China and
Russia, which have repeatedly vetoed UN Security Council draft resolutions on Burma
(“China and Russia”, 2007; Human Rights Watch, 2011).
Human rights abuses against women
Throughout Burma, poverty, discrimination and human rights abuses disproportionately
affect women (United States Department of State, 2010; Ward, 2002). In addition to
low literacy rates, women in Burma today have low participation levels in all aspects of
public, political and professional life (International Service for Human Rights, 2008).
Sexual assault of ethnic minority women and children is a serious concern of
humanitarian organisations in the area (Alternative ASEAN Network on Burma, 1999)
and many have published reports documenting acts of sexual violence perpetrated by
Burmese military troops, frequently naming perpetrators (Karen Women’s
Organisation, 2004, 2007; Shan Human Rights Foundation & Shan Women’s Action
Network, 2002). Reports of gang rape, sexual enslavement and various methods of
sexually oriented torture (e.g., genital penetration by knives and mutilation of breasts)
are common (Apple & Martin, 2003; Caouette, Archavanitkul, & Pyne, 2000; Ward,
2002). In a harrowing report, the former UN Special Rapporteur on Myanmar,
Rajsoomer Lallah (United Nations General Assembly, 2010b) suggested that sexual
violence is a strategic weapon of war, purposively used by the military government in
Burma:
These violations have been so numerous and consistent over the past years as to
suggest that they are not simply isolated or the acts of individual misbehaviour
by middle- and lower-rank officers but rather are the result of policy at the
highest level, entailing political and legal responsibility. (p. 16)
The UN Convention on the Elimination of All Forms of Discrimination against Women
(2008) has echoed these concerns and lamented the “apparent impunity of the
perpetrators of such violence” (para. 24). According to the United Kingdom Home
Office (2009), regime authorities have been known to “arrest and prosecute women who
reported being raped by police or soldiers” (p. 24). Spousal rape is not a crime unless
46
the wife is under 14 years of age, and there are no specific laws relating to domestic
violence or spousal abuse (United States Department of State, 2010). The leading
women’s organisation operating inside Burma is chaired and controlled by wives of
military junta leaders (United States Department of State, 2010). Ethnic minority
communities are also disproportionately affected by human trafficking, forced
prostitution and sexual enslavement (Crawford, 2006; Ward, 2002). These human rights
abuses have been linked to high mortality in a population of Karen refugees (Checchi,
Elder, Schafer, Drouhin, & Legros, 2003).
3.2.3 Religion and culture in Burma
This section briefly outlines the national religious and cultural pre-migration context in
which the participants of this study lived. It is followed by a more detailed exploration
of Karen culture in particular.
Historically an animist society, Burma is now predominantly Buddhist. There is no
official state religion but the military junta have strongly demonstrated their support for
Buddhism, as well as their dismissal of Christianity and Islam, each represented by
approximately 4% of the population (Central Intelligence Agency, 2010). In practice,
Burmese citizens enjoy fluid boundaries between religions, and most follow a spiritual
practice that is an amalgam of Buddhism and animist beliefs such as nat (spirit beings)
worship (Bodeker, Neumann, Lall, & Oo, 2005; Platz, 2003). Anthropologist David
Phanner (1966) points out that it may be “artificial to try and distinguish between
Buddhist and animistic elements in the Burmese religion” (p. 93). Nat worship was
dominant in Burma prior to the introduction of Buddhism and Hinduism from the 11th
century (Suu Kyi, 2010). Today, traditional nat festivals remain important social events,
and nat spirit mediums have retained their roles as conduits between the human and
spirit world (Tint Way, 1985). Belief in spirits, ghosts and witches (humans with
supernatural powers) is common; these entities are considered to be easily offended,
sometimes malevolent, beings who punish wrongdoers and even cause illness and death
(Spiro, 1969).
Astrologers, numerologists and mediums also feature strongly in Burmese belief
systems, and have been described as the Burmese “counterpart of the Western
psychiatrist” (Singh, 1993, p. 110). Today, important events (e.g., naming ceremonies
47
for children) and large-scale decisions (e.g., military government economic decisions)
continue to be based on auspicious numbers and dates. One well-known and disastrous
example was the military leader General Ne Win’s decision to change Burma’s
currency into multiples of his auspicious number, nine (Steinberg, 2010).
For Buddhist Burmese, values and metaphysical beliefs in karma and merit are said to
underpin daily life. Merit is, in part, accumulated through donation to the monastic
orders (Tint Way, 1985). Under British rule, Christian missionaries sought to eradicate
both Buddhist and animist practices. Burmans were largely hesitant to convert to
Christianity but the missionaries were notably successful with the Karen (see Section
3.3.3), of whom between 15% and 30% are thought to be Christian (Karen Human
Rights Group, 2008; Thawnghmung, 2008).
Burmese traditional medicine similarly represents an amalgam of Buddhist and animist
belief systems, as well as aspects of Indian Ayurvedic and Chinese medical systems
(Rao, 1968). The human body is thought to be comprised of four elements (earth, water,
fire and air). Illness is caused by an imbalance of these elements, and healers (including
traditional healers, Buddhist monks and astrologers) prescribe prayers or meditation and
herbal medicines as well as dietary and lifestyle changes to bring the elements back into
alignment.
Unlike neighbouring India, Burma has no caste system. Deference to elders is a noted
feature of society (Brant & Khaing, 1951). Historically, traditional social structures
were matriarchal with women enjoying high economic, political and social status
(Khaing, 1984; H. I. Marshall, 1997; Muller, 1994; Sein, 1958, February; Steinberg,
2010). Anthropologist Melford Spiro (1997) even described Burmese women as
enjoying “economic, legal, and social equality … unsurpassed either in Asia or in
Europe and North America” (p. 11).
Numerous anthropologists have also noted that marriage and divorce customs
emphasised the equal sharing of property and other assets (H. I. Marshall, 1997; Muller,
1994; Singh, 1993; Spiro, 1997). However, Brant and Khaing (1951) have described a
marked “double standard of sexual behaviour” (p. 443) whereby a husband’s sexual
infidelity was more likely to be quietly endured than a wife’s. It also seems that gender
parity has “coexisted with a belief in the innate superiority of males” (Muller, 1994, p.
48
613) derived from Burmese Buddhist discourse which deems men to be spiritually
superior to women (Spiro, 1997).
Today, as overall human rights in Burma have deteriorated, human rights organisations
have become increasingly concerned about gender inequity and, as noted (see Section
3.2.2), particularly gender-based violence (Muller, 1994; Shan Human Rights
Foundation & Shan Women’s Action Network, 2002; Karen Women’s Organisation,
2004, 2007). The male-dominated military has inhibited women’s ability to exercise
influence in government (Muller, 1994). There are conflicting opinions about the status
of gender equality in urban centres. Steinberg (2010) believes that urban women enjoy
gender parity in education and economic participation whereas the UN Convention on
the Elimination of All Forms of Discrimination against Women (2008) has observed a
deterioration in women’s participation across all domains.
3.3 Karen
Academic literature on Burma and the Karen remains sparse (Selth, 2010; South, 2007)
and available resources are often heavily biased in favour of particular political and
religious subgroups. In the following account of the history and recent experiences of
this group of people from Burma I have sought to present a balanced perspective.
The Karen (kəˈrɛn) people of Burma are comprised of several different but related
subgroups who together represent the second largest ethnic minority group in the region
(S. Smith, 2010). Estimates of their population vary from three to six million (Barron et
al., 2007; Karen Human Rights Group & Delang, 2000; M. Smith, 1994)
They are said to descend from the same ancestors as the Mongolian people (Karen
Human Rights Group & Delang, 2000) and are thought to have migrated to Burma from
Tibet and Southern China sometime “after the Mon but before the Burmese” (Bisht &
Bankoti, 2004, p. 294). The Karen are often referred to as the hill tribe or forest people
as large numbers live(d) in isolated mountainous rural areas of eastern Burma. The term
Karen is thought to originate from derogatory Burmese names for inhabitants of the
forest and mountain areas (H. I. Marshall, 1997). At any rate, the modern usage of the
term appears to have been legitimised and made respectable by missionaries and British
colonisers.
49
The Karen State (Kawthoolei) spans northwest to southeast along the Thailand-Burma
border (Neiman et al., 2008) (see Figure 1). Geographically the Karen population may
be divided into three groups: the Sgaw and Pwo (Southern), Karenni (Central), and Po-o
(Northern) (Barron et al., 2007). The Sgaw and Pwo subgroups together constitute over
70% of the Karen population (M. Smith, 1994). These and other subgroups are
linguistically and culturally dissimilar and each Karen group also has its own name
“that is different from the name by which they are known to outsiders” (Barron et al.,
2007, p. 28). The Pwo (pronounced “poh”) call themselves G’Ploung and the Sgaw
(pronounced “skaw”) call themselves Pwakenyaw1.
3.3.1 Language
Linguistic differences between subgroups are significant and various Karen dialects
“are for the most part mutually unintelligible” (Barron et al., 2007, p. 28). There are
three main Karen dialects, Sgaw, Eastern Pwo and Western Pwo (Platz, 2003), which
are vastly different. Sgaw uses abugida Burmese script, whereas Pwo uses Mon
characters. Karen languages are monosyllabic and tonal, and are members of the Tibeto-
Burman language group (Bisht & Bankoti, 2004; Manson, 2010). Within this language
family, Karen dialects are unique in their placement of the object after the verb (Bisht &
Bankoti, 2004; Manson, 2010). Many older Karen also speak Burmese and younger
Karen are often fluent in Thai due to living in refugee camps on the Thailand-Burma
border.
According to Sino-Tibetan language researchers at the University of California
Department of Linguistics (D. Solnit, personal communication, 1 February, 2011), and
other Karennic language experts (K. Manson, personal communication, 1 February,
2011), there is no standardised Roman script for transliteration of the Sgaw or Pwo
Karen languages. There are also few published language resources. However, Christian
organisations have produced a number of Karen language materials (Gilmore, 1898)
and other resources exist online (Barron et al., 2007; Drum Publication Group, 2011).
1 There is no consensus regarding the spelling of Karen words. Variations include Pwakenyaw (Bisht &
Bankoti, 2004, p. 292) and Pga k’nyau (Bisht & Bankoti, 2004, p. 293), P’ganyaw (Platz, 2003, p. 490),
Pgha K’Nyaw (p. 8) (H. I. Marshall, 1997).
50
The traditional Sgaw Karen naming structure has only a given name (e.g., Paw, Po,
Myint) and, for adults, includes the identification of Saw (Mr) or Na (Ms). Karen names
often hold meaning (e.g., flower or moon) and may also denote a significant event that
occurred before or around the time of a child’s birth. People are also addressed
according to their kinship relationship to the speaker (e.g., aunt, grandfather) and Karen
also generally refer to unrelated older men and women as uncle and aunt respectively.
3.3.2 Karen culture
It is customary in the sparse literature to describe the Karen as shy, simple, quiet and
peaceloving (Barron et al., 2007; Bisht & Bankoti, 2004; Gilmore, 1898; Karen Human
Rights Group & Delang, 2000; Manson, 2010; Neiman et al., 2008; Platz, 2003; S.
Smith, 2010). In the academic literature, this tradition appears to have been first
articulated by the anthropologist Harry Ignatius Marshall (1997), who first published his
account of the Karen in 1922, and noted:
I once asked an educated Karen what he thought was the chief characteristic of
his race, and he immediately replied that they are a people who can be afraid.
Centuries of subjugation and oppression have filled them with fear … The
Karen is led into all sorts of difficulties by his timidity. He is apprehensive and
desirous of avoiding trouble with officers or others. (p. 22)
Karen communities are collectivist and relatively egalitarian. In common with other
collectivist societies, displays of anger and confrontation are avoided (Barron et al.,
2007; Neiman et al., 2008). Accordingly, communication is often indirect. Karen may
modestly say “no” rather than enthusiastically receive a gift. Similarly they may politely
say “yes” to a request when they in fact mean “no”. As Platz (2003) observed of Karen
communities: “A straight answer is rarely given in a society built on avoiding conflicts”
(p. 486). As in Burmese society, absolute deference to and respect for elders and
seniority are expected.
Traditional Karen villages are formed by 20 to 30 nuclear families led by a village chief
and a council of elders who provide both spiritual and political leadership (Bisht &
Bankoti, 2004). In Burma, houses are made of bamboo and wood raised on stilts, and
set in a cleared section of the forest. Parents, children and grandparents often live
51
together in one hut with a central room for gathering and smaller areas for sleeping.
Emphasising the collectivist nature of the Karen village, H. I. Marshall (1997) reported:
There was little occasion for individual initiative among the Karen, on account
of the important part played by communal activity amongst them … This
communal sharing was so much the order of the day that personal rights were
more or less disregarded. If a man got a few seeds and planted a garden near his
house, he was fortunate, as is sometimes still the case in the hills, if he gathered
half the crop he had planted. His neighbors, asking no leave, helped themselves
generously without hesitation and perhaps without intending to steal. (p. 130)
Karen villages were traditionally patriarchal, but it is often said that Karen traditional
culture was characterised by relative gender equality (Barron et al., 2007; Bisht &
Bankoti, 2004; Neiman et al., 2008). Karen families and villages are linked through
their matrilineal descendants. Most young people are free to choose their marital
partners and, after marriage, live with the wife’s family (H. I. Marshall, 1997).
Premarital sex and divorce are strongly discouraged and untoward behaviour is
addressed by the village elders. Bisht and Bantoki (2004) note that, in the rare
circumstance of divorce, property was divided equally between the couple.
Karen families are typically large, and intergenerational parenting enables younger
parents to continue daily chores related to farming, food preparation and weaving. Adult
children assume responsibility for their elderly parents (H. I. Marshall, 1997) though, in
reality, this responsibility often falls on daughters (Bisht & Bankoti, 2004; H. I.
Marshall, 1997). Farming and agriculture form the centrepoint of daily life, cultural
practices, celebrations and economy. The Karen are also noted farmers as well as
hunters and elephant handlers (Barron et al., 2007; Neiman et al., 2008).
3.3.3 Karen religion
A merged Buddhist-animist practice is the dominant religion of all Karen groups in
Burma (Barron et al., 2007; Neiman et al., 2008). According to their traditional animist
beliefs, each person has 37 souls (kla) which reside in and around their body, are
essential for wellbeing, and are at risk of being lost or stolen by other spirits. In his
anthropological study of the Karen, H. I. Marshall (1997) noted that funeral customs
52
varied amongst Karen tribes, and could include animist practices such as animal
sacrifice as well as a host of other customs derived from Buddhist practices.
More than any other ethnic group in Burma, large numbers of Karen have converted to
Christianity, particularly Baptist denominations. Sgaw Karen approached Christian
conversion with remarkable enthusiasm and “on a scale unprecedented in Southeast
Asia” (Bisht & Bankoti, 2004, p. 302). Traditional beliefs in a God (Ywa) and other
legends appear to have overlapped with the messages of missionaries and were soon
appropriated to foster conversion. Legends also reportedly included the story of a lost
book that would be returned by a white man arriving by sea (Barron et al., 2007; H. I.
Marshall, 1997; Platz, 2003).
Existing political factions and nationalist sentiments may have also paved the way for
Christian missionaries seeking to convert the Karen. Having been second-class citizens
to the dominant Burmans, the Karen were able to rapidly secure access to resources
including schools and healthcare through their Christian links. An educated Christian-
Karen elite subsequently held higher social positions than non-Christian Karen and rose
through the ranks alongside Burmans as British colonial servants. Today Christian
Karen are overrepresented in refugee camps where, according to Keenan (2005), 65%
of Karen are Christian, and only 28% are Buddhist. In comparison, an estimated 70% to
85% of Karen in Burma are Buddhist (Karen Human Rights Group, 2008;
Thawnghmung, 2008). According to Platz (2003), today animist Buddhist and Christian
Karen coexist both within nuclear family units and as a broad societal unit. However, as
we will see, religious and political tensions (though often hard to perceive and quantify)
are distinguishing features of the Karen social climate.
3.3.4 Karen traditional medicine
Like traditional Burmese cultural and religious beliefs (see Section 3.2.3), Karen
traditional medicine combines several influences, most notably, Indian Ayurvedic and
traditional Chinese medicine systems (Barron et al., 2007; Bodeker et al., 2005). In
addition, Karen traditional animist beliefs emphasised the importance of maintaining
one’s personal souls (kla) to ensure health. Various ceremonies (e.g., the wrist-tying
ceremony) and practices are traditionally performed to retain one’s souls and to
maintain good health. Traditional healers may use a variety of herbs and plants to cure
53
and ward off spirits causing illness. Turmeric is one of the most commonly used plants
and it is applied both internally and topically. Historically healers would also make
animal offerings to drive away spirits and restore health though this practice is less
likely to be practised by Christian and many Buddhist Karen. Christian Karen are also
often opposed to the herbalist practices of traditional healers.
Finally, as the Karen have inhabited Thailand-Burma border refugee camps since the
1980s, many are also familiar with Western medicine through contact with various
humanitarian organisations working in the region. Bodeker et al., (2005) interviewed 59
(including 30 Karen) outpatient refugees on the Thailand-Burma border. The
respondents were asked about their knowledge and use of traditional medicine and
cumulatively reported 271 traditional remedies. Most had tried traditional medicines but
many were presently geographically distant from traditional healers. Less commonly,
patients also reported believing in nats (spirit entities) (29%) and witches (20%), and
perceived the spirit world as a potential cause of ill health. Most of those who believed
in the nats regularly engaged in observances such as wearing amulets or making
donations to appease them.
3.4 The Thailand-Burma border
This section sets the scene for refugee camp life on the Thailand-Burma border. This is
important subject matter as most refugees from Burma arriving in Australia and around
the world have been acculturated in this environment.
The refugee camp situation along the Thailand-Burma border has been described by the
UNHCR as “one of the most protracted in the world” (UNHCR, 2010a, para. 6). Today
around 140,000 refugees live in ten camp sites (see Figure 2), many of which were
established in the 1980s. The ethnic profile of the Thailand-Burma border camps is
predominantly Karen (79%) with smaller numbers of ethnic Karenni (10%), Burman
(4%) and Shan (0.5%), as well as others (Thailand Burma Border Consortium, 2010a).
Rohinga refugees are also present, though larger numbers of Rohinga refugee camps are
found in Bangladesh (UNHCR, 2010b).
Before describing refugee camp life it is important to note that the majority of refugees
from Burma do not successfully reach this relative safety. Civilians living in conflict-
affected areas frequently flee to the jungle within Burma’s borders and become
54
internally displaced people. The UNHCR estimates there are approximately 62,000
internally displaced people inside Burma, and a total of 800,000 stateless persons (not
considered as Burmese nationals according to legislation) (UNHCR, 2011a). These
people lack protection and access to food, shelter, healthcare and education. An
estimated further one to two million (Brees, 2008a, 2008b; Caouette & Pack, 2002;
Chalamwong, 2004) intermix (mostly as illegal migrants) in neighbouring countries,
with the largest numbers in Thailand and Bangladesh. Most of these refugees remain
stateless, lacking rights and protection from the host governments (Brees, 2010; Lee &
Glaister, 2008).
55
Figure 2: Map of internally displaced people and refugee camps along Thailand-
Burma border. Adapted from the camp population reports by the Thailand
Burma Border Consortium (n.d.).
3.4.1 Hosts and providers
The refugee situation is a sensitive topic for the Thai Government, who have remained
“reluctant hosts” (Thailand Burma Border Consortium, 2010b, p. ix) to refugees from
Burma. Thailand is not a signatory to the 1951 Convention on Refugees (UNHCR,
2010a) and technically does not recognise refugee status. More commonly, the Thai
Government has referred to those in refugee camps as “temporarily displaced”
(Caouette & Pack, 2002, p. 7). Some asylum seekers from Burma living outside the
56
camps have official work permits but many do not (H. Lang, 2001). Consequently, they
are considered illegal immigrants and subject to arrest and deportation. As in other parts
of the world, asylum seekers in Thailand are also often scapegoats for social problems,
and are perceived as a burden on the local economy and infrastructure in spite of the
economic benefits that Thai businesses gain from their cheap labour (Lang, 2001).
Early support for refugees on the border was, and remains, provided by the Thailand
Burma Border Consortium (formally the Committee for the Coordination of Services to
Displaced Persons in Thailand). This umbrella agency is, today, a consortium of around
a dozen humanitarian organisations who provide food, shelter and other relief assistance
to the refugees and internally displaced people (Thailand Burma Border Consortium,
2007).
In 1998 the Thai Government formally permitted UNHCR operations in the refugee
camps (Lang, 2001). Many UNHCR programs are implemented with, and through, the
Thailand Burma Border Consortium who retain the role of overseeing camp
management. With official UNHCR presence, camp residents were able to apply for
Refugee Status Determination and registration. However, in 2005, the Thai Government
halted the UNHCR Refugee Status Determination programme. Refugees arriving since
this time have had no opportunity to obtain official registration, recognition or
protection as refugees. The Thai Government permitted a camp registration program
(but not official Refugee Status Determination) in 2007, but any new arrivals in the
camp since 2005 have no guarantee of protection in Thailand (Lee & Glaister, 2008).
As a further outcome, official UNHCR camp population estimates differ vastly from
those of the Thailand Burma Border Consortium, who attempt to recognise all camp
residents (registered or not). For example, the UNHCR camp figures for August 2011
were 89,512, but the Thailand Burma Border Consortium provided assistance to a camp
caseload of 142,250. Around 40% of camp residents are not officially recognised as
refugees. After more than 25 years the situation on the Thailand-Burma border has been
described as “a marathon with no sign of a finish line” (Thailand Burma Border
Consortium, 2010b, p. 1).
57
3.4.2 Life in camps
Karen refugees are birds inside a cage that get fed on a regular basis but are not
able to fly. (Karen refugee quoted by Fuertes, 2010, p. 20)
Inside the camps, refugees live in makeshift bamboo huts similar to traditional village
housing. Most camps are surrounded by barbed wire and patrolled by Thai military
personnel and police. Residents are mostly dependent on aid as they are not allowed to
work. Camps are overseen by elected camp committees who work in conjunction with
the Thailand Burma Border Consortium (and numerous other humanitarian aid
organisations) to provide access to health, education and training inside the camps.
Many of these services are explicitly linked to Christian organisations and, in turn, the
Sgaw Karen ethnic group (or rather the educated Christian Karen elite) who dominate
leadership positions in the camps (Horstmann, 2010). Food rations and other resources
are distributed through the camp committees. These rations meet the World Food
Programme and UNHCR minimum standard of 2.1000 kilocalories per person, per day
and largely consist of rice, fish paste, mung beans and salt (Thailand Burma Border
Consortium, 2009).
One concerning effect of protracted camp situations is the “culture of dependency”
(Thawnghmung, 2008, p. 21) that can be fostered by long-term dependency on aid for
rations and all means of social support. Moreover, according to Fuertes (2010),
protracted camp living can also lead to the weakening of traditional knowledge and
customs. For example, in the absence of land to farm, children inside the camp lack
knowledge of traditional farming practices. Consequently, they lack necessary skills for
rural survival should they return to their homeland in Burma.
However, the image of refugees as passive dependents languishing in refugee camps,
while true for many, overlooks many aspects of refugee life (Saltsman, 2009). Refugee
agency should not be underestimated. Refugees who leave the confines of the camp are
in grave danger of arrest, abuse, exploitation and deportation. And yet, as noted, the
majority of refugees from Burma are not in camps. Brees (2008b) explored refugees’
reasons for bypassing camps and self-settling (often illegally) in Thailand. She found
that, most commonly, “they prefer to have no support than to lose their freedom of
movement and self-reliance” (Brees, 2008b, p. 381). Other reasons included fear of
entering camps because of rebel groups, and ethnic or religious differences with the
58
camp majority. Some avoided camp confinement so they could continue to search for
family members missing along the border region. With little hope of registration or
resettlement post-2005, others saw no option but to live illegally in Thailand.
Family-splitting is a recognised strategy of populations affected by forced migration and
is commonly used by refugees from Burma. Through splitting up, families spread both
risk and opportunities (for income) and increase their chances of survival (Brees, 2010).
They risk arrest and deportation to seek employment in Thailand and Malaysia where
they often find work in farming and fishing, construction work, sewing, domestic work,
carpentry, rubbish collection, food preparation, brewing alcohol and sex work (Brees,
2008b). They often face host community hostility but experience greater opportunities
than are available in camps. They maintain strong family ties and send remittances back
into the camps. Risk is spread but not eliminated.
Social, cultural and religious customs are also often strong in the camps. As Horstmann
(2010) explains, “While the mobility in the camp is highly restricted, the relationship of
people to God is intensified” (p. 21). Refugees in camps also raise money for
themselves and internally displaced people who remain in Burma. Despite limited
resources they create business networks, sell and barter, and seek to supplement their
rations. The fortunate few with televisions advertise movie nights, others sell car
batteries to be used as electricity generators (Vogler, 2006). Some obtain stipendiary
roles within the camps through international organisations such as the Thailand Burma
Border Consortium, UNHCR and Red Cross. At night, using candles or car battery
powered light bulbs, students and intellectuals study. Moreover, many refugees
maintain strong transnational relationships with friends and family, and through
religious or political organisations.
Safety
The refugee camps on the Thailand-Burma border are also environmentally and
politically dangerous. The land area provided by the Thai Government is frequently
hilly and often unsuitable for supporting the “bamboo cities” (Thailand Burma Border
Consortium, 2010b, p. 1) built to house the refugees. Their huts are vulnerable to
natural hazards including heavy rain and landslides (Vogler, 2006). Some camps are
also inaccessible by road during the rainy season. The provision of one blanket for
59
every two refugees is often insufficient during cold periods, though most have access to
nets to protect against malarial mosquitos (Vogler, 2006). Moreover, the camps are also
“a site of mobilization of young [ethnic army] soldiers” (Horstmann, 2010, p. 17).
Consequently, they have come under attack from the Burmese military. Saltsman (2009)
notes that the camps “can be equally if not more brutal than the situation at home from
which the forced migrant has fled” (pp. 3–4).
Health issues
Most of the ethnic minority populations who arrive in the refugee camps have not had
access to proper healthcare inside Burma2. They continue to face limited access to care
within the camps where problems with sanitation, overcrowding, infection and disease
are widespread. It is important to explore the health problems and healthcare
experiences of refugees as this information is relevant to understanding their wellbeing
in Australia.
Health problems inside the camp include hepatitis B infection, HIV/AIDS, malaria,
parasitic infections (Denburg et al., 2007), tuberculosis (Power et al., 2010),
malnutrition leading to stunting, anaemia and beri-beri (vitamin B deficiency and a
leading cause of high infant mortality rates) (Luxemburger et al., 2003); and high blood
lead levels in children (thought to be caused by traditional medicines and car batteries
used to power camp huts) (Mitchell et al., 2012). The rate of methamphetamine use in
the region has been increasing (Kobori et al., 2009) but more common intoxicants are
alcohol and betel nut. Betel nut is a mild stimulant that many Karen chew. Regular use
stains teeth and gums, and can lead to dental problems and oral cancers (Neiman et al.,
2008).
Various humanitarian organisations (including Malteser of Germany, American
Refugee Committee and the International Rescue Committee) provide limited
healthcare services including testing (and sometimes treatment) for tuberculosis and
HIV/AIDS, vaccinations, family planning and maternal healthcare. These services are
2 Inside Burma, when and where accessible, internally displaced people receive care from the Backpack
Health Worker Team and the Free Burma Rangers. These groups are mobile unarmed paramilitary units
of refugees who are trained to provide education, resources, advocacy and primary healthcare (Mahn et
al., 2008).
60
generally rudimentary and vary considerably between camps. In addition, camp
residents also attend a network of traditional healers in camps and in villages along the
Thailand-Burma border (Bodeker et al., 2005).
Refugees from camps closer to the Thai town of Mae Sot frequently seek medical care
at the Mae Tao Clinic, another very rudimentary service but one of the best available.
The Mae Tao clinic boasts a blood laboratory and blood bank, eye care department,
reproductive health unit, malaria treatment unit, prosthetics unit and surgical
department. These services are indispensable to refugees on the border but are also
limited and primitive. For example, as I witnessed during my time at the clinic in 2007,
amputations (a common surgery due to landmines) were not necessarily performed by
doctors. Moreover, with no anaesthetist and no general anaesthetic, patients were
conscious. They were treated and cared for mostly by fellow refugees who were trained
as medics. Currently, the surgical ward is staffed by medics and, for six months of the
year, a volunteer surgeon (Mae Tao Clinic, 2011).
Women’s issues
Refugee women in the camps are at risk of gender-based violence including domestic
violence (Lambert & Pickering, 2003) and rape (by fellow refugees as well as Burmese
and Thai military, Thai civilians and Thai police) and there is little recourse available
for survivors (Vogler, 2006; Ward, 2002).
The close quarters and lack of privacy between huts creates a noisy and chaotic
environment, and places pressure on women who are expected to maintain modesty.
Young women also “voluntarily” (in the context of limited choice) enter into
relationships with Thai solders. Such relationships may provide women with some
relative protection and access to resources (e.g., food, gifts and money). Some women
also hope that these relationships may lead to freedom from the refugee camp.
However, Thai soldiers are prohibited from marrying camp residents and many already
have Thai wives (Vogler, 2006).
In the absence of a formal state or government, camp committees (dominated by men)
address the behaviour of camp residents. According to Lambert and Pickering (2003),
camp committees often fail to adequately address women’s concerns. In turn, women
have expressed “their frustration over the inability to address the actions or inaction of
61
the camp committees” (p. 42). Vogler (2006) found that “speaking about domestic
violence remains a taboo subject among camp residents” (p. 10). However, despite their
silence, women appeared to freely utilise a domestic violence shelter established in the
camp.
In the past decade women’s organisations have been increasingly active in camps and
have pushed to ensure women are involved in camp committees and decision-making.
The Thailand Burma Border Consortium has supported these efforts and women now
comprise 33% of stipendiary camp committee members (Thailand Burma Border
Consortium, 2011a). Increasingly vocal about their rights and concerns, these women
can be disruptive towards traditional practices as they demand participation in decision-
making and political affairs (Brees, 2010).
3.4.3 Access to resettlement
As previously noted, official UNHCR operations on the Thailand-Burma border refugee
camps began in 1998. From 2004, the UNHCR also began a resettlement program
which has since assisted approximately 90,000 refugees from Burma (International
Organization for Migration, 2011b). However, despite the resettlement program, camp
numbers have not reduced due to new influxes of refugees fleeing the military junta
(Thailand Burma Border Consortium, 2011b). Moreover, since the Thai Government
halted the UNHCR Refugee Status Determination programme in 2005, refugees arriving
in the camp in the past seven years have no hope of resettlement.
This chapter has provided a thorough description of the pre-migration social, political
and cultural milieu surrounding Karen refugees. A more detailed discussion of the
Karen community in Sydney (where this research was undertaken) will follow Chapter
7, while Chapter 4 describes Australia’s refugee program and the services available to
those who resettle.
62
Chapter 4
The Local Context: Refugee Resettlement in Australia
4.1 Introduction
This chapter describes the Australian Government’s refugee-related policies and
programs, and briefly explores the prevailing social climate concerning refugee issues.
The social services provided to refugees who resettle in Australia are described in detail
in order to provide a context for understanding the research findings, particularly those
reported in Chapter 8.
Australia is a member of the UNHCR Executive Committee, and signatory to both the
1951 Convention (since 1954) and the 1967 Protocol (since 1973) (Department of
Immigration and Citizenship, 2011n). Within the international community, the
Australian Government provide international development assistance as well as
resettlement and, since the end of World War II, has formally resettled around 750,000
refugees (Department of Immigration and Citizenship, 2009a). Today Australia is one
of world’s top three refugee resettlement countries, as determined by the number of
places made available to the UNHCR. However, this reference is misleading as the
largest number of refugees are hosted by developing countries (Tribe, 2002; Zwi &
Alvarez-Castillo, 2003). Indeed, for each billion dollar of Gross Domestic Product
(GDP), Australia hosted 0.6 refugees and was ranked 77th in the world. In relation to
population size, Australia hosted 1.1 refugees per 1,000 head of population and was
ranked 68th (UNHCR, 2010c).
Between 1945 and the mid-1960s Australia first resettled refugees from Europe and
then from South America. Throughout this period, immigration received widespread
community support as the Australian Government actively aimed to increase population
size. In the wake of the Vietnam war, 150,000 refugees from South East Asia were
resettled. However, by 1978 the immigration program was completely reviewed as the
“demand for a new life in Australia exceeded the places available” (Department of
Immigration and Citizenship, 2010a, p. 268). The Determination of Refugee Status
committee was established and officials travelled to South East Asia to “select
refugees” and “dissuade” (Department of Immigration and Citizenship, 2010a, p. 268)
further migrants. Refugees from the Middle East and Africa also arrived in Australia in
63
the early 1980s, followed by refugees from Cambodia, China, Kosovar, East Timor and
Burma in the 1990s. Public and international interest in Australian immigration policy
grew in the mid-1990s as the Australian Government developed new strategies to
manage asylum seekers’ claims (Department of Immigration and Citizenship, 2010a).
4.2 Australia’s current refugee program3
Australia’s current humanitarian program has the following two components:
1. The offshore component for people who, whilst overseas, are found to be
refugees according to the Convention.
2. The onshore component for people who seek asylum in Australia but whose
refugee status has not yet been assessed according to the definition set forth in
the Convention.
During 2009–10 the majority (67.1%) of all humanitarian entrants to Australia were
processed through the offshore component and most refugees from Burma have entered
through this scheme. Burma was not among the top ten source countries of onshore
asylum seekers between 2007–10 and of refugees from Burma granted visas in
Australia during 2009–10, only 3.8% were processed through the onshore component
(Department of Immigration and Citizenship, 2010a). In 2011, only 33 adult men (and
no women) from Burma were living in immigration detention facilities for onshore
humanitarian entrants (Department of Immigration and Citizenship, 2011n). From these
statistics it seems that the onshore component is not particularly relevant to this thesis.
However, onshore component issues remain pertinent because they contribute
significantly to public opinion towards refugees in general and this social climate
affects the resettlement of Karen refugee women.
4.2.1 Onshore component
Most onshore asylum seekers enter Australia by air and the remainder by boat
(officially known as “irregular maritime arrivals”). Those who arrive by boat have often
endured harrowing sea journeys organised by human traffickers. Once in Australia, the
3 The Australian Government’s humanitarian program follows the financial year 1 July to 30 June
(Department of Immigration and Citizenship, 2011n). Consequently, all data related to refugees is
reported over the same twelve month period.
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processes experienced by humanitarian entrants under the offshore and onshore
programs are vastly different. Offshore humanitarian entrants are already granted
permanent residency. They are assisted with accessing accommodation in the
community as well as other social services. In contrast, onshore asylum seekers are
typically placed into immigration detention centres or community detention (residing in
the community and moving freely but ineligible to work or access some social services)
whilst their application for a Protection visa is lodged.
In the past several years, the Australian Government has faced intense local and
international pressure and criticism of its policy and protection obligations to refugees.
The Refugee Council of Australia has reported on the negative public discourse towards
onshore humanitarian entrants (particularly asylum seekers arriving by boat), which
erupted due to political rhetoric fuelled by “sensationalist” (Refugee Council of
Australia, 2011a, p. 129) media that portrayed these entrants as criminals, “illegal
immigrants” and “queue jumpers”. According to the council, this social climate has led
to increased hostility and racism towards humanitarian entrants in general. Indeed,
research has demonstrated Australians’ polarised and alarmingly prejudicial attitudes
towards refugees (Schweitzer, Perkoulidis, Krome, & Ludlow, 2005). The government
and numerous other organisations have recently sought to shift public discourse.
However, political divisions have remained and, at the time of writing, the topic and
debate regarding Australia’s legislation and international obligations towards onshore
entrants remained heated.
4.2.2 Offshore component
The following four Australian visas are available to refugees identified and referred by
the UNHCR (Department of Immigration and Citizenship, 2011o):
Refugee visa for people who have received UNHCR Refugee Status
Determination and are outside of their country of origin.
In country Special Humanitarian visa for people with UNHCR Refugee Status
Determination who remain in their home country.
Emergency Rescue visa for people who remain in their home country but are in
urgent need of resettlement.
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Woman at Risk visa for women and girls with UNHCR Refugee Status
Determination who are living outside of their country of origin and who have
increased protection and safety concerns.
In addition, the Global Special Humanitarian Program and visa was introduced in 1981
to allow citizens and residents of Australia to support applications for individuals (most
often immediate family members) who are subject to substantial discrimination in their
home country. Recipients of this visa subclass receive less support and are expected to
be assisted by their proposer in Australia (Department of Immigration and Citizenship,
2011o).
Australia has gradually increased the number of humanitarian program places over the
past few years and offered 13,770 in 2009–10. Refugees from Burma comprised the
largest refugee population (1,959) entering Australia during this period, followed by
refugees from Iraq (1,688), Bhutan (1,144) and Afghanistan (951) (Australian Bureau of
Statistics, 2009). Woman at Risk visas comprised 13.4% of all 2009–10 humanitarian
visas (Department of Immigration and Citizenship, 2010a). Refugee women from
Burma were the largest recipients of this visa during this period and second largest (next
to women from Afghanistan) during the three years prior.
4.3 Initial resettlement services for refugees
Procedures and protocols for UNHCR staff and host countries are provided in the
UNHCR Resettlement Handbook. However, the policies and procedures taken by
individual host countries are not universal and can vary considerably (UNHCR, 2004).
In Australia, the humanitarian settlement program is managed by the Department of
Immigration and Citizenship (DIAC). The following section outlines the procedures and
services DIAC provide to humanitarian entrants4. This information provides a context
for the findings, particularly those discussed in Chapters 8 and 13.
4 This description of the Australian Governments settlement program was correct at the time of writing
and generally describes the services that were available to the participants of this study. However,
refugee-related policies and services in Australia were undergoing review during the time of this research
and numerous aspects of the program were changed during the data collection.
66
67
4.3.1 Pre-departure
The following services are provided to refugees before their departure to Australia.
The Australian cultural orientation program
This one-week voluntary pre-departure program is delivered by the International
Organization for Migration on behalf of DIAC. The course is facilitated by a speaker
who shares the local language and provides refugees with information about living in
Australia including Australian geography, culture, communication, money management,
housing arrangements, public transport, law, healthcare, education and other social
services (DIAC, 2011g).
Pre-departure medical screening
Within 72 hours of departure, refugees coming to Australia undertake a mandatory
health check which, in most locations, includes: tuberculosis evaluation, testing and
treatment for malaria and parasites, and immunisations for measles, mumps and rubella.
Departure may be delayed in cases of active illness (DIAC, 2011h).
Travel and visa arrangements
Travel arrangements and visas are organised and paid for by the Australian Government
prior to departure for all humanitarian entrants (other than entrants under the Special
Humanitarian Program, who are sponsored by their proposer in Australia). As noted,
refugees arriving through the UNHCR resettlement program (e.g., refugees in the
offshore component) are given permanent residence in Australia.
4.3.2 Post-arrival: the humanitarian settlement services program
In 2005, the Australian Government implemented the Integrated Humanitarian
Settlement Strategy, the precursor to its current Humanitarian Settlement Services
(HSS) program (Refugee Council of Australia, 2011b). A range of federal, state and
local government agencies; non-government organisations; and not-for-profit
community groups are contracted by DIAC to provide HSS. Consequently, HSS
providers differ across and within states. This program is generally provided for around
six months but may be extended for refugees with greater need (DIAC, 2010c).
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Coordinated case management model
Some refugees have considerable support from friends and family already residing in
Australia. Others may already be proficient in English, and arrive relatively ready to
enter into the workforce. Consequently, case management plans are developed and HSS
provided according to need of individuals and their families. All entrants are assigned a
local HSS case manager who speaks their language and are assessed in relation to their
HSS needs.
Initial support
Initial settlement support provided by case managers includes:
1. Arrival reception at airport.
2. Transit to short- or long-term accommodation and provision of basic household
goods including some kitchen equipment, linen and food.
3. Initial orientation to, and information about, surroundings and culture.
4. Assistance accessing social services including
Centrelink (the Australian Government service responsible for social security
payments);
Medicare (the national healthcare system);
banking;
schools;
public transport;
health services;
long-term accommodation;
English language classes (see Section 4.4); and
further additional settlement services (see Section 4.4).
Entrants are expected to have adequately adjusted to life in Australia within six to
twelve months. According to DIAC, markers of refugee adjustment are:
residing in long-term accommodation;
linked to required social services;
school-age children enrolled and attending school; and
an understanding of “the critical messages of the orientation program [and] the
skills and knowledge to independently access services” (DIAC, 2011f, para. 14).
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Finances
Through Centrelink, refugees are entitled to the same social security payments as other
Australian permanent residents. As of March 2011, the maximum weekly allowance for
unemployed adults was $237.45 and $345.45 for pensioners, disability pensioners and
carers (e.g., people who care for family members with a severe disability or medical
condition) (DIAC, 2011l). Parents and guardians were also eligible for a range of
childcare rebates and payments (Department of Human Services, 2011).
Location
According to DIAC (2011l), “Refugees are often located close to family members”
(para. 10). Entrants without existing family links in Australia are, when possible,
located in metropolitan areas with low population growth.
Housing
Entrants are assisted with short-term accommodation but must begin looking for longer-
term solutions and must join waiting lists for public housing with other Australian
permanent residents.
4.4 Ongoing settlement services
The following additional settlement services are also provided by DIAC but differ in
that they are also available to other migrants (i.e., not just humanitarian entrants)
settling in Australia (DIAC, 2011i).
Adult migrant English program (AMEP)
English language tuition is provided under the AMEP, which is Australia’s largest HSS
program. Under the AMEP, eligible migrants and refugees are provided with 510 hours
of English language training, career counselling and general settlement assistance.
Participation in the AMEP is voluntary. Eligible migrants are required to register for the
AMEP within three months of arrival and commence classes within twelve months.
Free childcare is available for under school-age children during class times. Thirteen
service providers are contracted to provide AMEP services nationally and all follow the
Certificate in Spoken and Written English curriculum (DIAC, 2011b). Clients are first
assessed according to three levels: Level 1 classes provide education for students who
70
cannot speak or write English, Level 2 classes are directed at post-beginner students and
focus on basic transactional proficiency whereas Level 3 classes are for students with
functional English (DIAC, 2011k).
According to DIAC (2010b), clients may choose from the following range of learning
options:
Full- or part-time classroom tuition in formal or community-based settings; full-
time tuition requires a minimum of 20 hours of study.
Distance learning (supported by telephone contact with a qualified teacher).
The Home Tutor Scheme, which provides language assistance by a trained
volunteer in the client’s home.
Self-paced e-modules (a supplementary package for independent learning).
Through AMEP providers, refugees may also access the following programs and
services:
Fee-free translation of personal documents such as birth and marriage
certificates, medical reports and qualifications (DIAC, 2011m).
Settlement courses designed to assist with settlement and orientation to
Australian culture and society (including information about laws and social
services).
The Special Preparatory Program. This program provides additional hours of
education to entrants with limited pre-migration education or particularly
difficult pre-migration experiences (e.g., torture). Entrants under 25 years old are
eligible for an extra 400 hours of tuition. Older adults may be eligible for 100
additional hours. Students in this program are provided with bilingual support
during their initial weeks in language classes (DIAC, 2011k).
The Settlement Language Pathways to Employment and Training Program. This
program provides entrants with 200 hours of employment-focused English
language training including 80 hours’ work experience.
Translating and Interpreting Service (TIS) National
TIS is a nation-wide 24-hour service providing on-site and telephone interpreting
services in approximately 170 languages. These services are available to humanitarian
71
entrants as well as other Australian residents. Services may be free of charge or user-
pays depending on the circumstances which differ in public and private sectors. For
example, private medical practitioners providing Medicare rebateable services and
pharmacies are eligible for free TIS services (DIAC, 2009b). TIS contracts interpreters
who are accredited or recognised by the Australian National Accreditation Authority for
Translators and Interpreters Limited (NAATI).
Complex case support program
This program provides specialised case management for entrants with exceptional needs
including mental health, physical health and family violence difficulties for up to five
years after arrival (DIAC, 2011c). At the time of writing, this program was undergoing
significant change. The program had been implemented in 2008 and reviewed in 2010.
In 2011 DIAC announced a request for tender to redevelop a humanitarian service
panel. The panel will be comprised of organisations that are specialised to provide
services for clients with complex problems.
Subgroup support
Additional services and programs were available to subgroups of humanitarian entrants
and asylum seekers. For example, the unaccompanied humanitarian minors program
provides support to refugee children without parents or relatives in Australia (DIAC,
2011i). The community assistance support program assists asylum seekers with
complex physical, social or mental health needs whilst their applications for protection
are processed (DIAC, 2011e).
Settlement grants program
This program provides services to help entrants for up to five years after arrival, and
targets those with low English proficiency. Two types of services are provided through
this program:
1. Generalist assistance services including further orientation to Australia,
development of life skills, referral to social services and assistance engaging
with mainstream Australia.
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2. Specialist assistance services including support with immigration and housing
difficulties. In addition, ethno-specific funding is available for groups who wish
to build the capacity of newly arrived communities.
Torture and trauma counselling
The Forum of Australian Services for Survivors of Torture and Trauma (FASSTT) is
the umbrella agency for mental health services for humanitarian entrants and comprises
eight specialist rehabilitation services, representing one in each state and territory
(FASSTT, 2006). According to the FASSTT website, the services offered include
psychological assessments, individual psychotherapeutic interventions, group and
family therapy, youth activities, natural therapies and community development.
The local provider of torture and trauma counselling services in the study site (see
Section 7.2) was the New South Wales Service for the Treatment and Rehabilitation of
Torture and Trauma Survivors (STARTTS). In the years preceding and during data
collection, Karen refugees were routinely referred to STARTTS by their HSS case
managers as part of their needs assessment. Until 2011 DIAC funded torture and trauma
counselling services through the HSS program. However, at the time of writing the
funding and structure of this aspect of refugee service provision was under review
(DIAC, 2012).
4.5 The local scene
As we have seen, a wide range different service providers hold contracts with DIAC to
provide the HSS and other settlement services. Table 1 outlines the services provided in
Western Sydney at the time data collection began. Only those services are listed that
were used or mentioned by participants in this study.
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Table 1: Local service providers relevant to this study
Provider HSS target area ResolveFM Accommodation Navitas Ltd (previously known as ACL) Adult Migrant English Program
Case management Auburn Diversity Services Incorporated Settlement Grants Program Liverpool Migrant Resource Centre Settlement Grants Program The Hills Holroyd Parramatta Migrant Resource Centre
Settlement Grants Program
New South Wales Service for the Treatment and Rehabilitation of Torture and Trauma Survivors
Trauma and torture counselling
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Chapter 5
Methodology
5.1 Introduction
Empirical researchers are guided by paradigms or worldviews which shape how they
approach their field of study and illuminate their underlying beliefs regarding (a) the
nature of reality and all that exists within it (ontology), (b) the relationship between the
knower and what can be known (epistemology), and (c) how we gain knowledge of the
world (methodology) (Denzin & Lincoln, 2005). This chapter outlines the theoretical
paradigms and perspectives relevant to this research. The approach taken will be
justified for its ability to adequately address the research aims and questions discussed
in Chapter 1.
5.2 A critical realist approach
As a researcher I situate myself as most closely aligned with a critical realist paradigm
which spans the “either-or” divide (Danermark, Ekstrom, Jakobsen, & Karlsson, 2002,
p. 2; Oliver, 2011) that has traditionally split the natural and social sciences into
positivist and quantitative, and constructivist and qualitative approaches respectively
(Onwuegbuzie & Leech, 2005). The critical realist framework referred to here was
developed by British philosopher Roy Bhaskar (Bhaskar, 1978, 1986, 1989) and shares
theoretical orientations with pragmatism (Dewey, 1922, 1929, 1938; Dewey et al.,
1917; G. H. Mead, 1917). Subsequent developments and related perspectives include
the subtle realism approaches of Hammersley (1992) and Willig (1999) but it is
Bhaskar’s critical realism that has been most widely promoted and used by researchers
(Banfield, 2004).
Bhaskar first outlined the foundations for his critical realist framework in the book A
Realist Theory of Science (1978) and began his argument with answering the
ontological question of how reality is constructed (Bhaskar & Lawson, 1998). He
argued that the natural and social worlds are comprised of multiple levels of reality – an
empirical level (experienced events), an actual level (all events whether experienced or
not) and a causal level (consisting of the mechanisms by which events are generated)
(Bhaskar, 1978). All levels are recognised as real though not necessarily observable. For
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example, in the social world, psychological mechanisms (e.g., self-control) and social
structures (e.g., racism), though not necessarily observable, may be mechanisms that
casually impact on peoples’ lives and are real in their consequences. Similarly, in the
natural world, the presence and activity of neurochemicals at nerve terminals in the
human body was real (and real in its consequences) before it was revealed in 1903
through scientific research (Danermark et al., 2002).
Having outlined his ontological stance, Bhaskar then turned to the epistemological
questions of how we can acquire knowledge about reality. He criticised the “epistemic
fallacy” (1978, p. 36) of scientific research for reducing ontological arguments to only
the empirical level of reality, consequently reducing “what is to what we can know
about it” (Danermark et al., 2002, p. 21). With regard to epistemology, critical realism
distinguishes between two dimensions or objects of science – intransitive objects,
objects of reality (mostly in the natural world) which exist independent of human
knowledge about them; and transitive objects, the knowledge and theories produced by
researchers. Although (unlike natural intransitive objects) social phenomena exist only
because of human activity, critical realists do not consider them to be “only in people’s
minds … social constructions are constructions of something” (Danermark et al., 2002,
p. 30). Bhaskar acknowledged differences between natural and social objects of
scientific investigations, but maintained that the principles concerning reasoning or
theorising about external phenomena remain the same.
Bhaskar argued that the transitive objects of science – the theories scientists produce
about intransitive objects – are (like all forms of knowledge) influenced by the cultural,
political and economic conditions of the time. By extension, he maintained that
“Established facts are social products” (Bhaskar, 1978, p. 196) and, like all social
products, they are fallible and changeable. The effect of culture on perception and
experience can be marked and Danermark and colleagues (2002) argue “it is often not a
question of different ways of seeing things, but that we see different things” (p. 29).
Theories also rely on “the linguistic world of meaning” (Danermark et al., 2002, p. 29)
as they are shared through the use of language. When theories are formed and expressed
they already represent one biased interpretation or conceptual framework because, most
commonly, they employ one language (typically, in Western academia, English).
Language, however, is partly social and cultural in nature and the viewpoints or
76
conceptual frameworks of members of one language group may be vastly different from
those of another (Willig, 1999).
Despite acknowledging the inherent constructivist nature, and fallibility, of human
knowledge, critical realism also rejects naïve relativism and opposes the premise that all
truths are equally valid. Bhaskar viewed knowledge of reality as imperfect as it is
influenced by human perception and meaning making. However, he also stressed the
importance of striving towards some degree of objectivity in order to produce the best
understanding possible (Houston, 2001). For critical realists “knowledge is always
fallible, yet all knowledge is not equally fallible” (Danermark et al., 2002, p. 15).
Indeed, Bhaskar (1986) argued that there can remain “rational grounds” (p. 72) for
preferring one explanation or description of events to another. Critical realism does not
dictate any set of research methods (Danermark et al., 2002) or system to assess the
plausibility of different accounts. Rather, researchers informed by this philosophy seek
to generate a deep understanding of the mechanisms interacting with their object or area
of study (Connelly, 2001). They may utilise both qualitative and quantitative
methodologies and frequently conduct work that surpasses traditional disciplinary
boundaries.
Finally, a “centerpiece” (Houston, 2001, p. 851) of Bhaskar’s work has been his
criticism of value-free approaches to inquiry and insistence that the purpose of his
philosophy is not only to illuminate the mechanisms of life but to expose and challenge
institutions and mechanisms leading to inequity and oppression. In his more recent
works, Bhaskar (1998) has repeated his objection to “intellectualism or theoreticism” (p.
410) and called for an enhanced relationship between research and practice. This
emphasis on the “practical relevance” (Danermark et al., 2002, p. 24; Willig, 1999) of
inquiry has made critical realism a particularly useful and suitable framework for
researchers in healthcare, social work and health promotion settings (Connelly, 2001;
Houston, 2001; Oliver, 2011; C. Taylor & White, 2001).
5.2.1 Explanation and justification of a qualitative realist approach
As a pragmatic ontological middle path, a critical realist paradigm is relevant to this
inquiry. Firstly, an aim of this study is to frame recommendations for improving
services. This aim represents a practical real-world focus best achieved through the
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application of a realist-oriented approach. In this sense I hold a realist ontology – I am
interested in understanding and explaining Karen women’s wellbeing and distress. I
believe that there are some observable truths and real phenomena in nature. More
importantly, for me, research involving the explanation, prediction and control of
certain phenomena can result in facts or truths that are of benefit to humans. Lives can
be improved and people can be helped. I want my findings to reveal probable truths that
are relevant to helping these women.
I also share social constructivists’ viewpoints and believe that all knowledge is partial
and socially constructed, and that a certain degree of relativism is thus unavoidable.
Human beings cannot be devoid of the contexts that surround them and these contexts
are not universal – rather they include social, cultural, political and gendered factors that
are in states of flux throughout history. I believe that humans perceive, construct and
interpret reality in patterns that are shaped by these contexts. I agree with the point that
“What is defined or perceived by people as real is real in its consequences” (Thomas &
Thomas, 1928, p. 572). Humans may believe in phenomena that are not physically real
and their belief in those phenomena may significantly shape their experience and
behaviour – in short, they are real to them. In this study I aimed to understand the
contexts, experiences and perspectives of the research participants. I view myself as an
active participant in the research process from the initial inception of the research
questions and aims through to data collection and analysis. However, I reject naive
relativism because, although knowledge of reality is always imperfect, I believe we can
strive to attain some truth in our research findings. Within our imperfect knowledge of
human life, especially the human psyche, I believe that there are important contributions
to be made by representing truths and having something to say about them.
Lastly, critical realism is germane to my research, not only because it provides a
balanced approach between realist and relativist perspectives, but also because the
moral and emancipatory aspects of the perspective are aligned with the motivations
underpinning my inquiry. I reject the purely objectivist epistemological posture
concerning value-free, objective inquiry.
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5.3 Theoretical perspectives
In addition to their overarching philosophical paradigms, researchers are also situated
amongst a number of other theoretical perspectives and methodological traditions, many
of which are derived from different disciplines such as biology, sociology, psychology
and anthropology. Further traditions within these disciplines include feminist,
postcolonial, ethnographic and neo-Marxism perspectives to name a few (Carter,
Ritchie, & Sainsbury, 2009; Ritchie, 2001). Each approach includes particular methods
(or tools) for research, though these often overlap across perspectives. Researchers
choose amongst the variety of these perspectives by assessing which best addresses
their research question. Morse and Richards (2002) emphasise that no one particular
approach is perfect for a given research purpose and that researchers must choose which
is “most appropriate” (p. 6). Likewise, Patton (2002) strongly emphasises pragmatism
as the foundation of research, rather than sworn allegiance to particular theoretical
traditions. Denzin and Lincoln (2005) explain that researchers frequently use “more
than one interpretive practice in any study” (p. 4) as a means to better understand the
subject of inquiry in different ways. In this section the theoretical frameworks and
methods chosen as most relevant to this research will be briefly outlined and justified.
To begin with, from amongst the broad research traditions, qualitative research
methodologies are the most germane to this thesis as the primary axiological goal of the
study is one of understanding. Qualitative approaches are inductive and emergent
(Carter et al., 2009) and “seek to discover understanding or to achieve explanation from
the data instead of from (or in addition to) prior knowledge or theory” (Morse &
Richards, 2002, p. 2). The relevance of a qualitative approach to this study is indicated
by the several key characteristics of the study. Firstly, the study is exploratory due to the
absence of any previous studies exploring the suffering and distress of Karen refugee
women. Secondly, there are no existing valid or reliable measures for assessing the
psychosocial experiences of Karen refugee women. Qualitative methods are
recommended for contexts where existing measures are inadequate or non-existent
(Bolton & Tang, 2004; Creswell, 1998). Thirdly, this thesis seeks to explore cross-
cultural experiences and perceptions of emotional wellbeing and distress. The research
aims are concerned with developing an emic (insider’s) understanding which, as Pope
and Mays (1995) argue, is best achieved through qualitative research methods. Lastly,
qualitative methods aimed at documenting the truth of people’s experiences may
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become a source of empowerment by affirming their reality, raising group
consciousness and facilitating dissemination of their needs and concerns to a wider
audience (Banyard & Miller, 1998). These are important considerations for research
with disadvantaged populations such as refugee women.
5.3.1 Ethnography
The relevance of an ethnographic framework is suggested by the research aims and
questions, which are oriented towards understanding Karen women’s emic perspectives.
Ethnography is a theoretical perspective and set of methods that originated in the field
of cultural anthropology and focuses upon the identification and “thick” (Spradley,
1979, p. 3) or detailed description of patterns and themes within a cultural group from
the emic (insider) perspective. An ethnographic approach also situates this study within
contemporary approaches to refugee mental health research. According to Gozdziak
(2004), “ethnography is the real bridge to multicultural mental health practice with
refugees” (p. 207) and, as discussed in Chapter 2, researchers in this field have
increasingly used ethnographic methods to understand issues relevant to refugee
communities.
Participant observation has been described as the hallmark of ethnography and it is
through this process ethnographers come to immerse themselves in the culture of study
as fully as possible in order to gain a deep understanding of their participants’ lives,
meanings, actions, perspectives, behaviour and environment in context. Alongside
participant observation, ethnographers produce detailed field notes recording what they
learn and experience during their research. Field notes are typically written (or
recorded) as soon as possible during or following encounters and contain not only
observations and records of events but also the ethnographer’s reflexive account of their
experience. In addition to participant observation, interview methods feature strongly in
ethnographic research. Interviews are conducted with both “ordinary” community
members as well as key informants who provide a deeper level of access, insight and
interpretation of meaning to the ethnographer (Liamputtong, 2009).
Historically, most ethnographers immersed themselves in their culture of study for
extended periods of time, learning the local language and living within the local
community. Examples of this approach include the works of anthropologists
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Malinowski (1922) and M. Mead (1928). However, as Denzin and Lincoln (2005)
argue, “It is no longer possible to take for granted what anyone means by ethnography”
(p. xvi). Modern ethnographers have questioned the notion of immersion, and
contemporary ethnographic approaches have evolved to address the time-limited nature
of some research contexts (Bolton & Tang, 2004; Handwerker, 2001). Moreover, cross-
cultural researchers are now “Often … linguistically and culturally distant from their
research participants” (Liamputtong, 2010, p. 135).
Traditionalist ethnographers may be dismayed at some contemporary ethnographic
works and the rationale behind them, which sometimes fail to make any distinction
between general qualitative methods and ethnographic approaches and also fail to locate
the perspective within a scholarly anthropological setting. For example, contemporary
researchers have described their research as encompassing “ethnographic (or
qualitative) methods in that the interviewers rely on open-ended questions; avoid using
leading questions, comments or reactions; use non-leading probes; and record responses
verbatim” (Bolton & Tang, 2004, p. 98). Many ethnographers would argue that these
interview techniques are neither limited to an ethnographic approach nor encompass
ethnographic inquiry.
The present study represents a contemporary approach to ethnography that draws from
and builds upon recent ethnographies with populations affected by political violence
(Hubbard & Pearson, 2004; D. Pedersen, Kienzler, & Gamarra, 2010; Zarowsky, 2004).
I planned for a level of participant observation immersion adequate to the research aims
and questions but noted from the outset that the usefulness of this method was limited
by my inability to fluently speak all participants’ mother languages. Consequently, I
planned to draw heavily on interview methods in order to access richer and deeper
information.
Finally, my approach to ethnographic research is informed by a critical realist
perspective. Purely relativist ethnographers refrain from “taking a stand of any kind in
relation to groups of individuals” (Griffin & Bengry-Howell, 2008, p. 21). However,
according to Manicas (1998), the critical realist ethnography “needs to do more than
give a description of the social world as seen by its members … it needs to also ask
whether members have an adequate understanding of their world, and if not, explain
why not” (p. 315). Moreover, as I situate my inquiry also within a feminist perspective I
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view my research as, in part, committed to giving voice to women’s experiences and
taking a stand on issues related to their wellbeing and distress.
5.3.2 Feminist perspective
A feminist perspective is an ideological orientation indicated by several key
characteristics of the study. Firstly, in researching women’s perspectives and needs, this
study “presumes the importance of gender in human relationships and societal
processes” (Patton, 2002, p. 129). I was guided by a desire for gender equity and the
position that mental health support services for women should be built on and from
women’s experiences and needs. Several authors have pointed to the androcentric and
ethnocentric aspects of the psychological and psychiatric disciplines (Fine & Gordon,
1992; G. L. Fox & McBride Murry, 2000; Mirza, 1998; Scheper-Hughes, 1983) and
these issues have also plagued refugee mental health research. As we saw in the
literature review, the field of refugee mental health has been dominated by White
biomedically-oriented researchers whose agendas have shaped how refugees have been
represented (Warren, 2000) while indigenous knowledge and the experiences and
knowledge of refugee women was seldom represented.
Feminism is a diverse field which has been defined as both a political movement and a
theoretical orientation (Sparks & Park, 2000). At its core it is about human rights for
women and it is current wherever women’s issues are relevant. Like Reinharz (1992) I
embrace the notion that feminism is a perspective, not a research method, and the
feminist researcher may utilise a multiplicity of theoretical perspectives (including
ethnography) and research methods across multiple disciplines (Gergen, 2008).
G. L. Fox and McBride Murry (2000) contend that feminist research tends to be
collaborative, more reflective, change-oriented and questioning of existing disciplinary
paradigms. Whereas for Gergen (2008) feminist research “is designed to seek social
justice, to enhance women’s voice and influence in society, and to explore alternative
ways of understanding the world” (p. 280). These are all important aspects within the
aims of this research. This inquiry is located within Reinharz’s (1992) description of
feminist ethnography, which she argues seeks:
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(1) to document the lives and activities of women, (2) to understand the
experience of women from their own point of view, and (3) to conceptualize
women’s behavior as an expression of social contexts. (p. 51)
As a cross-cultural feminist ethnography, both postmodern (Olesen, 2005) and
postcolonial (Pilcher & Whelehan, 2004) feminist perspectives are also relevant to this
inquiry, which is an encounter between myself – a White, middle class researcher and
psychologist from New Zealand – and Karen refugee women from Burma. A feminist
questioning of the universal sisterhood is relevant to this research and has guided my
approach to inquiry. Feminist anthropologists “originally assumed the existence of a
universal sisterhood of womankind” (Scheper-Hughes, 1983, p. 112); however, these
assumptions were soon challenged by differences in class, culture and ethnicity
(Hammarstrom, 1999). In stark contrast to the ideal of the universal sisterhood, Meara
and Day (2000) argued that the power difference between White women and women of
Colour had grown wider as White women have gained more parity with White men. I
set out expecting that “a bond of sisterhood must be earned” (Reinharz, 1992, p. 65) and
used reflexivity to explore my own cultural perspectives (Harding, 1991; Scheper-
Hughes, 1983). Moreover, I made no assumption that by virtue of my gender as a
woman I would (a) be guaranteed access to Karen women’s lives and perspectives, or
(b) necessarily understand their lived experience. My approach to inquiry was also not
limited to observing and interviewing women. Many feminist ethnographers solely
research women but some also observe and interview both sexes (Reinharz, 1992).
Postcolonial feminists have also questioned the application of Western feminist models
with women from other cultures, and pushed for consideration of different forms of
feminism based on culture and context (Hartsock, 1983; Olesen, 2005). Reinharz (1992)
outlines the following assumptions guiding postcolonial feminist cross-cultural
research:
(1) the importance of cultural specificity, (2) the necessity of intensive study, (3)
the possibility of commonalities among women of different cultures, and (4) the
need for a critical evaluation of study materials. (p. 111)
Each of Reinharz’s (1992) guiding principles is relevant to this research project, firstly
because a commitment to recognising cultural specificity within mental health
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underpins the aims of the study. Secondly, as an ethnographic inquiry, this study is
oriented towards intensive study. Thirdly, the research design leaves open the
possibility of both disparate and common voices concerning distress and suffering
amongst women from different cultures. Lastly, a critical evaluation of available study
materials prompted the need for qualitative research methods to be utilised. This
approach invited Karen women to give voice to their experiences. I sought to avoid
imposing predetermined frameworks or hypotheses for conceptualising Karen women’s
realities and especially avoided assessing their wellbeing and distress according to the
imposed constructions of Western psychiatric diagnoses. Yet, at the same time I have
aimed to provide a “mirror” or point of comparison between the different cultural and
perhaps gender perspectives that might arise.
Nevertheless, an awareness of postcolonial feminist issues does not negate the fact that
cross-cultural research involves the translation of discourses from other cultures into
knowledge forms recognisable within a Western framework (Edwards & Ribbens,
1998). The White feminist cross-cultural researcher does not easily escape the influence
of ethnocentric and colonial frameworks. Indeed, it has been argued that “relationships
between First World feminist researchers and Third World subjects will inevitably be
exploitative, whatever the good intentions of the researcher” (Edwards & Ribbens,
1998, p. 3) and despite the use of reflexive research practices. There have been
criticisms of researchers for not studying women from other cultures and for
undertaking such research as outsiders. Reinharz (1992) has commented:
Western feminists are criticized for not studying “Third World” women (i.e.,
ethnocentrism) and criticized for doing so as outsiders to those cultures (i.e.,
colonialism). Feminists studying women in cultures other than their own are
criticized if they accept that culture’s way of subordinating women (i.e.,
misogyny) and are criticized if they repudiate the culture’s subordination of
women (i.e., ethnocentrism). (p. 122)
According to Olesen (2005), we “can never resolve all ethical dilemmas that arise” (p.
255) but a consideration of the feminist perspective encourages considerable reflexivity
and allows for the many issues of power and privilege in research to be considered and
actively tackled.
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5.3.3 Grounded theory
Finally, this inquiry is influenced by the tradition of grounded theory. From the outset it
must be made clear that this inquiry is not a grounded theory study per se. Rather,
aspects of the grounded theory approach are relevant to this inquiry because of their
ability to “add rigor to ethnographic research by building systematic checks into both
data collection and analysis” (Charmaz, 2006, p. 23). Grounded theory provides a set of
methods of managing and analysing qualitative data (Glaser, 1978; Glaser & Strauss,
1967; Strauss & Corbin, 1990, 1998). Most significantly, for the present inquiry, it
offers a collection of tools that encourage understanding and reasoning beyond existing
subjectivities to ground analysts’ findings in the real world (Strauss & Corbin, 1998).
As I aimed to understand the emic perspective of research participants, such tools were
necessary to somewhat manage my existing notions and subjectivities, and allow me to
compare, contrast and challenge my conceptualisations and interpretations of the data.
Grounded theory is a useful framework for qualitative researchers who are not
committed to purely constructivist or objectivist paradigms (Charmaz & Henwood,
2008) and consequently “highly compatible” (Oliver, 2011, p. 371) with a critical realist
philosophical framework. Moreover, it has long been considered well-matched to
ethnography (Spradley, 1979) and is now frequently used “in combination with other
approaches … as part of a flexible toolkit of methods” (Charmaz & Henwood, 2008, p.
254). In conjunction with the success and popularity of grounded theory there has been
a generic overuse of the label (Carter et al., 2009) as well as misunderstandings
(Suddaby, 2006) and incorrect application of its methods (Glaser, 1969). Perhaps
because grounded theory methods share many similarities with a range of other
qualitative inquiry approaches, the phrase is sometimes mistakenly used
interchangeably to refer to inductive, qualitative approaches (Carter et al., 2009).
Confusion and criticism arose from this scenario (Liamputtong, 2009). Moreover, the
divergent approaches (known as the Glaserian and Straussian versions) taken by the
founders of grounded theory have further fuelled confusion regarding conceptual
underpinnings and methods. The current inquiry borrows several basic research
processes from grounded theory including memo-writing, coding, categorising and
theoretical sampling to assist with the management and interpretation of the data. These
methods are described in detail in the following chapter.
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5.4 Summary
In this chapter I have outlined the theoretical paradigms and perspectives relevant to this
inquiry, and evaluated and justified the relevance of the approaches taken. I have chosen
a combination of ethnography, feminist and grounded theory perspectives and methods.
These frameworks encapsulate a critical approach to understanding the psychosocial
world of Karen refugee women and provide suitable tools to meet the research aims.
They also situate this inquiry firmly within the field of contemporary refugee mental
health research and allow this study to contribute to current research and academic
debate across the various disciplines that the inquiry transcends. The perspectives
guiding this study share a questioning of reliance on prior and dominant theory and
frameworks. In particular, ethnographic inquiry and grounded theory are useful methods
for mental health practitioners who find themselves “too constrained by psychology’s
traditional experimental and psychometric outlook” (Charmaz & Henwood, 2008, p.
249). A feminist perspective is current wherever women’s issues are relevant – a point
too long overlooked in the field of refugee mental health where a trauma discourse has
largely disregarded gender and context.
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Chapter 6
Method
6.1 Introduction
This chapter discusses the methods or tools used to address the research aims and
questions. As a qualitative inquiry, the approach to data collection was inductive and
emergent. Consequently, as the research evolved the focus and methods used were also
adapted. This chapter addresses the initial research and early processes. It is
complemented by a description of, and reflection on, the unfolding research journey in
Chapter 7.
6.2 Selecting participants
This study used several purposive sampling strategies commonly used to guide
emergent research (Blignault & Ritchie, 2009; Carter et al., 2009; Liamputtong, 2009;
Ritchie, 2001). Convenience sampling was used to launch the inquiry. This method
involves the use of participants who are easily accessible, available and often already
known to the researcher, and is a helpful means of “getting in” to hard-to-reach
communities (Liamputtong, 2009). Snowball sampling is another strategy often used in
studies of refugee and other “hidden” populations (Liamputtong, 2008; Spring et al.,
2003; Sulaiman-Hill & Thompson, 2011) and was used throughout the study. This
method requires participants to propose other potential participants who are then
contacted and invited to participate. As an ethnography, this research also involved the
use of opportunistic sampling methods in which data was collected in the form of
observations or impromptu interviews (Ritchie, 2001).
As the study progressed, additional purposive and theoretical sampling strategies were
used to follow-up hunches, ideas and emergent themes. Intensity sampling
(Liamputtong, 2009) helped to identify people with detailed or expert knowledge by
asking participants to list the most knowledgeable or respected individuals in relation to
specific topics. Revelatory case sampling (Liamputtong, 2009) enabled access to single
case participants who could represent previously undocumented issues (e.g., women
who suffered particular Karen idioms of distress). In addition, negative, extreme and
deviant case sampling as well as confirming and disconfirming cases (Charmaz, 2006;
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Liamputtong, 2009) were used to make comparisons of issues across participants and
add depth to emerging themes.
6.2.1 Karen women
Operationally, for this study, Karen women participants are defined as “ordinary”
community members (as distinct from others who held positions of significant
authority, trust or respect within the community). In the ethnographic sense, these
women were also key informants in that they may have been able to provide unique,
rich insight on a topic. For example, a woman suffering from a Karen idiom of distress
may be in a unique position to provide an insider view that others are unlikely to share.
However, for the purpose of clarity I have utilised a system of referring to these women
as “Karen women”, distinct from key informants (described below). As noted, Karen
women who participated in interviews were initially selected through convenience and
snowball sampling strategies on the basis of their availability and willingness. Later
women were purposively targeted based on their knowledge or experience of specific
topics of interest.
6.2.2 Key informants
Lincoln and Guba (1985) describe an informant as a committed and accepted member in
the local context who is able to provide inside views of norms, attitudes, constructions,
processes and culture. Operationally, for this study, key informants are defined as (a)
Karen community members who occupied positions of trust and respect, or (b)
individuals whose work (e.g., service providers) or other duties brought them into
regular contact with Karen women. Inevitably, some Karen women were also key
informants (e.g., Karen women employed as bicultural workers). For the purpose of this
study, these women are referred to herein as key informants to distinguish them from
“ordinary” women in the community.
6.2.3 Saturation
Redundancy or saturation is regarded as the most suitable criterion for appropriate
sample size in qualitative research. It is described as the point at which “a thorough
understanding of the phenomenon under study has been reached” (Kuper, Lingard, &
Levinson, 2008, p. 687), and when “no new information is forthcoming from new
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sampled units” (Lincoln & Guba, 1985, p. 202). Grounded theorists refer to saturation
as the point at which no new information regarding categories or the relationships
between categories emerges (Charmaz, 2006). However, saturation is a thorny concept
for ethnographic researchers who do not seek an endpoint but rather aim for continued
immersion into deeper and richer findings, learning more as they observe more. Having
said that, the pragmatics of modern research (and doctoral studies) require data
collection to be contained in some form. I employed saturation as a feature of analysis
and essentially continued collecting information until the data was rich enough to
support the desired analyses of the dimension(s) of interest. I continued to engage in
theoretical sampling of participants for interviews for a period of nineteen months
(November 2009 to June 2011) at which point I considered theoretical saturation of
categories to have been reached.
6.3 Participant observation
Participant observation is the primary method of data collection for ethnographers and
involves “systematically watching and recording people’s behaviours, clothing,
expressions, and interaction in a particular location or several settings” (Liamputtong &
Ezzy, 2005, p. 110). The participant observation approach used was informed by
Spradley (1980) and Strauss, Schatzmann, Bucher, Ehrlich and Sabshin (1964). Field
notes were written on the same day as observations or interviews occurred and noted
observations concerning the physical environment, social interactions (verbal and non-
verbal), activity, persons and emotional tone of interactions as well personal reflections
about the observed interaction and my place and performance within it. If I was too
busy or tired to write notes (for example, after a day of multiple interviews followed by
a community soiree in the evening) I simply dictated my notes in the car whilst driving
home and typed the saved recording at a later date.
6.4 Interviews
6.4.1 In-depth interviews
In-depth interviews were approached from an ethnographic and feminist perspective
and were oriented to fit with Spradley’s (1980) description of the ethnographic
interview as “a series of friendly conversations” (p. 58). Where possible I planned to
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meet with interview participants on more than one occasion (Rosenwald & Wiersma,
1983; Schweitzer & Steel, 2008) but I anticipated that time limitations on service
providers, particularly healthcare practitioners, might restrict their availability to a
single interview.
Interview guides
The semi-structured interview guide for service providers and key informant interviews
(see Appendices B & C) was loosely based on those recommended by Larson, van
Kooten-Prasad, Manderson and Frkovic (1998). The guide for Karen women (see
Appendix D) included extensive lists of themes, which were taken or adapted from
previous psychosocial research with refugee communities (Bolton & Tang, 2004;
Bolton et al., 2004; Miller, Omidian, et al., 2006). This guide was translated and back-
translated to ensure that key terms were accurate. The interview guide also prompted
my observations, reflections and notes regarding the interview context and participant
behaviour such as body language and tone. The bilingual research assistant’s
observations regarding cultural nuances were also recorded.
6.4.2 Group interviews
Group interviews are seen as particularly useful in exploratory research in different
social and cultural contexts, and in addressing sensitive research topics (Flick, 2002;
Stewart & Shamdasani, 1990). This method of data collection has also been particularly
embraced by feminist researchers as groups can represent a more natural part of
participants’ social life (Bryman, 2008), as well as a more collaborative and less power-
structured approach to inquiry (Kamberelis & Dimitriadis, 2005; Patton, 2002). The
approach taken was guided by Willgerodt (2003) and Kitzinger (1994) and aimed for
pre-existing and homogeneous groups of Karen women (i.e., subgroups who already
knew each other and shared characteristics such as membership of an organisation or
attendance at a regular support group) for the following reasons:
1. Previous research indicates that a shared socioeconomic characteristic amongst
group members is conducive to facilitating better communication and interaction
(Kitzinger, 1994; Stewart & Shamdasani, 1990).
2. Pre-existing social networks are likely to represent natural environments in
which one might discuss psychosocial issues (Kitzinger, 1994).
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3. The community of Karen refugee women in Sydney was so small that most
people knew of each other and consequently it would not be possible to conduct
a group with people unfamiliar to one another.
4. Mistrust is inherent in communities subjected to persecution. In such a context it
would not be permissible to introduce strangers into a group situation and expect
the group members to openly discuss their experiences and perceptions.
An intermediary guided group participant selection. She identified between six and
eight participants for each group, provided them with information about the study (see
Appendix E) and confirmed their willingness and availability to attend the interview at
the arranged time, date and location. Transport requirements were discussed via the
intermediary and, when necessary, I personally transported women who could not
otherwise attend the meeting. As the group members formed part of a pre-existing
social network, their regular childcare arrangements were discussed with the
intermediary. A disadvantage of the use of intermediaries is the possibility that “the
intermediary may act as an unwanted ‘screening device’” (Bloor, Frankland, Thomas, &
Robson, 2001, p. 32). To mitigate this potential problem, additional snowball sampling
strategies were also used.
Group interview guide
The purpose of the group interviews was to explore participants’ EMs of mental illness
and was guided by Kleinman’s (1980) EM framework (see Section 2.4.4). Vignettes
meeting DSM-IV diagnostic criteria were created to explore women’s EMs about
Western psychiatric constructs commonly reported in epidemiological studies of
refugee mental health: PTSD, depression and panic disorder. The vignettes depicted
aspects and features relevant to the lives of Karen refugee women so that they might
find the cases meaningful and easy to relate to. The characters were named “Aunty” as
it was common practice in Burma (Steinberg, 2010) and amongst the Karen to use the
positioning word for aunt to respectfully denote adult women in the community. The
diagnostic accuracy of each vignette was independently checked by a clinical
psychologist and a Burmese psychiatrist. The full interview guide, including vignettes,
is provided in Appendix F.
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A template was created to assist with identifying speakers during group interviews. The
two hour interview period was divided into five minute intervals in the left margin and
when participants spoke I noted their name in the corresponding time block along with
the first few words of the bilingual research assistant’s English interpretation of their
comments. I also adopted Stevens’s (1996) approach to guide my reporting of group
interaction, spending time alone or with the interpreter (when her time availability
permitted it), noting observations about the group process and participants’ interactions.
6.4.3 Recording, interpreting and transcribing interviews
Where participants consented, and environmental circumstances allowed, I planned to
digitally record interviews with a dictaphone.
A bilingual research assistant was employed (see Section 7.3) to interpret all group
interviews and in-depth interviews with participants who did not speak fluent English or
who wished to converse in their first language.
The approach taken to interpretation was guided by Hale (2010) who encourages the use
of consecutive (as opposed to simultaneous) interpreting in which each person has a
separate turn at speaking then pauses while the bilingual research assistant interprets.
Languages cannot be translated verbatim and complex and subtle differences such as
non-equivalence in words, concepts and assumptions must be navigated. The interpreter
was encouraged to prioritise conveying the meaning of speech in context rather than just
the literal meaning of words. I also planned to meet with the bilingual research assistant
outside of interviews to reflect on the process and trouble-shoot problems. Moreover, I
anticipated that interpretation dilemmas would arise and planned to resolve them with
the assistance of community leaders.
As discussed elsewhere (see Section 3.3.1), according to Sino-Tibetan language
researchers at the University of California Department of Linguistics (D. Solnit,
personal communication, 1 February, 2011) and other Karennic language experts (K.
Manson, personal communication, 1 February, 2011) there is no standardised Roman
script for transliteration of Sgaw or Pwo Karen languages. The approach taken towards
Romanisation of Karen terms in this thesis was developed in collaboration with the
bilingual research assistant; and with input from other Karen interpreters, translators
and knowledgeable key informants. It is not the aim of this inquiry to create a
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comprehensive typology of Karen idioms of distress but rather to explore Karen
women’s experiences and perceptions of emotional wellbeing and suffering. The
transliteration process of idioms of distress for this inquiry adequately meets the aims of
this research.
The conventions of Bloor et al. (2001) guided transcription of interviews. Emphasis was
given to content and overarching meaning, a level of analysis appropriate to the aims of
the study. Only spoken English was transcribed because I did not have the necessary
Karen linguistic skills to transcribe Karen dialects.
6.5 Ethics
Ethical approval for this project was sought and obtained from the Human Research
Ethics Committee of the University of New South Wales. Additional approval and
assent was also obtained from Karen community leaders and elders (Liamputtong,
2008).
Informed consent
Informed consent was obtained according to the requirements of the Human Research
Ethics Committee. Participants were given an information and consent form in English,
Sgaw Karen or Burmese (see Appendix E). All Karen refugee women participants also
had the information and consent form read aloud to them by the bilingual research
assistant. Key informants and service providers who wished to read the form without
assistance were able to do so. Participants were provided with an opportunity to discuss
any questions about the study and consent process before being asked to provide verbal
(recorded) or written (signed) consent. Participants were also asked if they were
comfortable with a dictaphone being used to record the interview.
Maintaining confidentiality and anonymity
Participant confidentiality and anonymity was ensured by (a) concealing the identity of
refugee women participants, key informants and organisations by using pseudonyms in
all written documents (field notes and interview transcripts), (b) ensuring the bilingual
research assistant understood and agreed to strict conditions of confidentiality, (c)
storing all audio-recordings, consent forms and transcripts in a confidential and secure
format and location, and (d) ensuring all publicly available information (such as
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publications and this thesis) was free from information that could potentially lead to the
identification of participants.
Protecting participants from risk and harm
A reasonable foreseeable risk of this study was psychological distress amongst
participants and strategies were planned to minimise the risk of adverse outcomes.
Firstly, all interviews would be carried out by myself (a trained clinical psychologist
with experience interviewing refugees). Secondly, participants who discussed
potentially distressing information would be followed up two weeks after their
interview to ensure they were not experiencing ongoing distress as a result of the
material discussed and, if necessary, referred to an appropriate service provider.
Protecting myself and the bilingual research assistant from risk and harm
Several risk-minimisation strategies were used to protect myself and the bilingual
research assistant from risk and harm. With regard to physical safety, the ethics
committee required that I carry a mobile phone at all times and provide contact details
to another person should a problem arise.
Additional strategies were used to mitigate and manage the potential stress associated
with researching marginalised and vulnerable groups (Dickson-Swift, James, &
Liamputtong, 2008). For myself these included: (a) reflection through the use of field
notes, audit trail and personal writings including poetry, (b) use of doctoral supervision
sessions to monitor my emotional responses, and (c) use of independent and
confidential support services should I feel overwhelmed and unable to manage the
emotional stress associated with the research. For the bilingual research assistant I
planned to (a) give great care to remain open, empathic, sensitive and patient to her
emotional journey, (b) engage in debriefing following each interview, (c) make myself
personally available should she need to call me for support outside of work hours, and
(d) encourage her to seek independent professional support if she experienced difficulty.
6.6 Data analysis
As noted (see Section 5.3.3), analytic methods borrowed from grounded theory guided
data analysis throughout this inquiry. NVivo 8 software was used to assist with the
management of data.
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In the grounded theory method, data analysis begins as soon as data collection
commences. Initial basic open coding or line-by-line analysis aims to identify recurrent
patterns present in the data. The analytic process then proceeds through stages in which
data is compared and categorised to explore higher-level relationships and theory. There
are a host of strategies and approaches to guide grounded theorists though they are not
prescriptive (Strauss & Corbin, 1998); this study was most significantly guided by
Charmaz’s (2006) constructivist approach.
Data analysis began during the earliest interactions in the field and whilst transcribing
the interviews. Initial coding (also known as open coding) consisted of line-by-line
analysis of notes and transcripts. This was done by hand and impressions and categories
were noted in a second column. This process resulted in rudimentary descriptive codes
to describe chunks of data (e.g., “transport problems” and “difficulty with children’s
homework”).
Additional coding processes shift analysis to a more conceptual level where properties,
conditions and relationships within and between such conceptual categories are
explored. At this stage, categories are developed into subcategories and their
corresponding dimensions until no new categories (or subcategories) are identified from
the data. As coding progressed I examined the codes, developed categories and concepts
and explored the properties of these concepts. I looked at codes I had created that could
be loosely grouped together and then I asked myself “Is this a type of [another code]?”
For example, I looked at the code “Prayer meetings” and asked myself “Is this a type of
coping strategy?”. I had coded other references to “coping” but began to note the
different ways in which women coped. Sometimes women shared their distress with
others and sometimes they did not. Moreover, to whom, where, when and what they
shared also varied. I developed subcategories for coping which included not only
approaches to coping (e.g., praying, seeking advice) but also coping contexts to explore
how women’s circumstances influenced their perceptions and experiences of coping.
Constant comparison – an analytic process in which comparisons are made between
“data with data, category with category, and concept with concept” (Charmaz, 1990, p.
1168) in order to test emerging themes and theory – was used to look at patterns, refine
and extend categories into subcategories. For example, I compared different
participants’ discussions of “freedom” and also compared the various categories that I
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had created concerning “freedom”. I realised that some notions of freedom were related
to parenting concerns and parent-child disagreements regarding appropriate levels of
children’s “freedom” in Australia. But there was also a lot more going on there. As I
compared categories I realised that, within “freedom” categories, a theme of “fear of
freedom” represented one aspect of a societal consequence of persecution. In addition to
these comparisons, I also compared different people’s situations and accounts.
The method of theoretical sampling is central to grounded theory. In this process,
analysis and data collection (including participant selection) occur simultaneously and
participants are selected to help advance the developing conceptual analysis. Theoretical
sampling of participants is continued until theoretical saturation is reached. This is
defined as the point whereby no new information regarding categories or the
relationships between categories emerges. As the study progressed and I constructed
concepts and themes from the data, I began to utilise extreme and deviant case sampling
to seek out participants who represented information-rich cases of the topics of interest.
The entire analytical process of grounded theory is supported by the writing of memos
which are essentially analytical field notes containing the researchers’ thinking process
throughout the study. I used memo-writing throughout the study, noting my
impressions, ideas, notes and drawing diagrams. I also used memo-writing to
reflexively explore my experiences, feelings and notions throughout the research
journey (Charmaz, 2006; Strauss & Corbin, 1998) (see Section 7.9.1).
6.7 Rigour
Qualitative researchers use a variety of methods to enhance the rigour or trustworthiness
of their research. However, there remains no universally agreed upon approach to
addressing rigour (Carter et al., 2009; Ritchie, 2001). Like all elements of research
design, the approach taken must be viewed against the backdrop of the theoretical
perspective(s) adopted (Barbour, 2001; Patton, 2002). As we have seen, critical realists
and qualitative researchers enjoy an extensive range of theoretical viewpoints. They
also hold multiple perspectives concerning rigour. Notable differences are observed
between qualitative researchers more informed by a constructivist philosophy, and those
whose viewpoint is located towards a realist philosophy (Cohen & Crabtree, 2008).
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An aim of my inquiry was to frame recommendations for improving psychosocial
support services for Karen refugee women, a real-world focus best achieved through the
application of “realist” approaches to rigour. As a result I adopted Kitto, Chesters, and
Grbich’s (2008), six-point realist-oriented criteria for rigour. This section describes their
approach including how each criterion was met in this study.
6.7.1 Criterion 1: Clarification, justification or theoretical rigour
This criterion requires demonstration and justification of the theoretical approach
guiding research; in this thesis this is addressed in Chapter 5.
6.7.2 Criterion 2: Procedural and methodological rigour
This criterion is met through explanation of procedure and methods including rapport
building; participant selection; and data collection, storage, coding and analysis (Kitto et
al., 2008). In this thesis, the present chapter explains the methods of participant
selection (Section 6.2), data collection (Section 6.3) and data analysis (Section 6.6)
employed. Further descriptions of the unfolding research process in relation to rapport,
ongoing participant selection and data analysis are described in Chapter 7. Together
these chapters provide a thorough audit trail (Flick, 2002); these are augmented by
additional documents and recordings including:
raw data (audio-recordings, participant consent forms, completed interview
forms, transcriptions, emails and letters);
participant observation field notes;
interview summaries and field notes;
research diary and memos (including decision-making steps during research
planning; development of methods; data collection, analyses and interpretation;
and mistakes, surprises and challenges);
minutes from supervision and decision-making meetings.
6.7.3 Criterion 3: Representativeness
Representativeness requires the justification of the participant sampling techniques used
and is addressed in Section 6.2 of the present chapter as well as in Chapter 7 (see
Sections 7.2, 7.4 and 7.5).
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6.7.4 Criterion 4: Interpretative rigour
Interpretive rigour was addressed through triangulation, respondent validation and
attention to negative cases (Kitto et al., 2008). Triangulation involves the utilisation of
multiple research methods or theories to offset the limits and reduce the biases that
come with the use of only one research method or theory (Blignault & Ritchie, 2009;
Guba & Lincoln, 2005; Ritchie, 2001). Ethnographic, grounded theory and feminist
methodologies provided a means of methodological triangulation and multiple data
collection methods (e.g., different types of purposeful sampling, participant observation,
in-depth interviews and group interviews) which further enhanced the rigour of the
inquiry. I did not have co-researchers to allow for intensive investigator triangulation.
However, my doctoral supervisors, colleagues and the bilingual research assistant did
provide some degree of investigator triangulation through their feedback on my research
and analysis.
In addition to triangulation, the trustworthiness of research may also be enhanced
through prolonged engagement and observation (Lincoln & Guba, 1985) – procedures
which are also central to ethnography. By contemporary ethnographic standards I
conducted prolonged fieldwork in the community by engaging in fourteen months of
rapport building and orientation to the community before the research formally began.
Once ethical approval was obtained I also engaged in over 200 hours of ethnographic
fieldwork for a period of twenty-four months (September 2009 – September 2011).
Member checking, respondent validation and inter-rater coding are further approaches
to establishing the rigour of qualitative research though these techniques are variably
defined and their use is widely debated (Morse, 1997; Ritchie, 2001). Guided by a
critical realist paradigm, I reject the positivist notion of objectivity and did not
undertake forms of member checking or inter-rater coding in an attempt to achieve
complete objectivity (Glaser, 1969). However, I did include these strategies to help
minimise the “intrusion of bias” (Strauss & Corbin, 1998, p. 43) in data analysis.
Ritchie (2001) suggests a practical approach to member checking which may occur at
any stage of the research and which may also be a formal or informal encounter. In the
process of interviews I frequently used summaries and reflections to check my
understanding and seek feedback from participants. In this manner I gave them informal
opportunities to correct my understanding of their experiences and perceptions. Lincoln
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and Guba (1985) further suggest checking transcripts with participants for accuracy and
general comment. As discussed above (see Section 6.4.3), transcriptions were made of
spoken English only. As a result, copies of transcriptions were provided only to
participants who were able to read English and who wished to receive one. This process
was helpful in prompting discussions with these participants at subsequent interviews
but participants did not generally comment on or question the accuracy of transcripts in
any significant way. In addition, I engaged in formal member checking and respondent
validation at the completion of the inquiry. With the help of community leaders, a
feedback meeting (see Section 7.9.4) was arranged and participants (as well as the wider
Karen community) were invited to attend.
For inter-rater checking, Ritchie (2001) suggests the use of peer researchers at different
phases of research (particularly during the analysis phase) and promotes the benefits of
shared interpretation. I engaged in frequent debriefing with the bilingual research
assistant immediately after interviews. Issues of meanings and translations were
discussed, checked and rechecked at every point in the research process; at the time of
interviews; and when interviews were transcribed, translated and analysed. In addition, I
met with three colleagues who each separately coded sections from my interview
transcripts. We then shared our codes. It was encouraging to see that all three coders
identified variables comparable to mine. Moreover, a discussion of these codes helped
me to articulate and further explore conceptualisations I noted in my memos.
6.7.5 Criterion 5: Reflexivity and evaluative rigour
Reflexivity requires explicit acknowledgement of the researcher’s values and
sociocultural position as relevant to the research inquiry and evaluative rigour requires
that the ethical and political aspects of the research are considered and addressed (Kitto
et al., 2008). In this thesis, reflexivity is first addressed in Chapter 1 (see Section 1.4)
and again in Chapter 7, where the ethical and political aspects of the research are also
explored in detail.
6.7.6 Criterion 6: Transferability
This criterion is understood and addressed in multiple ways. Kitto et al. (2008) provide
a twofold understanding of transferability or generalisability as (a) “the capacity to
make conceptual generalisations from the local context of a qualitative study to other
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settings” (p. 243), and (b) the applicability and usefulness of the findings to current
research knowledge, policy and practice. Contextually, Kitto and colleagues present
these criteria for authors and assessors of articles submitted to the Medical Journal of
Australia. In this biomedical milieu, positivist-oriented approaches to the transferability
of qualitative research findings may be more obligatory than in other qualitative
research environments.
There is considerable debate surrounding the concepts of transferability and
generalisation in qualitative research. The findings of qualitative research are often
made with reference to a specific setting in a specific social, historical and political time
period, and researchers may be “less interested in distribution across a population and
more concerned with a detailed understanding of people’s experience” (Daly, Kellehear,
& Gliksman, 1997, p. 99). Researchers may also wish to generalise in the qualitative
sense described by Flick (2002) as “the gradual transfer of findings from case studies
and their context to more general and abstract relations, for example a typology” (p.
232). Blignault and Ritchie (2009) explain that researchers may wish to explore a
phenomenon “for its own sake” (p. 142). Carter et al. (2009) urge qualitative
researchers to refrain from making apologies about the inability to generalise their
findings and maintain that “if you succeed in ‘proving’ that your participants were
‘average’ or ‘typical’ … you will probably thereby demonstrate that your sampling was
misdirected” (p. 109). Similarly, Patton (2002) argues that the aims, contexts and
questions of individual studies may not consider maximum variation to be a goal of the
research. Ultimately, the approach taken must be appropriate to the research aims and
researchers must be transparent about whether they seek to generalise their findings and
the degree to which this is achievable (Flick, 2002).
An aim of my inquiry is to frame recommendations for improving psychosocial support
services for Karen refugee women. In expressing this aim I am moving beyond an
exploration of the psychosocial experiences of Karen women “for its own sake”
(Blignault & Ritchie, 2009, p. 142). However, I am also not aiming to generalise my
findings beyond the research context, which would be “inconsistent with the principles”
(Carter et al., 2009, p. 109) of qualitative research and unjustified given the participant
selection strategies employed. In making clear my aims regarding generalisation and
transferability, I return to Kitto et al.’s (2008) approach whereby research is critically
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evaluated by its applicability and usefulness to current research knowledge, policy and
practice.
6.8 Logistics and limits
As a doctoral study, this inquiry was limited to a three-year duration. It was supported
by financial grants from the Australian Psychological Society, the New South Wales
Institute of Psychiatry and the University of New South Wales. Resources and technical
support such as office space and computer equipment were provided by the School of
Public Health and Community Medicine, University of New South Wales. Throughout
the duration of the research I also needed to work part-time and continue my
commitment to my business (in which I was self-employed). Through these financial
and resource means I was able to commit to a long-term period of involvement with the
community which spanned the three-year duration of the doctoral study as well as
several months of involvement with the community prior to undertaking the research.
6.9 Conclusion
This chapter has described the methods used to address (a) the research questions, (b)
ethics, and (c) rigour. It contributes to the audit trail for this inquiry and is augmented
by the following Chapter 7.
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Chapter 7
The Ethnographic Journey: A Researcher’s Reflections
7.1 Introduction
This chapter demonstrates the inductive and emergent nature of the inquiry. In it I will
provide a rich account of how the research unfolded and explore the difficulties and
challenges encountered along the way.
7.2 Identifying and entering the community
Identifying the Karen community was not a straightforward task and it took me a while
to do this. Like other resettled refugee populations (Spring et al., 2003), the Karen were
a relatively hidden community and, in Australia, published statistical information about
them was limited. The Australian Government did not require humanitarian entrants
from Burma to identify their ethnic affiliations and, consequently, could not
authoritatively determine the number of entrants from different ethnic minority
communities. As a result, some Karen (and other ethnic minority) entrants were likely
to be listed as Burmese. Sydney Karen community leaders were also unsure of the
precise size of the Karen community and, in 2009, estimated around 600 mostly Sgaw
and some Pwo Karen speakers. The community leaders confirmed information obtained
from the Australian Government’s DIAC database (2009c, 2011p) which indicated that
refugees from Burma residing in Sydney primarily lived in the western suburbs of
Parramatta (29%), Canterbury (20%), Auburn (16%), Blacktown (16%) and Fairfield
(10%). These suburbs are approximately 20 to 30 kilometres from Sydney city and are
amongst the most socially and economically disadvantaged in the state of New South
Wales (Australian Bureau of Statistics, 2006; Department of Education, Employment
and Workplace Relations, 2011).
The Karen community in Sydney was most easily identified by its political, social and
religious organisations. The Australian Karen Organisation and its subgroups (e.g.,
Youth and Women’s Group) and affiliates (the Australian Karen Cultural Association)
formed the largest of these groups and held regular meetings and celebrations. The
Australian Karen Baptist Church was the largest Karen-specific religious organisation
and community members were also established in the congregations of other Australian
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churches (e.g., Baptist, Anglican, Catholic and Seventh Day Adventist). Although
Karen in Burma were (and are) predominantly Buddhist (see Section 3.3.3), a
disproportionate number of refugees from Burma in Australia were Christian (DIAC,
2006).
Entering the community and building rapport was facilitated through my contact with a
few groups and community leaders as well as other individuals who served as “culture
brokers” (Liamputtong, 2010, p. 67). Through these contacts I was able to immerse
myself in the community. With the approval and endorsement of community leaders I
was introduced at a multitude of community events where I had the opportunity to
explain to the audience who I was and the nature of my research. It was critical for me
to establish rapport and approval through community leaders. However, I kept in mind
the numerous demands that researchers and organisations place on these individuals
(Liamputtong, 2008) and tried not to burden them unnecessarily. Moreover, I did not
rely on these contacts as sole gatekeepers and was aware that my connections to these
leaders, who were mostly men, might be detrimental to me gaining acceptance and trust
from women. I might – in the eyes of Karen women – be aligned with the elder Karen
men, their political and religious factions, and potentially other variables I could not
foresee. I therefore also made an effort to contact senior Karen women and arranged to
meet with a small group of them to discuss my research, answer their questions and gain
their approval and support.
It took approximately fourteen months to formally set up the study and obtain the
necessary financial support. During this time I established a relationship with the
community, built rapport, learnt about and mapped community sub-groups, attended
Karen language lessons, read literature to improve my knowledge of Karen culture and
history, and endeavoured to learn more about strengths, politics and factions (Morse &
Richards, 2002) within the community. By the time interview data collection began I
was already quite familiar with my research setting, had been invited to numerous
community functions and regularly attended weekly religious events. I had established a
reputation as a Westerner who was concerned for the welfare of the Karen people – “a
friend of our community” as one leader commonly introduced me. Towards the end of
the study, during a community feedback meeting, the most senior elder extended his
trust to me and described me as an “honorary Karen sister”. Though not an “insider” to
the community per se, such examples suggest that I gained access beyond that of an
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“outsider” (Merriam et al., 2001; Ritchie, Zwi, Blignault, Bunde-Birouste, & Silove,
2009).
My strategies for maintaining relationships and rapport with research participants
included compensation and reciprocity (Liamputtong, 2010). I viewed reciprocity as not
only a means of maintaining relationships and rapport but also as an ethical duty and
guiding principle within my methodological framework. In appreciation of Karen
women’s time and contribution I provided each with a $20 grocery voucher. I also was
able to help community members who asked for my assistance and engaged in many
forms of reciprocity including responding to requests for advocacy, writing letters of
recommendation for education and employment applications, providing help with
completing documents and assisting with transportation. These reciprocal activities are
common amongst researchers working in refugee communities (P. Guerin & Guerin,
2007). Many of these encounters were very useful – often as useful as in-depth
interviews – in helping me to learn about Karen women’s lives. For example, through
assisting a Karen woman who needed help accessing English language classes I was
able to observe the challenges faced by both herself and the service provider. I was also
able to witness how Karen women’s approaches to communication affected their ability
to engage with services and supports. Finally, research reciprocity included reporting
research findings to participants in an appropriate manner. At the conclusion of my
research I provided visual and verbal (with an interpreter) feedback to the community
(see Section 7.9.4).
7.3 Identifying and working with a bilingual research assistant
Not being fluent in Karen dialects meant I needed to find someone to assist with
interpreting and navigating cultural nuances (Hennink, 2008; Liamputtong, 2008,
2010). Interpreters and translators are not invisible conduits of information (Angelelli,
2004; Tribe 1999a). They are an active part of cross-cultural communication encounters
and add an additional layer of perception and meaning through which information is
conveyed (J. Bailey, 2008). In response to Hennink’s (2008) call for “greater
transparency” (p. 27) in how language and communication issues are addressed in
cross-cultural research, the following sections describe how the bicultural research
assistant was selected, her role(s) and our experiences during the study.
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The recruitment and selection process was lengthy and at times frustrating. I initially
aimed to use a qualified professional interpreter (Kapborg & Bertero, 2002) but found
there were no female Karen interpreters in Sydney accredited by the NAATI (R.
Ganesan, personal communication, 3 December, 2010). I next attempted to recruit
potential interpreters through the guidance of community leaders. This process took a
number of months but none of the proposed women were suitably available and some
lacked sufficient English language skills. I was also concerned about existing
community factions and wished to find an interpreter whose relationships within the
community would be less likely to jeopardise my ability to gain rapport and
information.
There are advantages and disadvantages to working with bilingual research assistants
who are distant or on the fringe of participants’ daily lives. Although participants may
feel more comfortable discussing topics with a relative outsider, the assistant may not
understand contemporary cultural meanings, expression or experiences of particular
groups (Edwards, 1998). However, as Liamputtong (2010) notes, “Small minority
communities may distrust cultural insiders because they fear that their issues may be
gossiped about” (p. 68). This perspective was endorsed by a male Karen key informant
who was also a well respected community leader and experienced interpreter.
After six months of failing to find a suitable bilingual research assistant I tried another
approach and asked local service providers to recommend Karen-speaking women they
employed for interpreting. My new recruitment process resulted in the recommendation
of two women, both of whom had considerable professional experience. I subsequently
invited Ms Naw to work with me in conducting the research based on (a) her personable
and empathic nature, (b) her relevant experience and competence (in multiple Karen
dialects) as an interpreter and health professional (nurse), (c) her strong bilingual and
bicultural background, (d) her time availability, (e) her relative distance from the
research participants, and (f) her interest and commitment to the research.
Ms Naw was well briefed on the purpose of the research and given training in the
interview methods and confidentiality (Tribe & Keefe, 2009). As we worked together
we trouble-shooted different problems and challenges. Of course, language cannot be
translated directly and inevitably Ms Naw needed to “actively select words or phrases to
accurately convey equal meaning” (Hennink, 2008, p. 26) when no exact translation of
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words, idiomatic expressions or concepts was possible. For example, there was no direct
translation for the term or concept of psychological trauma so Ms Naw had to convey
the meaning through describing the impact of extremely awful life experiences on the
wellbeing of one’s heart-mind. As the research progressed we became familiar with
common words and concepts that presented difficulty and spent time together
discussing meanings. I also explored the meaning(s) of these words and concepts in
meetings with Karen key informants including other interpreters.
Dialectal differences pose a serious challenge to researchers working with communities
of refugees from Burma and a “common interpretation problem is expecting one person
from Burma to understand another” (S. Smith, 2010). Mr W, a Karen key informant,
confirmed this problem when he explained: “Karen is not only one language. It is like
Aborigines here [in Australia]. So many dialects they don’t understand each other”. In
addition to recognised differences in dialects, participants also reported that Karen
speakers who were institutionalised in camps for long periods of time tended to speak
“camp Karen” versions of different dialects. Key informants explained that even within
the main dialect of Sgaw, different expressions could be used to describe emotion states
by persons from different villages or camps. Research participants in this inquiry were
predominantly Sgaw Karen speakers and a few spoke Pwo Karen. Ms Naw was fluent
in both dialects but still had to frequently check her understanding with participants to
ensure she interpreted as accurately as possible. Participants themselves negotiated and
navigated dialect differences during group interviews and key informant interviews with
two or more Karen speakers.
Ms Naw’s community and cultural knowledge and expertise were invaluable. In
addition to assisting with interviews she helped to plan and organise interview
opportunities and introduced me to some key informants. She actively contributed to the
ongoing research dialogue through interpreting and conveying cultural meanings but
was not involved in any other technical, administrative or analytic tasks and did not
influence any other decision-making throughout the research process. Debriefing after
interviews, and especially after potentially distressing encounters, is an important
process when working with bilingual research assistants (Liamputtong, 2008, 2010) (see
Section 6.5). After potentially upsetting interviews I contacted Ms Naw to (a)
acknowledge that the information we heard was potentially distressing, and (b) offer
support. Ms Naw did not wish to engage in extensive discussion about the sensitive
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information to which she was exposed. However, she appeared grateful that I checked
on her wellbeing.
7.4 Informal participant observation encounters
I made over 200 hours of observations over a twenty-four month period (September
2009 – September 2011) during which I attended dozens of cultural and religious events
as well as smaller gatherings with Karen women and their families. In addition to
interviews, I socialised informally with Karen women in their homes, in restaurants and
in cars while travelling. I also joined them in attending service providers, community
consultations and education classes. Across these various experiences the extent to
which I was a participant or observer was in a constant state of flux. In reflecting on my
place on the participant observer continuum, I refer to Gold’s (1958) description, which
I have adapted as a figure below:
Complete participant Participant-as-observer Observer-as-participant Complete observer
Figure 3: Four-point participant observer continuum (Adapted from Gold, 1958)
At the beginning of the inquiry I was almost always a complete observer. I knew few
people and at functions often felt unable to adequately communicate with the people I
met. Consequently, field notes from these early encounters were highly descriptive.
Though I was not able to access women’s perceptions during these encounters, I was
able to make behavioural observations of issues such as evident gender role rules and
expectations. As the inquiry progressed I became, at times, much more of a participant-
as-observer. For example, I helped a Karen woman access social services; physically
assisting her (she had several severe health problems and was unable to walk far) and
advocating on her behalf. I was a participant in her experience and at the same time I
was a researcher observing and trying to comprehend the encounter from the
perspectives of the various parties involved.
Although I wished to participate and observe women’s lives, it was not always feasible
to do so out of respect for community leaders. For example, at particularly important
community gatherings I was often separated from “ordinary” Karen women (who were
often working in the kitchen) as leaders requested that I sit at the front of the room with
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community leaders and distinguished non-Karen guests, such as local politicians. I was
often the only woman at the table. If I refused the request to sit at the guests’ table I
would have disrespected the leaders and the cultural custom of demonstrating esteem
towards people with graduate education (or other sources of authority). I also missed
other opportunities for participant observation due to personal and work commitments.
I found myself pondering ethical dilemmas early on in participant observation.
Presumably not everyone present at a community gathering had been informed about
my research by the leaders, and yet, here I was observing them. What about their
consent? Furthermore, what about the children I observed interacting with their mothers
– I am sure no one had told them about my research or sought their assent. The method
of participant observation is not without controversy as it raises complex ethical
questions regarding the rights and abilities of participants to consent to being observed
by the researcher. Deception and covert participant observation are hotly debated issues
and participant consent in relation to the method is “seldom clear-cut” (Griffin &
Bengry-Howell, 2008, p. 24). Covert research observation without the explicit consent
of those observed is considered unethical by many (Patton, 2002; Woods, 1992) while
others accept the use of this longstanding social science research strategy (Douglas,
1976). Some argue that absolute open consent is unachievable in the context of
ethnographic fieldwork as it is unclear to what extent consent from every single
community member included in the observation is obtainable (Daly et al., 1997).
Questions arise regarding the nature of consent and whether a hierarchy of consent is
acceptable (e.g., when senior members approve the observation on behalf of the
community) (de Laine, 1997). I referred to literature (Atkinson & Hammersley, 1994;
Li, 2008) and eventually I came to accept that I would do no harm provided I applied
the same ethical guidelines to participant observation as to interviews (including being
sensitive when writing up findings).
Ethnographers may face additional ethical challenges in relation to deception as their
research unfolds. For example, in order to participate in activities they may pretend “to
share values and beliefs” (Patton, 2002, p. 271). I grappled with this dilemma when I
found myself participating in political and religious activities that I did not personally
endorse. Was I deceiving those I observed by partaking in their customs and traditions?
I felt uncomfortable about this but ensured that I always informed people about my
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research. I also decided that should I be asked about my personal religious and political
affiliations I would be honest – throughout the research no-one asked.
Grills (1998) views the heart of ethnography as providing “perspective, or how people
see their world” (p. 4) and sees participant observation as central to that endeavour.
During the study I often wondered if the method resulted less in an understanding of
Karen participants’ perspectives, and perhaps, as much (or more in some cases) in
gaining understanding or insight into how their world perceived them. Indeed, perhaps
due to the limitation of not fluently speaking their language, my field notes were often
behaviourally descriptive. I saw how women behaved in their daily environment(s) and
I saw how others (e.g., native Australians, service providers, restaurant waiters, etc.) in
their environment(s) behaved towards them. For example, whilst joining Karen women
in an English language class I observed both the passivity of the women’s interactions
with their non-Karen classmates and teachers, but also, and most alarmingly, the often
negative responses of these other Australians to them. Such observation was still very
helpful and conducive to addressing the aims of my research as I was able to better
understand limitations with service provisions by observing interactions rather than just
interviewing women and asking about their perspectives of such encounters.
Over a two-year period through my engagement in Karen women’s lives I developed
strong relationships with many community members. However, I am not an insider in
the Karen community, rather I remain an accepted – perhaps even trusted by some –
outsider, fortunate enough to be allowed to partake in insider perspectives, activities and
experiences on occasion. Nevertheless, before and during research I also continually
questioned the degree to which my approach to participant observation aligned with
traditional ethnographic fieldwork and notions of what constitutes a “full ethnography”
(Griffin & Bengry-Howell, 2008, p. 17). Traditional ethnographers typically learn the
local language before undertaking research (Fielding, 2001) and engage in extensive
field work of a suggested minimum of six months to two years or more (Griffin &
Bengry-Howell, 2008; Liamputtong, 2009). I did not acquire sufficient knowledge of
the Karen language (or various dialects) to work with non-English-speaking Karen
without an interpreter but I did fulfil the recommended two years of prolonged
engagement in the field. I was also unsure about the extent of my immersion in Karen
women’s culture. According to Goffman (1989), participant observation fieldwork
involves:
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Subjecting yourself, your own body and your own personality, and your own
situation to the set of contingencies that play upon a set of individuals, so that
you can physically and ecologically penetrate their circle of response to their
social situation, or their work situation, or their ethnic situation. (p. 125)
I did not subject myself to the set of contingencies and ecological contexts that
characterised the lives of Karen women. I did not live in the same sociopolitical,
economic and built environment that my participants lived in and I did not experience
the joys and challenges of parenting their children day after day. I did, however, spend
time in their homes, in their broader physical communities and in their churches. I
joined in their community events and celebrations and I held their babies and played
with their children. I participated in women’s interactions and one day, en route to
attend a community gathering, a participant invited me to her home and bedroom where
she dressed me in traditional Karen garments. I joined Karen women in their education
classes and other social situations such as going out for food. But I cannot say that I
“ecologically penetrated” their lives. However, by engaging in activities alongside the
Karen women I have achieved extended immersion through what Daly et al. (1997)
describe as “periodic observations” consisting of “dropping in to see what is happening
at different points in time” (p. 158). The time limits imposed on a doctoral research
project and other practical limitations prevented me from a fuller immersion in the lives
of Karen women. My approach to participant observation is tempered somewhere
between Goffman’s and Daly et al.’s perspectives and was adequate for the purpose of
addressing the research aims and questions.
7.5 Formal interview encounters
I interviewed 10 Karen refugee women over a twelve month period from February 2010
to February 2011. Most women were interviewed only once, but some participated in
several interviews. I had initially envisaged the interpreter’s presence at all interviews
with Karen women who did not fluently speak English. However, after meeting with
each participant once or twice with the interpreter present and covering the key themes
of the interview guide I then engaged in informal encounters with participants who
spoke English reasonably well. Women generally preferred to be interviewed in their
own homes when other adults or school-age children were away. The average duration
of formal encounters with Karen women was two hours.
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All women consented to an audio-recording. Like Booth and Booth (1994), I did not
audio-record informal encounters during my participant observations. This gave me the
freedom to move around and talk in noisy or busy environments (e.g., when women
were cooking). After these encounters I wrote brief field notes of key themes or dictated
my observations into the audio-recorder, as soon as I returned to my car. These notes
were later (within 24-hours) expanded.
Over the period of November 2009 to February 2011, I formally interviewed 23 key
informants. These encounters took place at the participants’ own place of residence or
work and lasted, on average, one and a half hours. Though most key informants were
interviewed on one occasion only, four were interviewed on two or more occasions.
Interviews with English-speaking key informants and service providers were undertaken
in English and an interpreter was not present. The final selection of key informants
included:
Community leaders (e.g., pastors and elders)
Healthcare providers (e.g., doctors, psychiatrists and counsellors)
HSS providers (e.g., case managers, interpreters, counsellors and bicultural
workers)
Social service providers (e.g., interpreters and political advocates)
All but three key informant interviews were audio-recorded. Only one, a healthcare
practitioner, denied consent. On another occasion, technical difficulties with the
dictaphone prevented recording and during another interview I offered to cease
recording when I observed that the informant was uncomfortable with the dictaphone.
During my formal encounters I used interview guides that I refined as the research
progressed, research questions evolved and I began to focus on new areas not identified
in the initial plan. These new directions were guided by ideas and concepts generated
from data analysis (see Section 7.8). In hindsight, the thorough development and
translation of the guide for Karen women reflected my anxiety and desire to be prepared
prior to beginning interviews. The process of back-translation of interview guides was
lengthy and expensive. It was also ultimately largely unnecessary as I found a less
structured interview approach to be most helpful in establishing rapport and eliciting
information. Although I had begun with a semi-structured translated interview guide,
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my approach rapidly developed into a form more like the theme lists described by
Liamputtong and Ezzy (2005).
Like Liamputtong and Ezzy (2005), I found in-depth interviewing to be “a privilege” (p.
55). Aside from a few participants who appeared guarded, most were forthcoming with
information and I felt privileged that they trusted me with their stories and perspectives.
I believe that my involvement in their community fostered rapport with Karen
participants.
At the beginning of interviews I took care to situate each participant as the expert of
their own experience and positioned myself as a concerned and interested learner-
listener seeking to understand their story and viewpoint. During interviews (particularly
with Karen women) I also encouraged a “two-way relationship” (Egharevba, 2001, p.
233) in which I encouraged women to ask questions of me. Frequently, women wanted
to know personal information such as whether I had children. Many also asked about
my home country (New Zealand) and about my time on the Thailand-Burma border. I
answered their questions freely and believe that such self-disclosure encouraged
rapport. On many occasions women also asked questions to which I did not know the
answers. For example, women asked questions about immigration processes or social
welfare payment rules and regulations. When I did not know the answer to their
questions I freely admitted my ignorance. In some instances I was able to seek out the
information they needed or refer them to someone who could help. One participant
expressed suicidal ideation and I subsequently made a referral to a doctor and mental
health service.
I approached particularly sensitive topics with caution and, naturally, participants
differed in their level of knowledge and willingness to discuss issues such as sexual
violence. Karen women were often hesitant to openly discuss sensitive topics and I soon
learnt that contexts and physical gestures conveyed messages different to the verbal
content tied to them. For example, when asked if some Karen women experienced
domestic violence, a previously forthcoming participant might lower her head and eyes
and respond “no” or simply “some might, I don’t know”. Nevertheless, little by little,
these and other more puzzling communications became clear and I found myself
learning when “yes” meant “no” and “no” meant “yes”. In contrast, I found that key
informants were often relieved to be invited to articulate their thoughts about sensitive
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issues. For example, after a conversation in which a Karen leader discussed community
attitudes to single mothers, I pointed out that we had been discussing a difficult topic.
He replied: “It is, Paula. But thank you for asking me about these kinds of things; these
things are coming to me [from community members]”. Karen women also frequently
thanked me for visiting and talking with them: “Thank you for coming. I’m so glad that
you want to know what our problems are, I’m glad to talk about my problems” (Hpä
Hpaw Mu).
In reading over my transcripts I realised that, despite my best intentions, I had not
always listened well, especially in the earlier interviews when I had often been nervous.
Sometimes I was anxious about going over time and how I would afford the interpreter.
Other times I had not always heard the participant’s response because I was anxiously
trying to categorise their comments and plan the use of the remaining interview time – a
pitfall described by Liamputtong and Ezzy (2005). The quality of earlier interviews was
markedly different from the later ones. As the study progressed, I relaxed and allowed
myself to respond with a more flexible interview style, and match my approach to each
participant. For example, I found that some women did not feel confident directly
outlining the properties of particular idioms of distress. However, if I approached the
interview in a different manner, asking them to describe stories about third persons who
suffered from different conditions, they happily provided detailed accounts.
Balancing engagement and detachment during interviews became an ongoing process.
This was not difficult during all interviews but featured strongly in some. I had to be
careful not to slip into patterns of psychological therapy. I was there to learn and had to
ensure my research was rigorous. At the same time I had to be careful not to detach
myself so much that distance between myself and participants would reduce
understanding and rapport (Patton, 2002). As a feminist researcher I was interacting
with women on a personal level. I allowed myself to empathise with women. For
example, when Hpä Hpaw Mu described her experience of social rejection and isolation
I empathised and confirmed that her experience sounded very hard. I let her know that if
I was in her shoes I would have struggled with the experience too. I also validated
women’s bravery. When Htee Gloh shared her story of protecting her children from
bullets, I attested to her strength and courage. When I was humbled by women’s stories
I let them know. When I sat on the floor beside Lah Luh as she cried and spoke of
wanting to die it seemed appropriate to physically comfort her.
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During interviews with key informants, especially non-Karen service providers, I
generally found it easy to simply listen and observe even when I personally disagreed
with their comments – I was focused on understanding their perspective as this helped
me to better understand what was going on in Karen women’s lives in Australia.
However, in hindsight I wonder whether I should have taken on more of an advocacy
role. For example, during one participant observation encounter, I witnessed a service
provider make offensive and misinformed comments about Karen women in their
presence (see Section 12.7.2). At the time I felt embarrassed and angry but I followed
the lead of the Karen women I was with and did not challenge the service provider’s
point of view. The encounter gave me insight into Karen women’s lives and experiences
with this service provider. From one perspective doing nothing was the right thing to do
– I think the Karen women I was with would have been very uncomfortable to disagree
or challenge a service provider and I could have made them uncomfortable by doing so
in their presence. On the other hand I failed to show respect and dignity towards the
women I was with by not advocating on their behalf. I also failed to demonstrate to
them Australian cultural norms in which it is both safe and appropriate to disagree with
a service provider if they express offensive, prejudicial and incorrect views about an
ethnic group. Some weeks later I had the opportunity to meet the service provider in
private. I did not specifically refer back to the incident but, during our conversation,
provided some education about the experiences and context of refugees fleeing Burma.
7.5.1 Formal encounters with groups
Five group interviews were conducted between April 2010 and June 2011 to explore
vignettes. A total of 28 Karen women attended these interviews. One group interview
was held at a woman’s home whilst all others were conducted at a community centre
that the women were familiar attending. All group participants provided informed
consent and agreed to the audio-recording. One man attended the second group
interview and had been invited by one of the women. The group agreed that he should
stay and join the discussion. On reflection, his presence did not appear to alter the
information obtained from the women as the women’s discussions were comparable to
other group interviews and included the topics of menstrual blood flow and its
relationship to physical and emotional wellbeing. Each group interview was two hours
in duration; this was just sufficient to explore the three vignettes from the interview
guide (see Section 6.4.2).
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Rapport was easily established in group interviews. Most participants freely discussed
their perspectives about the vignettes and many also revealed details of their own lives
related to the vignettes. I believe this apparent comfort was largely due to the fact that
the intermediary, who assisted organising the groups, ensured that each group was
relatively homogeneous whilst demographic variation (e.g., age, political or religious
affiliation) was apparent across the different groups.
Time and participant lateness were the most persistent problems affecting group
interviews. Room availability was limited and we were often unable to go over time so
interviews were affected when women arrived twenty or thirty minutes late and then
needed to go through consent forms after everyone else had completed theirs. This
problem was not unique to my group interviews. Several Karen community leaders
joked about “Karen time”, meaning that Western concepts of time and punctuality are
not familiar to the Karen. Other organised events within the community often began up
to one hour after the scheduled start. In hindsight, this problem could have been
somewhat averted if I had been able to secure a venue for three to four hours rather than
the two hours available at the centre used.
Theoretical saturation of EM concepts (see Section 6.4.2) was thoroughly achieved
following three group interviews. Subsequently, I utilised the fourth interview to delve
deeper into (a) idioms of distress, and (b) properties of other concepts generated from
data analysis. To do this I moved beyond the planned methods for group interviews and
employed the storyboard interview techniques utilised by the Centre for Refugee
Research (n.d.). This approach has been used to identify, analyse and problem solve
issues of concern for refugee communities, particularly refugee women, and involves
asking small groups of participants to prepare panels (using drawing, pictures or
collages) to address questions that pertain to an issue of concern. Each group then
creates one large collage of their panels and presents their work to the wider group.
According to the Centre for Refugee Research, the six stages must take participants
through describing a problem or issue to be worked on, to a solution and an outcome.
I asked women to separate into groups of three or four people and select an issue of
concern from a summary list of problems identified from data analysis (e.g., parenting,
domestic violence and unemployment). Each group then prepared five pictures to
address the following questions about their chosen issue:
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1. What is the impact of this problem on the individual, families and community?
(How does it affect the people concerned? What happens to them? How does
this affect their families and their communities?)
2. What happens to these women and girls now? (What help is available to them
and do you feel it is effective?)
3. If you were in charge of services for refugees what would you provide for these
women and girls, their families and the community in order to address this
issue?
4. Who do you think could provide these services? Who would you want to do
this? What help would the community need to address it?
5. If all these services were available what would be the best outcome for these
women and girls?
The five pictures were then pasted onto one large piece of cardboard which the group
presented as a storyboard. The peer audience and I asked questions and gave feedback.
Women worked together very hard during the storyboard group session and appeared to
enjoy both the opportunity for group work and the chance to constructively discuss
problems that affected them. The level of detail obtained from this exercise assisted me
in understanding the emotional impact of life stressors on Karen women in a much
richer way and allowed me to explore more fully the ways in which women perceived
the problems in their lives. The following images present some of the storyboard panels
from the group interview.
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Image 1: Complete storyboard regarding employment difficulties
Image 2: Storyboard panel depicting women’s isolation
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Image 3: Storyboard panel depicting Karen women’s difficulties assisting their
children with homework
Lastly, I used the fifth and final group interview to check and further explore my
understanding of the experiences, perceptions and problems faced by single Karen
mothers. This group was a rare and valuable opportunity to meet with a homogenous
group of recipients of the Women at Risk visa subclass (see Section 4.2.2). I opened the
group discussion summarising what I had learnt from women so far, seeking feedback
and moving towards clarification of topics. Perhaps because of women’s familiarity
with each other, and their shared context (being single mothers), this group was one of
the most relaxed, frank and emotive of all group interviews.
7.6 Transcribing speech and presenting quotations
All audio-recorded interviews were transcribed in full, a process which took
approximately three to four hours per hour of recorded speech, depending on quality of
recording and differing accents. This process was most complex for group interview
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recordings where interruptions and multiple simultaneous speakers were common and it
was not always possible to identify all speakers (Bloor et al., 2001; Bryman, 2008).
Transcriptions were typed and saved with as little editing as possible. Published
quotations from interpreted interviews represented the bilingual research assistant’s
English articulation and interpretation of the participant’s statement and were tidied to
omit incorrect literal spellings and verbal noises such as “um”. I faced a dilemma in
deciding how to present quotations from interviews where an interpreter was not
present. Many participants (including key informants) were from non-English speaking
backgrounds and the literal transcriptions of their interviews were often clumsy and
difficult to ready. Of course, linguistic variety “is an important feature of cultural and
subcultural identity” (J. Bailey, 2008, p. 129) and there was also an argument to be
made for reliably conveying my encounters with key informants from non-English
speaking backgrounds in order to contextualise the interview data. However, these
literal transcripts risked portraying these respondents as inarticulate or less educated
than was the case (J. Bailey, 2008). I decided to employ standard English grammar and
spelling conventions for all published quotations. False starts, repetition and noises such
as “ummm” were omitted. Other verbal interactions such as laughs were included as
these were important to understanding the context and meaning conveyed in the verbal
message.
7.7 Ethics
Social scientists, and particularly those who work with vulnerable populations, are
encouraged to consider dimensions of ethical research practice beyond the aspects
traditionally addressed by ethics committees (e.g., informed consent, protection from
harm and protection of privacy) (Allotey & Manderson, 2003; Angrosino, 2005;
Fontana & Frey, 2005; Hugman, Pittaway, & Bartolomei, 2011; Liamputtong, 2010;
Liamputtong & Ezzy, 2005). Broader ethical and moral issues, encompassing what is
sometimes termed the “progressive social agenda” (Angrosino, 2005, p. 734) concern
the values that guide our work as well as our sensitivities to how our research is placed
in the local, cultural and political research environment in which we and our
participants live. The practicalities and challenges of addressing these broad dimensions
of ethics are explored in this section.
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As discussed (see Section 6.5), ethical approval for this project was sought and obtained
from the Human Research Ethics Committee of the University of New South Wales.
Despite our shared interest in protecting the wellbeing of participants I experienced
some difficulty balancing my commitment to conducting moral and culturally ethical
research with the procedural requirements of the ethics committee – particularly those
relating to informed consent.
The process of informed consent is important and seeks to ensure that informants and
participants are fully aware of the nature and purpose of the research including who is
undertaking it, what it involves and how the information will be disseminated.
However, informed consent is also a “Thorny Issue [which] can be intimidating to many
cultural and ethnic groups, particularly those who are doubly vulnerable like refugees”
(Liamputtong, 2008, pp. 12–13) and is made difficult by first language illiteracy as well
as negative experiences and fear caused by living under a repressive regime. Previous
research with Karen populations had encountered challenges with the Western concept
of written informed consent (Fuertes, 2007). I explained these concerns about the
written consent process to the ethics committee and suggested that refugee participants
be able to provide verbal consent. The committee initially rejected this approach but
eventually agreed to a process in which participants could provide written or verbal, but
audio-recorded, consent.
In most cases Karen women did not ask questions about consent – I think that some
would have signed the consent form without reading it – but I ensured that they held a
copy of the form whilst Ms Naw (bilingual research assistant) explained the content. All
of the women were happy to sign the form so I did not have to use the option of verbal
consent. My experience of willingness to provide written consent differs to that of other
researchers who have worked with Karen refugee communities (Fuertes, 2007) and I
cannot be sure of the reasons for this. However, I suspect that participants in my study
were more familiar with the process of signing forms as they now live in Australia
(Fuertes undertook data collection in refugee camps). It is also possible that my
extended period of contact and rapport building prior to data collection, as well as the
support I obtained from community leaders, also contributed to women’s willingness to
provide consent.
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7.7.1 Maintaining confidentiality and anonymity
The Karen community and surrounding community of support services was very small
and I needed to be sensitive to confidentiality and ethics. All Karen women were given
Karen pseudonyms (e.g., Mu Htòh) taken from Sgaw Karen names of flora, fauna and
other natural elements. However, I spent considerable time grappling with the task of
grouping or representing key informants in a manner that (a) protected their identity, but
(b) allowed for the data and different subgroups (see Section 7.5) to be accurately
conveyed. Some of my earlier attempts at protecting participants’ anonymity resulted in
a host of difficult to read acronyms (e.g., HCKI for healthcare key informant) and others
failed to protect participant anonymity. Ultimately I decided on a system whereby the
term “key informant” was used sparingly as a sole descriptor. Additional descriptors
conveyed other relevant participant demographics. For example, Karen (as opposed to
non-Karen) key informants were always identified as such. Cases where a key
informant was also a Karen woman were made explicit. The gender and ethnicity of
other key informants was reported if relevant to the inquiry. Key informants who were
doctors were identified as such. Due to the exceptionally small number of other
healthcare key informants (e.g., psychiatrists and counsellors) in the study, these
participants are not routinely distinguished from other service provider key informants
unless it was safe and necessary to do so.
7.8 The analytic journey
At times the cyclical pattern of grounded theory analysis seemed to be moving too
quickly. There were moments when I would have liked to have spent more time
analysing and developing key concepts before undertaking further theoretical sampling
but sometimes interviews with participants (especially busy key informants such as
doctors) had to be grabbed when the opportunity arose. Charmaz (1990) suggests that
“delaying focused theoretical sampling fosters gaining an in-depth understanding” (p.
1163). Whilst I agree with this sentiment, the reality of balancing opportunities and
involvement in the field with an ideal research process did not conform to such a
system. On the other hand, there were also times when I experienced forced delays in
theoretical sampling. For example, some informants who I sought to select on the basis
of my developing analysis were difficult to contact and even more difficult to arrange
an interview with.
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Early line-by-line analysis of transcripts helped me to immerse myself in the data and
also provided an opportunity to critique my interview technique. After a few interviews
I had dozens of descriptive codes, some of which were lengthy and vague. One early
code included “If it doesn’t work don’t do it” which referred to participants’ cultural
wisdom and commonsense advice that unhelpful mental practices, such as ruminating
over sad thoughts, should not be continued. Charmaz (1990) warns against unnecessary
jargon and encourages researchers to label their categories with simple, direct and vivid
words. Gradually, the labels and codes themselves were refined as common and
distinguishing characteristics of each code were formed and rudimentary categories
developed. I also soon realised that some codes seemed to be “types of” a number of
things and often these particular concepts continued to retain their importance as
analysis progressed. For example, “mistrust” was a type of problem encountered in
relation to “interpreters”. I also coded it as a property of “societal effects of war” and
additionally as a feature of “relationship difficulties” with peers. I then developed
further questions about mistrust – I wanted to know about the origins, experience and
impact of this issue.
As analysis progressed I developed and refined the relationships or connections between
categories. I found that many of my findings were interrelated. For example, health
issues were related to education and employment problems, which were, in turn, central
to financial woes and poverty. Refugee researchers P. Guerin and Guerin (2007) have
argued that it is “imperative that topics about refugee communities … cannot be treated
as separate or ‘compartmentalized’” (p. 154). As I analysed and wrote about the data, I
aimed to convey the interrelationship of many of the issues related to Karen women’s
lives and wellbeing.
The initial interviews led me to sense that the concept of feeling useless encompassed
far more for participants than frustration at their inability to achieve goals. But what was
it? I raised these observations and questions in my memo-writing and went on to gather
more data as well as re-analyse previously coded data. I went back through earlier
interviews and sorted material on “use / uselessness” and personal and collective value.
Looking back through the interviews with this interest now in mind prompted me to
look again at comments and accounts that reflected this topic. Such data had often been
coded as something else and now became coded in additional ways. For example, I had
previously created a code titled “bored” in which some women had made comparisons
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to their level of activity (e.g., work or volunteer involvement) pre-migration to their
current status and the boredom they experienced in Australia – I wondered if this
actually represented one aspect of “uselessness”. Subsequently, I built questions about
“use / uselessness” into later interviews, allowing me to gather a more complete picture
of the topic. As categories grew more detailed I proceeded to ask questions of the data
and of subsequent participants in order to more fully understand the properties of
emerging categories and concepts. Eventually I realised that both “use / uselessness”
and “identity” were interrelated concepts that were central to Karen women’s wellbeing.
As conceptual categories were developed I shifted into areas I had not expected to
study. I did not intend to study societal level relationships between culture and
experiences of persecution. However, I developed an interest in it as topics around
women’s daily struggles were located within this milieu. Key informants attached
significance to these issues, which, in turn caused me to look at them more
systematically, to look again at what women were telling me, and then raise new
questions such as how religious belief systems related to women’s beliefs about
suffering. Later on, how these issues intertwined with other themes and categories
became evident.
I occasionally found myself with disparate accounts within my data. For example, some
non-Karen key informants thought that Karen women did not particularly experience
domestic violence or other social problems whereas other participants did. The
following quotation from Charmaz (1990) was helpful in guiding me through analysing
disparate accounts:
Unlike some qualitative researchers, grounded theorists may show less concern
with ascertaining the “accuracy” of a specific piece of data than with its
theoretical relevance. Two people, such as an ill person and his or her caregiver,
may give different account for the ill person’s activities. Here, whose rendering
of reality comes closer to “truth” has less importance than the analytic issues
raised within each view … (p. 1167)
Through exploring conflicting accounts I was able to understand the processes by which
key aspects of women’s expressions of distress led to incomplete understandings of
their situation by others. I was able to draw together issues such as religion and culture,
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widespread or societal reactions to protracted persecution, and daily post-resettlement
challenges in order to see how these disparate views actually reflected the interaction of
these variables. In short, it was not about establishing accuracy, but rather gaining
understanding.
Writing draft after draft of documents for publication, conference presentation and
thesis assisted me to develop further insights and refine my analysis. Re-writing early
drafts following feedback from others also helped me to identify problems in my
analysis and make explicit my assumptions. Though I did not impose my preconceived
categories emanating from my disciplinary background during analysis, I did attempt to
view these categories through the lens of my data to try to explain both any similarities
and differences in concepts. Occasionally, pre-existing concepts fitted with the data I
observed. I felt confused about this – was I imposing bias and forcing the data into pre-
existing categories? I returned to the grounded theory literature and found guidance
from Glaser and Strauss (1967):
The core categories can emerge in the sociologist’s mind from his reading, life
experiences, research and scholarship; [furthermore] no sociologist can possibly
erase from his mind all the theory he knows before he begins his research.
Indeed the trick is to line up what one takes as theoretically possible or probable
with what one is finding in the field. (p. 253)
Similarly, Charmaz (1990) addressed this issue explaining that “Should grounded
theorists apply such concepts and categories – even their own previous ones – to new
data, they must justify them” (p. 1170). Where pre-existing theories appeared to fit with
the data (see Section 10.6.1) I explained and justified their use. The following findings
chapters demonstrate the “line-up” between the data obtained from participants and
various theoretical interpretations that aid explanation and understanding.
7.9 The reflexive journey
7.9.1 Memo-writing
Through the process of memo-writing I explored emerging ideas regarding data
analysis, both free from my theoretical background and within it. The “on-going dialog
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with self” (Charmaz, 1990, p. 1169) that arose produced many of the questions and
ideas which led to the creation of key insights and conceptual understandings.
My memos also contained comments that I later recognised to be my own stance and
allowed me to monitor myself as a research tool. Re-reading these memos I was able to
observe tendencies towards “going native” (Liamputtong & Ezzy, 2005, p. 169) (i.e.,
losing all objectivity). I consequently came to understand the aspects of women’s lives
that I was most able to integrate myself within, as well as those I could not. The process
also provided me with space for reflexivity in which I could express my frustrations,
doubts and self-observations:
I think that I’ve been bogged down in analysis. I need to pull my head up for
some air. I’ve been too caught up in descriptive aspects of this topic and not
thinking conceptually. Yet if I allow myself to simply write, I realise the
conceptual links that are there. (Memo: 12 October, 2010)
Further examples of my reflexive reaction to the research process can be seen in the
following two memos:
I’m struggling with contact with the community and guilt – [name removed]
seemed disappointed that I won’t be able to visit her or conduct another group
interview with the women until October. I feel bad. Inevitably as data analysis
proceeds I have periods where I spend less time in the community. I feel guilty
about this. I’m conscious of how this could be perceived – as though I came and
took what I wanted and then I left. This isn’t the case from my perspective and it
isn’t my intention. (Memo: 28 August, 2010)
I’ve been thinking about bias. By virtue of the kind of research question or
general research aim I begin with I am imposing my stance on the research.
Because of my background in mental health I’m interested in emotional
wellbeing. I bring this focus to my research. If the Karen community were to be
contacted and offered a doctoral student or researcher from the School of Public
Health and Community Medicine who would conduct research into a topic of
their choosing for a period of three years would they choose to focus on
emotional health? No. I don’t think so. There are so many immediate pressing
needs of physical wellbeing impacting this community. Sometimes I feel guilty
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to have all these resources and then to come to them with my bias. (Memo: 4
November, 2010)
7.9.2 Learning patience and being honest
Liamputtong (2008) suggests that cross-cultural researchers must have (a) tolerance for
ambiguity, (b) patience, (c) adaptiveness, (d) capacity for tacit learning, (e) courtesy,
and (f) respect for cultural beliefs and practices (p. 5). Similarly, Schweitzer and Steel
(2008) emphasise the importance of establishing trusting relationships and a willingness
to flexibly adapt to the needs and cultural approaches of refugee participants.
Throughout the research process I found that I was challenged and called upon to
develop these skills and qualities many times. I was particularly challenged with regards
to patience as my participants were accustomed to a more casual pace of life and
subsequently meetings and appointment times were often delayed and, consequently,
went longer than expected. In respect for Karen cultural practices I had to be flexible in
my expectations and courteous in my responses. To develop good rapport with
participants and the broader community I accepted many invitations to share meals,
attend family events and partake in community activities. Like Liamputtong, I found
that accepting such invitations enhanced my relationships and also contributed to my
goals of conducting ethical research practices by respecting the cultural practices of
research participants.
Throughout the research process I had to be very careful to ensure that I was honest and
transparent in my role and capabilities as a researcher. I frequently had to reiterate that I
was unable to make any promises that my research would directly benefit any
individuals or the community in any way. Similarly, I was always careful not to
contribute to disempowerment or dependency and situated the Karen as experts on their
own experiences and culture. I had to be careful not to claim to have authority or expert
knowledge regarding how to solve the complex problems faced by the community.
7.9.3 Distance and the “other”
As I grappled with the ethics of my research I also encountered confronting concepts
and questions from postcolonial (Macleod & Bhatia, 2008) and feminist (Gergen, 2008)
literature. My research was borne from my observation and experience of the hegemony
of Western mental health knowledge during my time on the Thailand-Burma border.
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Although ethnic hostilities were present between the Karen and dominant Burman long
before their more recent colonial history, British colonisation also fuelled and created
further disharmony (see Section 3.2.1). Moreover, as for many other postcolonial
nations, Burma’s current civil war may be most recently traceable to ramifications of
neocolonial domination. All of these things bother(ed) me, and yet, here I was (a White,
middle-class, able-bodied and educated woman) effectively attempting to “capture” the
“other” and represent and interpret her experience(s). Western imperialism exists in my
research. Linguistic imperialism is also present. There are inevitably contradictions here
that I cannot fully resolve. I can only explicate them and in doing so attempt to be as
sensitive, humble and careful as possible in all aspects of my research.
Sparks and Park (2000) describe the ethical dilemmas faced by feminist cross-cultural
psychologists working with non-Western refugee and immigrant women as work at the
“border” (p. 203). They recommend researchers have (a) an understanding of cultural
context, (b) an awareness of oppressive forces in the Western context, (c) enhanced self-
awareness, and (d) a flexible approach to solution finding. Reinharz (1992) describes
the challenge as one of “confronting two competing sets of ethics – respect for women
and respect for culture” (p. 123) and acknowledges that there is no one correct way of
working through these complexities. These feminist perspectives were highly relevant
to my inquiry.
Throughout my research and especially during analysis and writing up I continued to
question my legitimacy in researching and writing about the cultural “other”. I was, and
remain, external to the Karen community. Potential benefits of an “outsider perspective”
(Liamputtong, 2010, p. 115) include the discovery of new perspectives due to the
researcher not taking for granted the assumptions of participants, and participants
feeling safer confiding in someone external to their community. Ultimately, debate
remains as to the limitations and advantages of insider-indigenous versus outsider
researchers (Banks, 1998; Liamputtong, 2010) and I cannot be sure whether Karen
women would have shared different information if I had been an indigenous researcher,
though I imagine they might have been more forthcoming with their complaints and
perhaps more transparent about political, gender and ethnic tensions.
Gender, education and age are further features and differences that may be important
influences in ethnographic fieldwork (Liamputtong & Ezzy, 2005). I believe that a
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shared gender was helpful in establishing rapport and interviewing Karen women about
their personal lives. Having high academic status can serve to create distance
(Liamputtong, 2010). However, I believe that my credentials were mostly reassuring to
the Karen who demonstrate a great respect for education and balanced the potentially
negative effects of my younger age. Other social class differences also differentiated me
from Karen refugee women participants. I tried to minimise these differences through
dressing in a tidy yet relaxed manner. I also comfortably participated in aspects of
women’s lives (e.g., meals and helping children) to reassure them of my ease in their
surroundings and I shared my own experiences and stories where appropriate in order to
relate our lives. However, I remained very conscious of my social position and the class
differences between us. After interviews I left women’s homes (which sometimes
lacked heating or appropriate ventilation and had broken windows or no curtains) in low
socioeconomic areas and proceeded to drive between one and two hours home to the
suburb where I lived (where such poverty is practically non-existent). As an outsider I
worried that I might misunderstand and therefore misrepresent Karen women. Again, I
could only take steps to minimise this potential.
7.9.4 Representation and voice
Through my interpretation and writing I hold a position of power and authority. With
this power come several ethical dilemmas including issues of voice and representation
as well as the potential political uses of the research findings and their effect on public
opinion and dialogue. I was acutely aware of the need to take great care. During
analysis and early writing I became concerned that rather than convey participants’
voices, they would rather lose their voice as I presented and then interpreted their
messages, and became the “speaker” of the knowledge gained. As Harrison (2003)
notes:
Knowledge and power are produced through the ethnographer’s methods of
organising and interpreting the data through a metaphorical structure where the
participant’s position is inevitably displaced by that of the ethnographer. (p.
102)
Liamputtong (2010) raises the question of how we can avoid marginalising our
participants in the process of writing. This issue is highly relevant to my research. She
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suggests staying “closer to their lived experiences and the true meanings of their
experiences” (p. 213).
Research rigour, including member checking, is crucial here but there is more that can
be done. I sought to be accountable and transparent in my writing and therefore
established a community meeting for people to hear and discuss my research findings.
In total approximately 25 people attended the meeting, including community leaders,
service providers and four of the ten women who participated in in-depth individual
interviews. I presented the research findings visually (using PowerPoint) and verbally
(with the assistance of an interpreter) and sought feedback from the audience. I also
provided stamped, self-addressed envelopes so people could provide anonymous
feedback. Finally, copies of the feedback presentation were made available in printed
and electronic format to the audience and other interested people.
The feedback obtained from this meeting was invaluable and provided a firm source of
rigour through member checking (see Section 6.7.4) thereby enhancing the
trustworthiness of this inquiry. At the conclusion of the presentation one community
leader stated that my description of the community and their strengths and weaknesses
“was like looking in a mirror” for him. Others provided anonymous written feedback
stating:
I personally believe that this research provided and explore[d] true accounts of
refugee women’s experiences and their struggle in the third-world country. The
comparison of Western and traditional means of coping with stress and “Tha Ta
Hsar” is valuable for the service providers to adequately help those that are in
need … You’ve mentioned very notable points in your presentation (research)
and I hope that these will one day be put in action. (Community leader –
anonymous written feedback)
I was also concerned with how to manage data that might portray the community in a
negative light and thus effect their reputation. In some ways potential effects are so
varied that they may not be foreseeable. However, researchers have a duty to anticipate
probable misuses and attempt to counteract the possibility of misuse (Liamputtong,
2009). For example, a penetrating analysis of refugee life in Australia may have
implications for public dialogue about asylum seekers, race relations, poverty and
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politics concerning refugee communities. Again an ethic of care must dictate how
researchers convey their research findings in public media. I kept these issues in mind
when writing and publishing material from the study and did not, for example, call
attention to issues of domestic violence, alcohol or gambling when these matters were
not relevant to the topic being explored.
7.9.5 “Conversations with Karen”: positively using researcher power and the
reflexive journey
Besides memo-writing, I found alternative ways to engage in reflexivity and process my
reaction to some of the sensitive information that participants shared with me. Some
women’s situations seemed quite helpless and I, in turn, experienced feelings of sadness
and frustration. Poetry, writing and art helped me to express my thoughts. I used various
art mediums including felt typography and cross-stitch as depicted in the following
image:
Image 4: Cross-stitch depicting quotation from interview with participant Mr W
During the production of these art works I read Liamputtong (2010) and Hartnett and
Engels (2005) who encourage researchers to use power and representation positively
and to access wider audiences in new and creative ways through forums and mediums
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such as photography, short stories, poetry, theatre and art (Hartnett & Engels, 2005;
Liamputtong, 2010; L. T. Smith, 1999). I was inspired to hold an art exhibition titled
“Conversations with Karen” to present the works and provide education about the
Karen people and their plight. The exhibition was held during Refugee Week 2011 and
the artworks depicted the struggles and strengths in the lives of Karen refugees. Further
details of the exhibition are presented in Appendix G.
Positive and unforeseen events arose from this exhibition. To an audience of
approximately eighty people, a young Karen woman opened the exhibition and shared
her experience of forced migration. Many in the audience cried, the young girl and her
mother were also moved by the experience and afterward expressed their desire to
engage in further opportunities to educate the Australian public about their lives. Media
advertising for the exhibition led a number of people to contact me and I was able to
create relationships between the Karen community and people interested in helping
them. Profits from the sale of artworks were donated to Karen women who then chose
to purchase materials for a craft group activity.
7.10 Ending the study
During the research I developed many strong and trusted relationships with some
community members. Cutliffe and Ramcharan (2002) discuss the importance of ending
these relationships sensitively, especially when working with vulnerable populations.
Similarly, Patton (2002) recommends developing a disengagement plan. I kept
community members updated about the progress of my research. During feedback
meetings I also explicitly explained that my study was coming to an end. However,
other than no longer collecting data, my social relationships with the Karen community
have not significantly changed. At the time of thesis submission my social involvement
and political advocacy for the Karen community had not ceased though it had shifted
from the many personal visits I undertook during data collection to attending large-scale
community events as well as meetings with community leaders.
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Chapter 8
“Starting at zero”: Women’s Problems and the Sources of Distress
8.1 Introduction
This chapter presents and discusses some of the findings related to the question: What
issues are perceived to affect distress and wellbeing of Karen refugee women? Multiple
issues over multiple phases of the refugee experience led to emotional distress for Karen
women. Layer-upon-layer of distressing circumstances marked their refugee journey
through pre-migration (flight), refugee camp (limbo) and post-migration resettlement.
Women described their experiences of distress within the daily challenges of
resettlement – adjusting to life Australia and “starting at zero”. This chapter explores
women’s daily stressors, grouped around the key themes of (a) language and
communication problems, (b) lack of environmental mastery, and (c) women’s
challenges. The chapter concludes by drawing together the findings and further
examining how women’s encounters with these daily stressors may be understood
against their broad sociocultural background and through the Karen experience of
persecution.
8.2 “The biggest barrier”: language and communication
I’m telling you … the language barrier is the most, the biggest challenge. (Karen key
informant – Ms S)
Participants unanimously described difficulty with English language proficiency and
communication as the “number one” problem affecting women’s wellbeing in Sydney.
For them, language was a universal barrier that obstructed access to all other domains of
resettlement, generating or exacerbating further resettlement challenges and
psychosocial difficulties. This finding is hardly surprising (Higgins, 2009) but the
compounding factors, additional difficulties generated by it and the significant impact
on emotional wellbeing are important matters. This section addresses practical
challenges as well as the gendered, social and cultural and factors that contribute to this
issue. These issues (a) contextualise language problems within the unique sociocultural
position of the Karen, and (b) suggest possible areas for change within service provision
and policy.
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8.2.1 Barriers to language education
Australia’s AMEP (see Section 4.4) provides eligible migrants and refugees with 510
hours of English language training. However, many women experienced multiple pre-
and post-migration barriers affecting their ability to access and benefit from AMEP
classes.
Pre-migration barriers
Many women had not received formal education in Burma and were unable to read or
write in their native tongue. Their pre-migration education opportunities had been
limited by the sociopolitical situation as well as gender role beliefs and practices
locating women’s roles within the home:
In our culture the woman looks after the kids and stays at home and because of that
you don’t have a chance to learn English … Most of the women have lived more than
ten years in the refugee camp and before we came to the camps we have been running
around in the jungle moving here and running there. Many women have not even had
a chance to learn to read and write Karen. (Key informant – Ms S)
Lack of pre-migration opportunities for education and literacy affects people’s ability to
learn English (Hou & Beiser, 2006; van Tubergen & Kalmijn, 2009) and adapt to the
Australian education system. Low literacy and education meant many Karen women
were unfamiliar with holding pens and unable to utilise Karen-English / English-Karen
dictionaries to assist with communication. These limitations hindered their ability to
succeed within the AMEP. Many also struggled to adapt to an alien and formal
education experience in an unfamiliar environment (e.g., classroom), requiring an
unfamiliar sitting position (e.g., sitting on chairs rather than on the floor) and interacting
with unfamiliar persons (e.g., teachers and fellow students). These issues are common
to refugee students with low literacy (Adult Migrant English Program Research Centre,
2006).
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Post-migration barriers5
Gendered barriers continued to affect women’s access to education after arriving in
Australia. Women struggled to attend to their own education needs whilst caring for
children, acting as full-time carers for elderly parents or in-laws, as well as managing
household finances, groceries and maintenance. Typical of women’s comments, Htòh
remarked:
I already completed 510 hours [at AMEP], now I need to look after my father-in-law.
He is elderly and can’t stay at home alone, he has medical problems. (Htòh)
Additional cultural factors further encumbered women’s ability to benefit from English
language education. English language teachers described their Karen students as
“polite” and “compliant”, and noted that they expressed great respect for authority.
However, these cultural traits and social interaction patterns also impeded women’s
education experiences and led to behaviour that did not foster learning. For example,
women’s respect for teachers, and anxieties about failure and authority figures, led
some of them to avoid class or copy homework when they thought they were not
succeeding or believed they had not adequately completed their assignment. Women
also appeared embarrassed to practise their English and key informants spoke of the
“shame” of speaking English inadequately. During ethnographic observation I
repeatedly encountered how these factors impeded their development of English
language skills. For example, I often experienced great difficulty building the
confidence and trust of Karen women to communicate or practise their spoken English
with me. Women’s shame may also be understood through Lebra’s (2010)
conceptualisation of the role of self, shame and embarrassment in collectivist societies.
Lebra argued that in collectivist societies the ideal self remains inconspicuous.
Consequently, when one is focused upon – such as when getting feedback from a
teacher or practising English with a native speaker – one feels (and is expected to
convey) embarrassment or shyness.
Teachers, particularly those who appeared to lack sufficient understanding of Karen
culture, became frustrated with their Karen students’ avoidant and unassertive
5 The findings also brought to light service provider limitations and barriers. These and other issues
related to service provisions are explored in Chapter 12.
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behaviour. The following quotation from an interview with an exasperated teacher
reflects these challenges:
Sometimes I think they are on a different planet, not with the classroom … They don’t
want to participate in group activities [with students from different cultural
backgrounds] … Sometimes I think I don’t want to waste my time or their time doing
this work because they are not going to be happy. (Key informant / teacher – Ms M)
Hofstede (2001) notes that such complaints are common of teachers from individualist
cultures who work with students from collectivist cultural contexts. Karen participants
further contextualised their social anxiety and lack of assertiveness within experiences
of (a) persecution, (b) protracted camp confinement eroding opportunities for
interaction with a broader world, and (c) gender roles limiting women’s opportunities
for interaction beyond the home environment. The latter is depicted in the following
quotation:
They are scared of people, how to talk to them, how to deal with them. Because some
women have been living in the kitchen for a long time they have no confidence in
dealing with people outside. (Mu Htòh)
Finally, for many women, access to (and interactions with) AMEP services were further
limited by age, physical illness and disease. For example, older participants were
unfamiliar with classroom chairs and described experiencing physical discomfort. Key
informants reported that some parents and older refugees resigned themselves to
minimal or mediocre levels of educational and occupational achievement but
encouraged and expected their children to forge ahead in these domains. These findings
resonate with research that documents high unemployment and low education amongst
first generation humanitarian entrants, but higher than national average levels of tertiary
education and employment amongst the second generation (DIAC, 2011a).
8.2.2 Barriers to communication
Language and communication problems complicated resettlement through exacerbating
women’s difficulties navigating unfamiliar and complex social, legal, educational and
governmental systems and structures. Consequently, women felt confused, stressed,
isolated and helpless to the point that some, like Ta Heh Sōo, wanted to “go back to the
refugee camp” because they “can’t communicate” or “do anything” in Australia.
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Written correspondence from service providers was problematic for women, as most
were unable to read English adequately and consequently relied on translation help from
children, friends and community leaders. Staff at refugee support services also
frequently assisted with written correspondence, especially in situations that had
escalated into late payment fees and legal problems. A few women were proactive and
self-sufficient in resolving written communication challenges and used English-Karen
dictionaries to decipher letters from service providers. These women had received some
pre-migration education, were able to read Karen and were consequently more
confident about their English language skills.
Some social services depended heavily on telephone communication but did not use
interpreters. Women struggled to communicate with English speakers and often hung up
or relied on their children to interpret. In addition, the telephone was an unfamiliar
object of daily use for many women, especially older women whose lives had been
primarily village and refugee camp-based. Some service providers sought to
communicate with Karen women through interpreters but were often unsuccessful in
securing one due to unavailability. When attending services, Karen women were also
often assigned an interpreter who did not speak their language (e.g., a speaker of
Burmese). Moreover, women’s cultural communication patterns, shyness and mistrust
further obstructed face-to-face encounters with service providers and interpreters. These
factors compounded language and communication problems and were a source of stress
for women. This raises the issues of service provider oversight and limitations (see
Chapter 12).
8.3 “Everything is new”: lack of environmental mastery
For Karen women “everything is new” in Australia, the physical environment, the
culture, as well as the political and legal system. Not having implicit knowledge of the
Australian way of life, these women faced enormous challenges and “culture shock”, as
vividly portrayed by a key informant:
They came from the villages, get displaced, along the line they have a series of losses,
loss of husband, there are a lot of stories like that, people killed by landmines. They
lose children through malaria infection and having to wait in the refugee camps. Some
people spent about ten years in uncertainty not knowing where to go … During the
refugee period there is a lot of anxiety. And they are coming here unprepared. That’s
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what I find. Vast differences between the cultures. Culture shock is there, more so
than for some other groups. Because they come here really, really unprepared, not
informed of the legal system, welfare system, medical system, service delivery, their
rights, you know, all those things. They end up having to fill out a lot of forms,
Centrelink, housing, imagine all those things. Because of the knowledge gap, they
don’t speak the language. So they struggle, they struggle … So, looking at the
problems they’re facing here I will look at a very obvious area – the vast difference
between their life over there and getting resettled in a new country like metropolitan,
sophisticated, multicultural society like Australia with its complexities. (Key
informant – Dr F)
Women’s accounts confirmed that they struggled to master life in Australia. Besides
language and communication difficulties, they reported being most significantly
distressed by problems with (un)employment, transport, poverty and parenting in a new
cultural context. Their resettlement challenges seem to arise from what has been
described in the literature as “lack of environmental mastery” (Khawaja, White,
Schweitzer, & Greenslade, 2008, p. 493). In employing this phrase I wish to locate the
problems experienced within the Australian context and not within Karen individuals or
communities who may indeed lack mastery of life in metropolitan Sydney, but who
unquestionably mastered the skills necessary for survival in Burma and in refugee
camps.
8.3.1 Mastering space: fear of freedom
I think giving them the freedom to move is also restricting them and making them feel
insecure as well. (Karen key informant – Ms K)
Many women lacked environmental mastery of functioning in sizeable physical space
and experienced anxiety about (a) their distance from other Karen community members,
and (b) their “freedom to move”. Separation and distance from other Karen community
members greatly increased the distress experienced by new arrivals. Upon arrival in
Australia some women were sent to temporary accommodation in Mount Druitt –
approximately 30 kilometres away from the Sydney Karen community hub around
Guildford, Yennora and Fairfield. In another instance, two single mothers travelled to
Australia together but were then placed in separate accommodation suburbs apart. The
women had hoped to support one another through resettlement and described fearing for
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their safety and security when they were separated. In the following quotation, a Karen
key informant, Ms S, employs a Karen proverb to emphasise the importance of close
physical proximity to the Karen community:
You know, in Karen language, we say “You never live alone because if the enemy
wants to attack you they can easily swallow you, but if you stay together, no one can
come and destroy you”. (Key informant – Ms S)
This proverb contextualises the experience of separation and distress within a
sociopolitical history characterised by continual persecution. Many women also
struggled to adapt to their newfound freedom and had difficulty adjusting to an
unrestricted and unfamiliar physical environment. This struggle is clearly reflected in
the following quotation from an interview with Ms K, a Karen key informant:
Here it’s like open space. You don’t know who your neighbour is. You don’t know
whether someone will help you or not if something happens, how can you find
support? … Even though in the camp you don’t have a lot of space, you are cramped
in together but you still feel that your neighbour next door is there and they will hear
you [if you need help]. (Key informant – Ms K)
As Ms K suggested, these issues must be contextualised within women’s refugee
experiences of conflict and restrictive camp environments. During conflict, being
caught in an unfamiliar environment could be a dangerous situation. As we saw in
Chapter 3, being caught outside a refugee camp in Thailand could be equally dangerous.
After years or even decades in camps with up to 37,000 people restricted to a maximum
land-space of 4km2 (Thailand Burma Border Consortium, 2010b), unfamiliar and open
space in Australia appeared to provoke what I call a “fear of freedom”. Interestingly,
when I used this expression with Karen women they enthusiastically concurred with my
understanding and formulation of the phrase. Many women also expressed a desire to
overcome this fear. For example, during a group interview, women reported that they
were aware they were living within their “comfort zone” and desired to “get to know
what is happening in the outside world”. They explained that their children were able to
have contact with the outside world and interact with Australians of various ethnic
backgrounds at school but lamented that their own lives were more limited.
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8.3.2 (Un)employment
Overwhelmingly Karen women wanted and felt obliged to work but were held back by
the language barrier and their lack of work experience. This is clearly reflected in
Htòh’s words:
We need to work but on the other hand we can’t speak, we can’t communicate with
others – how can we get a job? Since we came here the government has looked after
us very well. We know we have to work, we have to do something to give back to the
government, but we can’t speak or communicate with others, this is the problem.
Language is not learned overnight. (Htòh)
The language barrier also affected women’s ability to interact effectively with staff at
Job Services Australia (the network of organisations contracted by the Department of
Education, Employment and Workplace Relations to help jobseekers find employment).
The following quotation describes a typical encounter with Job Services Australia and
the emotional impact on Karen women:
Every day [the Job Services Australia staff] provided me with the newspaper
advertisement and I had to call up for any job I could see. I tried, with whatever
knowledge I had, but when people answered I couldn’t really understand what they
were saying and when I asked about the job, they said “No job available”. One day
one of the managers asked me, “Are you sure you really looked for a job?” and I said
“Yes, here are all the numbers I called”. Then he called the numbers to check whether
I told him the truth and yes, it was true. Then he told me “You know, my mother
couldn’t speak much English when she came here, she couldn’t really speak at all, but
she was able to get a job, how come you can’t get a job?” I was so upset and hurt by
this. (Htee Gloh)
Htee Gloh requested help of a counselling service and a staff member there
communicated with Job Services Australia on her behalf. However, later on, she and her
husband chose to forgo receiving financial assistance to which they were entitled
through Centrelink in order to avoid further interactions with Job Services Australia. As
a result, their family of four relied on the limited and sporadic work income of Htee
Gloh’s husband to support the household.
For many women, negative interactions with Job Services Australia staff members
compounded the emotional impact of repeated failures at attempts to gain employment.
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Key informants, when asked about this issue, tried to balance the perspectives of both
sides. For example, Mr P, a Karen key informant reported:
I have been an interpreter at those interviews, [the Job Services Australia staff
members are] not too friendly but they are doing their job, their duty … that’s their
obligation. (Key informant – Mr P)
Community leaders also identified Karen women’s lack of experience with the demands
of a competitive individualistic employment environment as a problem. Moreover, like
other refugee communities in Australia (Colic-Peisker & Tilbury, 2007; Refugee
Council of Australia, 2010), they faced obstacles having their pre-migration
qualifications and skills recognised. Most lacked official documents evidencing their
qualifications. Key informants explained that qualified community members were
generally unable to afford the cost, and time, of university bridging courses whilst also
needing to support their families. Consequently, and consistent with a recent Australian
report (DIAC, 2011a), there were unemployed and under-employed nurses, doctors,
teachers, musicians and engineers within the community.
In a group interview Karen women visually depicted their feelings in relation to job
seeking and interacting with staff at Job Services Australia (see Image 5). The image
clearly reflected the immense emotional impact of (un)employment related difficulties.
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Image 5: Karen women’s visual depiction of the emotional impact of (un)employment
and interactions with Job Services Australia
The following explanation, offered by a speaker for the group, calls attention to both the
individual and collective impact of women’s (un)employment-related stress:
This picture is about individual stress. You came here and you need to look for a job
but you can’t get it because you come from an uneducated background. And you have
to attend a meeting [with Job Services Australia] every fortnight. You feel stressed.
You feel pressured. Some feel traumatised by this. It also impacts on the family, on
the children because the parents have to attend all these appointments [with Job
Services Australia]. It’s not only one person’s problem, it becomes the whole family’s
problem. The whole family becomes unhappy. Also, it puts pressure on the
community leaders because they need to help you to find a job … The colour
represents the sun it is very hot – it’s about heat. And not one sun – three suns! You
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feel pressure, sometimes you not only feel numb, you feel blank – although someone
is talking to you, you don’t listen, you just feel blank. (Participant in Group D)
Participants’ accounts of (un)employment-related problems were marked by fear,
failure and frustration. Women feared the consequences of unemployment and worried
“what will happen if we can’t get a job?”. Their stress was so great that some wanted to
“return to living in the refugee camp”. Again, key informants conceptualised women’s
fear within cultural attitudes towards authority as well as the experience of persecution.
Furthermore, women’s employment-related fear and stress was also conceptualised
within gender role practices that limited women’s opportunities for work and
interactions outside the home. Consequently, women lacked experience interacting with
officials or government agencies.
8.3.3 Financial hardship
What we get in income and our expenses becomes equal, so no extra money. (Mëh
Luh)
Financial hardship and lack of knowledge about financial systems was a major source of
stress for Karen women. Women’s accounts of their financial problems were related to
language and communication problems, their husband’s behaviours and their concern
for family left behind.
Like most stressors, financial difficulties were related to language and communication
problems as well as lack of experience. With few banks and virtually no automatic teller
machines in rural Burma (and certainly none inside refugee camps), many Karen
women had never used these kinds of financial systems. Their unfamiliarity led to
confusion and presented practical problems such as difficulty accessing money. For
example, Ms S, a Karen key informant reported: “they put it in the bank but they don’t
know how to take out the money”. Similarly, Pàw Lèh explained: “we don’t know our
PIN. In the bank there are withdrawals, enquiries and balances – we don’t know which
one to press”. Women were also stressed as a result of their unfamiliarity with
managing a budget and paying for services such as electricity, water and telephones.
Basic budgeting tips and example budgeting forms were available from HSS case
managers in addition to services and one-off seminars arranged by various other service
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providers such as Migrant Resource Centres. However, many women desired to learn
more about financial matters.
Participants described struggling to afford their basic needs including housing, food and
electricity, as well as paying for children’s school books. Most reported that if they
“planned well” they were able to adequately feed their families. Echoing findings from
a food security study of refugees in Australia (Gallegos, Ellies, & Wright, 2008), others
raised food security concerns and reported that they sometimes lacked enough food to
feed their family. During the course of this study, the Karen community were provided
with a community garden plot through Haven Australia – a consortium of refugee and
other social service organisations (Cachia, Zu, Chahola, & Meale, 2010) – but no
participants reported having accessed food through this channel.
Several women reported their financial hardships were worsened by their husbands’
alcohol and gambling problems. These findings add to literature documenting
disordered gambling amongst resettled refugees from South East Asia (Centre for
Culture, Ethnicity and Health, 2008; G. N. Marshall, Schell, Elliott, Berthold, & Chun,
2005; Petry, Armentano, Kuoch, Norinth, & Smith, 2003). Women attempted to assert
their family’s financial rights and developed strategies to control the budget (including
hiding credit cards). However, they inevitably felt unable to address their problems. Key
informants and service providers were also aware of gambling problems within the
community but noted that it was largely a hidden problem. They expressed concern that
Karen men were being introduced to poker machines and beginning to gamble at
younger ages.
Furthering their financial difficulties, women described regularly sending money to
friends and family left behind in Burma and in the refugee camps. Homeland remittance
is common amongst refugee communities (Refugee Council of Australia, 2010) and,
according to the World Bank (2011), outward remittances from Australia totalled US$3
billion in 2009. Brees (2010) has described this practice as one way resettled refugees
can meet their expected obligations within a collectivist culture. Similarly, in the
following interview quotation, Ms L, a Karen key informants, describes the cultural
context surrounding homeland remittance amongst the Karen:
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We are always sending financial [support] back home, there is never enough money
… With the [Australian] government, [family means] immediate family, like your son.
But with us, [family means] extended family … Everybody that comes here is using
some of their income to send money back there … For them to have their mental
balance, they need to know that their family members back home are okay. So the way
to address that is to send money, but it makes a big financial hole here when most of
them are in debt. (Key informant – Ms L)
Concern for loved ones left behind in the homeland is commonly associated with
psychological distress including stress and depression amongst refugees (Atwell,
Gifford, & McDonald-Wilmsen, 2009; Schweitzer, Melville, Steel, & Lacherez, 2006).
In this study Karen women desired to help others but also described feeling guilty if
they did not share their relative good fortune with their extended family. It appeared that
most were more distressed and concerned for those left behind than they were by their
own financial hardship and poverty in Australia.
Women developed strategies to survive and described borrowing money from friends to
pay bills, as well as seeking assistance from service providers such as Migrant Resource
Centres. However, they also spoke of the shame of poverty and expressed their unease
and reluctance to burden others with their difficulties.
8.3.4 Housing
Why does Australia continue to take refugees if there is not enough housing and jobs
available? (Karen key informant – Ms A)
Women described housing and tenancy problems as a significant source of stress. Like
other refugee communities in Australia (DIAC, 2011q; Ernst & Young, 2011; Higgins,
2009), they experienced problems with (a) availability of affordable and appropriate
housing, (b) increasing rental costs, (c) difficult landlord-tenant relationships including
landlords failing to meet necessary home maintenance obligations, and (d) poor
understanding of rights, responsibilities and laws in relation to tenancy and debt,
resulting in worry and fear of persecution. A further issue in relation to housing was the
Karens’ wish to live in close proximity to other Karen families (see Section 8.3.1).
The scarcity of appropriate and affordable housing resulted in Karen refugees accepting
unsuitable (e.g., barely affordable, old and dirty) rental properties and frequent property
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shifts, which often entailed further challenges such as children’s school changes.
Participant observation and interviews revealed women living in homes without
adequate insulation or heating and with holes in walls. Some participants attributed their
health problems (e.g., colds and headaches) to living in unsuitable, old and damp
homes.
Housing concerns impacted women’s mental or emotional wellbeing in multiple ways.
Most women feared homelessness and felt uncertain about their future ability to afford
housing. Their lack of environmental mastery in relation to language, tenancy laws and
practices also resulted in worry and fear of persecution. This scenario is conveyed in the
following quotation from an interview with a young Karen woman:
The number one problem is that you can’t communicate – you can’t discuss issues
with your landlord. So you might be scared that this landlord might come back
anytime to kill you or might hire someone to kill you. Even when you walk on the
street you might think, oh, my landlord might hire someone to attack me. (Participant
in Group B)
This quotation captures an extreme example of fear that can be contextualised within (a)
the broader problems of the language barrier and associated communication difficulties,
(b) culture shock and lack of knowledge with complex new social and legal systems,
and (c) fear of authority caused by pre-migration experiences. Accommodation
difficulties, like other social problems, created a reliance and burden upon community
leaders for advocacy and practical assistance. During the course of this research Karen
community leaders formed the Karen Community Housing Cooperative Limited (2011)
to address some of these issues and within a year ninety-five families had registered to
receive assistance.
No hot water in the jungle
Women also reported experiencing difficulties with housekeeping and managing the
family home – gender role responsibilities that they retained in the Australian context
(see Section 8.4.1). Many housekeeping problems were entwined with the language
barrier. For example, women were unable to read product labels or instructions and felt
burdened by the task of communicating with shopkeepers. In addition, most women
were unfamiliar with home appliances and other technology and had difficulty using
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household items. The following quotation from an interview with Ms C, a Karen key
informant and service provider, describes some of the many new household items and
practices women encountered in Australia:
We [HSS case managers] teach them how to use and eat things … They are provided
with some rice but we have to teach them how to cook it here, it’s a different way …
We have to teach them how to use cleaning products like floor cleaning, glass
cleaning, toilet and dishwashing. Because in the camp they didn’t have to take care of
this. We have to teach them how to use the water. Here they have cold and hot water –
in the jungle no hot water. (Key informant – Ms C)
8.3.5 Transport
Transport problems were another source of stress for Karen women. Their transport
difficulties were largely underpinned by factors already identified in this chapter, most
notably language and communication limitations, lack of familiarity or environmental
mastery, as well as shyness and fear of freedom. For example, women had difficulty
reading and understanding transport timetables as well as communicating with public
transport staff. They were also worried about getting lost in an unfamiliar environment.
Service providers also bemoaned the physical distance between the community and
some service provider facilities. They reported that transport problems hindered
community involvement with programs and interventions.
HSS case managers demonstrated the use of public transport during refugees’ first few
months of resettlement but many women still lacked the skills and confidence to do so
on their own. It is possible that newly arrived refugee groups such as the Karen could
experience anxiety and difficulty in relation to transport and travel due to a different
spatial ontology. Cognitive conceptualisations of route directions are variable (Richter
& Klippel, 2007). According to Hallowell (2010), one’s “spatiotemporal frame of
reference” (p. 35) is oriented by culture. It seems conceivable that Karen women from
rural Burma might hold cognitive spatial maps vastly different from those employed by
urban Australians.
A minority of women proactively addressed transport problems. These women sought
opportunities to practise using the public transport system and overcome their worries
about communication and getting lost. For example, Htee Gloh Poh reported:
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For us it is fine to travel by bus and train. Anywhere within Sydney, I can go
anywhere by train! I try to go everywhere so that I can know places. When people go
to the hospital or something by train I just go with them because I want to know how
to go everywhere by public transport. (Htee Gloh Poh)
Women like Htee Gloh Poh appeared to experience a sense of mastery from their
achievements and other women often requested their assistance. These women were
lucky to have had pre-migration literacy which had enabled them to make use of maps
and take detailed notes when travelling with their HSS case managers. In contrast,
others felt that they required greater support from HSS case managers to learn the skills
necessary for using public transport.
8.3.6 Health
Like other refugee communities (Higgins, 2009; A. Wilson, Renzaho, McCabe, &
Swinburn, 2010), the Karen were troubled by health problems particularly chronic
diseases such as diabetes and high cholesterol. Communication problems and lack of
familiarity with medical services and treatments compounded their health-related
difficulties and women expressed a desire to learn more about preventing and managing
illness and disease in the Australian context. Karen women did not appear to utilise the
free New South Wales Refugee Health Service general practitioner (GP) clinics as, at
the time of this research, refugee women from Burma only comprised between 1.1%
and 2.5% of patients attending the various clinic locations (H. Corner, personal
communication, 13 January, 2010). However, they did attend and actively participate in
health information sessions specifically created for them. For example, during the
course of research (February 2010) I was a participant observer during a sexual health
workshop co-hosted by the New South Wales Refugee Health Service and the Hills
Holroyd Parramatta Migrant Resource Centre, and facilitated by a staff member from
the Family Planning Association (assisted by an interpreter).
8.3.7 Parenting
All Karen participants spoke of the tremendous difficulty they experienced parenting in
the Australian context. Like other stressors explored in this chapter, women’s parenting
difficulties are shared by other refugee communities in Australia (Lewig, Arney, &
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Salveron, 2010) and were entwined with language and communication barriers, as well
as cultural issues.
The language barrier meant parents were unable to assist and monitor their children’s
progress at school, resulting in women feeling “frustrated” and “useless”. Women also
felt their authority slip away due to their growing dependence on their children and
often relied upon them to interpret at health and social service appointments. Some
children intentionally manipulated their parents’ dependency and, for example,
misinformed organisations (including schools) who attempted to contact their non-
English-speaking parents by phone. Equally, parental dependence was also detrimental
to children who occasionally missed school to accompany their parents to appointments.
Key informants prioritised parenting problems as central to Karen women’s distress.
The following quotation from an interview with Dr F, a key informant, illustrates
clearly the psychological implications of parenting problems, including feeling useless
and loss of identity:
Even though she was illiterate in Thailand she could look after [her children] and
manage her own money. Here the children learnt English very quickly. Now the
money is controlled by the son because she doesn’t know how to go to the bank, use
credit cards, withdraw the money and things like that. Her 18-year-old son is not too
bad but he does not explain things to her in a compassionate way. Her complaint is
that she feels useless. She doesn’t even know how much money she’s got. She’s got a
benefit – she knows that. The son will give her the money for the day. She doesn’t
trust the son, so that’s a problem. A social worker should be involved and she should
be given information, training. I tried to empower her in that area … [She had a] loss
of identity, needed to be empowered as a mother. (Key informant – Dr F)
Most Karen women came from collectivist, village-based communities where they had
enjoyed the benefits of collectivist childcare (whereby their children were watched and
cared for by numerous adults and older children) (see Section 3.3.2) and were
unfamiliar with monitoring the activities of all of their children at any one time. In
Australia they reported struggling to understand and follow vastly different childcare
practices and laws. In one instance, child protection services were notified when a
Karen child was injured whilst cooking unsupervised at home. The mother had been
unaware of her legal parenting responsibilities in Australia. In the refugee camp her
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children were frequently unsupervised and capable of cooking. Community Services
was the local government agency responsible for addressing the safety and wellbeing of
children. According to their website, they provided information about childcare and
explained Australian rules regarding child abuse in seventeen languages excluding
Burmese and Karen (New South Wales Department of Community Services, n.d.).
Karen cultural approaches to parenting were further challenged by older children who
were quick to adopt some Australian cultural values and attitudes leading to cultural
generation gaps and family tension. Intergenerational conflict due to mismatched
expectations and cultural dissonance has been frequently identified in migrant and
refugee communities (McMichael, Gifford, & Correa-Velez, 2011; Merali, 2004; P. V.
Nguyen, 2008). In Western society, adolescent challenges against parental authority are
viewed as a normative aspect of development (Allison, 2000; Bongers, Koot, van der
Ende, & Verhust, 2003). However, within their Karen community, such behaviour was
deemed unacceptable. Karen parents frequently lamented that their children were
abusing their new-found freedom and safety in Australia:
The teenagers are another problem … they see freedom. I see it like a freedom of
speech, a freedom of the mind. They see it as a freedom to do anything you want to do
– mess yourself. (Key informant – Ms L)
These findings parallel those of Atwell and colleagues (2009) who conducted
qualitative interviews with refugee families in Melbourne, Australia. Parents in Atwell
et al.’s study spoke of young people misunderstanding the meaning of freedom and
using the term to excuse themselves of family and cultural expectations and behave
improperly. In my study, parents and community leaders feared that Karen children
might neglect their cultural values, language and family responsibilities. As reflected in
the quotation below, their concerns also reflected differences between individualistic
and collectivist cultural values (Hofstede, 2001):
My concern is that they might follow the world, that is my concern. When I say the
world, [I mean] this world based on self. All about self, self, self, self, self, self. And
other things happen because of this self. This is my concern, their spirituality … It’s a
part of individualism: “I don’t care, I have a right to do”, that sort of thing – self. For
example, back home, whatever we do we think “I might make my family lose face, or
my nation, or my tribe”. We have that kind of etiquette. (Key informant – Mr M)
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Mothers also expressed astonishment about the sexual health education provided at
Australian schools:
When they are in high school they teach them about sexual relationships … They
come home and say they have a project to do about this, as a mother we feel shy … At
their age we never knew [about that]. Some people in Burma graduate from university
without knowing about this. Asians are very private about this. I said “How come the
school taught you all this?” … Is it part of syllabus? (Htee Gloh Poh)
Karen women’s concerns about sex education reflected in the above quotation signalled
their own pre-migration experiences and cultural beliefs. Their concerns are
contextualised by a recent study of Karen women’s reproductive health experiences.
Ussher et al. (2011) interviewed Karen women in Sydney and found that the majority
“had no knowledge about coital sex before their wedding night” (p. 6).
Karen adults were also concerned about the myriad of distractions and “immoral” “un-
Christian” temptations (such as alcohol, gambling and media laden with sexual and
violent imagery) available to children in Australia’s technologically advanced multi-
media culture. Parents also appeared to lack the necessary experience, skills and
confidence to effectively negotiate with their children in relation to new activities and
distractions such as television, mobile phones and money. Moreover, poverty and
welfare-dependency created circumstances where parents had little financial power over
their adolescent children. In some families children demanded full access to their
portion of the family Centrelink allowance. Mothers were unsure about their rights and
responsibilities in relation to their children’s allowances and described feeling “useless”
as parents; some even regretted bringing their children to Australia.
Women stated that their parenting problems were compounded by Australian laws and
“children’s rights”, which they perceived were opposed to their parental authority. They
explained that in Burma absolute obedience and respect for all elders was expected and
enforced. Talking back or arguing with parents or other adults was not tolerated.
Physical force was not condoned as a first solution to children’s disobedience but was
used if deemed necessary, with no social or legal ramifications for parents. Many
parents lamented Australian children’s rights and legal restrictions against physical
punishment and felt unable to discipline their children effectively. Parents’ problems
were compounded by their lack of knowledge about Australian parenting laws. Most
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were frustrated, confused and nervous about parenting in this context and struggled to
access parenting information and advice. In contrast, their children were given
information about children’s rights at school. As a result, some children confidently
asserted their rights to their bemused and confused parents, resulting in family conflict
and occasionally intervention from the police and justice system. The following
quotation from an interview with a Karen key informant highlights this troubling
scenario:
[Karen mothers occasionally smack or hit their children] … Initially the children will
not inform the police but when they grow up – maybe twelve, thirteen or fourteen –
they challenge: “Mum, don’t do that again, I will call 000, you will be in trouble” …
Burmese and Karen mothers give excuses like “I had you, I look after you, I take care
of you, why are you challenging me? I got a lot of worries about you because of your
attitude and your behaviour. Your response is quite rude. I’m a responsible person, a
responsible mother to teach you not to do that. That’s the reason I beat you. I will beat
you again if you call the police. I will go to the police station, I can go to the court, I
can go to the jail. It doesn’t matter. Mothers never surrender, never give up”. (Key
informant – Mr J)
8.4 “Power struggles”: gender role changes and women’s wellbeing
Participants explained that new gendered opportunities in Australia created (a) tension
within women (and men) themselves as they struggled with their options,
responsibilities and decisions, and (b) “power struggles” within couples, families and
communities as they adapted to Australian gender role beliefs and practices. Most
women (and men) struggled to strike a delicate balance between Karen and Australian
cultural values and, in some cases, gender role conflicts led to domestic violence.
Most Karen women did not complain about gender politics or the status of women
within their community. However, a number of key informants, including Karen men
and women, raised this topic and reported that Karen women were subjugated within a
patriarchal social structure. For example, Ms R, a Karen key informant, reported that
some Karen men “speak softly and they say they love their women but they tell them
what to do and don’t let them make decisions”. Ms R recalled an instance in a refugee
camp in which Karen elders (all men) complained about humanitarian organisations
who were providing information about “women’s rights”. The elders argued that such
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education dishonoured traditional customs. Ms R believed that such patriarchal attitudes
continued (though to a lesser degree) within the Karen community in Australia. She
reported that despite the presence of women’s groups and organisations, community-
level decision-making remained largely controlled by a small group of men. As an
outspoken, educated and political woman Ms R represented a minority of the Karen
women interviewed. Most participants felt that their rights as women were well
respected in Australia. However, a number of other Karen key informants corroborated
Ms R’s perspective and my ethnographic observations supported her views regarding
community decision-making. For example, I dealt almost exclusively with Karen men
when formally meeting with the community leaders whilst setting up this study.
In this discussion of gender relations and hierarchies I am particularly aware of walking
in a cross-cultural borderland. It should be borne in mind that I do not see Karen
women’s position “as a unidirectional, linear process, from ‘traditional’ women who
lack ‘freedom and control’ to ‘modern, autonomous women”(Mumtaz & Salway, 2009,
p. 1354). Rather, I have aimed to present and explore the complexities of Karen
women’s gendered lives and the post-migration challenges of renegotiating gender
roles.
8.4.1 “Too much responsibility”: increasing pressures on women
Many women were positive about their new opportunities for education and
employment in Australia, while others met them with a certain bemusement. However,
like other resettled refugee women (Kaplan & Webster, 2003; Tankink & Richters,
2007), most lamented that their gender role demands had increased post-migration
where, in addition to their new roles and demands outside of the home, they continued
their traditional roles as housekeepers and carers. Like Htee Gloh, many reported
feeling stressed and upset by these pressures:
You must study full time, five days per week from nine until two, as well as show Job
Services Australia that you are looking for a job. You also need to look after the
children and do the housework. It’s too much pressure, I even cried, I can’t take it. It’s
too much for me. (Htee Gloh)
In the face of increasing responsibilities some women also described feeling
unappreciated by their families. For single mothers, the daily stressors and parental
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difficulties described in this chapter were compounded. As Hpä Hpaw Mu exclaimed:
“you have to do everything by yourself”. In addition, single mothers described their
children’s behaviour and obedience as worsening in the absence of a father figure. Their
adolescent children no longer listened to them and mothers described feeling “useless”.
Women also faced additional gender role pressures from the Karen community.
Participants reported that some of the older women disparaged the Australian cultural
way in which they saw “women competing with men”. Younger women who embraced
Australian cultural values and stepped outside traditional boundaries were sometimes
met with gossip and scorn from other community members.
8.4.2 “Not enough responsibility”: men’s experience of gender role changes
Participants explained that Karen men struggled with a loss of identity as a result of
gender role changes in Australia and the resulting power struggle was viewed as a key
cause of domestic violence:
The interesting thing is, for the girls, once they arrive here, most experience this
complete role reversal in their marriage and relationship. Back home in Burma, most
girls are expected to have a housewife role. But here, the circumstances push you to
go out, learn and earn. Their confidence level somehow gets higher and higher. It’s
really encouraging and that’s the trend we are seeing. At the same time, marital
discord and domestic violence rates are on the rise … It has a huge impact on some
families. We have domestic violence cases because of this role reversal. The girls
become more assertive and more confident. So in order to hold onto their ego and to
exercise power and control, some men start to react violently and use physical force.
(Key informant – Dr V)
A Karen man concurred with Dr V:
When they come here the language changes, the world view changes, the women here
have more rights so that’s different to the [Karen] man’s view of the world … When
the man is feeling like his identity is affected then his anger is difficult to control.
(Key informant – Mr H)
These findings parallel those of Tankink and Richters (2007) who found that post-
migration changes to the gender roles amongst Dinka refugees in the Netherlands led to
domestic violence. Karen key informants also traced men’s loss of responsibility and
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identity to pre-migration experiences and protracted camp confinement. Protecting and
providing for his family and community had marked a Karen man’s role. For many
men, their experiences were characterised by repeated failures in fulfilling this identity
role. They may have failed to protect their land, livestock and village. They may have
failed to protect their wives, sisters, mothers and daughters from rape. In the camps
many had failed again and become dependent on camp authorities. In contrast, it
appeared that within the limitations and conditions of the camps, women were still able
to be relatively effectual mothers and homemakers to the extent that their usefulness and
gender role identity had remained somewhat intact.
8.4.3 Domestic violence
Many Karen participants appeared uncomfortable discussing the topic of domestic
violence. This is not surprising for many reasons including (a) the sensitive nature of the
topic, (b) cultural expectations and customs, (c) mistrust, (d) perceived authority and
power imbalance during interviews, and (d) concern for community credibility.
Consequently, it was difficult to get first-hand accounts of domestic violence.
All Karen women interviewed denied first-hand experience of domestic violence in
Australia (one spoke of experiencing domestic violence in Burma and Thailand) and yet
most reported that it was an issue for “other women” in their community. According to
key informants, instances of domestic violence within the Karen community in
Australia included forced isolation, restricted access to money, verbal abuse, threats of
violence (e.g., “threatening, I will kill you”) and physical assault resulting in broken
bones. Though by far most instances of domestic violence described by participants
involved male perpetrators, one instance of a female perpetrator was also reported.
One Karen woman, who was also a key informant, readily described various forms of
gender-based violence within the Karen community but emphasised that non-physical
forms (e.g., men controlling finances and decision-making) were more common. She
also reported that Karen women were socialised to believe that a “good Christian wife”
must “never refuse” her husband’s sexual advances. These reports are corroborated by
the findings of the recent reproductive health study conducted with Karen women in
Sydney. The researchers reported that Karen women said they were able to refuse sex
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but also that they were “expected” to have sex when their husbands wanted to (Ussher
et al., 2011, p. 7).
Some women and service providers denied or minimised domestic violence issues. In
the following interview quotation Ms S, a Karen key informant, confirmed the presence
of domestic violence in the refugee camps but denied that it occurred in Australia. I was
later told that Ms S was herself romantically involved with an abusive partner.
There is no violence. And especially I heard that here men cannot hit the women and
you cannot slap or hit or torture your wife. But there [in Burma], I tell you, men can
be the king in the house and they can abuse the wife, the children, whatever –
especially when they’re drunk. But when they come to Australia, they’ve been told
that it’s unacceptable and they don’t do it. (Key informant – Ms S)
Key informants described a traditional cultural context in which domestic violence was
not considered “a legal issue or social problem”. Shame and stigma – noted features of
collectivist societies (Hofstede, 2001) – also appeared to contribute to a culture of
silence and victim-blaming surrounding domestic violence amongst the Karen.
If a woman had been sexually harassed or assaulted, she doesn’t want to mention
those things over here so she blocks those things out. We call it denial, they call it
blocking out. So I would say sexual harassment and sexual abuse either by outsiders
or within the family is underreported that’s for sure. It’s a very judgmental society and
even if its not the women’s fault society tends to point a finger “Well you must have
encouraged him” or “You didn’t fight hard enough” – something like that. The poor
woman cops it all the time. (Key informant – Dr G)
Australian social and legal systems related to domestic violence were perceived to
encourage or result in family breakdowns and divorce which, for the Karen, was an
unacceptable solution and considered a “shameful” public affair. Consequently, women
avoided approaching the police or other Australian social services for help with
domestic violence problems. As reflected in the following quotations from interviews
with Karen key informants, marriage was “for life” and a woman should tolerate any
suffering in order to uphold this custom:
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Religiously, particularly for the Christians, once you get married that is for life … it’s
like a tattoo – you cannot erase it. Even if you have an abusive husband or wife, you
have to accept it. (Key informant – Mr H)
Elderly women, say [of domestic violence] “That happened all the time, why you
complain? Why you call the police? It means you try to destroy the family. Once your
husband hits you, you need to listen to him next time so you can prevent him from
hitting or smacking”. It’s not a solution Paula. But, some elderly people accept that
kind of minor domestic violence issues. (Key informant – Mr J)
Family and community leaders attempted to resolve marital discord and domestic
violence within the community as they had done traditionally (Ward, 2002) through
instructing the community in moral behaviour, verbally reprimanding and instructing
abusive parties, and seeking marital reconciliation6. Leaders had also adapted their
strategies to deal with domestic violence in the Australian context. They reported
educating community members about their rights and responsibilities under Australian
law. Though they encouraged adherence to Australian law this was finely balanced with
upholding traditional values and practices. This balance is reflected in the following
quotations from interviews with two Karen community leaders:
We have some problem with domestic violence … rarely, but we’ve got some …
Because we have got a very close knit community we take it by two prongs, the
church and the community. The church teaches them about morals, ethics and how to
be a Christian family. And in our community we talk about our national and cultural
value, to respect the law, to respect this country’s law and be appreciative. (Key
informant – Mr P)
Sometimes they call me from the court! [They say] “Now my husband is about to be
charged, what should I do?” What do you say Paula? … We become a judge
sometimes so we have to be very wise … I refer it back to them in a nice way, [I say]
“His future is in your hands and he has been kind to you quite a number of times.
Look at him, is he remorseful? Does he really regret his actions? Always remember he
is the father of your children”. I make her be aware of this. (Key informant – Mr W)
6 Leaders considered marital reconciliation as the best solution. However, in one case of severe physical
assault they encouraged divorce.
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Some service providers and Karen key informants were frustrated with how leaders
managed domestic violence but also empathised with their efforts. They believed that
the leaders genuinely wanted to stop family violence and also perceived that they
worked hard to present a positive image of the Karen community to the wider
Australian society. However, many also expressed concern about the effectiveness of
traditional approaches to domestic violence in the Australian context. They explained
that the Australian context did not permit leaders the same degree of monitoring and
control over the community as they had held in pre-migration contexts:
Some community elders, they are conservative. They would convince the wife or
maybe the daughter … “Okay, next time I will guarantee that he will not do that to
you”. That’s it. That’s action. He warns the husband, or maybe father, or maybe uncle,
“Don’t do that again, this is your wife, your daughter, or you niece, something like
that, don’t do that again” … But, who can guarantee it will not happen again? (Key
informant – Mr J)
8.4.4 Witches and bitches: single women negotiating gender
Single, separated and widowed women encountered additional gendered concerns.
Amongst the single women I met were (a) women whose husbands had died in battle or
during the refugee journey due to illness or accident, (b) mothers whose husbands had
abandoned them and their children for other women, (c) some who were separated from
their husbands after years of domestic violence and abuse, (d) single mothers who
raised children born as a result of rape and coercive relationships, and (e) women who
were unsure if they were widowed or abandoned by husbands from whom they had not
heard in years. Some of these women wanted to find new partners and most worried
about their physical safety:
They are concerned that they have no husband, there is no male in their house. They
are afraid that somebody might come in the night and touch them or look down on
them. (Pàw Lèh)
Single women were also concerned about financial security. Karen key informants
described the tenuous social position facing divorced and widowed women:
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In your opinion, what are the main emotional issues facing the women?7
Security. Security.
What do you mean by that?
In Western thinking … we talk about individualism. You know as you are a Western
woman, you don’t care if you have a husband, or if you have someone to protect you.
But in Asian or Karen culture, women’s status is weak and, you know, traditionally
Karen women would like to depend on a man. (Key informant – Mr B)
Kohrt and Hruschka (2010) observed similar gendered beliefs and practices in Nepal,
where the loss of a husband was perceived to be more traumatic than the loss of a wife
due to the “significant livelihood instability” (p. 330) endured by Nepali widows.
Many single and married women corroborated Mr B’s view. However, a variety of
opinions emerged when I discussed the topic of remarriage with a group of Karen single
mothers. On the one hand the group predominantly reported that they were presently
content with their situation, felt well supported by the Australian Government, and
therefore did not desire to meet a new partner or husband. Some also referred to Karen
traditional customs and noted that remarriage was uncommon in their culture. On the
other hand, many women contemplated their future marriage prospects during the group
discussion. Some reported feeling presently content but thought that in the future they
might want to (re)marry. However, they felt that their marriage prospects were limited.
They reported that single men within the Karen community were either “kids” or “too
old”. Women also believed that they could be “worse off” if they failed to find a “good
partner” and instead met a man who had problems with gambling and alcohol. Women
unanimously felt they were unable to meet men outside of the Karen community due to
language and cultural barriers. They were also certain that they would face community
gossip if they chose to date or (re)marry. In the following interview quotation Mr B, a
Karen key informant, described the dilemma faced by widowed and divorced women:
As a Karen you know, if they are remarried, or have a relationship without official
marriage, the people look down [on them] … In the camps they can’t do it. Here [in
Australia] are they going to do the same as Western women or will their culture or
traditions stop them? That’s what I want to know. Because as a woman they might
need a man to protect them … You see, Western women, after they break up they
7 In extended quotations from interviews researcher’s voice is given in bold.
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have another relationship, another marriage. But, how about Karen women, can they
do that or not? Will the elders and the community accept or not? … They are stuck in
between. To openly describe, they might need a sexual relationship as well … So, they
are in between two cultures … Only one or two [women] asked me [about this issue].
[They want to know] if they marry again will the community put them aside? If they
marry a white man are they going to look down on us? Can we go to Church again?
(Key informant – Mr B)
Similarly, Mr W, a Karen key informant, reported single women who engaged in sex
outside of marriage were likely to face community gossip:
So it really sounds like there is a negative label attached to these women?
I think so. Society is going to brand them as a witch. Witch or bitch or whatever. (Key
informant – Mr W)
Gossip served to monitor women’s behaviour and punish violations of accepted cultural
standards. Given the insularity of the Sydney Karen community, this method of social
surveillance appeared quite effective in controlling the behaviour of single women. The
detrimental effects of negative gossip have also been documented amongst Somali
women living in Melbourne, Australia (McMichael & Manderson, 2004). Ms R, an
outspoken Karen key informant, spoke of the vulnerable position of single women on
the Thailand-Burma border. She reported that single Karen women (especially those
who were separated or divorced as opposed to widowed) were seen as “available” for
“use” by men as legitimate objects for their sexual gratification. In addition, these single
women were ostracised by other women, who worried that they might lure away their
husbands. I was unable to obtain such frank opinions on this topic from other women
who, due to the sensitivity of the issue, often politely avoided my questions.
Single Karen women reported experiencing gossip in both the refugee camp and in
Australia. They described feeling hurt and upset by these experiences and explained that
some single mothers felt as though they did not “belong” within the Karen community.
However, most single mothers felt that community gossip was more significant in the
camps where they were more dependent on others for survival. In Australia they felt
well supported by the government and reported that gossip did not “really have a direct
impact” on their lives. Single mothers emphasised that they were “never excluded” from
community activities and were often “the first people to be invited” to events because
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the community was aware of their difficult circumstances. Moreover, during a group
interview with Karen women recipients of the Woman at Risk visa, a number of single
mothers spoke not only of the challenges of single motherhood but also the motivation
and courage they derived from their situation. These women appeared to have
developed a sense of identity, responsibility and strength from their situation.
8.5 War, culture and daily stressors: women’s problems in context
In addition to the daily stressors affecting women’s wellbeing, the findings –
particularly those from key informants – also call attention to the unique relationship
between daily stressors and large-scale social, cultural, spiritual and political issues
affecting the wellbeing of the community. These various issues intermixed and often
could not be separated. The political had shaped the spiritual, the spiritual had shaped
the cultural and so on. This section brings together the findings discussed in this chapter
and interprets women’s experiences of daily stress in Australia within the pre-migration
spiritual-socio-cultural-political melting pot described by key informants. This melting
pot – and in particular persecutory experiences – was thought to have led to extreme
compliance and tolerance of hardship and discrimination, fear of authority, apathy,
sponsored dependency and disempowerment. These macro or societal-level
consequences of the Karen experience of forced migration are highly relevant to
understanding the daily problems women encountered and how they reacted and
responded to those problems. They can be thought of as the collective trauma of a
community that has undergone persecution.
Here an oversimplified reorientation to Karen cultural patterns or “national character”
(Bhugra, 2005, p. 86) is warranted. As we saw in Chapter 3 (see Section 3.3.2), key
cultural characteristics of the Karen are their (a) communal, collective ideology and
social practices, (b) respect for wisdom, age, religion and authority, and (c) compliance,
quietness and avoidance of confrontation. Like other collectivist societies (Hofstede,
2001; Kagitcibasi, 1999) the Karen seek to avoid “losing face” and are reluctant to
make a scene. Direct confrontation is thought rude and disagreement in conversation
may not be represented by a clear “no”, but rather by a diversion of topic or a polite
“maybe” or even “yes”. According to Hofstede (2001), these various practices may be
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seen as a “consequence of living in a society that is very conscious of social contexts”
(p. 230)8.
The experience of persecution and war was layered on upon this pre-existing cultural
context. The protracted conflict and persecution experienced by the Karen was (and
remains) characterised not only by violence and warfare but also by social and
psychological tactics employed to instil mistrust and disrupt the cultural and social
fabric of the community (see Chapter 3). Expressing one’s opinion under the regime
was not just culturally discouraged: it was dangerous as it could easily disturb others
and upset a precarious political environment in which strength was necessary for
survival.
Under the rule of the junta’s soldiers, the Karen learnt (and learn) to adapt and survive.
Within their religious context they had already acknowledged suffering as a part of life.
Such religious and cultural practices continued but, according to key informants, as the
persecution persisted through generations, what was once aberrant became normal.
According to Karen community leaders, the bar of what became acceptable was lowered
and many accepted their “fate”:
Karen people said “Oh this is our fate”, general Karen people feel like that. Even
though they are not satisfied or content with that, they will come to think it’s
acceptable. “This is our fate, or, our way of life has to be like this all the time because
we have no legal powers for our rights”. So this becomes a limitation for us, the whole
nation. This kind of thinking is one of the effects of living in this situation for quite a
long time. (Key informant – Mr H)
Elders and key informants explained that, for some, acceptance of one’s fate and long-
term refugee camp confinement led to apathy, dependency and demoralisation. They
believed that the disabling nature of protracted camp confinement eroded self-worth and
self-efficacy. Except for the few who were employed by humanitarian agencies (as
stipendiary staff), most people could not work and most had no opportunity to study.
They were dependent on camp authorities for everything. As Dr G, a key informant,
8 These traits are mentioned here as cultural psychological patterns (Sapir, 2010) and this characterisation
is not meant to define the personality of any given Karen individual.
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noted, “there is a sponsored dependency on governments and organisations”. Other
Karen key informants also lamented the creation and effects of such dependency:
Most people, their mindset is “we are refugees, we need to be fed, the sun will rise
tomorrow, rice, fish paste and oil are going to be there and we are going to grow up
and live like that”. (Key informant – Mr W)
And because so many of them have been 15, 20, in this case 32 years in the camp,
they have got used to the Thai authorities and the NGOs [non-government
organisations] providing them with their food and other necessities. (Key informant –
Dr G)
Kibreab (1993) has criticised the “so-called ‘refugee dependency syndrome’” (p. 330)
discourse as it was applied to Somalian refugees in the 1990s. However, aid
organisations and researchers have continued to observe institutionalisation (Abdi,
2005; Lautze & Hammock, 1996), “forced idleness” (Colic-Peisker & Tilbury, 2003, p.
77) and “aid dependency” (Kett, 2005, p. 99) resulting from prolonged refugee camp
confinement. Karen key informants narratives suggest that protracted camp confinement
had the effect of disabling opportunities for individuals and communities to experience
efficacy, that is, to experience their ability to produce necessary or desired results. Their
conceptualisations share features with Bandura’s (1977) theoretical framework of self-
efficacy.
For Bandura “The capacity to exercise control over the nature and quality of one’s life
is the essence of humanness” (2001, p. 1). Bandura postulated that a person’s
expectations of self-efficacy (their personal capacity for effectiveness) determine the
degree to which they will take actions to change their circumstances. He predicted that
experiences of mastery or accomplishment (including seeing others demonstrate
success) are critical to perceived self-efficacy and that repeated failure lowers such
efficacy. Moreover, Bandura hypothesised that emotional arousal (e.g., states of stress)
can affect perceived self-efficacy and that individuals are less likely to expect success
when feeling agitated or stressed.
The empirical literature exploring self-efficacy amongst refugees remains sparse,
despite hints towards its potential relevance (Benight & Bandura, 2004). The most
recent review of self-efficacy and trauma (Luszczynska, Benight, & Cieslak, 2009)
found that low self-efficacy was associated with greater PTSD symptom severity,
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depressive feelings and somatic symptoms. However, of the twenty-seven studies
reviewed, only one (Ferren, 1999) concerned a refugee population. Moreover, Ferren’s
(1999) study indicated that, amongst refugees, the relationship between the effects of
forced migration and self-efficacy may not be as linear or as one-directional as might be
predicted as adolescent Bosnian and Croatian refugees with symptomatic PTSD
exhibited higher positive self-efficacy than their non-PTSD and non-traumatised peers.
Ferren surmised that survival of trauma might actually protect and maintain high self-
efficacy because, in the context of ethnic persecution, survivors of particularly horrific
trauma are recognised by the community and more likely to receive social support. In
contrast, other research (Colic-Peisker & Tilbury, 2003) supports the view of Karen
leaders and suggests that the refugee experience, and particularly prolonged refugee
camp confinement, leads to hopelessness and loss of belief in one’s capabilities. It
seems that further exploration of refugee wellbeing from a self-efficacy perspective is
warranted.
Karen key informants also described mistrust and fear of authority as “undeniable, very
common” problems impacting on community resettlement as depicted in the following
quotations:
They are very compliant with everything. For example, you have to comply with
Centrelink, you have to comply with your doctors appointment, you have to comply
with any group trying to meet you even though you don’t know who they are and what
they are doing. You have to, you have to, you have to. Because that’s what they have
experienced in the camp where you are conditioned to comply or else you aren’t going
to get supplies or you can’t stay in the camp. So I think the fear [is] that if you don’t
comply you are going to suffer. (Key informant – Ms K)
Because [of] the language barrier it’s hard to understand how the system works – how
to find your way through this legal system, or the government system – so then they
have no confidence to complain, or to express their feelings, emotions towards
hierarchy … They don’t want to talk to officers [in] coats [uniforms]. (Key informant
– Mr H)
These findings locate the social effects of persecution and camp confinement as critical
determinants of how Karen women experienced the stress of resettlement and bring
attention to three cross-cutting themes of culture, gender and environmental mastery.
This context helps to explain women’s interactions with service providers in Australia,
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particularly their fear of Job Services Australia staff (see Section 8.3.2), as well as their
pervasive feeling of uselessness and the emotional impact of failure and unemployment.
8.6 Summary and reflections
This chapter has presented findings related to issues perceived to affect distress and
wellbeing of Karen refugee women. Women overwhelmingly gave attention to
problems that are relatively predictable in underprivileged populations, and which have
been documented before in relation to refugee women (James, 2010; Pittaway &
Bartolomei, 2001) including refugee communities in Australia (Allotey, 1999; Sheikh-
Mohammed, MacIntyre, Wood, Leask, & Isaacs, 2006; J. Taylor, 2004) and Karen
refugees in the United States (Kenny & Lockwood-Kenny, 2011). Literature supports
their perspective that post-migration problems with education, poverty and financial
stress, food insecurity, housing, social class, interpersonal conflict, parenting and
separation from family are pertinent sources of psychological distress (Lund et al.,
2010; Marmot, 2005; Nicassio & Pate, 1984; Porter & Haslam, 2005).
Due to lack of local (i.e., Australian) knowledge women struggled to effectively access
and utilise a range of systems, services and resources. While these issues appear against
the backdrop of language and communication difficulties, they are also characterised by
additional pre- and post-migration factors. This is dense and salient subject matter. A
visual model of these issues would be one with many arrows as the factors interact in
multiple ways. For example, language difficulties and anxiety result in reluctance to use
public transport. Reduced mobility results in less access to education and supports. Lack
of education reduces chances of employment, which in turn hampers financial security.
Lack of money leads to failure to access necessary medical care. Cycles of poverty and
disempowerment are created and perpetuated by multiple factors and players, including
but not limited to those mentioned in this example. But multiple factors and multiple
players mean multiple possible areas and entry-points for change and improvement to
take place. In order to explore solutions it is first necessary to understand the problem.
Unfortunately, as flagged throughout this chapter, many elements of women’s daily
stressors were generated and exacerbated by the limitations of service providers. Such
limitations will be explored in detail in Chapter 12.
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This chapter has largely been about problems. It is important to remember that the
Karen are a relatively recent arrival population in Australia’s humanitarian program.
Getting “a feel for the game” of Australian daily living is most difficult for first
generation arrival populations. Most participants reported that they sought resettlement
to provide a better life for their children and they held high expectations for their
children’s education and futures. This finding resonates with recent Australian research
demonstrating “the significant contribution” of humanitarian entrants in Australia. The
government-funded research found that humanitarian entrants place high value on the
education of their children (DIAC, 2011a). The research highlighted the substantial
barriers facing first-generation entrants but noted that second-generation humanitarian
entrants enjoy educational and occupational achievements on par, and better than, their
non-immigrant, same-age Australian-born peers. Such findings are encouraging but
should not negate the need for further efforts to enhance the wellbeing of humanitarian
entrants. These findings bring attention to the need for research and improvements in
relation to HSS policy and service provision (see Chapter 14).
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Chapter 9
A Suffering Heart-mind:
Conceptualising, Experiencing and Explaining Distress
9.1 Introduction
This chapter further explores women’s conceptualisations and experiences of distress
through examining their idioms of distress.
9.2 A suffering heart-mind: women’s idioms of distress
In this section the Karen idioms hso k’moe dha, tha, tha dha hsar and dha blu are
introduced and their meanings described.
9.2.1 Thinking too much: hso k’moe dha
Women spoke of their distress using the Sgaw Karen phrase hso k’moe dha. This phrase
may be broken up into hso k’moe: to think, thinking, give concern to; and dha: to
excess, too much, now, in the present. Listening to women’s descriptions of hso k’moe
dah it seems that English words such as fretting, worrying or ruminating might be the
most precise translations. However, the more literal translation “thinking too much” was
the most commonly used by bilingual Karen-English speakers. Moreover, this literal
translation allows for ease of reading and links to literature documenting “thinking too
much” idioms amongst refugees from Burma (Lopes Cardozo et al., 2004), other South
East Asian populations (Frye & D’Avanzo, 1994; D. E. Hinton & Otto, 2006) and
populations elsewhere (Guarnaccia, Lewis-Fernandez, & Marano, 2003; Kohrt &
Hruschka, 2010; Parker, Chan, & Tully, 2006; D. Pedersen et al., 2010).
Hso k’moe dha (thinking too much) was characterised by persistent worrying thoughts
about past or current stressors. The chronic daily stressors discussed in Chapter 8 were
the most commonly cited causes. Women considered hso k’moe dha to be a mild state
of distress experienced by everyone at some stage in life but also explained that
excessive or chronic thinking could lead to more serious states of distress, sickness and
even mental illness:
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Everybody can have thinking, but some people think and think and think and the
thinking never comes out of their mind and becomes sickness. (Participant in Group
B)
9.2.2 A suffering heart-mind: tha…
Karen women used expressions relating to the heart (tha) to describe further states of
emotional distress:
Everything is about the heart, everything is about the heart … when your heart is
heavy then your whole body is heavy. (Key informant – Ms S)
The word tha refers to both the physical heart organ and the symbolic heart as the seat
of emotions. When used to denote emotional suffering it is more aptly translated as
“heart-mind” as women perceived emotions and thoughts to be interrelated. A variety of
suffixes were added to tha (heart-mind) to describe different states of physical and
emotional distress. For example, ba do means hurt, thus, tha ba do is a state in which
one’s “heart-mind is hurt”. Most women’s descriptions of tha (heart-mind) distress were
limited to tha da mu (upset), tha ba do (hurt) and tha dha hsar (sickness of the heart-
mind). Karen key informants and women with more education also referred to several
other states; however, they emphasised that many terms overlapped or reflected
differences in dialect. Interestingly, participants emphasised that in comparison to the
English language, Karen dialects do not have so many different words or phrases to
describe emotions.
Women explained that common states of tha distress – such as feeling tha ba do (hurt)
or tha da mu (upset) – were frequently caused by daily life stressors and were not
abnormal or debilitating forms of suffering. Rather, the experience was part of “normal”
life experience and encompassed a range of experiences and reactions from acute
instantaneous shock or fright reactions through to prolonged worry, anxiety and grief
after receiving no news from a loved one missing in the war. These common forms of
tha distress represented the most undefined of the various idioms and could potentially
be likened to Western idioms used to express stress and worry. For example, many
English words are used to refer to a state of stress though they may emphasise different
aspects of the cause or experience (e.g., stressed, nervous, hassled, frazzled, worried or
pressured). These states were also potential precursors to more severe suffering. If a
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person should continue to hso k’moe dha (think too much), their acute and common
state of tha distress could become a more severe “sickness” of the heart-mind (tha dha
hsar) or mental illness (dha blu).
9.2.3 Sickness of the heart-mind: tha dha hsar
The idiom tha dha hsar described a more serious state of heart-mind distress. Dha hsar
means any disease or sickness, thus, the term tha dha hsar means “sickness of the
heart”. It related to physical heart sickness such as cardiovascular disease as well as to a
state of emotional distress characterised by irritability, anger and somatic complaints:
Tha dha hsar, directly it is heart disease but it can also mean emotional, [there are]
two sides to it. (Key informant – Mr H)
Women had unanimously agreed on the universal prevalence of more common heart-
mind distress (e.g., tha da mu and tha ba do) but their perceptions differed regarding the
prevalence and seriousness of emotional tha dha hsar. Some thought it was a more
severe but still common state of distress whereas others believed it was rare and quite
debilitating, though still something you could recover from. Participants also expressed
a gendered notion of distress and believed that women were more likely to suffer tha
dha hsar. Some attributed this to the stress of women’s social roles and responsibilities.
Others, such as Mu Htòh, believed that women were “weak” and simply less able to
cope with stressors:
Women can get [tha dha hsar] more … The men can think about the bright side and
relax more than the women who worry too much. (Mu Htòh)
Tha dha hsar shared similarities with common (and unstigmatised) conditions such as
tha ba do (hurt). However, it was also considered to be closer to the state of dha blu
(mental illness). As Pàw Lèh stated, tha dha hsar “means mostly a mental problem”.
Consequently, it was more highly stigmatised, which might explain women’s reluctance
to identify their suffering in this way.
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9.2.4 Madness: dha blu
The idiom dha blu described the most severe state of suffering, which is translated here
as madness or mental illness9. It was characterised by inappropriate and incoherent
behaviour and speech, such as walking in public naked and talking nonsense. Dha blu
was distinguished from other idioms by an emphasis on “mental” as opposed to
emotional (e.g., heart-mind) features. Moreover, it was considered to be relatively
untreatable. Participants also clearly conceptualised this state of suffering as an
extension of unresolved tha distress and explained that very severe tha dha hsar
(sickness of the heart-mind) could be indistinguishable from dha blu (mental illness or
madness).
Women’s idioms of distress could be placed along a continuum from normal reactions
to life stressors (e.g., hso k’moe dha / thinking too much and common states of tha /
heart-mind distress) through to rarer (e.g., tha dha hsar / sickness of the heart-mind) and
eventually debilitating (e.g., dha blu / mental illness) forms of distress. Ms K, a Karen
key informant, explained that the idioms could not be clearly categorised as distinct
entities:
If you don’t care for yourself here [points to tha dha hsar written on a piece of paper]
you can go there [points to dha blu written on a piece of paper] … We can’t
differentiate [distinctly between states] because we just don’t have that way of
thinking. (Key informant – Ms K)
In most instances the gamut of idioms of distress shared underlying causal explanations
and experiential features. These are explored in the following sections.
9.3 Causes of distress
Women’s aetiological beliefs about emotional distress can be grouped into four
categories: daily stressors, persecution and forced migration, biological and
supernatural.
9 Dha blu was overwhelmingly the most common Sgaw Karen term employed to describe this state of
mental illness. However, participants explained that other dialects used additional and different terms
such as tha te tea.
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9.3.1 Daily stressors
All participants described the daily life stressors detailed in Chapter 8 as the most
significant causes of their emotional and mental (e.g., heart-mind) distress. They
believed that daily stressors caused all people to occasionally hso k’moe dha, saying:
“[it’s] normal, too much thinking – you have, I have”. The following quotations were
typical of women’s discussions about daily stressors and emotional suffering. Htòh
located the source of her hso k’moe dha within daily resettlement concerns:
We came here as refugees and we can’t even sleep, we think a lot and worry … We
came here empty handed, we have nothing and we know nothing. We feel really
down. People are pressuring you to look for a job. We are thinking what will happen?
What will happen if we can’t get a job? That is our main worry … It will become a
sickness if you go on thinking a lot like that. Even I get headaches when I think too
much. (Htòh)
Married women described changing gender role practices and marital discord as central
causes of suffering. Like Cambodian refugee women (D. E. Hinton et al., 2010;
Liamputtong Rice, 1999a), they described suffering heart-mind distress due to their
husband’s excessive alcohol consumption, gambling and sexual infidelities. Typical of
their comments, Ta Heh Sōo described marital and parenting problems as the cause of
her friend’s distress:
She’s got a lot of thinking regarding her relationship with her husband. Before she
came here to Australia her husband had an affair … She asked him to come back but
he won’t … The children want their father … This makes her stressed, she’s thinking
too much. Also … she can’t discipline the children. When she was back in the camp at
least she can discipline the children, but here it’s hard. (Ta Heh Sōo)
Women also drew attention to other interpersonal stressors, particularly community
gossip and peer rejection. As the Karen community was small, collectivist and relatively
insular, it is understandable that social exclusion was a significant stressor.
Others, like Mu Htòh, described real and perceived experiences of outsider
discrimination as resulting in hso k’moe dha and isolation:
Sometimes when we are shopping, especially in the Asian shops, they look at how we
are dressed and talk unkindly about us. A few feel afraid by this … They think “We
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are refugees, we can’t talk the language and we have no job”. Some people think
about that and then later they move away from those who discriminate and they want
to interact only within their Karen community. (Mu Htòh)
Typical of many women separated from their children, Mëh Luh described her suffering
as caused by worry for her friends and family in the homeland:
Sometimes if we think a lot we tend to have sadness. Here we live in a country that is
peaceful, we don’t have to worry for anything at all … But when we think about
people who live in either the refugee camp or in Burma we feel sad … I feel sad when
I hear about the situation in Burma, especially when I hear that the military is
targeting the ethnic groups and burning down their villages. (Mëh Luh)
9.3.2 Persecution and forced migration: loss and traumatic war stressors
Although women emphasised the prominence of daily stressors, they also explained that
losses and traumatic war experiences caused varying degrees of emotional suffering
including hso k’moe dha, common heart-mind distress, tha dha hsar and dha blu.
Loss, war and common heart-mind distress
Women experienced hso k’moe dha and common tha distress as a result of their
cumulative “series of losses” (i.e., loss of land, culture, possessions and loved ones), as
well as from exposure to general war trauma such as hearing gunfire. They did not
pathologise their suffering but considered it to be an understandable consequence of
their experiences. They also used the idiom of the heart-mind to describe a wide range
of encounters and emotion states including acute fright reactions (e.g., the psycho-
physiological response experienced when faced with a menacing dog or incoming
gunfire) and memories of loss and trauma. Tha ba do (hurt) was the most common
idiom used to describe distress caused by loss and trauma.
Tha ba do … is suffered by anyone affected by some distressing memory … When a
person suffers tha ba do [he is] upset, he is hurt, his mind is hurt. (Key informant – Mr
H)
Women typically portrayed their experience of these memories in the same matter-of-
fact manner as Ta Heh Sōo and Htee Gloh who described the impact of past traumas as
occasionally making them feel tha da mu (upset):
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I grew up with bullets all around me. When I first came here it was Christmas time
and there were a lot of fireworks and I thought is it a gun? I was scared because the
sound of fireworks is a lot like gunshots. We can still think a lot and because of that
thinking you feel scared and upset.
What is the Karen word for what you felt?
Tha da mu [upset]. Tha da mu. Tha is heart. (Ta Heh Sōo)
Your memory is not lost … BOOM, I heard big bombs too many times. And then
when we moved here I heard the thunder and I thought the bombing had come here. I
don’t like loud noises. It makes me feel afraid. (Htee Gloh)
Like other participants, these women did not consider their reactions to be abnormal or
alarming.
Loss, war and more severe suffering
Women believed that particularly awful experiences (both war-related and chronic daily
stressors) could cause more severe heart-mind distress (e.g., tha dha hsar) and all
believed there were grades or “degrees” of loss and trauma. For them, everybody
suffered but some people suffered “too much”. Loss(es), trauma(s) and chronic daily
stress(ors) with serious negative social consequences were deemed worse than those
without and considered more likely to cause severe emotional distress.
The chronic daily stressors (described in Chapter 8) considered most severe and likely
to cause severe distress were interpersonal; specifically domestic violence, marital
discord and alcoholic or sexually unfaithful husbands. When participants recalled
instances of severe tha dha hsar and suicide in the refugee camp(s), they described
women who were married to abusive or “alcoholic” men. With regard to war, loss and
trauma, participants explained that witnessing the death of an unrelated individual was
unlikely to have significant social consequences and was not as severe as enduring the
death of one’s husband – a situation with grim social ramifications for Karen women
who were culturally prohibited from remarriage and yet were considered to need a
husband for physical safety. In the following interview quotation Mr P, a Karen elder,
succinctly illustrated this view:
It’s a normal life in our country, tha ba do [feeling hurt] and everything. Only when
your relative, husband or children are killed, that one is a big issue. But when you only
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have to flee or you see someone being killed but physically they are not related to you,
it’s a normal thing. (Key informant – Mr P)
Witnessing the murder of one’s family member was ranked as highly distressing but,
again, there were degrees depending on the social implications of the traumatic event.
Enduring the loss of children was considered to be harder if one was unable to conceive
any more children. Losing all of one’s children or all children of one gender (e.g., death
of all daughters) more so. Severe tha dha hsar could also result from one’s children
being raped or abducted and sold to human traffickers for prostitution. Again the
relative salience of this experience appeared linked to its social ramifications; rape and
prostitution had serious social implications for both mother and child.
Interestingly, women tended to locate current life stressors as a more significant cause
of tha dha hsar than previous life difficulties and believed that war-related loss and
trauma could not cause severe emotional suffering in the absence of additional chronic
daily stressors:
I think in our community, in the Karen situation we don’t think about the past
background. Only about these problems, current problems [pointing to our list of daily
post-migration stressors].
Is tha dha hsar sometimes caused by old memories?
No [laughs]. Old memory is the thing about the past?
Yeah.
No, no. (Mu Htòh)
9.3.3 Biology and inherited vulnerability
Women did not attribute biological causes to common types of distress (e.g., hso k’moe
dah and tha distress). However, many reported that more severe suffering (e.g., tha
dhar hsar and dha blu) resulted from an interaction between life adversity and an
inherent vulnerability or predisposition towards emotional instability. Participants
proposed some sort of mixed biologically and socially inherited familial predisposition
to psychological fragility. Similar beliefs regarding inherited vulnerability have been
documented in other cultures (Guarnaccia et al., 2003; Liamputtong Rice, 1999a,
1999b) and share features with a Western stress-diathesis model (Rabkin, 1982) of
mental illness. Additional biomedical explanations for dha blu included brain injury,
epilepsy, cerebral malaria and poor prenatal nutrition.
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9.3.4 Supernatural
Women attributed supernatural causes only to dha blu, explaining that it could be
caused by witchcraft, black magic (e.g., curses by enemies) and bad fates (caused by
offending spirits). Mr H, a Karen key informant, explained: “when the cause is
unknown people generally believe this is black magic or spirits”.
9.4 Experiencing and expressing distress
9.4.1 Aching heads and aching bodies: somatic complaints
Women gave precedence to somatic symptoms over affect states. They explained that
hso k’moe dha often naturally resolved over a matter of days but reported that it also
commonly led to a temporary depletion of physical and mental energy and to somatic
complaints including headaches, sleeping difficulties, loss of appetite, lethargy,
tachycardia, and aches and pains. Like participants in Rosbrook and Schweitzer’s
(2010) study of refugees from Burma, Karen women also described experiencing their
distress in physical terms “as exhaustion, heaviness, insomnia and poor appetite” (p.
164). Mëh Luh described the symptoms of hso k’moe dha, reporting:
They won’t feel well, they will feel sick … Once you have too much thinking you
have no appetite … Once you lose your appetite you will not be able to sleep because
you think a lot … and you feel lethargic … Then it’s very easy to get sick and catch
diseases … People with this issue are impatient and get angry easily … They will feel
their body aching … maybe their hands, legs, and sometimes the whole body aches
and pains. (Mëh Luh)
Common tha (heart-mind) distress caused women to feel “shaky” and “dizzy”, and
experience tachycardia and “chest pain”. These somatic complaints were often
experienced as acute instantaneous reactions to stressors. For example, women
described feeling acute shakiness after misunderstanding road rules and nearly getting
hit by traffic or after hearing thunder and being reminded of bomb blasts and gunfire.
The same somatic complaints were also reported for more enduring heart-mind distress
caused by chronic daily stressors such as marital discord. Women who suffered tha
distress due to complex social stressors explained that their distress was characterised
by additional difficulties including irritability, poor memory, poor blood circulation and
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persistent worry. In the following quotation Hpä Hpaw Mu describes feeling tha ta mu
(upset) due to social exclusion and relationship difficulties:
I feel upset, I lose my appetite, I feel dizzy … I can’t sleep. I also have difficulty
breathing, especially at night. I’m afraid that if I die at night no one will know. When I
want to think of something I can’t recall the things – loss of memory. The heart is
beating fast. My feet and fingertips are very cold … Sometimes I feel like I don’t want
to do anything and become lazy. The blood circulation doesn’t work well and I feel
completely heavy. (Hpä Hpaw Mu)
Hpä Hpaw Mu had informed her GP of her symptoms but lamented that he could not
find anything “wrong” with her. Women experiencing more severe distress also spoke
of their distress in relation to specific bodily organs and gave graphic depictions to
convey the physical embodiment of their distress. For example, Lah Luh reported:
Whenever my daughter [misbehaves] I feel like something pops in my stomach,
something like a bullet pops in my stomach and goes straight to my head and I have a
big headache … Sometimes without thinking or without having any problems I feel
something pop in my tummy and pop into my liver or my heart. A sharp pain radiates
up to my head and I feel headaches. (Lah Luh)
Karen women also experienced psychological distress as dysregulation of blood flow.
They considered blood pressure, menstrual blood flow and blood circulation to be
important factors for physical and emotional health. These beliefs appear to have their
origins in traditional Karen medicine, which includes components of both Ayurvedic
and traditional Chinese medicine, both of which stress the importance of unrestricted
blood flow (Bodeker et al., 2005). Women believed that blood pressure problems were
caused by both physical illness and social stress. They feared that blood dysregulation
from thinking too much and emotional distress could lead to serious health
consequences:
Some people might even get high blood pressure from hso k’moe dha [too much
thinking]. If you can’t control the blood pressure you could even get a stroke.
(Participant in Group C)
Cambodian refugees have described similar fears of strokes and heart-attacks (D. E.
Hinton et al., 2010), attributable to their comparable traditional medical
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conceptualisations about blood flow. Anthropologist Monique Skidmore (2002)
similarly reported that, for Burmese women, the regularity and volume of menstrual
blood was a primary indicator of health. Abortion and childbirth were thought to be
particularly vulnerable times for women. Her description of women’s
conceptualisations of blood flow shares similarities with Chinese medical systems in
which the metaphor of unrestricted blood flow is more akin to the notion of a flowing
river than a heart-pump system. Similar to both Ayurvedic and Chinese systems,
traditional Burmese medicine addressed women’s blood-flow difficulties through diet
and the nutritional and taste qualities of hot, cold, sweet, sour, bitter and salty foods. In
my study women tended to attribute their blood flow concerns to poverty, social
stressors and medical problems.
Women’s descriptions of somatic symptoms paralleled comments made by GPs who
explained that their Karen clients primarily focused on the somatic aspects of their
emotional distress:
They somatise … They don’t really come straight out and report to you “I’m
depressed” or “I have difficulty dealing with this”. They present with a headache, or
tummy ache, or chest pain, or fatigue, lethargy. The problem is that they are not
coping. [The somatic complaint] means that she is tired. It means “I’m not coping”.
(Key informant – Dr F)
Somatisation of distress has been consistently observed amongst Asian (D. E. Hinton &
Otto, 2006; Kohrt & Hruschka, 2010) and other populations (Escobar & Gureje, 2007;
Gureje, 2004; Gureje, Simon, Ustan, & Goldberg, 1997; Kirmayer, Groleau, Looper, &
Dominice Dao, 2004; A. Kleinman & Becker, 1998; Lock, 1993) but is also common in
the West where people often speak of stressors as a “pain in the neck”. Chronic low
back pain is another common somatic manifestation of psychosocial distress amongst
White Western patients (Sikorski, Stampfer, Cole, & Wheatley, 1996). Indeed, A.
Kleinman and Kleinman (1985) argue: “from the cross-cultural perspective, it is …
psychologization in the West that appears unusual and requires explanation” (p. 435).
9.4.2 “I have a problem”: social complaints and social expressions
Women also described a social conceptualisation of distress. Social stressors were
perceived as a leading cause of emotional suffering and were often the means by which
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women conveyed their distress to close friends or family women. Some key informants
interpreted women’s tendency to emphasise the social causes of their distress as
reflective of an inability to express one’s feelings. Others, like Dr G, believed that both
somatic and social expressions of distress served as a means of avoiding stigma
associated with emotional and mental problems:
To label oneself as suffering from a mental health problem creates a stigma and
people tend to find somatic or bodily symptoms to explain these things. They might
say “Oh, I’m worried about my children and their schooling” or something, they won’t
label that as anxiety. They will put the cause onto the children or the husband and then
we have to tell them very gently “Look, OK, we take those into account but you are
the one who is suffering from this so this has become your problem so we will have to
help you deal with that”. So it’s about ongoing education. (Key informant – Dr G)
Although stigma may contribute to how women express and experience distress, women
also appeared to genuinely perceive their distress as intimately entwined with damaged
social relationships and other environmental or social stressors. Emotional suffering
occurred not only within their bodies and minds, but within their social environment.
Some social causes of distress were considered to be more private affairs (e.g., serious
marital discord) and consequently were unlikely to be expressed openly, though women
might privately discuss their difficulties with closely trusted friends, family or
community leaders. In contrast, other stressors (e.g., parenting problems, financial
difficulty and grief) were not shrouded in such weighty stigma and embarrassment, or
the need for privacy. Overt social expressions of grief (e.g., crying) were culturally
approved reactions to loss but disproportionate or ongoing expressions were considered
abnormal and problematic:
The way of grieving is you quietly cry and you don’t make a big scene out of it, you
know, not the physical hitting and stuff like that. You pick yourself up afterwards and
you don’t go on forever even though you are going to sort of, but yeah, you don’t
show it. (Key informant – Ms K)
Ms K, a Karen key informant, went on to describe the difference between normal grief
and “crazy” reactions to loss:
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The duration [is important]. If people behave in a certain [way for a certain] period of
time, in a very short time they are not considered crazy. [If you lost your child] and
you saw the child that you just lost and if you behave [grieve overtly e.g., crying] then
people do understand that this is your loss. But if you start to behave [in a manner
that] they can’t rationalise, for example, you might have lost a brother or somebody
else or something and grieved for a period of time but six months down the track it
comes up again, then they couldn’t find a reason why the person is behaving that way,
then they start to think that person is crazy … They won’t see any relevance to it [the
loss of the loved one]. (Key informant – Ms K)
Ms K’s description relates to the notion of degrees of loss and trauma described above.
Expressions of distress were expected to vary according to the degree of loss or trauma
and had to fit a culturally approved form and time course or else individuals risked
being identified and stigmatised as suffering from dha blu (mental illness). The
American Psychiatric Association (2000) similarly distinguishes between normal and
pathological grief. Bereavement is expected to resolve within two months and not be
characterised by functional impairment or severe problems such as suicidal ideation and
psychomotor retardation.
9.4.3 “I am useless”: expressing failure and frustration
“Feeling useless” could be considered a cause of distress, but women generally talked
about it as an experience and expression of their heart-mind distress. They felt useless in
a number of areas including language, education, employment and performing daily
tasks such as shopping. Some felt useless in contrast to their pre-migration life
including their previous occupational and social roles (e.g., professional and volunteer
positions). As we saw in Chapter 8 (see Section 8.3.7), women felt particularly useless
as parents in the Australian context. Similarly, when Karen key informants spoke of
Karen women who suffered emotional distress they also described them as feeling
useless:
Like, the old woman sitting in the corner … she always says “I’m useless”. She feels
that she is useless and her life is useless … [Her] daughter does not listen [to her]
anymore. This is the difference. When they were in the refugee camp, then they might
not be different because of the tradition, because of the culture. But here, you know,
you go your way, I go mine. So, the culture has been changed and she feels isolated.
She says “I am useless. I am useless”. (Key informant – Mr B)
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The bilingual research assistant predominantly used the English word “useless” when
interpreting women’s discussions. Similarly, key informants speaking English
employed the same term when conveying what Karen women had said to them about
their distress. However, through examining women’s accounts of feeling “useless” it
seems that multiple meanings may be inferred. Women described experiences related to
feeling purposeless (without purpose), unoccupied (not used by anyone or anything),
worthless (of no social value) and incompetent (lacking necessary skill or ability).
The following quotation comes from a group interview in which women had chosen to
discuss unemployment. I had asked the women to explain the emotional impact of
unemployment. To answer they cut out a magazine picture of a salad (see Image 6) and
explained the symbolism of the image:
Image 6: Picture of a salad – used by women to make an analogy between
nutritional value and the value inherent in women
That bowl of food represents a woman. That food is nutritious, it gives you energy,
you will be healthy. If a woman or a person is strong enough to stand by herself it will
be very helpful for the community … Food has value, it has things like vitamins that
are beneficial. As women we have that power but nobody takes that power to be used.
If someone takes that power it will be helpful for her and everyone.
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Okay, so everybody has skills but nobody is able to give their skills or use their
skills because they can’t find work.
The woman or the person is represented by the bowl of food, someone must use her
for her to be beneficial. If you don’t use it, it is useless. It must be used. Food is for
someone to eat. A person is for someone to use in some way. Otherwise they are
wasted. (Participants in Group D)
Helplessness and cessation of action were consequences of feeling useless. For
example, when discussing parenting and feeling useless, Mu Htòh reported that some
parents gave up trying to instruct and discipline their children and simply “let them go
and do whatever they want”.
Key informants spoke of the importance of “self-esteem” and “self-reliance”. They
emphasised that emotional wellbeing significantly depended on people feeling effective
in their daily lives. These findings share similarities with other ethnographic research.
Failure in gendered life domains was identified as a cause of distress amongst Nepalis
(Kohrt & Hruschka, 2010). Nepali women emphasised the negative emotional impact of
failing to maintain good household and family relationships, and produce male children.
Men were more negatively affected by professional failure or loss of social status.
Similarly, Watters (2010) reported that failure to fulfil one’s social role is central to
distress for Sri Lankans. The pivotal role played by the discourse of feeling useless
suggests that understanding this idiom of distress could provide policy makers,
researchers and service providers with new ideas for enhancing the wellbeing of Karen
women.
9.4.4 “I remember”: remembering suffering
Tha (heart-mind) distress was also experienced as memories of loss, persecution and
trauma. For example, Mëh Luh described seeing memories of fighting in her eyes:
I myself had to flee from one place to another. I have seen fighting and burning
villages. Even I sometimes remember that and I see it in my eyes.
Is that a problem for you?
Not really. Not really. Sometimes maybe I might feel a bit sad. But it doesn’t really
hurt me a lot or interrupt me at all. Because we always learnt not to think about things
that are meaningless and things that don’t help you at all. (Mëh Luh)
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Mëh Luh reported that her memories were not problematic despite causing short-term
feelings of sadness. Her matter-of-fact approach to memories was also conveyed by
other participants including Pàw Lèh who reported that dreams about fighting did not
affect her daily functioning:
I always have dreams about my homeland, the Karen State … [Dreams of] always
running, fleeing to another place. Dreaming that I am not in Australia, that I am in the
Karen State … I dream about the running and I dream about the property, and the
fighting and war there … It’s not a problem. After I’m dreaming about it I’m okay,
dream is dream! (Pàw Lèh)
Several Karen key informants corroborated this pragmatic and accepting approach to
war-related memories and dreams. In the following quotation, Mr M, a Karen leader,
described his own experience of “a few years” of nightmares following a traumatic
experience in which he was wounded. Interestingly, Mr M’s words suggest that
remembering may not necessarily be functionally impairing:
When I first came [to Australia] I had a nightmare in which I had the same scenario
but with different settings where I got wounded. But it never came back after a few
years …
When you were having this did it cause you some concern, were you worried or
upset?
Only for a while, only when I woke up and remembered about the nightmares but later
on it does not affect me badly.
Did you or do other people in your community go and get help for this kind of
problem?
No, I didn’t think I needed help [laughs] …
Is there a word for it [your nightmares]?
Yeah, remember, remembering.
So remembering is not considered a problem?
No, not if it doesn’t affect your day-to-day work.
Does it affect some people’s day-to-day work?
It might, I don’t know. (Key informant – Mr M)
Consistent with prior research (Parker et al., 2006), acculturation or familiarity with
Australian culture influenced participants’ descriptions of local idioms of distress. In
contrast to Karen women, other Karen and non-Karen key informants, particularly those
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employed in health professions, were more likely to employ Western idioms of distress
(e.g., “flashbacks”) to describe the emotional impact of war and trauma, and
conceptualise these experiences as psychological problems. The different perceptions of
professional and lay participants is consistent with ethnographic research in Nepal
where counsellors, health professionals and program administrators gave greater
importance to traumatic experiences causing mental health difficulties than did Nepali
lay-persons who emphasised the importance of chronic daily life stressors (Kohrt &
Hruschka, 2010). A Karen key informant, Mr P, hypothesised that heart-mind distress
resulting from trauma could result in some functional impairment:
I was imprisoned as a political prisoner. After I was released I experienced nightmares
all the time when I was in Burma. When I came to Australia I even experienced the
nightmares for another three years. At night I dreamt about being in prison. I was very
angry in the middle of the night, [I thought] “why do you keep on troubling me, I’m in
a free country already, why do you keep troubling me here? That was my bad
experience in my past” [laughs]. But now I am not troubled by them any more … In
our country we don’t know how to get assistance for it [mental health], this is a
normal life. Only when we are here because of the information given to us we know
that we need help, to get help regarding our mental health. Mental health in our
country is poorly looked after … Karen people just think it’s a normal life. But
actually it’s not. It will affect them, their quality of performance. If they have bad
dreams all the time they can’t perform well at work or study, they can’t concentrate.
(Key informant – Mr P)
To summarise, women experienced memories and nightmares of their suffering(s)
(including loss, trauma and daily stress) but did not perceive these to be problems and
did not pathologise their experience. It appeared that Karen cultural wisdom prescribed
that it was nonsensical to dwell on unhelpful emotions, thoughts or experiences (e.g.,
nightmares). This seemed to promote a pragmatic approach to how women experienced
the psychological sequelae of loss and trauma.
9.4.5 “I want to die by crying”: severe distress
More severe heart-mind distress (e.g., tha dha hsar / sickness of the heart mind) was
experienced and expressed through the same somatic and social manifestations as
common states of suffering (e.g., hso k’moe dha / thinking too much and common tha /
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heart-mind distress). In addition, it was also characterised by greater overt expressions
of distress (e.g., complaining, crying and distressed “facial expressions”), self-isolation,
sensitivity to bad news and suicidal ideation. Hpä Hpaw Mu explained “they might go
into shock and even faint. Some even can’t control themselves and they lose their mind
and become dha blu [mad]”.
In the following quotation Lah Luh describes wanting to die by crying. She experienced
considerable physical health problems, social stressors and emotional distress, and her
peers identified her as suffering from tha dha hsar. Her words reflect the confusion she
felt in defining her experience:
Sometimes I even think I want to die. I came here and now I have so many problems
… Because of [my son’s bad behaviour] I have a lot of headaches. I hso k’moe dha
[think too much] … I feel tired and weak, my heartbeat is very fast. Sometimes I cry
and I think that if I cry out loud and burst out I will die. I want to die by crying. I cry
out loud but I am still not dying … I’m not sure how to give a name to this problem,
I’m just suffering … Is it because of the hso k’moe dha? Or am I having physical
problems? … I’m not sure whether this is tha dha hsar or not. I did ask my doctor if I
have tha dha hsar and he said no. I am afraid of having tha dha hsar. I don’t want to
have that.
Why don’t you want to have tha dha hsar?
I don’t know someone who suffers from tha dha hsar, what does that look like? How
do they feel? I don’t know … I know that I am suffering but I don’t know how to
name it. (Lah Luh)
9.4.6 Feeling fierce: tha dha hsar and anger
Anger was another distinguishing feature of more severe emotional distress and women
described tha dha hsar as being characterised by feeling “fierce” and “hateful”. Some
Karen key informants emphasised the role of persecutory and traumatic experiences in
causing anger and emotional distress. Here too these informants were all fluent English
speakers with greater exposure to Western worldviews including models of mental
health and trauma. They often did not refer specifically to Karen idioms of distress
unless explicitly asked to do so. Rather, they spoke of “unresolved” issues relating to
war, especially “trauma” and ongoing anger. They expanded the meaning of tha dha
hsar beyond its common use by Karen women. For example, Mr P, a Karen key
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informant, explained that there are both positive and negative sides to tha dha hsar. He
depicted it as the energy and passion that provided purpose and fuelled survival through
extremely difficult circumstances. However, he also illustrated an emotional or mental
flipside and described the suffering caused by an inability to forget injustice and the
desire “to kill … want revenge”. Mr P emphasised that forgiveness and healing was
critical to psychological wellbeing and necessary for overcoming the negative aspects of
tha dha hsar. In the following quotation, recounting his own personal journey, he
clearly illustrates the role of forgiveness for his recovery:
Tha dha hsar … it keeps on encouraging you to live on – that’s one thing … That’s
why I survived, without that I wouldn’t have survived … But [it] also emotionally
hurts you because you can’t forgive, you are never free … Even me for example,
when I came out of prison my main objective was to get back at them … One of the
pastors asked me, “If General Ney Win [former Prime Minister of Burma] came to
you and let you chop off his neck, would you chop it off?”. I said, “Oh no – more than
one cut – I will chop and chop”. But now that sort of mentality is gone for me and
then it made me free. We only know that one day the injustice will be gone and
freedom and justice will prevail. As Christians or as Karen people we have to stand
for justice and freedom, this is our duty, not out of hatred not out of tha dha hsar. That
is our duty. Also, the International Declaration of Human Rights [says that] all are
created equal, so we have all equal rights, this is universal rule of law. Only then I can
free myself emotionally. (Key informant – Mr P)
Mr P described tha dha hsar (sickness of the heart-mind), and specifically the
component of anger, as an instrument of survival and social change. Other oppressed
and disenfranchised groups have similarly used their expressions of anger as tools for
social movements (e.g., civil and gay rights). In many circumstances anger is a
justifiable response to discriminatory sociopolitical conditions but it can also lead to a
“social psychology of victimhood” (Bumiller, 1988, p. 3). Mr P warned that such anger
must eventually subside. As an educated community leader he was easily able to engage
in advocacy for Karen refugees and directly oppose the oppression of the people of
Burma. He said he had forgiven his oppressors and that his continued commitment to
social change was now fuelled by his enthusiasm for the International Declaration of
Human Rights. But resolution of anger and forgiveness might be harder for community
members who are deprived of social and political roles within their own disenfranchised
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communities. As Dr F’s words below illustrate, when there is no alterative way of
channelling or venting anger it could result in women feeling “helpless”:
A lot of them have been through trauma [but] trauma need not be pathologised – not
everyone will have PTSD. We don’t have to pathologise … These women say “I’m
very angry”. [One Karen woman was talking about] how she had to flee because of
military onslaught and how she lost her son. She was talking about the whole village
getting burnt down, even the livestock. [She talked about] the scare techniques and the
gang rapes, you know like the women being raped, and the husbands being taken as
porters, enslaved there. She had all those sort of things happen and then she came here
and she was very angry. Angry about how the military dictator can do this ethnic
cleansing … She’s very angry about it but she said “There’s nothing I can do. I want
to retaliate but I feel helpless”. (Key informant – Dr F)
Numerous Karen key informants conceptualised anger as a central characteristic of
more severe emotional distress. They described a severely emotionally distressed
woman who had survived a violent traumatic experience in Burma and afterwards
began to physically assault her family members. Mr W, a Karen key informant,
described witnessing Karen women crying and banging their heads against walls, which
he attributed to “suppression of their anger”. His description suggests that women turn
on themselves when they have no other means of externally expressing or acting upon
their distress:
They had to run for their lives over there … [it’s] about injustice. Unjustly being
treated and not being able to express their own emotional pain and stress. The
emotional outlet has been blocked. They never had a chance to express [their pain].
(Key informant – Mr W)
Mr K, another Karen key informant, explained that although Karen women generally
attributed the cause of their distress to their social world, he felt that an important
underlying issue of anger and injustice remained. Similarly, Dr N reported that some
Karen refugee patients “are angry, the hatred is there but they try to avoid [expressing
it]”. Mr M emphasised anger as an effect of war and also explained that it could
manifest as ethnic tension. His words illustrate how forgiveness is a necessary aspect of
coping with anger and demonstrate the relationship between unforgiveness and mental
illness as well as ethnic tension:
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Emotional effects [of the war and fighting] – the first thing I can see is hatred. That is
the most obvious thing … They can’t let it go, even though I preach [that] we have to
forgive. Even some people say, I can accept this but I can’t do it [forgive]. (Key
informant – Mr M)
9.4.7 “Eating grass”: manifestations of madness (dha blu)
Individuals with dha blu (mental illness or madness) were described as “crazy” people
who “eat grass”, “walk around naked” and “won’t even remember their husband or
children”. Like sufferers of tha dha hsar (sickness of the heart-mind), they were also
considered at risk of suicide. In addition, dha blu was described as stigmatising for
sufferers and their families.
Participants described having seen people with dha blu in Burma and in refugee camps
but explained that no Karen in Sydney suffered this problem. They attributed this to the
pre-migration screening process saying: “I don’t think Australia will take you … they
will screen you very good” and “if you have something like that … you can’t come
in”10. When participants recalled instances of dha blu (mental illness or madness) the
individuals they described were often married women experiencing severe marital
difficulties or men whose wives and children had died. As with other idioms of distress,
some key informants gave more detailed descriptions and occasionally compared and
contrasted emic (Karen) and etic (Western) idioms of distress. They explained that the
duration of symptoms or behavioural change determined whether someone was
considered to have dha blu or a less severe, acute grief reaction. Participants were not
optimistic that a person suffering from dha blu could ever recover.
9.5 Summary and reflections
9.5.1 Trajectory of distress
This chapter has explored the collection of idioms women used to talk about distress.
Women did not actively impose a formalised classification system in regard to their
emotional world. Rather, they described a trajectory of emotional distress (see Figure 4)
10 The Australian Government’s Humanitarian Program does not specifically exclude applicants with
mental illness. Applicants must be free from tuberculosis and any disease or condition that is a risk to
public health and safety (UNHCR, 2004).
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from hso k’moe dha (thinking too much) through various states of tha (heart-mind)
distress such as tha ba yo (worry) and tha dha hsar (sickness of the heart-mind),
culminating in dha blu (madness or mental illness). As the trajectory of distress
suggests, Karen women’s conceptualisations of suffering could not be separated into
“discrete Linnaean classification schemata” (Guarnaccia et al., 2003, p. 340) but rather
overlapped and encompassed the experience of suffering in many forms. Normality and
abnormality appeared to be relative terms and, in the Karen context, existed on a
continuum.
Most common and least severe Least common and most severe Hso k’moe dha Tha… Tha dha hsar Dha blu
Thinking too much
(Common) Heart-mind distress
Sickness of the heart-mind
Crazy
Figure 4: Trajectory of distress
As I learnt women’s conceptualisations and sought to understand their idioms of
distress I initially fell into a trap whereby I attempted to neatly match expressions with
translations and tidily group these representations. Ultimately, I came to understand the
trajectory or continuum inherent in women’s discussions. I also came to understand that
their idioms were ambiguous in nature; each had multiple interpretations. Linguistically,
the collection of idioms provided the foundation for discourse on a variety of forms of
suffering and violence. The effects of poverty were described with the same terms used
to express physical disease of the heart organ. The loss of a child, a brutal murder or the
disappearance of a loved one was conveyed with the same expressions used to address
marital conflict and social isolation.
Women’s idioms of distress were embedded in the physical, gendered and socio-
political circumstances of their lives. The most significant of these was the social and
their sense of wellbeing emanated from their collective connections with others; their
interpersonal and emotional worlds were closely tied. Women believed (according to
their experience and cultural wisdom) that some degree of emotional affliction was
normal in the context of their lives as persecuted people. Consequently, experiences
such as nightmares were not deemed abnormal or necessarily concerning.
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Karen women experienced emotional distress through the body (e.g., physical aches and
pains) and the mind (e.g., thinking too much or remembering past suffering) but
avoided a Cartesian division of the two. Rather, their heart-minds were hurt (e.g., tha ba
do / hurt heart-mind). They also expressed their distress somatically (e.g., physical
complaints such as dizziness) and socially (e.g., reporting problems and grieving
openly). Guarnaccia et al. (2003) note that such “somatopsychosocial” (p. 348)
conceptualisations and culturally prescribed patterns occur in many cultures, but differ
in terms of the “particular configuration of experiences” (p. 348). For Karen women, the
perceived severity of a loss or traumatic experience – and in turn the expected and
accepted level of overt expression of distress – appeared to be largely determined by the
social implications of the event. Women who broke from accepted patterns of
experiencing and expressing distress and engaged in culturally inappropriate (e.g.,
excessive overt expression of distress or anger) or abnormal (e.g., disoriented behaviour
such as eating grass and talking nonsense) behaviour risked stigma and being labelled
crazy (dha blu).
9.5.2 Similarities and differences
There are similarities between hso k’moe dha (thinking too much) and idioms of distress
in other cultures. Thinking too much (fikuru boduvun) has been documented as an idiom
of distress amongst women in the Maldives (Razee, 2006). In South East Asia the same
idiom is commonly reported amongst Cambodian (Frye & D’Avanzo, 1994; D. E.
Hinton et al., 2010) and Karenni refugees (Lopes Cardozo et al., 2004). The idioms
padecer de los nervios (suffering from nerves) and estar enfermo de los nervios (being
ill with nerves) described among Caribbean Latinos are characterised by having “too
many thoughts” (Guarnaccia et al., 2003, p. 351). Similarly, D. Pedersen et al. (2010)
describe the Quechua idiom pinsamientuwan (full of worrying thoughts) as a key
category of distress linking worrying thoughts to more severe states of distress.
Moreover, factor analysis of Chinese and non-Chinese Australian participants’
responses to the 35-item Depressive Symptom Questionnaire has indicated that
“thinking too much” (Parker et al., 2006, p. 144) is part of a group of core symptoms
accounting for greater variance than either somatic or cognitive (e.g., anhedonia and
thinking about death) symptoms. Karen women’s notion of a separate though
interrelated heart-mind also parallel conceptualisations of distress reported in Uganda
(Okello & Ekblad, 2006) and Zimbabwe (Patel, Musara, Butau, Maramba, & Fuyane,
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1995). In Cambodia, researchers have reported a similar progression of mental distress
entailed by “thinking too much” and leading to “broken down heart-mind” (van de Put
& Eisenbruch, 2004, p. 137).
It is noteworthy that in contrast to other research with South East Asian refugees (Kohrt
& Hruschka, 2010; Liamputtong Rice, 1999a) no participants in this study reported
karma (the Buddhist concept of good or bad deeds determining prosperity or suffering)
as a factor influencing vulnerability to negative life events or emotional distress. It is
also important to note that participants overwhelmingly did not report traditional Karen
animist beliefs in spirits or souls. The absence of key Buddhist and animist beliefs is
most probably explained by the long-held Christian faith of many community members.
Large-scale Christian conversion occurred in Vietnamese and Khmer refugee camps as
refugees scrambled to access Christian-sponsored resources and resettlement
opportunities (Horstmann, 2010; McLellan, 2004; Smith-Hefner, 1994). Post-
resettlement conversion to Christianity was also common amongst Hmong refugees
(Winland, 1994). It seems likely that these later converts would retain aspects of their
culture’s traditional religious beliefs. In contrast, the Karen are not new to Christianity
and many refugees are likely to have been raised in Christian homes. As Horstmann
(2010) notes: “the Christian Karen are old Christians who have a tradition of
proselytizing among their own ethnic group and other ethnic minorities” (p. 8).
9.5.3 The ubiquity of uselessness
Women’s expressions of heart-mind distress often represented “commentaries on a
social world out of control” (Guarnaccia et al., 2003, p. 348). Women felt “useless” in
their social roles and in their daily lives in Australia. The salience and configuration of
suffering through this idiom is unique and interesting, particularly in the Karen context
of persecution, protracted camp confinement and forced migration. This short plaintive
expression says much about Karen refugee women’s social position. This phrase may
also convey the personal experience of what key informants termed the sponsored
dependency of protracted camp confinement. As we saw in Chapter 8 (see Section 8.5),
Karen elders lamented the societal effects of refugee camp institutionalisation and spoke
of disempowerment, low self-efficacy, apathy and sponsored dependency.
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The notions of uselessness, power(lessness) and loss of self-efficacy share features with
Seligman’s (1975) theory of learned helplessness model which postulates that people
whose efforts to control or improve their lives have been futile may respond by giving
up. Learned helplessness refers to “the feeling that no amount of effort can lead to
success” (Eggen & Kauchak, 1999, p. 412) and may result from repeated failure at
tasks. Few studies have specifically explored the notion of learned helplessness in
relation to refugee populations (John-Langba, 2004). Other research has, however,
noted the potential relevance of the framework for refugee mental health (Colic-Peisker
& Tilbury, 2003; Goran, 2005; Nicassio, 1985). The learned helplessness model seems
particularly suited to contributing to understanding findings from this study with Karen
women where the issues of protracted camp confinement, low self-efficacy, sponsored
dependency and feeling useless were critical to understanding community and
individual wellbeing. Moreover, there is now a substantial body of literature supporting
this model which refugee mental health researchers might draw on in developing further
insights in order to delve deeper into understanding different dimensions, experiences
and needs of refugee populations.
The concepts of demoralisation, entrapment and defeat may provide further useful
frameworks for conceptualising Karen women’s accounts of feeling useless and
distressed. Demoralisation has been described as “one reaction people exhibit when
basic defensive maneuvers – symbolic mastery, escape, or attack – seem futile against a
serious threat” (Frank & Frank, 1991, p. 445; Kissane, 2001; Kissane, Clarke, & Street,
2001). Few studies have explored demoralisation in relation to refugee wellbeing.
However, Briggs and Macleod’s (2006) findings support the notion that, amongst
refugees, depression and demoralisation may indeed be different constructs. The notion
of demoralisation also shares features with Gilbert and Allan’s (1998) argument that
entrapment and defeat (specifically failure in conflict situations) are important factors in
explaining psychological distress. I was unable to locate further published
investigations of Gilbert and Allan’s model in refugee mental health literature aside
from Bhugra’s (2004) suggestion that their model might be useful to refugee
psychology.
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9.5.4 The importance of anger
Participants conceptualised anger (both internalised as hate and externalised as
aggression or suicidal ideation) as a distinguishing feature of more serious states of
emotional distress. These findings have implications for healthcare professionals as,
among Karen, anger may be a better indicator of emotional distress than Western
symptoms such as nightmares. These findings also resonate with anthropology research
documenting cross-cultural differences in the meaning assigned to experiences and
expressions of anger (Briggs, 1970; Lindholm, 2005). Research with Cambodian (D. E.
Hinton, Hsia, Um, & Otto, 2003; D. E. Hinton, Rasmussen, Nou, Pollack, & Good,
2009; Nickerson & Hinton, 2011) and other (Basoglu et al., 2005; Lopes Cardozo,
Kaiser, Gotway, & Agini, 2003) refugee populations also suggests that anger is a
common expression of distress for refugees experiencing psychological problems.
Research with Western trauma survivors has similarly documented a relationship
between anger and PTSD (Chemtob, Hamada, Roitblat, & Muraoka, 1994; Nickerson &
Hinton, 2011). For the Karen, the experience of anger appeared to pose a dilemma. On
the one hand expressions of anger contravene accepted and expected cultural modes of
communication. On the other hand suppression of anger is thought to be harmful and
pose risks to one’s emotional or mental wellbeing. Disentangling this scenario may help
to further understand the emotional experiences and expressions of Karen women.
9.5.5 Balancing ethnopsychiatries
Table 2 provides a summary of the trajectory of distress described in this chapter and
presents a synopsis of the causes, expressions and experiences associated with each
idiom. Like Gaines (1992) and Guarnaccia et al. (2003) I encourage a cultural
constructivist approach to mental health research and intervention which views Western
psychiatry and indigenous ethnopsychiatries as equally culturally constructed.
Nevertheless, I also agree with Miller and Rasco (2004) who contend that “although it is
important to avoid cultural and psychological imperialism, we must be careful not to go
to the opposite extreme and romanticize all things indigenous” (p. 406). In this chapter I
have sought to take seriously and respect Karen women’s conceptualisations of
suffering and the experiences that contribute to their distress without romanticising their
emic beliefs and practices. Kohrt and Hruschka (2010) also caution that idioms of
distress:
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may easily become a vocabulary list without a cohesive framework detailing the
significance of these terms and how they fit into a broader understanding of
suffering and wellbeing in a given cultural context. (p. 326)
Women’s conceptualisations of emotional distress reflected their cultural understanding
that suffering is a universal and inevitable aspect of life. In recent decades Karen culture
and society has encountered rapid change; unsurprisingly I found that participants
expressed “a strange amalgam of modern and traditional beliefs, values, and
institutions, held together in varying patterns of assimilation, complementarity, conflict
and contradiction” (Kleinman, 1980, p. 37). The findings demonstrate that Karen
women’s explanations and experiences of emotional distress reflect cultural values (e.g.,
collectivist social attitudes) and beliefs (e.g., Buddhist and Christian) within Karen
society and are embedded in the context of sustained persecution. Women appeared to
hold a sociocentric and interdependent conceptualisation of self, a notion shared by
other collectivist societies (Geertz, 1979; Hollan, 2010). This collectivist orientation
could explain women’s concern with social harmony and emphasis on interpersonal
explanations for suffering.
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Table 2: Karen women’s trajectory of idioms of distress with causes and descriptions
Trajectory
of distress
Most common and least severe Least common and most severe
Hso k’moe dha Tha… Tha dha hsar Dha blu
Thinking too much Common heart-mind distress Sickness of the heart-mind Crazy
Idiom Hso k’moe dha Thinking too much
Tha… Common heart-mind distress (e.g., tha ba do /
hurt, tha ta mu / upset)
Tha dha hsar Sickness of the heart-mind
Dha blu Crazy
Causes Daily stressors (marital conflict, parenting problems, daily resettlement concerns, worry for those left behind and discrimination) Loss and traumatic war experiences
Daily stressors with emphasis on resettlement stressors especially language, responsibilities of women and interpersonal relationship difficulties (e.g., marital discord and social rejection) Loss, grief (“series of losses”) and trauma (with emphasis on losses and traumas with negative, serious and often permanent social consequences)
Daily stressors with emphasis on marital and family conflict Loss and trauma with emphasis on losses and traumas with negative, serious and often permanent social consequences Inherent vulnerability towards emotional instability
Unresolved tha dha hsar Trauma (witnessing or surviving murder) Genetic or inherited predisposition Supernatural (e.g., witchcraft, spirits and curses)
Experience and expression
Physical complaints (headaches, sleeping difficulties, loss of appetite, lethargy, tachycardia, aches and pains, and high blood pressure)
Physical complaints with emphasis on feeling shaky, dizzy, chest pain and poor blood circulation Focus on social cause of distress Feeling “useless”
Physical complaints Focus on social cause on distress Feeling “useless” Crying and other overt expressions of distress Wanting to die Anger, hatred or desire for revenge
Incoherent speech, talking nonsense Abnormal, disoriented behaviour (e.g., public nakedness or eating grass)
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Chapter 10
We All Suffer. We All Cope: Managing Emotional Distress
10.1 Introduction
This chapter addresses the findings related to the question: How do Karen women
cope with emotional distress? Four categories reflect women’s coping strategies: (a)
self-control, (b) collective self, (c) religion, and (d) professional support. Certain
cultural, spiritual and sociopolitical themes – including those introduced in Chapters 3
and 8 – are reflected throughout women’s discussions on how they deal with distress.
10.2 Self-control
Women firmly located responsibility for coping with emotional distress within
themselves and spoke of the need to “control”, “console” and “calm” oneself when
suffering. This approach is captured in the following quotation from an interview with
Htee Gloh Poh:
I don’t think anyone can help, this just depends on yourself. If you have too much
worry and think a lot you will suffer. You have to control yourself and talk to
yourself; you need to calm yourself down. (Htee Gloh Poh)
Being “strong”, not complaining, concealing or suppressing distress and seeking to
resolve one’s problems before asking others were highly valued virtues. Women
generally had confidence in their own personal strength as well as that of other
women and the wider Karen community and emphasised that Karen women “do not
complain” but simply get on with their daily lives. Women described using several
intrapersonal, cognitive strategies to achieve self-control. In the following sections
these are grouped according to the themes of (a) thought control, (b) distraction, and
(c) acceptance.
10.2.1 Thought control: “think about your thinking”
Women used culturally commonsensical strategies such as thinking about one’s
thinking and then seeking to curb unhelpful thoughts. One group participant
explained: “for me I never keep on thinking things that will make me sick or become
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a problem, I never think of it”. Others in the group nodded in agreement but also
explained that such willpower is easier for some than others.
Leaders reiterated women’s reports and explained that the Karen were familiar with
questioning whether their thought patterns are beneficial and then attempting to
change unhelpful patterns through willpower and recognition of the harm that
unhelpful thinking can cause. Such conscious analysis of the value and quality of
one’s thoughts was promoted as a venerated approach to coping with distress. Mr M,
a Karen key informant, described this cultural wisdom as the primary antidote to hso
k’moe dha (thinking too much): “they put it into practice they think ‘does it work if I
keep feeling like that?’”.
10.2.2 Distraction: “think about something else”
Women also commonly used distraction to avoid troubling thoughts and emotional
distress. By keeping their minds occupied with other activities they found temporary
relief from their suffering. Approaches to distraction included explicitly solitary
activities, some of which were religion-oriented (e.g., praying or reading the bible)
and some of which were not (e.g., reading a secular book or watching television).
Women also distracted themselves through their religious and secular interpersonal
connections.
Both women and Karen key informants implied that some methods of distraction
(e.g., media, gambling, sex and alcohol) were “not the right way” and considered
them to be less desirable than sheer willpower or religion-oriented approaches. This is
reflected in the following quotation from an interview with Mr M, a Karen leader:
They try to forget about [their problems] … by watching movies in Thai, Burmese,
even Korean … Even I find myself [distracting] this way. Whenever I have a lot of
pressure when I look at the TV I forget about that. I know that’s not the right way.
(Key informant – Mr M)
Opportunities for “quick fix” distractions though frowned upon strategies had
proliferated in resettlement. Accessible movies, television and pokies were a recent
phenomena for many Karen. Most were originally farmers or rural villagers prior to
spending years or even decades in refugee camps where access to technology was
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very limited though substances such as betel nut and alcohol were readily available
(see Section 3.4.2).
In contrast to the “negative” distraction strategies, community-oriented and
interpersonal distractions were generally described in wholly positive terms. Women
described “keeping busy” by visiting friends and family, and joining in community
and religious activities. This helped them to distract from their problems and
overcome or avoid isolation. Moreover, through their connections they found
opportunities to help others, which in itself was viewed as a coping strategy (see
Section 10.3.3). In the following quotation Dr V captures the various benefits of
distraction through connection:
Coping strategy? They keep themselves busy. I encourage them to join any
volunteer groups just to keep them busy. Those who are depressed or have anxiety
tend to see and think negatively once they have spare moment. Some of the
survivors of domestic violence and past trauma are now quite happily involved with
their own religious group activities. They feel part of the community and part of the
events. It is quite a rewarding experience to see them doing something for others –
which helps them at the same time. (Key informant – Dr V)
These solitary and collective approaches to coping were implicit in women’s
discussions though they did not explicitly distinguish between them. Collective or
interpersonal approaches to coping are explored in greater detail in Section 10.3.
10.2.3 Acceptance: “you have to accept reality”
Women also coped through acceptance and frequently spoke of “accepting the
reality” of their situations. In the following quotation, Hpä Hpaw Mu articulates this
widespread commonsense approach to coping with distress:
You talked about your experiences after your son died. Did you have tha dha
hsar [sickness of the heart-mind] then?
For those who are not able to control their mind they will get tha dha hsar … For
example if one of your loved ones dies, you need to accept the reality. You need to
know that we are just human beings, we are born one day and we will die one day,
acceptance. (Hpä Hpaw Mu)
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Women described coping through accepting both negative internal (physical,
psychological and emotional) and external (e.g., interpersonal and environmental)
experiences as unavoidable aspects of human life.
10.2.4 Contextualising a controlled self
To better understand the importance, complexity and role of self-control for the
Karen, it is necessary to examine their religious and sociopolitical context.
Karen women’s matter-of-fact approach to self-control through (a) sheer willpower,
(b) distraction, and (c) the application of cultural beliefs regarding the acceptance of
suffering shares distinct similarities with Buddhist principles and teachings which
promote:
(a) adopting an observational attitude to affective and mental processing, (b)
controlling attentional focus, [and] (c) maintaining a present-oriented mental
state (in contrast to a past-oriented mental state, e.g., anxious expectation). (D.
E. Hinton, Safren, & Pollack, 2006, p. 279)
Kleinman (1995) argued that all of the world’s major religions consider human
misery as “a defining condition of people’s existential plight” (p. 181). However,
acceptance of the “ubiquity of human suffering” (Hayes, 2002, p. 58) appears to be
made most explicit in Buddhist doctrine (Kinzie & Friedman, 2004; Levine, 2006;
Rotem, 2003). In her research with Cambodian refugees, Liamputtong Rice (1999a)
described “acceptance and detachment” as “distinctly Buddhist approaches to mental
health” (p. 215). However, it is important not to over-emphasise religious
characteristics as the central mechanism steering women’s approaches to coping. It is
seductive and easy to fall into the trap of conceptualising refugee communities as
culturally static (P. Guerin & Guerin, 2007) and reducible to traditional
characteristics. Eisenbruch (1983) also warned against making assumptions about the
importance and relevance of traditional or religious belief systems in the lives of
migrants. He wrote:
Individual patients are usually unaware of the details of their “great tradition”,
whereas the well-intentioned Western observer, having read the classic texts
… may superimpose his own construction of Eastern beliefs upon his
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preexistent Western medical viewpoint. This may well distort, rather than
clarify. (p. 325)
Karen culture is dynamic and currently in rapid transition as a result of forced
migration and the majority of participants did not conceptualise acceptance as a
religious or spiritual practice. Karen culture is, historically, firmly rooted in a
Buddhist tradition and though many Karen refugees are now Christian, long-held
Buddhist beliefs appear to be reflected in their cultural wisdom. It is sometimes
difficult, and perhaps artificial, to make distinctions between culture and religion as
the two are so deeply entwined and multiple religious perspectives so readily
combined amongst the Karen (Platz, 2003) and Burmese (Pfanner, 1966).
A sociopolitical lens provides further insight into the origin and role of self-control,
acceptance and stoic silence. The findings concerning the importance of stoic silence
and self-control resonate with research from anthropology and psychology which
demonstrates that Asian and other collectivist cultures encourage emotional
suppression more than Western-European populations (Butler, Lee, & Gross, 2007;
Goodman, 2004; Liamputtong Rice, 1999b; Wierzbicka, 1994).
In collectivist societies powerful expressions of distress or anger are typically
discouraged and behaviour kept in order by the threat of shame to the guilty party as
well as her family (Gudykunst & Bond, 1999; Hofstede, 2001). Karen key informants
similarly located cultural attitudes towards the expression of affect within this
religious and cultural milieu:
This is a cultural issue, Paula. Purely cultural issue. Even the Karen women who are
Christians, the Buddhist teaching is deeply rooted in the society. So that’s the reason
they don’t express their, I think, real feelings and real emotions in front of the other
people … they never or they never shout or cry … Karen women never do that.
(Key informant – Mr J)
Karen women similarly conceptualised the practices of controlling one’s thinking and
expressions of distress as a means of avoiding shame and stigmatisation. Expressed
psychological distress was seen as a weakness and women reported that it was
“shameful” to indulge in talking about one’s own distress (except perhaps to one’s
closest confidant). Stoic silence demonstrated strength and women expressed
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admiration for people who showed patience and endurance in the face of adversity.
As discussed in Chapter 9 (see Section 9.4.2), women who overtly expressed distress
or reacted excessively to a situation considered traumatic were likely to be labelled
“crazy”; a label they would carry “for the rest of their life”:
We have this conception that if you are feeling something you don’t show it, you
don’t express it, you sort of keep it to yourself … By showing emotional pain or
stress or anxiety, it’s sort of [like], people see that it’s a weakness. So when a
woman starts to, you know, behave outside of that perception then they would
automatically say that she is having a mental breakdown, so it’s sort of like she’s
going crazy. That’s why people don’t often show their distress. (Key informant –
Ms K)
Some key informants described self-control, and particularly stoic silence and
acceptance, as a “kind of denial” creating “hidden problems inside”. They were
concerned about the potential ramifications of not expressing distress and thought that
women’s ability to cope could in fact be hindered by unexpressed and unresolved
emotional suffering.
The development and strengthening of a “controlled self” may also be seen as a
consequence of (and an approach to managing) conflict and persecution. In short,
stoic silence and self-control may be necessary for survival. Within the Karen context
of persecution, overt expression of distress could easily disturb others and agitate the
insecure political environment. Unstable and overtly distressed individuals could
place the safety of the wider community in jeopardy. These factors are reflected in the
following quotation from an interview with Ms K, a Karen key informant:
I think it’s more than [loss of] face … Because we have been in war, if you look at
the history generation after generation have been through war so people have to be
strong. It’s become hit into your head so much that you don’t show weakness, you
have to be strong for your family … Karen people are very collective people they
are always together, do stuff, work together. So if one person doesn’t show
weakness, other people won’t either. They might be doing it [suffering] quietly, you
don’t know. (Key informant – Ms K)
Stoic and phlegmatic reactions to war-related suffering are not unique to the Karen.
For example, in his World War II memoirs, Scotsman George Fraser (1992),
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described the potential harm and social disruption of overt expressions of distress. For
Fraser “The celebrated British stiff upper lip, the resolve to conceal emotion which is
not only embarrassing and useless, but harmful, is just plain common sense” (1992, p.
89).
Protracted war is likely to have influenced Karen women’s beliefs about, and
approaches to coping with, distress and suffering in other ways also. As we saw in the
previous chapter (see Sections 9.3.2 and 9.4.4) women accepted sleeping difficulties,
nightmares and sadness as normal given their experience of persecution and forced
migration. Experiences such as nightmares were described as “very small things”
while, as Mr P, a Karen key informant, noted: “the big thing is to survive”. Mr P
located the experience of nightmares and emotional distress within a context in which
daily survival needs remained a priority, consequently reducing the perceived impact
and attention paid to sufferings less vital to maintaining life. This understanding is
analogous to Maslow’s (1954) hierarchy of needs. Maslow postulated that basic
physical needs must be adequately addressed before individuals and communities
address other aspects of human life. The historically recent Western pastime of
analysing one’s emotional experiences is not likely to be relevant in situations where
survival is the number one priority. As Ms K, a Karen key informant, reported:
The Karen people who were born on the borderline before they went into the camp,
normally they have lived through the whole revolution, the whole civil war, they
might consider that this is you fighting for your freedom and everyone goes through
it, they don’t see any effect. Not that it isn’t affecting them, but they just don’t have
the time to analyse or process it, they are just trying to live. Trying to live and trying
to cope. (Key informant – Ms K)
Mere survival has dominated life for Karen refugees, thus reducing opportunities for
intensive self-reflection. Resettlement in Australia may be viewed as another phase of
learning to “survive”. Many participants still struggled with daily living, poverty and
the acquisition of skills required to simply survive in the Australian context (see
Chapter 8). Those who were focused on addressing their daily needs were perhaps
unlikely to have the time or inclination to analyse their emotional worlds. Moreover,
hyper-analysis of suffering is not a feature of Karen culture. Their emic models of
distress and mental illness (see Chapter 9) dictated that thinking about one’s suffering
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was nonsensical and was both a cause and symptom of mental illness. Emotional
suffering such as periods of sadness were normalised and generally regarded as likely
to “settle down” with the passing of time. An understanding of these various issues
helps to contextualise women’s approaches to coping, particularly their emphasis on
self-control.
10.3 Collective self
A sense of collective solidarity and communal identity or self was also implicit in
women’s approaches to coping.
10.3.1 The collective self and communal suffering: accepting and normalising
suffering
The concept of acceptance was extended beyond a diffuse acknowledgment of human
suffering into a specific acceptance and normalisation of the suffering of the Karen
people. Women were able to normalise their own adversities and distress within that
of their peers and reached acceptance through this shared suffering. For example,
when Lah Luh described witnessing the brutal murder of her family she did not
ruminate over the severity of her experience or her suffering. Rather, she concluded:
“my experience was the same as other refugees”. Karen key informants reiterated that
women found some relief in knowing they were not alone in their suffering:
Traditionally Karen women are very quiet. And, they strongly believe that people
always suffer from different kinds of things. So, they are not alone. So, let’s say
[their] husband [is] killed, or maybe [their] children [are] killed, they are thinking
“Ah, I am not alone”. (Key informant – Mr J)
Suffering was not only accepted within women’s cultural worldview, it was their
dominant sociopolitical experience. Participants emphasised that encountering
extremely traumatic and difficult experiences was the normal state of affairs and had
been so for generations of Karen. It was accepted and normalised because it was the
normal experience, as clearly reflected below in Ms K’s words:
They start to see traumatic experiences as part of their daily life, so they sort of
normalise [it] and they wouldn’t see anything [wrong with it]. It’s [not] un-normal
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because this is what they would grow up with, their parents and their grandparents
[too]. (Key informant – Ms K)
Leaders and other Karen key informants concurred with Ms K. In the following
quotation, Mr J illustrates how one woman coped through contextualising and
normalising her suffering within that of her peers:
She said “my husband was killed by the Burmese soldiers in front of me, my
daughter was raped by many Burmese soldiers in front of me, my children were
killed by Burmese soldiers in front of me. I feel terribly sad for my family. But,
what can I do?” … Even she can say, “I can cope with that kind of situation because
nobody [is] free from suffering, so many Karen women have similar experiences
like mine”. (Key informant – Mr J)
Women often compared their loss(es) and trauma(s) to those of their peers and went
on to minimise their own adversities through explaining that certain features of other
people’s loss(es) were more severe than their own problems. Here again, women’s
accounts conveyed the degrees discourse of stress, loss and trauma (introduced in
Section 9.3.2) in which the seriousness of a stressor correlated with the negative
social implications associated with it.
The strategy of normalisation is shared by other populations affected by political
conflict for whom “collectivizing personal trauma” (Guribye, Sandal, & Oppedal,
2011, p. 2) is identified as a coping strategy. For example, Tamils perceive of
themselves within a larger traumatised community rather than as traumatised or
suffering individuals (Guribye et al., 2011; Somasundaram, 2010).
Key informants likened acceptance and normalisation to “psychological
desensitization” that made one “immune” to severe mental health problems. To these
participants such coping is quite predictable and common to war-affected populations
as reflected below:
I’d say that we all have to desensitise ourselves, we all do. Particularly those who
are coming out here as refugees. It’s a coping mechanism for them. I doubt that we
would be any different to the millions of Poles who went through the second World
War and the Nazis in the camps over there. (Key informant – Dr G)
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The findings suggest, perhaps paradoxically, that some people may cope better with
widespread suffering than individualised and isolated negative experiences. Indeed,
the collective and universal nature of Karen women’s suffering appeared to help them
make meaning of their own personal adversities:
There are so many [people with] similar problems in the community so they think “I
am not alone”. It is a kind of solution. If a Karen woman faces that kind of problem
alone – if other women [were] free from that kind of problem – [then] maybe [she
would feel] very sad when she [looks at] other women happy and with children and
husband … [Then she would think] “Oh, I lost my husband, I lost my children, I lost
my property, my rice, my paddy, everything, you know”. But, in [the] Karen
community, most of the Karen women suffer you know, similar problems, so [she
thinks] “I am not alone. So many people suffer like that. It’s normal. So I have to
face it, I have to adapt”. It’s a kind of solution I think. (Key informant – Mr B)
However, key informants often also conveyed a flipside to the benefits of such
collective acceptance and normalisation and expressed conflicted views about its
function and value. Some hypothesised there could be psychological consequences
“happening inside” because of accepting, normalising and not expressing one’s
troubles, although they were unclear on how that might manifest:
Karen women feel “everybody suffers like that so I am not alone”. So, it’s a good
thing in one way but I feel we should try to help them because of hidden problems
inside. (Key informant – Mr J)
Key informants described acceptance as (a) a cultural characteristic of the Karen, (b)
a protective and adaptive coping strategy, and (c) a harmful consequence of forced
passivity in refugee camps. As discussed in Chapter 8 (see Section 8.5), these leaders
explained that cultural attributes such as acceptance, quietness and reluctance to
complain were strengths that had partly helped the Karen to survive war and forced
migration. However, they lamented that years of persecution and particularly
protracted camp living had warped these cultural traits into forms of fatalistic
acceptance and apathy, idleness, helplessness and emotional distress. Some leaders
also indicated that coping strategies such as acceptance were not as effective in the
resettlement context. They bemoaned instances of fatalistic acceptance and apathy
amongst community members and perceived this as a major hindrance to them
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successfully navigating life in Australia’s “individualistic” and “competitive” society.
Their reports echo Bhugra’s (2004) argument that acculturation into individualistic
cultures may be particularly difficult for migrants from sociocentric societies.
The paradox of acceptance and normalisation was articulately described by Mr W, a
Karen key informant. He began by describing the Karen as accepting and “easy
people” who “are content” and will endure the hardship of persecution and camp
living if their basic needs are met. However, he then described the demoralised
“mindset” and dependency of those who lived in refugee camps for decades as
characterised by “lack of ambition, lack of purpose, just one day at a time”. To him
their acceptance of an inhumane and restricted existence had gone too far. Yet, Mr W
acknowledged “acceptance” of fate and taking “one day at a time” as a coping
mechanisms that enabled people to “still sing” despite their suffering:
[Acceptance and taking one day at a time] can be negative and yet can be positive
too. Why are they still singing when they don’t have eyes? They don’t have legs.
They don’t have hands. You have been there on the border, you’ve seen the
landmine victims – they are still singing. It’s heart breaking isn’t it? But inside them
there is a part that can still sing. (Key informant – Mr W)
10.3.2 The collective self and communal support: “we support one another”
Collective solidarity and the collective self also helped women cope by providing
them with access to emotional support as well as material necessities and practical
help. Within their community, Karen women described turning to family, friends and
community leaders. They reflected on such social support as a fundamental and
critical component of their wellbeing and daily survival in Australia and explained
that these support networks were generally their first point of contact for material and
practical needs such as money, childcare, transport or help translating a document.
Karen women seldom publicly expressed their distress though they described
exposing their intimate feelings to family members, same-sex peers and, occasionally,
community leaders. Women’s wider group of friends and family also provided them
with casual support via distraction through engaging in pleasurable activities such as
picnics, as well as emotional support through informal discussions of their problems
and sharing experiences. Women chatted and shared their problems informally during
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communal activities such as food preparation. Participant observation provided
several opportunities to witness and partake in women’s collective discussions about
their problems. In these group contexts women were forthcoming in sharing their
common daily stressors (e.g., parenting) and often used humour to lighten the load of
their shared fate. The following quotation comes from an interview with Mu Htòh in
which she described a group of women discussing their marital problems whilst
cooking food and washing dishes at a community gathering:
They express their feelings sometimes, [they say] “her husband is like that”, “[my]
husband is like this”. But we cannot solve the problem, only talking, expressing
their feeling. (Mu Htòh)
In the above quotation Mu Htòh emphasised that the women were “only talking”
rather than solving the problem. This distinction was another important theme in
women’s conceptualisations of coping. It brings to light distinguishing features of
how women sought support and the type(s) of support or service they expected to
obtain. Women had difficulty articulating exactly how “only talking” helped them to
cope. Like Mu Htòh they referred to “expressing their feeling”. When “only talking”,
women occasionally received some advice, information or ideas in relation to their
own problems. However, obtaining advice on problem solving did not appear to
define the benefit women obtained from sharing experiences with their friends.
Rather, relating to each other’s “shared” experience appeared to be a critical factor for
coping through “only talking”.
Community leaders also made clear the subtle but crucial distinction between (a)
“only talking” or emotional support, and (b) practical support. They reported being
most commonly called upon to provide practical support including information,
referrals and advice but also noted that some people sought their emotional support.
When women sought support from leaders, the implicit or explicit acknowledgement
of a shared experience remained vitally important. Women valued their leaders’
advice because they had experienced comparable situations and could offer their
wisdom, experience and knowledge of how to cope. This suggests that, for Karen
women, emotional or psychological support (i.e., talking therapies) are perceived as
beneficial when provided by one who shares the same social (i.e., cultural,
experiential or political) or circumstantial experiences and understandings. Leaders
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also explained the ways in which women expected and accepted their support.
Women were unlikely to schedule regular meetings but rather sought “informal”,
irregular contact when needed. These findings have implications for service providers
which will be explored in Chapters 12 to 14.
Karen communities have traditionally sought support from community leaders for a
variety of matters from relationship disputes to macro-level decision-making affecting
the community (H. I. Marshall, 1997). In the refugee camps, Community Elders’
Advisory Boards, in conjunction with other organisations, oversee the management of
camp communities (Thailand Burma Border Consortium, 2011a). In the Australian
resettlement context, community use of leaders also appeared to reflect the sponsored
dependency and helplessness that leaders spoke of (see Section 8.5) as many women
expected quite exhaustive support from their community leaders. Community leaders
confirmed that they had become a “one-stop shop” for resettlement needs including
immigration issues, resolving family disputes, parenting, translating documents,
arranging transport and finding housing.
The demand and need for support from community leaders was patently clear during
participant observation encounters. When I visited their homes, new requests for their
assistance would come in regularly. Community leaders were also proactive in
providing support. In some instances their help was not directly sought but, rather,
they heard of people or families in difficulty and consequently visited their home.
During those visits the specific problem or suffering would not always be explicitly
discussed. Sometimes the leaders would simply provide a social visit and all present
would pray together, an approach depicted in the following quotation from an
interview with a Karen leader:
Even when there is a problem between kids and mum or kids and dad and we hear
about that sometimes we go. We don’t say anything about it [the problem], we just
go and pray with them and give support. (Key informant – Mr P)
In the following quotation another leader, Mr H, acknowledged the role of religion in
the support provided by elders, as well as the importance of shared experience:
What sort of help would they be seeking?
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To console them … maybe through words and maybe through some, how do you
say, some treatment we will say – you know, being friendly in manner, empathy and
sympathy, something like that, consoling words with some scripture or something
like that … Not only with these scripture things, they [the elders] console them with
sharing their experience, what they have been through, what they think, how they
coped with the situation, that sort of thing. (Key informant – Mr H)
10.3.3 “Sharing and caring”: helping others to help oneself
Social engagements in the Karen community often involved activities directed at
helping others. For example, most community celebrations aimed to raise funds
(through food stalls) to send back to people in Burma or on the Thailand-Burma
border. As discussed (see Section 8.3.3), women also personally sent money back to
help friends and family. In addition, women helped fellow Karen in Australia with
financial support, accommodation, understanding correspondence, childcare, transport
and language difficulties. During the course of the research some Karen women (and
other community members) also travelled back to the border temporarily in order to
help and share professional skills and knowledge they had acquired in Australia.
Women explained their desire to help and their happiness to do so though a few also
acknowledged the stress this placed on them and their families.
Seems like I’m a busy person now – no time to stay home. After I drop the children
at school someone will call, definitely someone will call. They ask “will you be
available to accompany me somewhere?” Even today, the neighbour has asked
whether I will be available this evening. One of his sons has an appointment and
wants to go and look for the venue tonight so he doesn’t get lost tomorrow. I want
to help people wherever I can. (Ta Heh Sōo)
Because of her English language proficiency Ta Heh Sōo was often asked to spend
entire days assisting community members. She frequently acted as an unofficial
interpreter at hospital and GP visits. Whilst Ta Heh Sōo sometimes found this
demanding, she also appeared to gain pleasure from helping and a sense of self-worth
from possessing skills that others valued.
Karen key informants highlighted the value of helping others as an important feature
of Karen cultural approaches to coping and healing. This may be understood as an
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extension of a collectivist culture whereby “maintaining the group’s wellbeing is the
best guarantee for the individual” (Hofstede, 2001, p. 211). It is also a distinct
characteristic of Buddhist (Nash, 1966) and Christian (Wuthnow, 1991) religious
traditions, which are prominent among Karen. One Karen key informant who had
suffered imprisonment and torture due to his political opinions spoke of the
transformation of such a negative experience into “positive” emotions through a
commitment to helping others:
I was detained. I had some sort of maybe serious anger against authorities,
interrogators, men with uniforms, dark rooms, solitary cells. I still remembered
those things … When I met with [other] former political prisoners in Thailand I
asked them, did you visit counselling services once or twice? I learnt a lot from
them … [They said] “we don’t solve anything medically [or] psychologically” …
They told me that as a former political prisoner the best way for me [to cope] is to
help other political prisoners. I’m very happy to know that. So what I mean is … the
Karen women face, I think, very terrible situations. They lost their husbands, they
lost their children. So many terrible things, the best thing [for them is to] join some
sort of community group to support [other] women and children who lost their
families. Sharing and caring … We transform our emotion into a positive way. This
is the reason I stayed doing this advocacy. In my case, somebody asked me “why
are you crazy about advocacy?”. I am not crazy about advocacy! I am trying to help
my people be free from torture and free from disappearing without informing their
family members. Free from arbitrary detention. As long as I help them I am happy. I
don’t have money but I am happy. (Key informant – Mr J)
Mr J’s words reflect the notion of altruism and his observation of the positive impact
of altruism on mental health is supported by previous research (Baetz & Toews,
2009). Like Mr J, other participants contextualised their altruism through their
politically-motivated concern for the Karen people. In addition, several Karen key
informants reported being guided by their religious convictions (i.e., to serve others as
God’s work):
In every way that we possibly can we’re involved and I try to help, that’s our
mission, that’s all I can say. It’s God working through us. (Key informant – Dr G)
According to research, such strong political and religious beliefs may enhance
psychological wellbeing. Brune et al. (2002) conducted a retrospective analysis of
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therapy outcomes for 141 refugees treated at therapy centres in Germany and Sweden.
The refugees had received psychotherapy accompanied by medical and social support
for an average of 21.5 months. There were no significant differences in patient
outcome (as measured by psychometric test scores) between the type or duration of
psychotherapy offered or the use of psychopharmacological treatment. A firm belief
system (either political or religious) was the only predictor of symptom reduction.
Altruism as a coping strategy has been reported in research with Burmese political
dissidents living in exile (Allden et al., 1996), Sudanese refugee youth in America
(Goodman, 2004) and Holocaust survivors (J. P. Wilson, 1995). In his thesis on Karen
refugees on the Thai-Burma border, Fuertes (2007) reported:
Helping is a dominant theme among Karen refugees in terms of making them
feel useful about themselves and validate their belief that refugees as they are,
they can still make a difference in the lives of other people … [it] gives many
of them a sense of meaning and purpose in their life (p. 367).
Refugees in Australia are noted to regularly engage in volunteering activities
(Refugee Council of Australia, 2010) and refugee women who volunteer report
gaining benefit from viewing themselves as actively shaping and improving society
(Working Lives Research Institute, 2005).
Whilst women did enjoy altruistic and loving relationships within their families and
community, these findings do not negate (and should not obscure) the reality of
intragroup tensions and divisions that restricted some women from accessing social
support. The social relations of resettled refugee communities are characterised by
continuations of war-related partitions and hostilities, and the repercussions of broken
trust. Women’s social networks were also conditioned by gendered and sociopolitical
structures that often limited their ability to assume roles and responsibilities within
their social networks. Like McMichael and Manderson (2004) I found that gossip
served as a source of distress and “a mode of community surveillance” (p. 95) of
women who violated accepted cultural mores. Tilden and Galyen (1987) have called
for attention to the “darker side of social support” (p. 9) after reviewing evidence that
social conflicts may relate more strongly to wellbeing than social supports.
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This section has explored how Karen women coped through their collective
community networks. Women expressed a strong sense of connection to the wider
Karen community in the homeland and abroad and this was visibly apparent in their
homes. In every home I entered, Karen national calendars, posters of Karen national
leaders, and maps of Burma and the Karen nation hung on the walls. Women made
meaning of their problems through accepting and normalising the collective suffering
of the Karen community. They sought support from their friends, family and
community leaders. They also coped through being of use to others. All Karen
participants distinguished between (a) “only talking” or emotional support, and (b)
practical or material assistance. Both types of support were primarily obtained within
the Karen community and both were underpinned by the value placed on the shared
experience. These themes continue to weave throughout the remaining sections of this
chapter, which explore how women coped through religion and by way of
professional support services.
10.4 Religious coping
The only way to heal is through the spiritual – Buddha or Christ (Statement heard
during participant observation on 20 September, 2009).
10.4.1 “Through God’s strength”
Most participants (whether Buddhist or Christian) spoke of their religious faith as
central to their emotional strength and wellbeing. The following quotation from an
interview with a Karen key informant clearly suggests the importance of religion to
most Karen:
[Those who] cannot accept [their suffering], just yield it to God or to the righteous
one, something like that. Some spiritual figure, or spiritual belief. Bear what we can
bear, but if we can’t, just hand it over. Where? Who? We don’t know exactly, but
the righteous one, the almighty one, creator, or God almighty. Even with animist
Karen, it’s like sort of, creator or the owner of the universe or this land, something
like that … They try to console themselves, or comfort themselves, because of their
spiritual belief. I don’t want to say religious belief, but spiritual belief. (Key
informant – Mr H)
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Participants’ accounts suggested that, for some Karen women, encountering adversity
may have led to a deepening of their religious faith. Models of posttraumatic
psychological (Tedeschi & Calhoun, 2004a, 2004b) and spiritual (Bray, 2010; Grof &
Grof, 1989) growth similarly suggest that people can experience positive changes in
their personal philosophy or worldview and religious or spiritual understanding after
severe life stressors. Karen women reported that their faith provided them with a
sense of “strength” and many spoke of “surrendering” their problems to God:
If that person is a Christian, it is our religious point of view that they should
surrender their sickness, their worry or their thinking to God. Also, in the Bible, it
says you don’t have to worry, you surrender everything to God and you will be free.
So, pray harder. (Mëh Luh)
Like Mëh Luh, several other Christian Karen women reported that they were
encouraged to “pray harder” as prayer was expected to resolve their suffering:
The other thing is, before you can have a nightmare, you are always told, I think
everyone is told this, not only women, if you are Christian you are told to pray
before you go to bed so you don’t have a nightmare. So, that’s one of the reasons
that the first question someone’s going to ask you if you have nightmares is “Did
you pray last night?” (Key informant – Ms K)
These comments suggest that people who suffer nightmares might be blamed for
failing to protect themselves through religious practices. Baumeister and Exline
(1999) note that individual judgment and guilt with regard to failures to exert self-
control are prominent in Christian thought. In his review of religion, spirituality and
mental health, Koenig (2009) also noted that religious teachings (of any tradition)
have the potential to exacerbate fear and guilt amongst followers. I did not
specifically inquire as to whether participants felt blamed or guilty in relation to their
nightmares. However, the apparent ease with which a large number of participants
(including key informants) provided first-hand accounts of nightmares suggests that
they did not feel ashamed or stigmatised for having failed to prevent their dreams.
10.4.2 Religious community
Religious organisations formed the centre of the Karen community in Sydney and
religious gatherings and practices marked some of the most widely attended and
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regular social activities for most Karen women. Participant observation confirmed the
critical importance of the religious community. I not only attended dozens of religious
events but also noticed that women often introduced or identified other Karen women
by clarifying which religious subgroup they belonged to. Most religious events in the
community were Christian-oriented. Buddhist participants appeared to attend fewer
faith-based social events but still regularly visited their local Buddhist temples and
also meditated and prayed in their homes. In the following quotation, Ms K, a Karen
key informant, emphasises the significance of the religious community. The practice
of normalisation is also woven into her account of coping through religious
involvement:
Grief is part of life … everybody’s going to go through it and when it happens your
whole community or the church, monastery, temple will support you … Mostly they
cope with religion, even the Buddhists cope with religion as well. The Christian too
… The other thing is the degree of getting involved with the religion, some women
sort of devote their life to church and church activities. For them it’s a coping
strategy. (Key informant – Ms K)
Others such as Dr F similarly emphasised the importance of the religious community
in women’s lives:
What are women’s main coping styles?
Spiritual, spiritual coping fits with their lifestyle. The lifestyle for women is more
about communal activities, supporting others, extended families, friends, that sort of
thing. So the church or the monastery is the main one … Rituals are very important.
Church, congregation, support, pastoral care, I think these are very important. (Key
informant – Dr F)
For Christians, pastoral care was an important aspect of religious-oriented coping.
Pastors played a pivotal role in the community and often visited (or were visited by)
congregation members experiencing stressful life circumstances or emotional distress.
Like other community leaders (see Section 10.3.2), pastors were quick to highlight
that, in the Australian context, they were increasingly called upon to help with
practical resettlement concerns such as housing and document translation as well as
legal and medical emergencies.
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The research findings suggest that religion served multiple functions in the lives of
Karen women. Women’s religious faith appeared to give meaning to their suffering.
Religious organisations also offered distraction, normalised problems and suffering,
provided opportunities for self-efficacy (e.g., through helping others) and gave
opportunities for informal problem solving. Pastors, like other community leaders,
were seen as a “one stop shop” for spiritual care, advice and practical assistance with
a host of resettlement needs. Religion also permeated women’s intrapersonal coping
strategies where they used prayer and scripture to aid their self-control and acceptance
of hardship. These findings are consistent with Pargament, Koenig and Perez’s (2000)
model of religious functions as sources of meaning, control, comfort, spirituality,
intimacy and life transformation.
These research findings also resonate with coping research around the world and
amongst both general and psychiatric populations (Koenig, 2009). According to
Schuster et al. (2001), 90% of Americans surveyed after the terrorist attacks in 2001
reported coping through “turning to religion” (p. 1507). Similarly, research across
multiple refugee populations has reliably identified religious coping as a primary
means of accessing spiritual, emotional and practical or material support (Brune et al.,
2002; Goodman, 2004; Halcon et al., 2004; Khawaja et al., 2008; Pahud, Kirk, Gage,
& Hornblow, 2009; Sachs, Rosenfeld, Lhewa, Rasmussen, & Keller, 2008;
Schweitzer, Greenslade, & Kagee, 2007; Wuthnow, 1991). Religious involvement
post-resettlement may also help refugees to re-establish identity and can provide both
physical and mental links to the homeland (Mayer, 2007). Notably, a recent
ethnographic study of the resettlement processes of Karen refugees in the United
States similarly found that Christian organisations were central providers of support
(Kenny & Lockwood-Kenny, 2011).
10.5 Professional support: coping and service providers
Women described seeking external help from service providers only as a last resort.
They also again made a subtle but important distinction between practical (e.g.,
financial or medication) and emotional (e.g., “only talking”) support, noting that
professional service providers were most relevant to their practical needs only. This
section explores how and when women sought support from Australian service
providers.
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10.5.1 Doctors
Doctors were seen as essential to wellbeing and all women interviewed reported
attending a GP. Women were adamant that anyone suffering from tha (heart-mind)
distress or severe mental illness should immediately visit a doctor. They also almost
universally expressed the belief that medical care could only address the physical
aspects of their suffering. Consequently, they thought it was nonsensical and
inappropriate to discuss their broader social problems with their GP:
Definitely the doctor can’t help with family issues, children issues or husband
problems – he can’t help with this. She should go to the community and some of the
organisations that specifically help children. (Participants in Group C)
Similar attitudes have been documented in other populations. Like Chinese
Australians, Karen women primarily viewed doctors as a source of medication only
(Chan & Ritchie, 2011). Al-Busaidi (2010) found that some Omani women believed it
was “inappropriate culturally to talk to the doctor about their private lives” (p. 8)
despite viewing their psychosocial stressors and physical health complaints as
interrelated. This distinction between the physical and social was made clear in the
narrative of Lah Luh, whose somatic and emotional expressions of distress included
“popping” sensations in her stomach and sharp pains radiating to her head as detailed
in Chapter 9 (see Section 9.4.5). In addition to suffering from hypertension, Lah Luh
attributed many of her physical complaints to the stress of her son’s behaviour
problems. She frequently cried and spoke of wanting to die but although she regularly
visited her GP she did not consider it appropriate to tell him about her emotional and
social distress. Instead she spoke only of her “body” problems. Likewise, Mu Htòh
clearly explained that such concerns were not topics to discuss with one’s doctor:
Not about that, no! Never, never! This is our private affair, we only go to the doctor
for our headaches or body problems. For the mental we never go … never tell him.
We only tell him “I can’t sleep, I can’t eat”. (Mu Htòh).
Some GPs were aware that their Karen patients were unlikely to freely disclose their
emotional suffering and social problems. They explained that Karen women more
commonly sought their help for the somatic aspects of their distress – particularly
headaches, high blood pressure and abdominal pains. Dr N reported that medical
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professionals must be attuned to Karen women’s cultural expressions of distress or
they could misunderstand their patients’ problems:
They dare not express it, they won’t say “I’m depressed”, [or] “I’m down”. No
[instead] they will say “I’ve got a headache, stomach-ache” because the mental
illness is stigmatised. But if the person giving the treatment isn’t familiar with this it
will be missed. (Key informant – Dr N)
Other key informants also highlighted the role of stigma and shame. They believed
that Karen women were particularly unlikely to discuss their problems associated with
rape and domestic violence:
For the women to come out and tell you openly that she has been raped or sexually
harassed, oh no, we have to be very subtle about it … [Also] there is a stigma
attached to mental illness and they suspect that. They will tell you that they can’t
sleep and then when you take it further the insomnia might be flashbacks actually,
or it might be certain deep anxieties or whatever. You have got to probe a little bit.
(Key informant – Dr G)
10.5.2 Australian service providers
In addition to doctors, participants suggested using a range of other service providers
(e.g., psychologists, psychiatrists and counsellors) to help with emotional distress.
Women speculated that these service providers might be “helpful” but were generally
unsure of “how” such professionals could help other than providing medication or
helping to practically deal with one’s problems. I was unable to obtain any first-hand
accounts from women who would disclose having sought emotional support (rather
than practical assistance, e.g., document translation) from counsellors, psychologists
or psychiatrists outside of the standard mental health assessments undertaken as part
of resettlement and orientation (described in Chapter 4). Unanimously, women did not
perceive these services as relevant to their own personal needs and therefore did not
identify them as strategies for coping with their own distress. However, when
discussing idioms of distress, women explained that a psychiatrist or psychologist
might be necessary to help someone with severe tha dha hsar (sickness of the heart-
mind) or dha blu (mental illness). Typical of women’s comments, Mëh Luh reported:
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I’ve never been there. I’ve never heard of my community people having been to
counselling but this is what they [the service providers] have said – for those who
are having these problems, especially thinking a lot on their problems, to go to a
counsellor and talk about your problem. It is helpful, this is what they say but I’m
not sure, I’ve never been. (Mëh Luh)
These findings are similar to those of Whittaker, Hardy, Lewis and Buchan (2005)
who explored Somali refugee women’s perceptions of psychological wellbeing. Their
participants listed psychologists and counsellors as sources of help but reported that
they did not personally utilise those services. Karen women may have been reluctant
to admit utilising these services due to shame and stigma. Participants’ perceptions of
mental health services are discussed in greater detail in Chapter 13.
10.6 Summary and reflections
Women coped with hardship and emotional distress through controlling their minds.
They sought to identify and challenge unhelpful thinking patterns and also distract or
avert their minds from troubling thoughts. Women also coped with hardship and
distress through stoic silence and acceptance, and a strong conviction that human life
is characterised by suffering which one must endure. These approaches to coping are
situated within a religious, cultural and sociopolitical milieu of persecution and forced
migration. Interpersonal emotional and material support from family, friends and the
wider community (including community leaders) was also highly valued. Feelings of
collectivity and community provided women with support (emotional and physical)
and protection against the hardships of resettlement. Helping others provided
distraction from one’s own suffering, a sense of purpose and value as well as an
opportunity for social interaction. Religion and spirituality permeated both
intrapersonal and social coping strategies. Women prayed for strength and their faith
gave meaning to their suffering. In addition, the religious community also provided
them with access to social networks as well as material and emotional support. Karen
women sought assistance from Australian service providers to cope with practical,
physical and material concerns but rarely for emotional support. Rather, they
perceived that sharing experiences with fellow Karen was the most appropriate means
of addressing emotional needs.
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In relation to coping, here too (see Section 8.5) Bandura’s theoretical accounts of
efficacy provide a platform for conceptualising the research findings. In his more
recent works, Bandura (2000, 2001) extended his theory to account for interpersonal
or socially mediated forms of efficacy: proxy and collective agency. Proxy agency is
actioned by people who rely on capable others to mediate or obtain the outcome they
desire. Collective efficacy or agency refers to a group’s shared belief in its
interdependent ability to achieve a desired aim. The research findings suggest that
Bandura’s model may not only provide a useful framework for conceptualising the
negative effects of forced migration and camp confinement (as discussed in Section
8.5), but the notions of collective efficacy and interdependent agency might also be
helpful in understanding women’s resilience and approaches to coping. For example,
the findings discussed in this chapter demonstrate that despite low individual self-
efficacy, participants conveyed a strong sense of proxy agency and collective efficacy
(within the Karen community). They relied on (and desired help from) other
community members, particularly leaders, to assist them with their problems. Teasing
out such findings and further exploring self-efficacy and wellbeing may help to
elucidate not only pathways to suffering but mechanisms of strengths and resilience
also.
As demonstrated in Chapter 9, women’s conceptualisations of emotional distress and
suffering could not ignore the body, the psyche and the sociocultural context.
Similarly, their approaches to coping with emotional distress encompassed strategies
that sought to manage the psychological, political (e.g., helping others through
advocacy), economic, spiritual and sociocultural dimensions of the refugee
experience.
My literature search located only three published studies that have discussed coping
strategies amongst refugees from Burma. Lopes Cardozo et al. (2004) assessed mental
health problems among Karenni refugees in camps along the Thailand-Burma border
using psychometric questionnaires (the Hopkins Symptom Checklist-25 and the
Harvard Trauma Questionnaire). They also interviewed key informants to identify
coping mechanisms and included additional questions about coping in their survey of
495 participants. These authors reported coping mechanisms of sleeping, thinking
about their homeland, singing or playing music, visiting the clinic and drinking rice
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wine. The predominance of distractive (over informational or practical help-seeking)
approaches to coping may reflect the camp context of the research, where seeking
assistance was unlikely to result in significant changes to one’s problems or lifestyle.
In another study, also using the same psychometrics, Allden et al. (1996) reported on
the coping mechanisms of Burmese political dissidents living in Thailand. Seventy-
five per cent of participants reported “continuing the pro-democracy struggle” as a
strategy to deal with life and suffering in exile. Allden et al. also mentioned “desiring
to help the people of Burma” (p. 1567) as another coping strategy. Participants who
reported coping through contact with friends or other comrades in exile, and those
who coped through weira (a Burmese Buddhist concept), had lower symptom scores.
The authors described weira as a “strategy of self-confidence … a Buddhist concept
of resolve and determination to use one’s innate talents and strengths to deal with
one’s karma” (p. 1567). Like politically active participants in my study, Allden et al.’s
participants emphasised coping through collective solidarity and helping others.
Finally, Fuertes (2004, 2007) similarly found that helping others was the dominant
approach to coping among the Karen on the Thailand-Burma border. In his study,
Karen refugees conveyed a concept of healing that entwined social, economic and
political restoration and “transforming the negative impact of their war experience
into something beneficial” (2007, p. 301). Collective solidarity and the reintegration
into community life as a nation were part of their paths to healing. Likewise, my
research findings indicate that Karen women in Australia coped through collective
solidarity, transforming and making meaning of negative experiences, and helping
others.
10.6.1 Emotional and practical support
Women’s division of emotional and practical support shares a likeness to the Western
model of emotion-focused and problem-focused coping styles. Western psychological
literature on coping commonly distinguishes between these approaches and considers
problem-focused coping to be more effective for dealing with traumatic experiences
(Agaibi & Wilson, 2005; Lazarus & Folkman, 1984). When using problem-focused
strategies a person might learn skills or seek information in order to resolve a stressor.
Emotion-focused strategies, as the name suggests, include a host of techniques to
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manage the emotions associated with a stressor. Techniques include distraction,
relaxation and cognitive restructuring (e.g., re-appraising the meaning of the stressor).
The emotion- and problem-focused coping framework has been adapted and applied
to conceptualise refugees’ coping strategies. Colic-Peisker and Tilbury (2003)
identified “active” (p. 61) refugee coping styles such as political involvement and
goal-oriented resettlement activities. They found that refugees who used active coping
strategies were generally those who had spent less time in refugee camps. Refugees
who had endured a protracted migration were more likely to demonstrate a passive
approach to coping with resettlement and tended to conceptualise themselves as either
“endurers” or “victims” (p. 72). Similarly, Khawaja and colleagues (2008) described
passive approaches to coping including resignation, avoidance of confronting
problems and framing the situation as out of one’s control in their study of Sudanese
refugees.
10.6.2 Shared experiences
The importance of seeking help from someone with shared sociocultural and
situational experiences was prominent in women’s narratives of coping. This process
appeared to help women through (a) accepting, normalising and making meaning of
their adversities, and (b) problem solving and learning through the experiences of
others.
One refugee study has specifically drawn attention to the importance of the shared
experience within social support and intracommunity help-seeking (Simich, Beiser, &
Mawani, 2003). That research similarly documented that refugees in Canada sought
support within their own communities and valued help from others who shared their
experiences.
The importance of the shared experience to help-seeking was explicitly addressed
over two decades ago by Thoits (1986) who sought to uncover the processes by which
social support protects against the adverse mental health effects of stressful life
events. She explored the aspects of supportive social relationships that promoted
coping and argued that “sociocultural and situational similarity” (p. 420) enhance the
perceived acceptability and effectiveness of coping assistance. Of the two, Thoits
considered a shared situational experience to be most critical. She argued that the
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nature of the shared experience provides help-seekers with a comparison for self-
evaluation and modelling, as well as empathic understanding, guidance and
reassurance that is considered valid. Thoits also identified exceptions to the shared
sociocultural and situational model in cases whereby shame, embarrassment or
anticipated rejection might prevent an individual from seeking help within their social
network. This is an important reminder, as the Karen collective (like any community)
is not devoid of intragroup tensions and divisions. This area warrants further
investigation.
10.6.3 Acceptance and normalisation
The themes of acceptance and normalisation were woven throughout women’s
accounts of coping. These practices appear underpinned by traditional religious and
cultural worldviews and the sociopolitical experiences of recent generations. Previous
research with Karen refugees has also reported acceptance as an aspect of coping.
Fuertes (2007) reported that Karen refugees “accept the reality” (p. 356) of being
refugees, share their experiences with fellow refugees and pray to cope with their
situation. He explained that “acceptance of reality serves as an overarching form or
mechanism that enables them to cope with the reality of being refugees” (p. 357).
Fuertes argued that this approach was positive, explaining “acceptance of reality does
not mean giving up their hopes and dreams of a better future” (p. 357-358).
Participants in Allden et al.’s (1996) study of Burmese political dissidents in Thailand
also reported coping through accepting their inability to return to Burma as well as
continuing their political activities and helping others. These coping strategies did not
show significant association with any of the symptom scales measured by the
psychometric questionnaires. However, Allden et al. did not explore the broader
concept of acceptance beyond “accepting one’s inability to return to Burma” (p.
1567). Nor did they further explore relationships between acceptance and domains of
distress and wellbeing as measured by the psychometric tests.
For Karen women, the psychological and behavioural outcomes of acceptance and
normalisation such as stoic silence appeared to move along a continuum. At one end
they are positive and adaptive as they foster resilience and enable women to endure
and survive hardship. At the other end they may lead to apathy and demoralisation.
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Western psychiatric literature has typically associated accepting one’s fate, stoic
silence and emotional suppression with negative social and psychological outcomes
(Gross & John, 2003). However, the consequences of stoic silence or suppression
appear to differ across cultures and research has demonstrated that it may be an
effective coping strategy for Asian populations (Butler et al., 2007). In Sri Lanka, G.
A. Fernando (2005) demonstrated the role of religious faith in mediating vulnerability
to depression amongst children exposed to war and violence. She found that Christian
children were more vulnerable to depression than Hindu and Buddhist children and
speculated that active acceptance of pain and suffering might be a protective factor.
Researchers have proposed that Japanese traditions such as accepting one’s fate,
masking feelings and enduring adversity may partially account for lower rates of
PTSD amongst Japanese American Vietnam Veterans (Freidman, Schnurr, Sengupta,
Holmes, & Ashcraft, 2004).
Research also suggests that Western approaches seeking to alter practices such as
stoic silence can be harmful. For example, D. Pedersen et al. (2010) observed that
silence and stoicism can function to preserve community cohesion. In Sri Lanka, a
complex cultural system of silence and speaking in euphemisms allowed members of
Sinhalese Buddhist communities to refer to traumatic events during the civil war
without giving explicit detail (Argenti-Pillen, 2003). This system also kept control of
revenge violence quite successfully. The community members who violated the social
code of silence and euphemistic speech were seen as careless, “fearless” (Argenti-
Pillen, 2003, p. 162) and dangerous. When Western trauma counsellors entered the
village they legitimised the behaviour of the fearless outspoken community members,
encouraged verbalisation about traumatic events and suffering, and pathologised the
local custom of silence and euphemistic speech. A delicate social balance was
damaged without insight into the potential consequences.
Karen women also normalised their suffering within their collective community and
coped through knowing that they were not alone in the problems they faced. Such
normalisation is a documented coping strategy amongst other populations affected by
war and persecution (Goodman, 2004; Guribye et al., 2011; Schweitzer et al., 2007;
Somasundaram, 2010). Goodman (2004) described a similar theme of collectivity and
the communal self and explained that young Sudanese men coped through recognition
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of their shared experience of suffering. Like the Sudanese men that Goodman
interviewed, Karen women also conveyed a sense of a collective self and referred to
the suffering of “we” (the collective community of Karen refugees). However, the
current research findings have demonstrated that in addition to normalising and
accepting suffering, Karen women also appeared to minimise their losses and
traumatic experiences relative to those of their peers (see Section 9.3.2).
Recent research with 769 Tibetan refugees provides some insight into the potential
role and function of minimisation for refugee populations whose cultural traditions
include Buddhism. Sachs et al. (2008) asked the Tibetan refugees to provide a social
comparison rating in which they appraised “the severity of their experiences
compared to those of other Tibetans” (p. 204). Most participants (including survivors
of severe torture) rated their experiences as less severe than their peers. Subjective
appraisals of trauma experience as less severe than that of others mediated the impact
of trauma on psychological functioning. Those who minimised their own problems
had better mental health outcomes than those who did not.
The Tibetan refugee study provides a point of interpretation for the findings of
normalisation and minimisation as a coping strategy amongst Karen women. Few
studies have noted the role of “social comparisons” or minimisation and even fewer
have explored the relationship of this factor to emotional suffering. Negative social
comparisons (in which a trauma survivor ranks their own suffering as less than that of
others) would generally be referred to negatively as minimisation or even “denial” in
Western psychiatric and psychological literature. However, Sachs et al.’s (2008)
findings suggest that minimising one’s suffering in relation to others may reduce
symptom severity and thus represent an adaptive coping strategy. It is unclear how
such social comparisons might enhance resilience. Acknowledgement of the suffering
of others may provide (a) religious or cultural meaning-making (e.g., “it is a universal
truth that everyone suffers”), (b) a means of distraction, (c) social connection through
shared experiences and care giving, or (d) opportunity to develop an identity role and
self-efficacy (e.g., “I can be useful”, “I can help someone else”). The clinical and
theoretical implications of my research findings, and the congruence of my findings
with those of other research such as Sachs et al.’s, will be discussed further in
Chapters 13 to 15.
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Chapter 11
Bridging Idioms:
Karen Women’s Explanatory Models of Western Psychiatric
Constructs
11.1 Introduction
This chapter presents and discusses the findings related to the question: What are
Karen women’s explanatory models (beliefs regarding illness) for the Western
psychiatric constructs of depression, panic and PTSD? It begins with a brief review of
the methods used to address this aspect of the research before presenting the findings
in relation to each of the vignettes. The findings will be discussed in relation to the
literature and the implications of women’s EMs explored.
11.2 Vignettes and explanatory models
As detailed in Chapters 6 and 7 (see Sections 6.4.2 and 7.5.1), for this aspect of the
study women participated in group interviews during which they were asked
questions to elicit their EMs about three separate case vignettes. The vignettes each
met DSM-IV (American Psychiatric Association, 2000) diagnostic criteria for either
PTSD, major depressive disorder or panic disorder, and the stories depicted features
relevant to the lives of Karen refugee women.
11.3 Vignette A / Aunty A: DSM-IV Major Depressive Disorder
Aunty A arrived in Sydney from a refugee camp on the Thai-Burma border in the last
few years. Recently, she appears to be sad most of the time. Sometimes she
experiences headaches, poor sleep, tiredness, backaches, stomach-aches and other
physical discomforts. Much of the time Aunty A seems to have lost interest in life and
seems to think too much. She does not seem to be able to think clearly or concentrate
and appears restless. It seems as though Aunty A has no hope for the future and thinks
that it would be better if she were not alive.
All participants identified the vignette symptoms using the label tha dha hsar
(sickness of the heart-mind) and believed that this was a case of tha dha hsar caused
by hso k’moe dha (thinking too much). They associated the condition with everyday
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problems of living, particularly resettlement difficulties and poverty. Women also
speculated that Aunty A probably lived alone and struggled with daily problems due
to lack of family support. They explained that women without family and older
women were more likely to worry and suffer tha dha hsar due to resettlement stress
and an uncertain future. Marital conflict and family problems were also identified as
pertinent in the aetiology of the symptom picture:
By looking at their family situation you can tell [if] a particular person is more
likely to have tha dha hsar. (Participant in Group C)
Additional psychosocial precursors to Aunty A’s symptoms included related elements
of homesickness, loneliness, lack of community support and isolation (particularly
separation from immediate family members). Women emphasised that stress and hso
k’moe dha (thinking too much) caused by everyday problems were not sicknesses but
could lead to sickness of the heart-mind (tha dha hsar):
Stress is not a sickness. No, stress is not a sickness. Sometimes if you carry on
having stress long-term then it will become a sickness. (Participant in Group B)
Women also related their own experiences in response to the vignette:
When I think a lot I feel like that – stomach-ache, sometimes backache. When you
think a lot if affects you physically. I have three sons. One is in Australia, one is in
Burma and one is in the refugee camp. When I think of my sons it makes me sick –
I miss them. I feel worried, especially for the second son in Burma. I have no idea if
he is alive or dead due to the political situation. We had to flee and now I have no
idea if my son is alive. I can’t sleep at night. I wake up in the middle of night and
just read the bible or pray to get all the thinking out of my mind but it is still there,
especially about my son. As a mother you think a lot when you can’t get news from
your child … I myself might even go mad soon. (Participant in Group A)
A number of women disclosed having had similar problems. They described acute
episodes of distress (which they commonly termed tha ba do / worried) after the
death(s) of their children and reported having been inconsolable during those times.
Participants drew direct relationships between social causes, thinking too much (hso
k’moe dha) and physical symptoms:
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Whatever circumstances you suffer and your body is related to each other. When
you think a lot you can’t sleep. If you can’t sleep you get weak. If you feel sad you
don’t want to eat. If you don’t eat you get a stomach-ache. (Participant in Group A)
Social isolation was identified as a serious cause and consequence of Aunty A’s
problems. Physical effects were lack of appetite, trouble sleeping, stomach-ache and
headaches. Women explained that someone with tha dha hsar (sickness of the heart-
mind) could also become sensitive to further stressors, easy to frighten, tearful,
irritable, distracted and could fail to find pleasure through activities with other people.
They believed that Aunty A’s level of functioning might potentially be impaired and
she “might not be interested in looking after her children”. Her family would also be
affected due to their “worry” about her.
Aunty A’s thoughts of death were cited as indicative of a serious level of distress and
women thought that she could become mentally ill (dha blu) and commit suicide. A
number of women recounted instances of suicide in the refugee camps. They reported
that the deceased had suffered tha dha hsar (sickness of the heart-mind) but had been
unable to control themselves and became mad. They attributed one woman’s suicide
to her “family situation”, particularly her husband’s alcoholism. Most other suicides
were noted to occur after the death of a spouse or child(ren). Participants reported that
women were more likely to suffer tha dha hsar but men were more likely to commit
suicide: “men are worse, when they experience tha dha hsar they commit suicide”.
Reflecting self-control coping practices described in Chapter 10 (see Section 10.2),
women unanimously reported that Aunty A needed to have controlled her thinking
especially in the early stages of stress and hso k’moe dha (thinking too much) to
prevent deterioration into tha dha hsar (sickness of the heart-mind):
The emotional issue is not caused by itself. It’s caused by you because you are the
one who thinks a lot. You cannot control yourself. Always worrying, always
thinking. That’s what causes emotional problems. It’s how you manage it.
(Participant in Group A)
They stressed the importance of personal responsibility: “if you do nothing it will get
worse”, and spoke of their religious faith as helping them cope with stress and
thinking too much:
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For me a lot has happened but I never keep it in my mind. I never put it in my mind
and save it. I hear news, especially from my children, that never makes me happy
but I never think of it. I’ve got children but God will take care of them. I read the
bible and the bible makes me calm and happy. There is no point keeping things in
your mind – no point keeping on thinking those things – it will give you sickness.
(Participant in Group A)
Another participant in the same group agreed that it was important to try and alleviate
troubling thoughts through religious coping but reported that she was unable to stop
her worrying and believed she might go mad:
I pray and pray to God to give me some news about my daughter. But maybe God
never listens to me. (Participant in Group A)
Community support through visits and prayers from friends and religious leaders
formed the next approach to coping suggested for Aunty A’s difficulties:
We Karen people, if we have a problem or face difficulties our close friend used to
visit our house and sleep over with us. (Participant in Group C)
All participants agreed that overcoming isolation through social support was central to
coping with the symptoms of tha dha hsar. One participant said: “by talking to
someone her problem will be less”. Two younger and outspoken women in Group C
reported that they would not hesitate to ask friends and community members for
support. Other participants, particularly older women, spoke of feeling embarrassed
about revealing their emotional distress to their peers. However, most reported that
they would tell their best friend. Women’s descriptions of coping through social
support again revealed the importance of the shared experience (see Section 10.6.2) as
well as self-disclosure on behalf of the supporter. In addition to sharing feelings,
participants felt that the community should also help Aunty A resolve the specific
causes of her tha dha hsar:
If this problem is because of the children she might need community help to
recorrect the children’s problems. Or if the husband is the one who is the problem
then the community should help her. (Participant in Group C)
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Women in all groups agreed that Aunty A should consult a doctor, particularly
because she expressed a desire to die. They felt that the doctor could relieve her
somatic complaints but not other aspects of her distress:
The doctor, the most he can treat this person is only physical sickness. For mental or
for emotional [problems] the doctor may not be able to help this lady. So even
before she consults a doctor, community people should visit her … Religious
leaders should visit and pray for her. (Participant in Group A)
In Group B one participant disclosed that she had visited her GP specifically due to
emotional distress. She described feeling dissatisfied with seeking support this way:
“when I go to the doctor if they treat me like nothing [is wrong], if they don’t console
me, if they don’t treat me I may get angry and leave”. This woman had hoped to
receive either emotional support (e.g., “console me”) or medical treatment but was
disappointed and frustrated after receiving neither.
In summary, all groups conceptualised external stressors, especially loss and
interpersonal conflict, as the primary cause of Aunty A’s suffering. They described a
psychocentric element in the aetiology of these problems as hso k’moe dha (thinking
too much) caused her emotional (heart-mind) distress. They believed that an element
of self-control was crucial to good mental health and described a notion of meta-
cognitive awareness whereby thinking about one’s thinking was an important
component of psychological wellbeing. With support and self-control women
expected Aunty A to get better. However, they felt that her thoughts of wanting to die
were indicative of severe suffering and feared that she could progress towards mental
illness and possibly suicide.
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11.4 Vignette B / Aunty B: DSM-IV Panic Disorder
Aunty B arrived in Sydney from a refugee camp on the Thai-Burma border in the past
few years. Recently, she appears to be worried and is scared as if something terrible
is going to happen. Sometimes her body trembles and she also experiences dizziness,
sore muscles and feels that her heart is beating very fast. Aunty B also has trouble
concentrating, has sleeping problems and frequently appears tired or low in energy.
Sometimes she is worried that something is wrong with her, is scared of something
bad happening or keeps thinking the same worrying thought and seems unable to
control her worry. Aunty B also avoids situations that she is scared of.
Women easily related to the symptoms described in the case vignette of Aunty B.
They described their own similar stories but struggled to identify any particular name
for the symptom picture. The majority of participants regarded the symptoms as
indicative of some type of common emotional (heart-mind) distress caused by
physical health problems, hso k’moe dha (thinking too much) about daily social
stressors or both. Women noted that the symptoms described did not yet constitute tha
dha hsar. As one participant observed: “[Aunty B has] too much hso k’moe dha but
not yet tha dha hsar … if she doesn’t control herself she will get tha dha hsar”.
Group members talked amongst themselves as they considered a variety of possible
terms for Aunty B’s symptoms. They debated with each other and lively discussion
followed but ultimately no specific Karen term could be identified. They put forward
a variety of stress-like states including tha ba yo (worry) and explained the difference
between these and tha dha hsar:
Sometimes you have too much tha ba yo [worry]. Especially about your children.
They want to go somewhere and you worry but they go anyway. If nothing happens
you had tha ba yo. If something happens you will get tha dha hsar [sickness of the
heart-mind]. Now you know the difference [laughs]. (Participant in Group C)
In addition to worrisome thoughts, hso k’moe dha and stress caused by social
problems (particularly parenting and interpersonal conflict), participants also gave
attention to Aunty B’s somatic problems. In contrast to their discussions of the
depression vignette (Aunty A), women were more likely to cite physical or biological
causes for Aunty B’s symptoms. They related her physical symptoms to pre-migration
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nutritional deficiencies, especially for people who spent long periods of time in
refugee camps. They also related the symptom picture to health problems such as high
blood pressure and diabetes, which they partly attributed to post-migration lifestyle
and nutrition changes. Women appeared to have gained some familiarity with
Western biomedical models and terminology through their contact with humanitarian
aid organisations in Thailand as well as their experiences with healthcare providers in
Australia. Social stress and hso k’moe dha were also described as causes of high
blood pressure. Finally, and consistent with women’s idioms of distress discussed in
Chapter 9 (see Section 9.4.1), a minority of participants reported poor blood
circulation (including irregular menstruation) as a potential cause and consequence of
Aunty B’s symptoms.
As with the first vignette, women speculated that the Aunty was likely to be an older
woman who experienced “family problems” or lived alone. The old, lonely woman
with family problems and emotional distress appeared to be a cultural stereotype
amongst Karen participants. They conveyed an acceptance of Aunty B’s symptoms as
relatively normal and believed that she could still perform her daily tasks and function
in the community. Participants recounted their own similar experiences. Older women
related Aunty B’s symptoms to their experiences of high blood pressure and
worsening physical health during times of increased social stress. Younger women
reported experiencing similar symptoms which they attributed to external stressors
and their fears of “something” bad happening to them in Australia:
This story is similar to mine. I have also experienced this. Here in Australia
everyone has human rights and you can report or complain if something happens to
you. You are told you can call the police. But if you call, something might still
happen to you. If the police don’t come what will you do? I’m afraid that something
might happen. (Participant in Group B)
Women reported that they read the bible, prayed, listened to music and visited their
best friends when they experienced Aunty B’s problems. Again they emphasised the
importance of social support and kind words from friends and family. Group C also
explained that Aunty B should continue to avoid the situations that make her feel
afraid or exacerbate her symptoms.
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Having emphasised the role of physical or medical factors in the symptom profile,
women also thought it was important for Aunty B to visit her doctor. However, a
number of women reported experiencing similar symptoms but were dissatisfied with
the medical assistance they had received: “but when we see a doctor they say nothing
is wrong with you”. After mentioning self-control, social support, religion and
medical care, participants in Group C also suggested counselling, though they
continued to place importance on self-control:
Is there anyone else she should see to get help?
(GC:1) Counselling – see a counsellor.
Can a counsellor fix her problem?
(GC:1) No.
(GC:5) Not one hundred per cent. But maybe the counsellor can talk to her and say
“you are not the only person, we have many people like you”. But the main thing is
that she must control herself.
In the preceding quotation, the concept of normalisation (see Section 10.3.1) is again
apparent. In relation to Aunty B’s difficulties, participants in Group C believed that
counselling could be beneficial if the therapist normalised Aunty B’s experiences and
problems. When symptoms were explained as physical health problems (including
physical tha / heart problems such as high blood pressure) women expected that
Aunty B would require medication but would also need to “control” herself and her
thinking in order to avoid deterioration in her condition. Similarly, when social
stressors and hso k’moe dha were cited as aetiological factors, women again
emphasised the need for self-control in order to avoid further deterioration.
In summary, when discussing Vignette B women conveyed an implicit
conceptualisation of mind (psyche) and body (soma) as intimately interrelated.
However, they also distinguished between somatic illnesses that are independent of
the mind-self (e.g., diabetes) from those that may have a psychological aetiology
(e.g., high blood pressure from thinking too much). Physical and psychological
distress involved one another, and when women described psychological causes of
distress (e.g., hso k’moe dha) they endorsed physical consequences (e.g.,
palpitations). Similarly, physical causes of distress (e.g., high blood pressure) were
conceptualised as involving psychological consequences (e.g., difficulty
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concentrating). Aunty B’s symptoms of common tha (heart-mind) distress were
perceived as less severe than Aunty A’s. This was, in part, because Aunty A wanted
to end her life but also because Aunty B’s somatic symptoms were so familiar to
participants. Importantly, women did not have a specific label or idiom unique to this
particular vignette and often struggled to differentiate aspects of Vignette B from
Vignette A. They employed a variety of idioms of distress, all of which related to the
heart (tha). This again (see Section 9.5.1) suggests that the women’s EMs for mental
illness do not view the Western psychiatric constructs of depression and anxiety as
radically different but rather perceive variation in symptoms along a continuum of
suffering.
11.5 Vignette C / Aunty C: DSM-IV Posttraumatic Stress Disorder
Aunty C had awful experiences before arriving in Australia last year. She feared for
her life in Burma and saw a lot of violence including seeing her brother killed. Aunty
C continues to have thoughts or memories of seeing her brother killed, and then soon
feels scared and tense. Sometimes she has nightmares and she often has trouble
sleeping. Recently Aunty C has been acting differently, she is avoiding certain people,
activities and situations that remind her of the terrible things she saw in Burma and
she appears to be very fearful. Aunty C sometimes seems unable to experience normal
happy emotions and she seems to have a deep sadness. Sometimes she complains that
her heart is beating fast and sometimes she also feels dizzy, trembling or choking
sensations.
Women in all groups called the symptom picture presented in Vignette C (Aunty C)
severe tha dha hsar (sickness of the heart-mind). They perceived the symptoms as
similar to Aunty A’s (depression vignette) but many felt that Aunty C’s symptom
profile was more serious and closer to the stage of mental illness or madness (dha
blu):
This is more than tha dha hsar already … we can’t say tha dha hsar or dha blu –
What shall we call it? What can we call it? (Participant in Group B)
This is severe tha dha hsar but the next step is dha blu. (Participant in Group B)
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In Group C participants also struggled with labelling the symptom profile but
collectively decided that it was probably closer to dha blu (mental illness or
madness). A participant in Group B who spoke fluent English and was familiar with
Western psychiatric conceptualisations of mental illness reported: “in our country we
don’t have the [term] trauma but we still have this kind of experience, we call it
‘suffer too much’”. This comment parallels findings from individual interviews (see
Section 9.3.2) in which women described severe suffering as caused by “too much
experiencing” and “too much suffering”.
Most of the women’s causal explanations for Aunty C’s problems were the same as
those identified for the preceding vignettes (A and B) (e.g., thinking too much about
one’s stressful experiences). However, Aunty C’s problems were distinguished as
being caused by “too much experience”. Her experiences were considered more
severe and likely to overwhelm an individual’s ability to cope. This might have
suggested that the women conceptualised a direct relationship between Aunty C’s
symptoms and the traumatic experience of witnessing her brother murdered.
However, as with the previous vignettes, women speculated that Aunty C’s
experience was also characterised by a lack of family support and social isolation.
Here again, Karen women’s collectivist cultural context framed their interpretations
of distress. Women routinely emphasised social and relational factors over all others.
As we saw also in Chapter 9 (see Section 9.3.2), when describing instances of “too
much experience” women consistently included severe family (or social) difficulties
or consequences in their narratives. Women also again explained that the social
implication of the event indicated its severity and the likelihood of the survivor
suffering severe heart-mind distress. Some suspected that Aunty C might have only
had one brother and consequently expected her suffering would be worse than that of
someone with several brothers. Some participants conceptualised Aunty C’s severe
tha dha hsar in response to traumatic experiences as normal and believed her
symptoms would naturally abate with time:
Maybe her experience is very recent and it is still warm so she remembers it. She
can still feel it but she needs to take time, you’ll see. (Participant in Group B)
Women did not spontaneously attribute other causes to Aunty C’s problems.
However, when asked to list all potential causes of dha blu (mental illness or
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madness) they cited additional biological (e.g., genetics) and supernatural (e.g.,
witchcraft) factors, as reported in Chapter 9 (see Section 9.3.4). It remains unclear
why women who identified Aunty C’s suffering as dha blu did not spontaneously list
these other causes. It appeared that they were hesitant to attribute her suffering to
causes generally reserved for cases of dha blu because they were unsure whether
Aunty C had tha dha hsar or dha blu. In addition, as women’s concept of genetics
(see Section 9.3.3) appeared to include both biologically and socially inherited
familial predispositions, it seems plausible that they would have needed further
contextual information about Aunty C and her family before considering genetic
factors.
Participants recited stories from the refugee camp(s) to describe people with problems
similar to those of Aunty C:
It’s like mental illness. You think too much and become mentally ill. I saw a man
whose wife and son died. He got crazy from this experience. When you are
experiencing a lot, when you think a lot and experiencing awful situations and you
can’t control yourself you may lose your mind. We call this dha blu [mental illness
or madness]. (Participant in Group C)
Aunty C’s symptoms were perceived as suggestive of mental illness and a loss of
control of the mind. Consequently, women did not suggest self-control as a coping
strategy. Rather, they emphasised the importance of the community in providing
physical and emotional support. They thought that family members should strictly
manage and monitor Aunty C’s eating and sleeping and take her to church.
Furthermore, participants agreed that the symptoms would likely require care from a
doctor and perhaps admission to a psychiatric hospital:
Maybe the doctor can give her tablets for her heart beating fast. Also sleeping pills
to help her sleep. (Participant in Group C)
Women believed that Aunty C’s degree of emotional distress was severe and
potentially life threatening. Participants in Group B mentioned the need for good
blood circulation and reported that if you think a lot, about current or past “awful”
experiences, your blood circulation may be affected and your heart will beat fast. As
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the group discussed the consequences of poor blood circulation they described the
potential seriousness of this problem:
If you think a lot, worry a lot, fear a lot and your heart is beating fast there might be
a point in time where the heart stops beating. It is beating fast and then might stop.
(Participant in Group C)
Those who thought the symptom profile indicated dha blu reported that Aunty C
could eventually lose knowledge of reality, cry and laugh irrationally, talk nonsense
and walk around not recognising anyone. Women unanimously spoke of witnessing
such symptom profiles amongst men and women in the refugee camps but again (see
Section 9.4.7) reported no such instances within the community in Australia.
11.6 Summary
The findings from this exploration of EMs resonate with data collected for other parts
of this study and provide a form of triangulation of methods. The trajectory of distress
(see Figure 5) introduced in Chapter 9 (see Section 9.5.1) is again apparent, this time
in relation to women’s EMs of Western psychiatric constructs.
Most common and least severe Least common and most severe Hso k’moe dha Tha… Tha dha hsar Dha blu
Thinking too much
(Common) Heart-mind distress
Sickness of the heart-mind
Crazy
Figure 5: Trajectory of distress
Three EMs emerge from women’s responses. In order of importance these are: (a) the
social model, (b) the psychological model, and (c) the biological model. Women’s
narratives revealed a strong interconnection between these models and, in practice,
they held multiple causal models simultaneously – a finding consistent with previous
EM research in a number of populations (Bhui et al., 2006; Williams & Healy, 2001).
11.6.1 Social model
Women made sense of problems described in vignettes through the characters’ social
environment (past and present) – through poverty, loss and interpersonal conflicts.
This finding is consistent with EM research in Zambia (Aidoo & Harpham, 2001),
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India (Patel et al., 1998) and amongst Western populations (Bhui et al., 2006;
Williams & Healy, 2001). Women’s social narratives also revealed two further social
subcategories consisting of (a) material and (b) relational factors. Material factors
included post-resettlement hardships such as housing, unemployment, transport and
difficulty accessing support services. Relational explanations included family and
community-wide relationship problems (especially household problems, parenting
and the quality of marital relationships). In almost all interviews group participants
attributed multiple material and relational resettlement stressors to the vignettes.
As discussed previously (see Section 9.3.2), some external social stressors were seen
as more severe than others. Upsetting (e.g., death of a family member) and traumatic
(e.g., witnessing the murder of a family member) experiences with significant social
consequences were deemed more severe. For example, the death of a spouse was
perceived as more serious in the absence of other family members to care for the
widow/er. The impact of any post-resettlement stressor was perceived to be greater in
the absence of family support. Marital disharmony was a particularly pertinent and
serious source of stress. Women’s emphasis on social, particularly socioeconomic and
interpersonal, stressors is consistent with other EM mental health research (Aidoo &
Harpham, 2001; Chipimo, Tuba, & Fylkesnes, 2011). Community surveys in Western
societies also show that the majority of people similarly believe that mental illness is
socially rather than biologically rooted (McKeon & Carrick, 1991; Priest, Vize,
Roberts, Roberts, & Tylee, 1996).
It is striking that interpersonal conflicts played such a significant role in women’s
EMs even though they were not explicitly suggested in the vignettes. Karen women’s
emphasis on social and particularly relational factors may be understood as a feature
of their collectivist cultural context. Women’s identities were bound to others through
interpersonal networks and interdependency was highly valued. Consequently, they
felt vulnerable and stressed when experiencing threats to their interdependency and
collective identity. Material resettlement stressors (e.g., housing and poverty) were
also used to describe the vignette characters’ emotional distress but were generally
given less emphasis.
Notably, drugs and alcohol were not identified as factors directly causing the
symptoms described in the vignettes and this could be explained by the use of a
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female character in the vignettes. Participants reported that substance use problems
were markedly more common amongst Karen men and identified their husbands’
alcohol problems as a source of stress (see Section 8.3.3). My study focused on
women and revealed gendered aspects to emotional distress for both men and women.
Future research is needed to explore issues with Karen men.
11.6.2 Psychological model
Psychological factors played a central role in women’s causal explanations for all of
the vignettes. Symptoms of emotional distress were conceptualised as problems
related to mind and cognition – most commonly as thinking too much (hso k’moe
dha) about one’s difficulties. Thus, the relationship between social stressors and
emotional distress was not seen as direct. Rather, the effects of external (particularly
interpersonal) stressors were mediated by the ability of the mind-self to control the
impact of these experiences.
Concepts of self and mind appeared implicit within Karen women’s EMs of mental
illness. However, we should be wary of making assumptions about the nature of their
perceived mind and self. Several lines of empirical evidence suggest that notions of
self and mind differ both cross-culturally and historically (Cromby & Standen, 1999;
Hollan, 2010). Specifically, Western cultures emphasise a Cartesian dualism between
mind or self and social persona. In a widely quoted portrayal, Geertz (1979) described
the Western notion of self as a:
bounded, unique, more-or-less integrated motivational and cognitive universe,
a dynamic centre of awareness, emotion, judgement and action, organized into
a distinctive whole and set contrastively against other such wholes and against
a social and natural background. (p. 229)
In contrast, several other cultural groups tend to convey a sociocentric concept of self
and emphasise a sense of interdependent personhood (Bhugra, 2004). Similarly,
Karen women’s narratives tended to integrate discussions of self with their collective
and social context.
Karen women’s psychological narratives for depression were similar to those of the
Baganda people in Uganda. Okello and Ekblad (2006) used a vignette of depression
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and found their Baganda participants identified the problem as an “illness of
thoughts” (p. 290), an affliction but not a medical condition caused by thinking too
much about social problems, especially (amongst women) marital relationship
problems. The Baganda women believed that a person should seek to control their
thoughts. Similarly, Karen women invoked themselves as contributing to emotional
distress and mental illness through a failure to control one’s thinking. These findings
also share similarities with EM research in Western populations (Bhui et al., 2006).
For example, first-time patients attending a community mental health service in
Wales described an implicit sense of “mind/self” which lacked “strength” (Williams
& Healy, 2001, p. 471) to control cognitive functioning.
The causal notion of failing to control one’s thinking holds potentially interesting
moral consequences and implications. In the Karen cultural context psychological
causal explanations of distress and the concept of the mind-self might be understood
as a feature of religious context (see Section 10.2.4). Meta-cognition (thinking about
thinking) and mental regulation is a central tenet of Buddhist doctrine (Toneatto,
2002). Similarly, self-control as a “moral muscle” (Baumeister & Exline, 1999, p.
1165) is also a noted feature of Christian thought. In this study participants did not
appear to make a moral distinction between those who could control their own minds
and those who failed. During group interviews some women freely, and without an
apparent sense of self-deprecation, noted their inability to control their thinking. Other
women openly expressed confidence in their ability to control their minds. However,
women who explicitly acknowledged their failure to control their mind also tended to
emphasise the severity of their external stressors. As Karen women’s causal
explanations for emotional and mental distress are multifactorial it is possible that
emphasising the contributory nature of external causes buffered moral judgment
related to weak self-control.
It is noteworthy that women’s EMs, particularly for the depression vignette, did not
refer to guilt, which is a cognitive feature of mood disorder in Western psychiatry
(American Psychiatric Association, 2000, p. 356). In her research with Chinese-
American women, Ying (1990) also noted the absence of guilt as a feature of EMs of
depression. She suggested that Chinese cultural conceptions of mental health
emphasised both intra- and interpersonal harmony whereas Western psychiatric
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frameworks are influenced by Northern European Protestant traditions that are
individualistic and oriented towards guilt as a feature of emotional distress.
Baumeister and Exline (1999) similarly note that individual judgment and guilt with
regard to failures to exert self-control are prominent in Christian thought. Collectivist
cultures have been described as “shame cultures” (Hofstede, 2001, p. 229) where
socially undesirable behaviour is kept in order by the threat of shame to the guilty
party as well as her family. Controlling one’s thinking and expressions of distress
may be a means of avoiding shame and stigmatisation. Lebra (2010) came to a
different conclusion, arguing, with reference to Japanese society, that guilt is at least
as prevalent as shame. However, Karen women’s EMs seem best accounted for by
Hofstede’s model and, in part, Ying’s elucidation.
11.6.3 Biological model
Women’s biological or biophysical narratives attributed worry, stress and symptoms
of distress such as sleeping problems directly to physical ailments such as heart
disease. In addition, women’s bio-narratives ascribed physical illness and symptoms
to social stressors and psychological problems. For example, thinking too much about
one’s marital problems could cause high blood pressure.
Irregular menstruation and general blood circulation (including high blood pressure)
were identified as potential causes and consequences of the symptoms described in
the vignettes of depression and panic disorder. Women feared that blood
dysregulation from thinking too much and emotional distress could lead to serious
health problems including strokes. As previously noted (see Section 9.4.1), such
beliefs appear to have their origin in traditional Karen medicine which, having
components of both Ayurvedic and traditional Chinese medicine, stresses the
importance of adequate unrestricted blood flow (Bodeker et al., 2005). Women
reported “genetics” as a cause of dha blu but did not offer this cause as an explanation
for any of the vignettes including Aunty C (who some believed was suffering from
dha blu). As discussed, this may reflect their uncertainty as to whether Aunty C
actually had dha blu and women’s hesitancy to suggest genetic causes in the absence
of additional information about Aunty C and her family.
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11.6.4 Course, severity and impact
Women’s narratives about the vignettes revealed EMs in which mind (psyche or
thinking), body (soma) and environment (material and relational) were separate
though interrelated domains. Each domain could cause, exacerbate or help heal
emotional distress. Although women described psychological impacts (e.g., difficulty
concentrating, irritability and anhedonia) of emotional distress and mental illness,
most postulated the experience and impact of these problems as somatic (e.g., aches
and pains) and interpersonal (e.g., impaired social relationships). Participants believed
that Aunty A and C would likely be impaired performing their daily tasks such as
parenting and education, but thought that Aunty B would be able to carry on despite
her difficulties. Social isolation was deemed a serious cause and consequence relevant
to all the vignettes.
11.6.5 Explanatory models and treatment
All participants described community support as essential regardless of the vignette or
casual explanation assigned to the symptoms. Triangulating the findings reported in
Chapter 10, Karen women described lay help from family, friends and community
leaders as the primary source of interpersonal help. Women also ascribed a
psychological model to healing and emphasised that people suffering from the
symptoms described in the depression and panic disorder vignettes should seek to
control their own minds. However, self-coping was not suggested as a feature in
relation to the PTSD vignette which was identified as both severe tha dha hsar
(sickness of the heart-mind) and dha blu (madness).
That community support was central to recovery from emotional distress and mental
illness is not surprising given that interpersonal conflict was identified as a salient
cause of suffering. The women valued strong social networks and viewed isolation is
both a cause and symptom of suffering. Participants’ perceived causes and relevant
coping or treatment strategies were multifactorial which meant that their EMs were,
by and large, internally consistent. EM research suggests that this is not always the
case and beliefs regarding causes and treatments of mental illness do not necessarily
always correlate. For example, in Bhui et al.’s (2006) study White British participants
who endorsed spiritual causal explanations nevertheless preferred medical treatment.
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Among Black Caribbean participants who endorsed spiritual causes, self-coping and
complementary therapies were the preferred treatments.
Women did not tend to emphasise a need for professional medical or mental help.
When doctors or hospitals were suggested, it was also understood that simultaneous
community support would be crucial to recovery. However, most participants
believed that some of the physical symptoms of emotional distress and mental illness
could be helped by Western biomedicine. This was emphasised more for the PTSD
vignette as well as for the physical complaints identified in the panic vignette.
Western medicine and medical treatment were thought to be beneficial for physical
ailments causing distress, as well as for some psychological symptoms (e.g., women
thought that medication to aid sleeping might assist someone who is thinking too
much). However, women did not generally ascribe the need for psychopharmacology
for suffering attributed to social stressors. They appeared to view such symptoms as
transient problems likely to resolve by an improvement in social circumstances.
11.7 Reflections
This account of EMs has described how these Karen women interpreted and
organised mental phenomena. The findings demonstrate that the emic (Karen
women’s ideologies) and etic (Western ideologies) notions of emotional and mental
distress shared many similarities. For example, community surveys in White Western
countries have similarly found that anxiety and depressive disorders are most likely to
be attributed to social rather than biological causes (McKeon & Carrick, 1991; Priest
et al., 1996). However, there were also some important distinctions. The Karen
women did not endorse a clear dichotomy between mind and body but viewed the
two, as well as the broader social environment, as interrelated. Harmony in all
domains (including blood flow) was considered important to emotional and mental
wellbeing. Although the symptoms of common mental disorders (anxiety and
depression) may be cross-culturally valid, the conceptualisation of these problems as
psychiatric disorders appears less applicable to the Karen.
The information obtained from these EM group interviews reinforced data collected
for other parts of the study and again confirmed that serious mental illness such as
psychosis (e.g., dha blu) were not perceived to be prevalent in the Karen community
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in Australia. These findings in no way establish that Karen refugees in Australia do
not experience severe mental illness. However, it is conceivable that (as Karen
participants suggested) people and families with such problems do not tend to resettle.
It is also possible that participants wished to present a positive image of their
community and were hesitant to discuss instances in Australia. This latter explanation
seems less likely as participants freely recounted numerous stories suggestive of
serious mental illness in the refugee camps. Although UNHCR resettlement
determination criteria do not explicitly exclude applicants with severe mental illness
(UNHCR, 2004), it seems feasible that these individuals fail to adequately complete
the application and screening process. It therefore seems that participants were
describing a kind of healthy migrant effect in which immigrants are, on average,
healthier than the native-born population (Fennelly, 2007; Razum, Zeeb, &
Rohrmann, 2000). Notwithstanding that refugees experience poor physical health in
most domains (Hollifield et al., 2002), the notion of a “mentally healthy refugee
effect” warrants further investigation. It has implications for humanitarian and health
service policy and service provision.
It is noteworthy that the supernatural did not feature strongly in women’s accounts of
the vignettes. Murdock, Wilson and Frederick (1978) developed a system for
categorising causation theories of illness. According to their model, supernatural
beliefs include mystical (e.g., fate, astrology, luck and ominous visions), animistic
(e.g., spirit possession and soul loss), and magical (e.g., witchcraft and sorcery)
explanations. Murdock et al.’s dimensions do not exhaustively cover all EMs
documented in cross-cultural research (Eisenbruch & Handelman, 1989) and have
been criticised as “anthropologically unacceptable” (Eisenbruch, 1990, p. 713) due to
the insistence on fitting emic concepts into Western categories. However, their
framework provides a point of reference for understanding different types of
supernatural explanations.
Karen women did not describe witchcraft, magic, spirits and God as causal
explanations for the vignettes although they considered supernatural factors
(especially God) as highly relevant to healing or coping and reported supernatural
causes as relevant to dha blu (see Section 9.3.4). One participant mentioned that God
never listened to her when she conveyed her distress about her missing children, but
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none directly cited God as causing their emotional distress. These findings contrast
with EM studies in a number of African, Asian and White Western populations
(Aidoo & Harpham, 2001; Bhui et al., 2006; Eisenbruch, 1983; Okello & Ekblad,
2006; Patel, 1995). Zambian women’s EMs for common mental disorders included
causal explanations based on fate, spirits and God (Aidoo & Harpham, 2001). In the
United Kingdom Bhui et al. (2006) compared the EMs of Bangladeshi, White British
and Black Caribbean participants. They found that independent of ethnic group,
participants with a common mental disorder (depression or anxiety) were more likely
to give a spiritual explanation for their distress.
The relative absence of supernatural causal explanations in Karen women’s EMs of
mental illness may be attributable to genuine changes to traditional Karen cultural and
religious beliefs (see Section 9.5.2). A second possible explanation is that women
were reluctant to acknowledge such beliefs due to social pressure and the
predominance of Christians amongst Karen in Sydney (and consequently in the group
interviews). Karen women may have been reluctant to express viewpoints or endorse
perspectives that are not supported by the Christian church as most were emotionally
and practically supported by Christian organisations. It is therefore conceivable that
participants might have held traditional supernatural beliefs relating to emotional
distress and mental illness but abstained from expressing these beliefs in a public
forum.
11.7.1 The ordinariness of suffering
Refugee researchers P. Guerin and Guerin (2007) have spoken of the importance of
showing the “ordinariness” (p. 159) of refugee communities as well as highlighting
their unique characteristics. Accordingly, this chapter has identified parallels between
Karen women’s EMs and those of White Western lay participants in other EM studies
(Bhui et al., 2006; Williams & Healy, 2001). It is apparent that these groups shared
many similarities when it came to beliefs about the cause(s), course and treatment of
emotional distress. The findings support the observations of Williams and Healy
(2001) who stated:
Although cultural variation in definitions of mental illness do exist this does
not necessarily support the argument that mental illness is entirely socially
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constructed … Interpretations may be influenced by cultural factors but the
inherent nature of the phenomena may constrain the possible variety of those
interpretations. (p. 466)
Women’s models described stress and pressure as building up and resulting in
emotional distress as well as a trajectory of distress along which a person with a
vulnerable personality or disposition might travel. They believed that social factors
led to stress manifested somatically (aches and pains), psychologically (as thinking
too much) and socially (as interpersonal anhedonia and social withdrawal). Failure to
control thinking and seek resolution of social stressors (through problem solving and
support from others) in turn led to a worsening of somatic, social and psychological
symptoms. Here Karen women’s prominent conceptualisations share features with the
Western folk notion of the nervous breakdown which, as Williams and Healy (2001)
suggest, “is likely to be the most familiar folk illness” (p. 466) in Western society. In
an American community survey, EMs for nervous breakdowns emphasised stress and
pressure as central causes (Omark, 1980).
Prior to 1980, when it was controversially removed from official psychiatric
nomenclature (American Psychiatric Association, 1980), the concept of neuroses had
been central to Western psychiatric discourse (Bayer & Spitzer, 1985; Koppe, 2009).
The term had been used to represent the “nervous” personality and encompassed a
broad range of mental illnesses (now mostly assumed under the rubric of mood and
anxiety disorders), specifically excluding psychotic states. The Oxford English
Dictionary defines neurosis as any “psychological disorder in which there is disabling
or distressing anxiety, without severe disorganisation or distortion of behaviour or
personality” (“Neurosis”, 2011). In contemporary psychiatric discourse many
researchers now refer to “common mental disorders” as a “a group of distress states,
previously termed neuroses, that describe states of anxiety and depression” (Cooper et
al., 2008; I. A. Lang, Llewellyn, Hubbard, Langa, & Melzer, 2011; Patel et al., 1998,
p. 135). Karen women’s EMs contribute to cross-cultural research suggesting that the
concept of neurosis aptly captures the complaints of primary healthcare patients
across a range of cultures (Aidoo & Harpham, 2001; Ormel et al., 1994). Similarly,
when researchers explored the emic Zimbabwean concept of kufungisisa / thinking
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too much they suggested that it seemed to be “closest to the Euro-American concept
of neurotic illness” (Patel, Gwanzura, Simunyu, Lloyd, & Mann, 1995, p. 1192).
11.7.2 Talking about trauma
The vignette EM method allowed for Karen women’s discourse about the impact of
discrete war-related stressors and daily social stressors to be examined. Their
emphasis on the salience of post-migration problems echo findings from a recent
investigation into the relationships between psychometric test scores and pre- and
post-migration stressors. Carswell, Blackburn and Barker (2011) found an association
between higher numbers of trauma events and greater emotional distress. However,
when post-migration problems were added to their regression models, number of
traumas was no longer a significant predictor of distress. Rather, resettlement
difficulties were associated with higher PTSD symptoms. Loss of culture and low
social support was predictive of emotional distress.
Karen women believed that most survivors of war-related trauma could cope well
with their life circumstances. They acknowledged that under certain circumstances a
minority of community members would suffer severe and chronic distress in part
related to traumatic war events but the social consequence of a trauma appeared to
mediate the perceived severity of the experience.
Women’s accounts also indicated that traumatic experiences exist “along a
continuum” (Kohrt & Hruschka, 2010, p. 339) and suggest that the “trauma”
experienced by refugee populations may be very different to the discrete horrific
incidents experienced by the majority of Western-European trauma-survivors who
comprise the bulk of participants in trauma-related research (and whose experiences
have guided the development of contemporary treatment protocols). It would be
wrong to assume that the post-resettlement lives of Karen women are characterised by
the absence of traumatic stress. Acute traumatic life events (as commonly
conceptualised in Western psychiatric nosology) represent one end of the spectrum.
At the other end of the continuum are poverty and other daily stressors which, for
refugees, include continued fear for the safety of friends and family left behind in
refugee camps and war zones.
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Women’s accounts of the PTSD vignette revealed that Karen conceptualisations of
suffering and distress did not explicitly account for anything similar to the Western
psychiatric diagnosis of PTSD. Indeed, it seemed difficult to speak about the
emotional effects of trauma due to the lack of a linguistic corollary. Researchers have
noted the absence of linguistic corollaries for psychological trauma in other Asian
populations (A. Hinton, 2007; Kohrt & Hruschka, 2010). Previous research with
refugee populations from Burma has also reported the absence of an exact translation
for the term trauma. Lopes Cardozo and colleagues (2004) studied 495 Karenni
refugees and noted the absence of a PTSD-like concept. In his doctoral thesis with
Karen refugees in Thailand, Fuertes (2004, 2007) too documented the lack of a
linguistic corollary and conceptual crossover. However, he noted that contact with
humanitarian organisations had led some Karen refugees to come up with a local term
to match the foreign term utilised by these agencies. Fuertes worked with his Karen
participants to develop a working definition of trauma and arrived at a phrase
meaning “scar of suffering” (2007, p. 185). In the present study I did not ask
participants to come up with a Karen word for the English term trauma and
participants did not spontaneously offer one. In the Karen context, the experience of
trauma was absorbed within existing cultural idioms of distress.
Participant observation provided triangulated confirmation of the findings from
interviews. At a local service provider’s community consultation with Karen
community members, a Karen man described the lack of cultural fit for the term: “we
are not familiar with ‘trauma’. I don’t think it is useful for us, it doesn’t relate to our
daily experiences” (Statement heard during participant observation on 28 March,
2009). The inner logic of trauma as a wound to the psyche does not appear to be
apparent in Karen conceptions of their emotional world. These findings add support to
reservations about the utility and ethics of imposing a Western psychiatric nosological
category in other cultures where it may not correlate with local understandings of
distress (D. E. Hinton & Lewis-Fernandez, 2010a; Kleinman, 1980, 1995; Kohrt &
Hruschka, 2010; Marsella, Friedman, & Spain, 1996).
11.7.3 Illuminating diversity
These findings illuminate the depth and diversity of cultural idioms and EMs. They
also provide a lens through which to illuminate Western cultural assumptions and
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beliefs about emotional distress and mental illness and the human mind. In
documenting the diversity of Karen women’s idioms of distress I remain wary of their
potential for misuse. Ethnographic methods and understandings of local idioms of
distress have produced, in some instances, a rather confused logic with potentially
harmful ramifications. Service providers of refugee mental and psychosocial
healthcare have been noted to simply use “culturally sensitive” idioms of distress as
linguistic tools to pair with Western psychiatric diagnostic categories (Abramowitz,
2010). It is important to preserve cultural models of mind and human behaviour. As
Hollifield (2005) has stated “The world loses culture when dominant countries export
their views and countries lose historical artifacts” (p. 1284). Similarly, Watters (2010)
warns that “Indigenous forms of mental illness and healing are being bulldozed by
disease categories and treatments made in the USA” (p. 3). He refers to cross-cultural
mental health researchers (psychiatrists, psychologists and anthropologists) as
“psychology’s version of botanists in the rain forest, desperate to document the
diversity while staying only a few steps ahead of the bulldozers” (p. 7). With refugee
mental health services continuing to be framed within a trauma discourse, the
diversity of distress is likely to be compacted. These research findings suggest that a
more collectivist and socially located discourse of human suffering might better
capture Karen women’s experience of emotional and mental suffering.
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Chapter 12
Invisible Clients and Invisible Problems:
Experiences and Perceptions of Settlement Services
12.1 Introduction
This chapter begins to explore the findings related to the research question: How are
some of the current services provided for Karen refugee women perceived and how
might they be improved?
When participants were invited to speak about service provisions they did so broadly,
discussing both generalist resettlement services such as housing provided under HSS
as well as specific health and mental health services. This thesis focuses on mental
health and did not aim to comprehensively explore issues related to the generalist
HSS program. However, as discussed in Chapter 8, many of the causes of women’s
distress were social and related to environmental mastery, language and
communication as well as limitations within the HSS programs designed to address
these issues. Given the importance of these issues to women’s wellbeing, it would be
irresponsible to dismiss the study insights relating to service limitations. Hence this
chapter addresses the findings relating to generalist HSS services and Chapter 13
focuses upon health and mental health services. Implications and recommendations
for both generalist and mental health service providers are discussed in Chapter 14.
12.2 Positive perceptions
12.2.1 “Here it’s the best”
Overall, women were extremely grateful to the Australian Government and all HSS
providers. They wished to “say a big thank you” because they felt “well looked after
and supported in many ways”. A significant strength of current service provisions was
assistance with meeting women’s critical basic needs of shelter, safety and food, as
well as access to education and healthcare. Though many women continued to
experience difficulty in these domains (see Chapter 8), all felt “secure and safe” in
comparison to living in Burma and refugee camps where they “always had to be
afraid of people”.
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12.2.2 Community connection
Women unanimously perceived the Sydney Karen community as a critical provider of
support and a key link connecting them to HSS providers. A major strength of HSS
providers was their association with Karen community groups and leaders. In many
cases these links were created and maintained through the employment of Karen
community members as staff. These links appeared to be crucial to the ability of
organisations to disseminate information and provide support to the Karen refugee
community.
12.3 Learning about limitations
Karen women praised helpful and pleasant service providers but they often hesitated
to verbalise direct criticism when dissatisfied. Instead, they employed certain phrases
and gestures to make non-committal or ambiguous responses when asked about
negative experiences. For example, if asked about problems with GPs, a woman
might say “some women experience that” or “yes, something like that happens”, but
not give a detailed account. In this manner, women managed their discussions of
negative or sensitive topics. Very few women took a clear-cut stance on potentially
sensitive issues. Those who did had often worked with or been trained by human
rights organisations in the refugee camps. Most women spoke allusively and
cautiously, and avoided directly criticising service providers. As Hofstede (2001) has
noted, these patterns of communication are common in collectivist societies.
However, socio-political explanations might better account for women’s reluctance to
criticise service providers. In Burma fear, distrust and danger have dominated social
life (Suu Kyi, 2010) and, as Argenti-Pillen (2003) explains, equivocal discourse may
be employed as an “efficient safety mechanism” (p. 116) in such contexts.
Despite their evasive communication, women did, in their own way, express their
attitudes. They remained silent when asked whether an encounter with a service
provider had been satisfactory, pleasant or helpful encounter. Their silence stood in
stark contrast to their praise, providing a tacit understanding of their perspective. I
positioned women’s silences and ambiguous discourse alongside the comments of key
informants to understand perceptions of service providers. Interpreters were
particularly pertinent sources of information as they had witnessed the encounters
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first-hand and were also often privy to women’s remarks that were not expressed to
the service provider.
12.4 Case management and orientation support
HSS case managers were most women’s first point of contact in Australia, meeting
them at the airport upon their arrival. As outlined in Chapter 4 (see Section 4.3.2),
case management was provided through DIAC’s HSS and consisted of six
components: (i) needs assessment and case management plan, (ii) transit assistance,
(iii) reception, property induction and initial food provision, (iv) essential
registrations, (v) orientation, and (vi) health services (Refugee Council of Australia,
2011b).
Most women reported positively on the quality of case management support that they
received but felt that the duration was too short. Case managers assisted women with
tasks such as using public transport, attending a GP, going to Centrelink and using a
bank. However, most women explained that they were assisted with each of these
activities “once or twice”. This duration of support seemed to be inadequate as several
women reported that they did not feel comfortable to repeat them alone. Moreover,
although recipients of visa subclass 204 (Women at Risk visa) were reportedly told
they would receive an additional six months’ support, many reported that they did not.
Finally, a minority of women perceived that their case manager provided them with
less support because they did not share their religious or political ideologies. The
presence and ongoing impact of political factions is common to all communities and
has been noted to affect other resettled refugee populations (McMichael &
Manderson, 2004).
12.5 Communication issues
Difficulty accessing appropriate interpreters was one of the most salient problems
affecting Karen refugee women when using service providers. As discussed in
Chapter 4 (see Section 4.4), DIAC funded the TIS to assist people who do not speak
English and the service providers who work with them. TIS provided the following
interpreting services: (a) pre-booked telephone interpreting (available for all
languages), (b) 24-hour automated telephone interpreting (in 18 “high-demand”
languages not including Karen), and (c) on-site interpreting (which may be booked up
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to 28 days in advance). Doctors were eligible for free TIS services and access to a 24-
hour priority line (DIAC, 2009b). TIS contracted interpreters who were accredited or
recognised by NAATI. At the time this research was undertaken NATTI reported 11
Accredited and 8 Recognised Karen interpreters in Australia (three of the eight
Recognised interpreters were in NSW) (Personal communication, R. Ganesan,
NAATI, 1 December, 2010). The following were the key communication- and
interpreter-related problems Karen women experienced.
12.5.1 Not Korean, not Burmese
According to participants, some service providers lacked awareness of the Karen
ethnic group. They misunderstood when Karen refugees requested a Karen interpreter
and provided them with a Korean interpreter instead. Participants often discussed this
problem with humour – “they think we are Korean! [laughs]”, an observation also
made by Karen refugees in Minnesota (S. Smith, 2010). For Karen women in Sydney
such problems led to lost time, interruptions to education and employment and
reduced access to quality healthcare. This problem also negatively impacted families
and communities as women relied more heavily on leaders and the few community
members who were proficient English speakers. The following quotation from a
group interview highlights the frustration that many women felt:
We request for an interpreter but we get the wrong one. We feel very angry and
upset because we have to return home empty handed without getting any assistance.
We feel that they don’t want to attend appointments any more. You don’t know –
next time it may happen again then you have wasted your time, your day, and you
return home with nothing. We are supposed to go to school but we have to cancel
our class to attend appointments yet we end up with nothing. It’s very frustrating. It
happens again and again. (Participant in Group D)
A related issue was lack of understanding of ethnic differences amongst refugees
from Burma. Some service provider staff assumed that all people from Burma speak
Burmese. Karen with very limited English language proficiency had trouble
articulating the difference. They were then provided with a Burmese-speaking
interpreter whom they could not understand.
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12.5.2 (Mis)trust and ethnic tension
According to Dr N, phone interpreters may be good for a “non-traumatised
population” but perhaps not refugees from Burma who were accustomed to
surveillance by military intelligence services. She reported: “they are paranoid, they
don’t know who it is. Is it government intelligence? How can they know who they are
talking to?”. Another key informant reported that her refugee clients did not always
trust that their interpreter(s) accurately conveyed their conversations:
I have referred them to [mental health services] but their feedback is “I don’t know,
the interpreter in between is saying things, like mixing it up”. (Key informant – Ms
L)
Dr N and Ms L raise issues of (mis)trust that resonate with research by Hynes (2003)
who referred to a “boundless social universe of mistrust” (p. 2) affecting refugees
from Burma. Ethnic and political mistrust amongst populations affected by
persecution and forced migration has been widely documented (Daniel & Knudsen,
1995) and the potential effects on interactions between refugees and service providers
noted (Thampy & Buhgra, 2004; Tribe, 1999a). Karen refugees have suffered years of
persecution under the Burmese military regime and for some this had resulted in
hostility towards Burmese as reflected below:
Is there a problem with ethnic issues, like not trusting Burmese?
Oh, yeah, yeah. Some are still there! We should change our mind but some are still
there. They come from the hills and mountain areas so they don’t have much
education or experience dealing with other [non-Karen] people. They came from
there and ran, ran, ran. They came to refugee camps and then here to Australia. In
their mind they think “Burmese is not good” because they had a brother or father
killed by a Burmese soldier, they still have it in their mind. (Mu Htòh).
The hostility towards Burmese that Mu Htòh alludes to above was also noted by Dr F
who spoke of “problems trusting the interpreter” in situations where “the interpreter
belongs to a different group like Burmese” because of the “atrocity [the Karen]
experienced”.
Interestingly, none of the Karen women explicitly verbalised their own prejudice
against Burmese (or other ethnic groups) and appeared uncomfortable when explicitly
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asked about this issue. This is likely due to women’s general reluctance to overtly
criticise or complain and their avoidance of political dialogue. However, when given
a choice of preference between Burmese-Karen and Karen interpreters, all reported
that they wished to utilise Karen-speaking interpreters. I did not inquire as to whether
the women preferred a Karen-speaking interpreter whom they personally knew within
their community or not. However, some key informants highlighted issues of
confidentiality, pointing out that in certain circumstances women preferred Karen-
speaking “outsiders” (i.e., community members not personally known to them).
12.5.3 Interpreter availability
Participants described being unable to secure an interpreter when needed and
experienced this problem at Job Services Australia, HSS providers, hospitals and GP
clinics. The findings from this study contrast greatly with the TIS 2010 client
satisfaction survey findings which reported that 98% of respondents were able to
engage a TIS telephone interpreter every time or most times they requested one
(“Client satisfaction survey”, 2010). Some women preferred to use on-site interpreters
when available and found this service more reliable than telephone interpreting. The
following quotation from an interview with a key informant depicts a “catch-22”
situation in relation to women’s communication with Centrelink:
Centrelink say to call this number if you need an interpreter … but they can’t get the
Karen interpreter so we don’t know what’s going on … [However], Centrelink [are]
not very happy if you bring your own interpreter. They want their interpreter yet
they can’t call their interpreter for you! (Key informant – Ms S)
Other women similarly reported that Centrelink staff became frustrated when friends
or family members assisted them with interpretation and translation. This situation
was especially problematic for illiterate women who reported that staff were irritated
by their need for assistance to complete forms. Women were upset when Centrelink
staff reacted negatively to them bringing their friends to interpret. Typical of many
women, Lah Luh reported that such reactions from staff made her “get a headache”
and “want to cry”. However, the Centrelink staff were unlikely to perceive such an
impact as many of the women avoided overt expression of their distress. Interactions
with government service providers such as Centrelink and Job Services Australia
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were a significant source of distress amongst Karen women (see Sections 8.2.2 and
8.3.2).
12.6 Lack of bilingual, bicultural and female service providers
Karen women expressed a preference for female service providers – especially when
addressing sensitive (in this context meaning body or private) topics – but seldom had
access to them at social support services. Male Karen HSS providers explained that
their female Karen clients were uncomfortable discussing sensitive issues such as
relationship problems or sexual violence with them. For example, typical of male
HSS providers, Mr H acknowledged that Karen women “culturally speaking don’t
want to talk about [sensitive issues] at all” but explained that they are even less likely
to disclose problems to a male service provider. Another male Karen service provider
also explained that discussing such topics placed him in a thorny social position as he
risked offending leaders and being perceived to support behaviour(s) (e.g.,
remarriage) at odds with traditional Karen cultural customs (see Section 8.4).
When given the opportunity to suggest positive changes to HSS, a number of key
informants identified the employment of Karen women as cultural brokers to
disseminate information and provide support to the community. For example, Dr N
encouraged the use of Karen health educators to provide information and education
about nutrition. She described her Karen patients as “very quick learners”, adding:
“but it has to be from someone who speaks their language”. Other key informants
emphasised that cultural brokers shared more than language – they shared a “way” of
understanding and a cultural context. For example, Dr F argued that bilingual,
bicultural staff could bridge cultural gaps and provide support within Karen clients’
“model” of mental health:
Otherwise what happens is that this [Western] model and that [Karen] model are
different. The patient’s construct of illness and of mental health is different. (Key
informant – Dr F)
Literature supports Dr F’s view that shared language alone is not a magic solution to
communication in mental health contexts. For example, Sue (1998) argued that shared
cultural characteristics (e.g., attitudes and identity) may be more important in
therapeutic encounters.
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Karen bilingual service providers confirmed that their clients were grateful and “more
comfortable” when able to communicate in their first language. They also reported
that shared knowledge of cultural idiosyncrasies helped them to understand their
Karen clients. However, even bilingual female service providers did not assume that
ethnic matching would automatically bring rapport. They emphasised that, from a
cultural perspective, Karen women were reluctant to disclose personal problems in a
professional context and also drew attention to their pervasive mistrust of others due
to their experiences of persecution.
12.7 Barriers to English language education
Language barriers were the most significant resettlement stressors encountered by
Karen women, especially those who arrived with low literacy due to gendered and
other pre-migration factors (see Section 8.2). This section explores further service
provision barriers including accessibility, availability and quality that compounded
women’s language problems.
As discussed (see Section 4.4), the Australian Government provided 510 hours of
English language tuition to humanitarian entrants through the AMEP. An additional
100 hours of tuition was available through the Special Preparatory Program to
humanitarian entrants with special needs including those with limited pre-migration
education and survivors of torture and trauma. Refugees were required to register for
the AMEP within six months of arrival and commence classes within twelve months.
According to DIAC, AMEP clients could choose from a range of learning options
including full- or part-time classroom tuition, telephone supported distance learning
or home tutoring with volunteer teachers (DIAC, 2011b). At the time of this study
thirteen service providers were contracted to provide AMEP services nationally.
12.7.1 Access barriers
Most Karen women (assisted by their HSS case managers) began classes at the AMEP
within their first few months in Australia. However, health or social factors restricted
some women’s ability to engage with AMEP at this time and they subsequently
slipped through the cracks. Unfamiliar with their rights and the services available, and
without advocacy, they had not instigated further educational support. Other women
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had been unsuccessful in accessing home tutoring and encountered long wait-lists,
hindering their ability to adequately adjust to resettlement.
For example, Pàw Ta Shu had been living in Australia for over a year but had not had
access to AMEP services. Upon her arrival in Australia she had been unable to attend
AMEP classes due to serious health problems. Her case manager had explained that
she could receive English tuition from a home tutor but this had not been followed up.
During fieldwork I assisted and observed Pàw Ta Shu as she attempted to register
with and engage AMEP services. During her initial AMEP assessment there was no
bilingual assistant available despite Pàw Ta Shu having requested one when the
appointment was made. She was assessed as eligible for the Home Tutor Scheme and
informed of a three month waiting list, as volunteers must be matched with a student
by geographic area and gender. Seven months later Pàw Ta Shu had still not been
contacted by the AMEP service provider.
Prior to beginning classes, AMEP service providers conducted an assessment of each
individual’s English language skills. Despite women’s limited pre-migration
education none of the women I interviewed had received additional tuition through
the Special Preparatory Program. This suggests that the Special Preparatory Program
was failing to identify and provide services to eligible Karen refugees.
12.7.2 Classroom and teaching barriers
Cultural and societal characteristics (e.g., compliance, fear and saving face) appeared
to impair women’s ability to benefit from AMEP services because of (a) how they
utilised these services, and (b) how service providers perceived and reacted to their
behaviour (see Section 8.2.1). Women were reluctant to overtly express emotional
distress or dissatisfaction and, as a result, some AMEP providers overlooked their
needs and difficulties. The following participant observation field note regarding an
AMEP classroom encounter demonstrates this issue. It makes evident the necessity of
cross-cultural training and sensitivity to different refugee communities.
Inside the classroom there were 12 students, all sitting in rows facing the
teacher and white board. There were 4 Karen students and 8 from another
country sitting on different sides of the room. The lesson was about how to get
a ticket to catch a train, students were writing on paper and also on the white
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board. Teacher D sat down and spoke with me briefly while the students
worked on their writing. He asked about my research and I explained my
interest in the emotional wellbeing of Karen women. He immediately
responded by saying that I should be studying the refugee women from the
other country and not the Karen. He reported that refugee women from that
other country had “been through a lot” and remarked that some of them had
“lost their children”. He reported that they cry a lot when they think of or
speak about their past and are sometimes so distressed that they need to leave
the class. Teacher D went on to say that the Karen “don’t have those
problems”. He made these comments in front of Karen students, implying that
their experiences and needs were not as critical as those of their classmates.
(Participant observation field note: date removed to protect confidentiality)
This encounter at an AMEP service provider raises doubt about the cross-cultural
competency of the teacher observed. The DIAC Review of the Adult Migrant English
Program (DIAC, 2008b) addressed the “need for support in the training of teachers in
areas of: more information on clients’ cultural backgrounds and experiences, and
cross-cultural training” (p. 26). This ethnographic observation demonstrates that this
issue remains an important and urgent problem.
Further factors in the AMEP learning environment emerged as additional barriers to
language proficiency and were reiterated through ethnographic observations of AMEP
classes where Karen students participated. Firstly, most teachers were not native
English speakers, consequently students learnt pronunciation in heavily accented
second language English. Moreover, during observation I encountered teachers
frequently communicating in their own native language during class-time despite the
presence of students from dissimilar linguistic backgrounds. For example, Teacher C
frequently spoke in his native language, sometimes combining his native language
and English in a sentence. Many of the students in the class spoke the same native
language as Teacher C; however, many did not. Most did not have access to a
bilingual assistant teacher (from their own native language). Teacher C was
employing bilingual teaching methods in a multilingual class. Such observations draw
attention to some serious impediments affecting the ability of students to benefit from
the tuition provided and describe a classroom culture that fails to provide a respectful
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learning environment. According to Karen women and AMEP teachers, limited
access to bilingual assistants in AMEP classes impacted negatively on women’s
ability to participate in, and benefit from, language tuition:
From my point of view, if there were an interpreter at [AMEP] school it would be
great. At the moment we attend and there is no interpreter there. Once in a while we
have one but there is only one interpreter and she needs to attend different classes so
she can’t be with us all the time … Although they teach us using pictures we still
can’t understand … we need someone to interpret. (Htòh)
Similarly, AMEP teachers valued the input of bilingual assistants but noted that
funding limited their availability:
They need bilingual support just to understand. [For example], if I ask them to
please read the questions and answers, they don’t know what it means to read the
questions and answer them so the bilingual support can explain that to them. (Key
informant / AMEP teacher – Mr E)
Karen women avoided directly criticising the Australian Government and AMEP
services and staff, aside from expressing their desire for more language tuition and
greater access to bilingual support. When Karen key informants were asked to
comment on the aforementioned participant observation encounters they concurred
with my trepidation regarding the AMEP service provider as well as the teachers
observed. One community leader explicitly stated that despite concerns he did not
make use of known avenues for complaint. Here too it seems that cultural patterns are
relevant to understanding their resettlement experiences and difficulties. This quiet,
compliant conduct may be detrimental to the wellbeing of the Karen community in
Sydney as their needs are easily overlooked and their problems unvoiced.
Various reports (DIAC, 2008b; Maher, 2006; Nega, 2008) have questioned the
adequacy of the number of hours of English language education provided to refugees
in Australia. This study suggests that number of hours is only one component of
effective education. Students’ learning is likely to remain hindered, despite increased
hours of tuition, if classroom practices and teaching methods are not also addressed.
Findings of this study also strongly indicate that the gendered aspects of refugee
education are important. Women had less pre-migration education than men and faced
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difficulties both attending and engaging with English language classes in Australia.
This is similar to what is already documented in literature (Hatoss & Huijser, 2010).
In light of the limitations that Karen women have in accessing and utilising language
education services in Australia a “one size fits all” approach to refugee education is
likely to be suboptimal (Hatoss & Huijser, 2010, p. 149). The Australian Government,
education providers and researchers should explore barriers to language proficiency
and alternative solutions to meet the learning needs of different refugee communities.
Here too (see Section 12.3) this research has highlighted the need for future
researchers to use sensitive research methods to overcome refugees’ reluctance to
complain or criticise service providers. The National Client Satisfaction Survey report
(DIAC, 2008a) found 84% of clients reported overall happiness with their AMEP
classes. However, a twelve month DIAC-funded AMEP Research Centre
ethnographic study of AMEP clients completed in 2009, while reporting high client
satisfaction (DIAC, 2010a) noted that few participants, particularly students with
lower English language proficiency, criticised their AMEP experience.
12.8 Face value: limited perceptions of Karen women’s needs
Some cultural characteristics of the Karen appeared to contribute to inequalities in
access to services. Service providers’ failure to understand these cultural
characteristics is a limitation in current HSS service provisions for Karen refugee
women.
Karen participants collectively referred to themselves as “shy” and “easy people” (see
Section 8.5) and, in literature, are often portrayed as quiet and avoidant of conflict
(see Section 3.3.2). Typical of their comments, Ms K, reported: “[people] see the
Karen and they say, ‘Your people – how come [they are] so laid back?’”. Many of
these traits are common to collectivist societies (Gudykunst & Bond, 1999; Hofstede,
2001; Kagitcibasi, 1999). These customary characteristics also appear to have been
strengthened and in some cases distorted by persecution, prolonged political conflict
and forced migration. This is reflected in the following quotation from an interview
with Mr H, a Karen key informant.
It’s the culture … Karen people love to live quietly, simply, they don’t want to
disturb others … So when they are oppressed and when they are mistreated … they
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try to control their feelings and emotions, rather than expressing and bursting out
with emotion. (Key informant – Mr H)
These patterns of behaviour were confirmed by my observations at service providers
where other community groups were far more vocal and visible whereas Karen clients
were reserved. The Karen community were perceived by both Karen and non-Karen
service providers to be adaptable and resilient. Service providers linked Karen
resilience to their strong religious faith, collective- and community-oriented approach,
and also to their normalisation of suffering. Most also described the Karen as “easy-
going”, compliant and non-complaining. Overall, the service providers I met liked
working with Karen clients, describing them as “proactive”, “hard working”, “a
pleasure to work with”, “adaptable”, “receptive”, “easily content” and “shy”.
Concerningly, some non-Karen service providers took their Karen clients’ self-
presentation at face value. These participants often described the Karen as “simple”,
“compliant”, “polite”, “smiling” and socially unsophisticated. They presented
positively skewed perceptions of the community and some lacked knowledge of
serious problems and issues affecting Karen women. For example, one non-Karen
service provider reported that domestic violence was not a problem in the community
“because they are Christian”. But, as explored in Chapter 8, domestic violence was
indeed a problem amongst the Karen community. The AMEP encounter with Teacher
D (see Section 12.7.2) also revealed that some service providers perceived the Karen
to be “fine” in comparison to other refugee communities, and believed they had not
endured suffering as severe as other (more vocal and emotionally expressive) refugee
populations.
The perceptions of Karen service providers differed from the face value approach
adopted by some non-Karen staff. Some Karen service providers believed that Karen
approaches to coping and resilience (such as not expressing distress and normalising
extreme suffering) could mask deeper emotional suffering and pain (see Sections
10.2.4 and 10.3.1). Karen service providers tended to view the community as shy and
troubled but also stoic and resilient. These findings point to the need for adequate
cultural competency training in order to orient service providers to the unique
circumstances of different refugee communities.
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12.9 Elder and service provider burnout … “the profacticals”
As we saw in Chapter 10 (see Section 10.3.2), Karen leaders were central to
supporting the Karen community and were frequently the first point of contact for
women experiencing problems. They were relied upon for both practical assistance as
well as guidance and emotional support. It was therefore important to address their
perceptions of current service provisions as well as their perceptions of their own
roles. Service providers confirmed the important role of community leaders. For
example, a health service provider said his Karen patients were more likely to attend
follow-up appointments when their pastor encouraged attendance and helped to
arrange appointments. A limitation of current service provisions appeared to be the
excessive workloads and lack of support for Karen HSS staff and Karen community
leaders who often struggled to meet the demands of their roles.
Some of the Karen and Burmese community members employed as service providers
experienced a dissonance between the expectations and demands of their employers
and those of their community and clients:
I can’t, I just can’t, I [feel like] crying, I can’t explain. She [my employer] doesn’t
realise that I’m burning out. (Key informant – Ms L)
[My employer says] you work too much overtime. You have to take time in lieu.
How can I take time in lieu? They are ringing me all the time … I mean [you could]
say that we help the community, 24-hours, 8 days a week [laughs]! (Key informant
– Mr B)
Participants viewed their roles in the community as crucial. They explained that
effective support for community members required outreach and could not just be
provided in an isolated professional environment. Moreover, they felt that they would
lack credibility and “lose trust” in their professional roles if they attempted to distance
themselves or cease to meet the “after hour” demands of their clients. One key
informant coined the term “profactical” to describe the role of within-community
service providers:
We need to be practical and realistic … You are between professional and practical
… that’s why I have created a [new] word … profactical … As a [service provider]
your role is professional [but] from the community perspective you are doing
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practical things. The word professional, professionalism talks about boundaries and
this and that. But when you are working in the community that doesn’t work
always. That is why I created the word [profactical]. (Key informant – Mr H)
Some leaders described a cumulative effect of pressure building from responding to
the needs of the community here in Sydney as well as listening and responding to the
needs of those who remained in Burma and on the Thailand-Burma border. These
pressures also affected their families and, in one case, severely affected a community
leader’s ability to maintain other commitments such as employment. In contrast, non-
Karen / non-Burmese service providers did not mention these problems. The
following quotations depict Karen key informants’ experiences and expressions of
burnout:
People talk to me unofficially, which makes me tired. I’m tired of this stuff … It’s
heavy. I get pain. I get neck pain. (Key informant – Ms L)
Even Saturday, Sunday, early morning, midnight, they ring me. You know, I can’t
handle it any more. (Key informant – Mr B)
You know they are quite demanding to the leaders and elders, so these people
become burnt out or, you know, exhausted … My position is with the community
[here and] also back there [in the refugee camps]. I [still] have a lot of connections
back there. So from the camps, over the border from time to time they contact me
with information, particularly needs and concerns so then it is hard to forget and
how do you have weekends or respite time? I mean 24/7 is not enough. During the
weekend, even regardless of day or night-time, the phone is ringing, information is
coming. (Key informant – Mr H)
Karen leaders and within-community service providers spontaneously explained their
motivations for continuing to help the community in their professional and
community-based volunteer capacities. For some their reasoning was based around a
moral desire to help others. Others perceived a “duty” and “obligation” related to the
historical and political context of the Karen people. Some helped as a means of
honouring those who had died throughout the many years of conflict:
[We leaders tell each other] don’t be demoralised because some people [in Burma]
gave their life and are fighting the Burmese [military]. They even gave their lives
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and died … In serving them [the community] we don’t expect them to praise us, it’s
because of our duty and obligation. (Key informant – Mr P)
A few community leaders mused over their concern for each other and worried that
their commitment to the community was in fact (a) “burning” the community out with
too many events and expectations, and (b) “burning” the leaders out because their
motivation, although “good”, also stemmed from their own suffering. Participants
suggested that this problem is shared by elders in other refugee communities. The
potential for refugee community leaders and bilingual staff to face burnout has been
noted before (Baron, 2002; de Jong, 2002; Fadiman, 1997) but is seldom further
explored. These research findings suggest that this topic should be addressed in future
research.
12.10 Lack of awareness, understanding and cohesion between service
providers
During the course of research I heard of, and observed, some positive examples of
community organisations, HSS providers and other service providers (e.g., GPs)
working together well. For example, one health service provider shared a strong
relationship with a Karen community leader who regularly referred clients for
healthcare appointments and also monitored and encouraged ongoing attendance.
However, I often encountered misunderstandings, disparities and confusions between
different service providers. Most were aware of other organisations but did not always
fully understand precisely what was available from other providers. For example, an
AMEP teacher said he did not know what kind of support HSS case managers
provided. Some service providers lamented that short funding rounds hindered (a)
their capacity to provide and plan services, and (b) the ability of organisations to
become familiar with one another. Moreover, some HSS providers had doubts about
the appropriateness or ability of others to address the needs of their Karen clients. The
following quotation comes from an interview with a service provider who expressed
confusion and doubt about the relevance of another refugee support organisation and
their ability to meet her clients’ needs:
I really don’t know about how STARTTS work? How would [they] assess her?
That’s what I don’t understand. (Key informant – Ms L)
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This issue was particularly pronounced in relation to informants’ opinions about
mental health support services. Further questioning revealed that health service
informants perceived a mismatch between services offered and the cultural beliefs of
their clients. A mismatch of perspectives and a lack of cultural fit regarding mental
health service provisions for Karen was also highlighted by Karen women and a
number of Karen key informants. These issues are addressed further in Chapter 13
(see Section 13.4).
12.11 Summary
Women generally expressed positive perceptions of services that helped to address
their most pressing needs. Their less positive opinions were not always transparent
but women did express their dissatisfaction with the duration of management support
and AMEP as well as their access to interpreter services. Other limitations noted by
key informants, some of whom were also Karen women, included ethnic tension
between Karen clients and Burmese service providers, lack of female and especially
female Karen service providers, quality and duration of English language tuition,
elder and service provider burnout, and, lastly, a lack of awareness and cohesion
between service providers. Implications and recommendations for generalist HSS
service providers are addressed in Chapter 14.
Many of the material and systemic sources of stress and suffering experienced by
Karen refugee women are hardly surprising and certainly not unique. They are the
shared fate of the disenfranchised and the systemic socio-political factors affecting
these communities have been well documented (Albrecht, Albrecht, & Murguia,
2005; Blakemore, 2000; Chow, Jaffee, & Snowden, 2003; K. S. Collins et al., 2002;
James, 2010; Pittaway & Bartolomei, 2001; Sheikh-Mohammed et al., 2006; J.
Taylor, 2004). The shared fate of poverty and sociopolitical inequality amongst many
communities has provided frameworks, models and examples of interventions that
might be applied to the Karen context. For example, we might be able to learn from
programs implemented in disadvantaged Indigenous Australian Aboriginal
communities to enhance social and emotional wellbeing (Purdie, Dudgeon, & Walker,
2010; Tsey et al., 2007).
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However, whilst the systemic aspects of poverty in Australia are shared, the refugee
experience is not common to all communities of poverty. Refugees’ experience of
poverty in resettlement is positioned between pre-migration experiences and post-
migration sociopolitical prejudices and problems specific to humanitarian migrants
such as increasing public and media discrimination against asylum seekers (N. Grove,
Zwi, & Allotey, 2007; J. Taylor, 2004; Tribe, 2002). We might therefore also look to
ecological interventions with other refugee communities (Goodkind, Hang, & Yang,
2004). Yet, each refugee community is unique in its sociopolitical and cultural
context. In this thesis I have sought not only to report women’s stressors and concerns
but also to examine how their encounters with daily stressors might be understood
within the Karen-specific context – the broader spiritual-socio-political-cultural
(including gendered) melting pot. These issues need to be considered if service
providers and policy makers wish to work with Karen women to enhance their
wellbeing. The findings demonstrate that women’s problems intersected with gender,
culture, politics and persecution. Moreover, this thesis has demonstrated how fear of
freedom, fear of authority, absolute compliance, and sponsored dependency or
helplessness generate or exacerbate daily stressors faced in the Australian context.
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Chapter 13
“It’s good … but it’s not very effective”:
Experiences and Perceptions of Health and Mental Health Service
Provisions
13.1 Introduction
This chapter explores Karen women’s experiences and perceptions of primary and
mental healthcare services in Australia.
13.2 “Extra special” care from GPs
Women perceived a number of organisations and individuals to have been particularly
sensitive to their situation. In addition to many HSS providers, a small handful of GPs
who did not work exclusively with refugee clients were particularly sensitive to the
needs of Karen refugee women and provided “extra special” care and attention. When
interviewed, these GPs – in contrast to others – reported that more time, extra work,
education, social support and advocacy (e.g., budgeting, parenting and assertiveness
advice) was required to adequately care for their refugee patients. For example, Dr G
reported:
Another problem is advocacy for these people … It’s about giving them information
and ringing up on their behalf and making appointments. Dealing with immigration
and the health bureaucracy on their behalf. (Key informant – Dr G)
It is possible that GPs with a special interest in Karen or refugee patients were more
likely to participate in the research as an equal number of doctors declined or did not
respond to repeated invitations to participate. In order to seek out negative cases
(Charmaz, 2006), GPs about whom participants or key informants had expressed
dissatisfaction were specifically targeted and recruited. These GPs explained that they
did not require any extra time for consultation with refugee patients and did not report
assisting refugee patients with advocacy or accessing social services.
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13.3 Primary health and healthcare services
13.3.1 Encountering healthcare and illness
Karen women suffered from numerous (and often serious) illnesses and diseases and
valued their access to healthcare in Australia. A recent study of 156 refugees from
Burma living in Australia reported high rates of Helicobacter pylori infection (80%),
latent tuberculosis (70%), vitamin D deficiency (37%) and strongyloidiasis (26%)
(Chaves et al., 2009). Most Karen women were encountering complete primary
healthcare for the first time and, while grateful for receiving assistance, many were
saddened to discover that they had disorders and chronic diseases, something they
were not previously aware of. Some women were fearful of the implications for their
wellbeing and, as one GP explained, were often seriously alarmed because diseases
such as diabetes are “death sentences” in Burma and in the refugee camps.
Some Karen women experienced frustration accessing services and particularly with
service protocols and waiting times. Htee Gloh explained that some women did not
comprehend the custom of making appointments. GPs did not raise any concerns in
relation to Karen patients accessing and attending their services other than language
and communication. These findings suggest that Karen women might benefit from
more education about (and assistance accessing) Australian health services than is
currently provided through the HSS orientation.
13.3.2 Mismatched expectations
GPs varied greatly in terms of their level of interest, knowledge and involvement in
the political, social and medical issues of their Karen refugee patients. Most appeared
attuned to their Karen patients’ expectations regarding treatment. However, a number
of Karen women were dissatisfied with the care they received. Women expressed
stress and dissatisfaction with GPs when they felt that they were not properly assessed
and when no medicine, intervention or referral was provided. Women were especially
frustrated and disheartened when their doctors could not find “anything wrong”
despite their experience of various aches and pains. At the same time, Karen women
were also bewildered by what they perceived to be Australian health service
providers’ preoccupation with unnecessarily analysing emotional or psychological
suffering:
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When I go to [the] antenatal clinic, the first time they interview you, you have to fill
out the form to say that, “I feel very sad, very often”. We laugh because for [us]
that’s normal. Sometimes you feel sad and then you can’t sleep, those things for [us]
it’s normal … For the Westerner, they think everything is serious, especially when
you’re pregnant, they’re really concerned about it. (Key informant – Ms S)
Karen key informants and women participants located their experience of general
healthcare in Australia against the backdrop of their encounters with health services in
rural villages and refugee camps and explained that most Karen were not familiar
with attending medical services. One participant in Group B explained: “in our
country we rarely go to see the doctor, only when we are near death”. Consequently,
when women attended Australian GPs, they expected some form of tangible treatment
or referral for further testing. Moreover, women’s pre-migration experiences of
treatment were aggressive by Australian standards (in large part because healthcare in
the camps was rudimentary and patients were only likely to receive medical care in
the later stages of illness). Many were familiar with using antibiotics and other
medications rarely prescribed in Australia. For example, during participant
observation an elderly Karen man lamented the “weak” pharmaceuticals available in
Australia and praised the benefits of isoniazid (a first-line anti-tuberculosis treatment)
for curing a variety of ailments including sore throats and asthma. Most doctors were
aware of their Karen patients’ expectations concerning treatment. For example, as Dr
G explained:
They all expect some kind of treatment … They love injections … [and in the
refugee camps] have been made to rely on [them] … it might just be a B-12 shot or
some kind of B-complex mixed up in twenty millilitres of water and each person is
getting one tenth or one twentieth but the colour is nice and yellow so they think
they are getting something good … That’s part of the education that they need in
Australia, that in Australia we don’t just give injections willy-nilly. (Key informant
– Dr G)
Some doctors had developed creative solutions to meet their patients’ “high”
expectations and prescribed multivitamins as a “placebo” treatment and means of
reassurance. GPs highlighted the need to give explicit information about treatment
regimens for chronic diseases as many of their Karen patients expected treatment to
be “one-off”.
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GPs were aware that Karen patient dissatisfaction led to frequent “GP-hopping”,
stating: “[they think] if this doctor doesn’t give me a treatment I’ll go to another and
he might give me an injection”. They also noted that, in part as a consequence of
dissatisfaction, some women accessed traditional Burmese medicine. Resettled Karen
refugees in America have been noted to arrive with, import and use a variety of
traditional medicines (Power et al., 2010). Karen key informants in this study
confirmed Power et al.’s (2010) findings and explained that many arrive with
numerous traditional medicines as well as medications such as antibiotics obtained in
Thailand. GPs differed in their perceptions of the use and availability of traditional
medicines amongst Karen refugees. Some believed that traditional medicines are not
available in Sydney whereas others were aware of their use. Research in America
found high levels of lead in some traditional medicines used by refugees from Burma
(Mitchell et al., 2012) and some service providers were worried about the contents of
traditional medicines used in Australia. Several months after the interviews with
service providers in Sydney, the local government health authority released a health
warning to avoid Burmese traditional medicines due to concerns they might contain
high levels of arsenic (New South Wales Department of Health, 2012).
Women experiencing more severe emotional distress were especially dissatisfied with
the care offered by their GPs. It is possible that, in addition to cultural factors,
language and communication barriers limited discussions between Karen patients and
GPs such that only physical health issues have been discussed in detail. An additional
possibility is that GPs may not have sought to explore their patients’ EMs for their
distress due to lack of time in short consultations. A third possibility is that some
doctors have limited awareness of the importance of a cross-cultural appreciation of
EMs. Finally, GPs may have felt unable to adequately address the psychosocial needs
of these patients and thus avoided opening a can of worms. Recent research with GPs
treating ethnic minority patients in Australia found that doctors felt unable to address
the structural issues affecting refugee patients and offered medication instead (Furler
et al., 2010).
As discussed in Chapter 9, women conceptualised their physical and emotional or
mental health as interrelated and often attributed their distress to social and
psychological (e.g., thinking too much) causes. However, when it came to physical
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manifestations of distress (e.g., aches and pains) they expected a physical biomedical
solution. Moreover, women often sought medical treatment for their physical
symptoms of distress but explicitly separated their physical and psychosocial
complaints to the degree that they did not inform their doctor of the broader
circumstances of their distress. This scenario is exemplified in the following quotation
from an interview with Lah Luh, a woman who experienced severe emotional
difficulties. During this section of our conversation I was concerned about Lah Luh’s
mental health needs and sought to understand the degree to which she had informed
her GP of her distress:
I am not well most of the time. If possible I want to find out what is wrong with my
whole body, I want to check it out. I always feel sick … I have no idea what’s
wrong with me. Is it my gastric problems? Is it liver problems? What part of my
body has something wrong? … I want to find out what the problem is …
Did you tell him [your GP] about the body problems?
Yes.
And did he give you help?
He said it’s because my diabetes affects other parts of my body.
Did you tell your doctor about your crying?
No.
Did you tell the doctor about sometimes thinking that it would be better if you
were not alive?
No point talking to the doctor because I am the one who suffers, not them! If they
don’t understand my suffering they might scold me. I am the one who suffers, not
him.
Why might he scold you?
Sometimes when I see my GP he says, “You have so many problems, I can’t find
your problem, I can’t help any more, I am not God, I don’t have a power like God
so I can’t help you”. (Lah Luh)
Part of Lah Luh’s anxiety about her doctor’s reaction may relate to fear of authority.
Her behaviour might also have reflected a despondency towards medical treatment as
a result of her pervasive and chronic undiagnosed health problems.
The issues and mismatched expectations noted here speak, in part, to the notions of
cultural congruence and cultural competency. The construct of cultural congruence
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refers to the cultural competence of a health provider (or organisation) in relation to
the cultural needs of the client (Betancourt, Green, Carrillo, & Park, 2005;
Constantino, Malgady, & Primavera, 2009; Hardy & Laszloffy, 1995; Hwang, 2006;
Manderson & Allotey, 2003). Here Kleinman’s (1980) EM framework is relevant. It
seems that GPs and Karen women often held different EMs in relation to women’s
suffering. That is, their cultural conceptualisations of women’s experiences were
incongruent. In many cases, the cultural competence of GPs was insufficient to bridge
their differences.
13.3.3 “They should be fine”: communication barriers and GPs
Upon Karen women’s arrival in Australia HSS case managers assisted them with
arranging and attending GP appointments. These appointments were (without
exception amongst participants in this study) with Burmese-English speaking doctors
practising in Western Sydney. Many HSS case managers spoke multiple languages
and could converse with the GPs in either Burmese or English. However, a number of
their Karen clients spoke neither of these languages and were reliant on their case
manager for communication. Officially, case managers were prohibited from
interpreting at medical appointments though in reality all women reported that they
did because no other interpreter was made available.
Women’s communication with their GPs became difficult when assistance from HSS
case managers expired. Doctors and Karen participants overwhelmingly reported that
they did not use professional interpreters for GP consultations. Karen women who
could not speak Burmese or English enlisted friends or family members to assist them
with communication. Women were more likely to continue to attend Burmese-
speaking GPs because they could more readily find friends who spoke proficient
Burmese (as opposed to English). In this way they made a choice between two
imperfect alternatives. As Pàw Lèh explained: “if you go to an English Australian GP
you need an interpreter [who speaks English], it’s more difficult”. Echoing prior
research (Rosenberg, Richard, Lussier, & Schuldiner, 2011), participants in my study
also reported that women were less likely to discuss sensitive health concerns when
assisted by informal family interpreters.
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Unfortunately, women were not always able to find a friend to translate. As a result
they attended appointments alone and communicated in whatever limited Burmese or
English they possessed:
For those who can’t speak Burmese or English, [Dr X] knows so he doesn’t say
much, he just does whatever is necessary and prescribes the medicine that the
patient needs [laughs]. I think most Karen people, although they don’t speak
Burmese, they can understand a little bit of Burmese, so they should be fine. (Ta
Heh Sōo)
In these circumstances things were not always “fine” and women were not always
satisfied with the level of communication. Moreover, they often did not understand
the content of the consultation. On occasion miscommunication resulted in
mismanagement. For example, Lah Luh experienced serious physical and mental
health problems – including thoughts about killing herself – and attempted to convey
her distress to her GP but did not have access to an interpreter and had not received
adequate care. This raises a crucial issue in terms of the implications of GP
communication for the wellbeing of Karen women, particularly those who may be
suffering from mental health issues, and could mean that women’s mental wellbeing
is compromised. Interestingly, despite feeling dissatisfied, women did not complain to
their doctors about communication issues. They frequently continued to attend the
same GP or changed to another Burmese-speaking doctor.
Most GPs reported having difficulty using the TIS service and, in this context,
considered the use of family and friends as interpreters to be an adequate solution to
communication problems. These findings parallel research with GPs treating refugee
patients in Ireland where doctors believed that they could sufficiently communicate
using sign-language, minimal English and informal assistance from others
(MacFarlane, Glynn, Mosinkie, & Murphy, 2008). Like Ta Heh Sōo, most GPs in this
study were optimistic that their methods of communication “should be fine” for their
patients. However, some acknowledged having had difficulty explaining treatment
regimes. Others queried the ethical and legal implications of the scenario. These
issues are depicted in the following two quotations from interviews with doctors:
Often times I’ve seen from my own practical experience when you ask someone a
question and they reply sometimes the interpreter, their friend, tells you what they
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think you are asking and not what the patient is replying… That is why I feel the
phone interpreters are better … However, trying to get a phone interpreter is not
easy and having an interpreter visit unless you are a specialist is not allowed … I
think it has to do with funding. (Key informant – Dr G).
The first time they [Karen refugee patients] are brought to me by their case
managers. Most of the case managers can speak Karen and Burmese. For the second
visit they bring their friend who can speak Karen and Burmese.
Have you ever used the telephone service?
No, I’ve never used [it] … Time is very important to us. I can get any [information]
I need because when they come to see me most of their complaints are very simple.
For example, blood tests, simple complaints, fever, coughing, running nose – I can
easily understand that [without an interpreter]. Some of them, if they can’t talk
[Burmese] I think they can understand what I say in Burmese … So far I don’t have
any problem [using their friends as interpreters] but I don’t know exactly from the
legal point of view whether I am right or not … maybe I’m wrong or risky, I don’t
know. In our centre the specialists don’t use any interpreter [either]. (Key informant
– Dr L)
These findings add to a growing body of literature indicating that telephone
interpreting services are sub-optimal for healthcare providers in Australia (Atkin,
2008; Bird, 2008; Department of Immigration and Multicultural and Indigenous
Affairs, 2003; Huang & Phillips, 2009).
Numerous reports describe problems with interpreting services from the perspectives
of doctors, service providers and (occasionally) clients. However, the voices of
interpreters are largely and remarkably absent. Interpreters are not invisible conduits
of information (Angelelli, 2004). They both affect and are affected by the
communication encounters in which they work. In this study the perspectives of
Karen interpreters offered valuable additional information as to why interpreting
services appear to be so difficult to utilise. Many of the NAATI interpreters in the
Karen community were themselves refugees, often struggling to address their own
resettlement concerns. Interpreters were paid ten dollars per fifteen minute phone call.
The work was sporadic and consequently many interpreters took on other
employment. As one interpreter stated: “we cannot sit around all day in case we might
get a thirty-five minute job”.
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Adding to GP communication problems, the impact of ethnic tension and mistrust
(see Section 12.5.2) was also apparent in relation to Karen women’s interactions with
their doctors and was identified as a cause of “GP-hopping” whereby Karen
community members utilised multiple GPs:
They don’t normally talk about that [ethnic-related mistrust of Burmese GPs] but I
can imagine that they have it in mind. So … they just find another [doctor] … They
don’t openly say “Oh, this is because [they are a] Burmese GP”, but they have it in
mind. (Key informant – Mr H)
All but one of the Burmese doctors minimised the issue of ethnic prejudice,
explaining that this was not an issue with their clients. Typical of their responses, Dr
N reported: “they don’t see me as Burmese, they see me as their doctor”. Taken
together, these findings point towards an urgent need to address the effectiveness of
primary healthcare services for Karen refugee women, including current interpreter
services for GPs as well as GPs’ awareness of ethnic (mis)trust issues.
13.4 Mental health services: cultural differences and paradigm clashes
Refugees in Australia could access a range of mental health services, most notably:
Mainstream mental health services such as psychologists, psychiatrists and
counsellors in private or public practice;
Specialist mental health providers for people from non-English-speaking
backgrounds (e.g., the Transcultural Mental Health Centre); and
Specialist DIAC-funded services for refugees and torture survivors. As noted
in Chapter 4 (see Section 4.4), FASSTT was a network of eight such specialist
rehabilitation services representing one in each state and territory (FASSTT,
2006). In New South Wales this service had been provided by STARTTS
since 1988. In addition to STARTTS services, refugees were able to access
education-related counselling through the AMEP. In New South Wales,
Mission Australia provided counsellors to the AMEP program. These
counsellors assisted with educational counselling, referrals and “personal
problems” affecting learning (ACL, n.d.).
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During interviews all participants were asked about their experiences and perceptions
of Australian mental health service providers. Their feedback centred around nine key
areas of concern which highlighted cultural differences between Karen and Western
psychotherapeutic approaches to healing and emotional or mental wellbeing. In this
section I will use the nine key areas as a platform to present participants’ experiences
and perceptions of mental health services.
Overwhelmingly, participants referred to STARTTS when discussing their
perceptions of mental health services. This is not surprising, because, as discussed
(see Section 4.4), refugees were routinely referred to STARTTS as part of the needs
assessment undertaken by HSS case managers. Most Karen women also knew that
psychologists, psychiatrists and counsellors were also available in the healthcare
system and through other services such as adult education institutions. No participants
specifically mentioned the Transcultural Mental Health Centre.
Nine points of difference
1. The first factor: “what is counselling?”
Karen women (including key informants) were generally aware of the availability of
mental health services but noted that they did not necessarily understand how such
services purportedly helped people. Similarly, healthcare key informants who worked
with Karen refugees observed that their clients often did not understand what
counselling was about despite regularly attending sessions:
Do you think they [Karen clients attending counselling] know what is being
offered to them?
Not really. I don’t think so. Even those experienced [counsellors] – ten or fifteen
years working here – they have some clients who after ten or twelve sessions [still]
don’t know what counselling is. (Key informant – Mr H)
Karen women and Karen key informants frequently explained that counselling “is a
Western concept”. Indeed, with “no traditional term” for counselling it could not be
directly or even easily translated in their language.
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2. The prebooked healing hour
At Australian service providers refugees were expected to self-disclose and address
their suffering (at least in part) within regular sixty minute pre-booked intervals. This
contrasted strongly with Karen forms of healing whereby supportive interactions took
place when and as needed, for unspecified durations and at locations determined by
the level of need and situation of the distressed person. For example (see Section
10.3.2), Karen leaders and pastors visited homes, sometimes in small groups, to
provide support and healing. Women contacted their peers, leaders and pastors when
they needed support and, according to leaders (and service providers), were
particularly unlikely to attend follow-up or prescheduled appointments. Karen key
informants explained that Australian psychotherapy sessions were viewed as “very
formal” and women were described as “reluctant to join that formal session”. One
Karen leader went on to explain: “even if you have counsellors no one will go to him
or her”.
3. Disclosure to a professional stranger
When seeking help, women valued the opinions and empathy provided by others who
shared their situational and sociocultural circumstances. In contrast, Western
counselling is often an interaction with a stranger who does not necessarily share
similar experiences, beliefs or cultural nuances. Findings from this study resonate
with anthropology and cross-cultural mental health literature (Calabrese, 2010;
Gudykunst & Bond, 1999; Sue & Zane, 2009), including refugee studies (B. Guerin,
Guerin, Diiriye, & Omar Yates, 2004), and suggest that Karen women do not
understand or perceive value in disclosing one’s problems to a stranger.
4. One-on-one individual healing versus communal group process
Though the distinction between individualist and collectivist societies is often
overemphasised, it is helpful for understanding differences in therapeutic systems
(Calabrese, 2010). Karen society is collective. Moreover, because of widespread
persecution, most of Karen women’s problems, losses and traumas were shared by
others in their community. Consequently, when women did engage in interpersonal
approaches to coping, they tended to do so in groups. Even formal support from
elders and pastors was obtained in people’s homes where families would often
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converse and pray together. In contrast, Western psychotherapeutic interactions (with
the exclusion of family and group therapies) are typically characterised by one-on-one
encounters. Moreover, Western trauma-oriented psychotherapies for refugees
personify political violence and transform social problems into problems of the
individual (Kleinman, 1980). Notably, STARTTS did offer some community-oriented
group activities such as women’s swimming classes. Interestingly, Karen women
reflected positively on such activities but did not conceptualise them as counselling
per se. Rather, they accepted and enjoyed these activities as opportunities for social
interaction and the chance to learn new skills.
5. Verbalisation and self-disclosure
Researchers have long noted that the cultural attitudes of several communities
(Moodley & West, 2005) – including Hispanics (Cortese, 1979; Meadow, 1982),
Philipinos (Ponce, 1974), Asians (Kim, Sherman, & Taylor, 2008) and Blacks (Calia,
1966) – contradict the perceived value of talk therapies that encourage self-disclosure
and introspection about emotional suffering. Indeed, the belief in the need for
disclosure and the catharsis of confessing one’s most intimate thoughts and feelings
has been attributed to Western and Judaeo-Christian thought (Summerfield, 2000).
Foucault (1998) used psychoanalysis as an example of how previous Christian
practices of confession have spread to secular private life. Today, confession through
verbalisation remains a noted feature of Western society (C. Taylor, 2009). Within
this setting, modern Western therapies have tended to emphasise the need to confess,
control and analyse one’s thoughts, feelings and behaviours. This approach is distinct
from the healing methods and therapies common to most other cultures which are
oriented towards acceptance, harmony, understanding by awareness, contemplation
and mind-body-spirit unity (S. Fernando, 2010). As van de Put and Eisenbruch (2004)
have argued: “There is certainly no cultural analogue in any of the Asian healing
ceremonies to the type of self-disclosure encouraged in psychotherapy” (p. 152).
Karen leaders and women described established patterns of help-seeking in which the
help-seeker could say very little if desired and the help-provider could give explicit
and specific advice and instruction if that was deemed appropriate. The healer was
expected to have, at some time, endured comparable problems. Consequently, through
their experience and wisdom they could illustrate pathways (via self-disclosure) for
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the help-seeker to overcome their difficulties. In contrast, Western psychotherapy also
tends to eschew therapist self-disclosure. Seen from a cultural perspective, it would be
unsurprising that some Karen women might perceive confessing intimate feelings as
nonsensical or counterproductive (Ekblad & Jaranson, 2004). The findings suggest
that Australian mental health services, particularly talking therapies such as
counselling and psychotherapy, were not well matched to Karen women’s approaches
to healing and beliefs regarding coping.
6. Secular versus spiritual
Karen women emphasised the centrality of religious beliefs and the religious
community to healing – approaches that contrasted sharply with the secular
orientation of mental health services. It is only relatively recently in Western history
that mental and emotional healing has become devoid of spiritual or religious aspects
and this division is rarely found elsewhere (Calabrese, 2010; Moodley & West, 2005).
The differences between Western secular and Karen spiritual approaches to coping
can be framed as cultural incongruences and mismatched EMs. Anthropologists,
psychologists and psychiatrists (Kleinman, 1980; Lawler-Row & Elliott, 2009;
Thoresen, 1999) have consistently drawn attention to the significance of spirituality
for wellbeing and Nagayama Hall (2001) has pointed to the importance of a shared
spirituality as an aspect of culturally competent psychotherapy with ethnic minorities.
7. Crazy people
When we discussed the presence of mental health services women were often eager to
report that they had not personally utilised these services beyond attending required
resettlement assessments or when seeking assistance with some practical problem
such as liaison with immigration services. This likely reflects the shame and stigma
surrounding the topic of mental illness amongst the Karen. For example, key
informants reported that, because of stigma, they had difficulty encouraging Karen
community members to seek help from mental health services:
They won’t go if I refer them to a psychiatrist. They at once assume that I am
considering them crazy. (Key informant – Ms L)
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You don’t want to label them because labelling is not good at all. When you label a
Karen woman, that label sticks to her forever, for the rest of her life. (Key informant
– Ms K)
In contrast, there was no stigma attached to traditional models of help-seeking. Karen
community members could obtain help from leaders and pastors without risking
gossip or social exclusion. Of course, stigmatisation of mental illness and
psychotherapy is not unique to the Karen or even refugee communities and such
attitudes are common amongst the Australian public also (Griffiths et al., 2006).
However, the collectivist cultural framework of the Karen and the small size of the
community could potentially contribute to increased stigmatisation due to fears of
social judgements, gossip and rejection.
8. Don’t just sit there – do something
Karen women believed that explicit help-seeking encounters (such as counselling)
should result in some sort of practical solution and failed to perceive any benefit if
they did not receive some material or tangible help. As Htee Gloh explained:
Counselling shouldn’t be about just talking. For example, if I had a problem with
my children, the counsellor should give me some ideas for how to solve the problem
– some ideas for action. (Htee Gloh)
Women reflected positively on their experiences with service providers who had been
able to assist them with their practical concerns during their needs assessment period.
However, at the conclusion of the assessment (and after receiving the desired or
maximum practical help available), most declined offers of continued appointments
for further counselling. A rare few had proceeded beyond the required attendance and
engaged in voluntary counselling appointments. However, they had attended with a
lack of knowledge about the type of help available, or what the term counselling
meant, and had hoped to receive assistance with practical problems (such as liaison
with government agencies like Centrelink). If their practical needs were not met
women generally did not attend further appointments. Karen women’s expectations
for assistance are not unique. For example, Sue and Zane (2009) similarly noted that
clients from other Asian backgrounds generally expect some sort of assistance or
direct benefit from treatment from the outset. Similarly, a recent study of Chinese
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Australians (Chan & Ritchie, 2011) reported that participants expected mental health
professionals to be directive and instructive rather than reflective or facilitative.
Karen leaders also highlighted the mismatch and confusion between Karen
community members’ understandings and expectations of what Australian mental
health services could and should offer and the approach taken by such services:
I don’t know exactly what they [mental health services] are doing [laughs]. My
friend told me “the [mental health workers] are always coming to ask me what
happened”. What happened! [laughs] My friend was angry … They [mental health
services] ask us “do you have any problem?”. If you say “oh yes, I need money”
they say “I can’t support you with money” [laughs]. You can’t support me so okay,
don’t ask me any more! (Key informant – Mr O)
The quotation from an interview with Mr O conveys participants’ frustration with
mental health service providers and their sense of annoyance that these organisations
were unable to address their most pressing needs such as poverty.
9. Ontology of suffering: now versus then
Women’s expectations of practical help related to another difference in approach:
focusing on the now versus the then. Women reported that they primarily sought help
from others to cope with and resolve their current problems. In contrast, they
perceived their spiritual faith and informal support networks as the key sources of
help for suffering related to past events (e.g., grief) that could not be resolved through
material means. For the Karen it was nonsensical to talk about past events that caused
suffering. This mismatch was vividly apparent during interviews with Karen key
informants who had experience interpreting for service providers and, in their
interpreting roles, had been privy to Karen clients’ perceptions of and experiences
with Australian mental health services. The following quotations clearly show that
patients often did not understand the purpose of recounting past traumas:
Privately [after the STARTTS appointment] the woman said she could not
understand why she was being asked to repeat her story and discuss her bad
experiences. The woman did not find the process helpful but agreed to return to
future appointments simply because the staff member asked her to. (Key informant
– Ms Z)
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I talked to one Karen woman and she said, “They [STARTTS] invited me [to
appointments] two or three times and the first time I told them all my stories and I
cried already. Why do they ask me to come back again and again and talk about that
issue? I don’t want to go any more”. So after the third time she ignored the
invitation. (Key informant – Mr B)
Some people just openly say, “No, we want to forget these past experiences and go
ahead with life here [but] STARTTS are making us tell the story back”. (Key
informant – Mr H)
The first two quotations also relate to the role of compliance in Karen women’s
interactions with service providers. Women continued to attend appointments if asked
to, even when they were offended or upset by a service provider. These quotations
also strongly suggest that the Karen do not perceive a need for disclosing past losses
and traumas and may not find the therapeutic encounter beneficial. Observing a
similar scenario in relation to a Rwandan refugee, Summerfield (2010) pondered:
“The question also [raised] here is what constitutes informed consent when asylum
seekers have so little social clout” (p. 105). If Karen women do not see benefit in
psychotherapy and do not wish to attend but lack confidence to cease attending
appointments, then service providers must critically reflect on the ethical predicament
they find themselves in.
Some Karen and non-Karen key informants expressed concern that therapeutic
cultural mismatches could be harmful. For example, Dr G expressed his reluctance to
refer clients for counselling after one of his patients experienced negative
consequences from therapy:
You know, because when I did refer somebody and he went to STARTTS when
they were taking him back over that [his experiences] he started having flashbacks
and things like that. Those people, not knowing the language and culture, they
couldn’t cope with him. This man, he didn’t know what they were doing [or] why
they were making him regress back to that and deal with that. So in the end we had
to get him to stop going. (Key informant – Dr G)
Again these findings are not unique to the Karen. A present-time orientation has been
observed in other populations (Sue & Zane, 2009). Cambodian monks have reported
that Khmer refugees, although sometimes angry about the injustices caused by Pol Pot
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and the Khmer rouge, tended to seek help for current problems rather than past
suffering (Nickerson & Hinton, 2011). The monks perceived that talking about past
suffering and injustice could actually be harmful to one’s mental balance and
wellbeing. Karen key informants similarly expressed concern that trauma-focused
mental health interventions could negatively affect individual and community
wellbeing through contributing to dependency. Somali refugees in New Zealand have
reported that Western treatments “focus too much on past experiences (trauma), rather
than problems in the current situation” (B. Guerin et al., 2004, para. 29). According to
Bemak, Chung and Bornemann (1981), the frustration is also mutual and mental
health professionals similarly find that refugees do not want to delve into the past:
Many professionals find themselves faced with refugee clients who are
initially far more interested in understanding and effectively adapting to the
world around them than in delving into intrapsychic and interpersonal
problems or psychosocial adjustment issues. (p. 250)
These differences constitute what Calabrese (2010) refers to as a “paradigm clash” (p.
311). Paradigm clashes or cultural mismatches in psychotherapy have been
consistently linked to limitations and inadequacies in mental health service provisions
for non-Western populations. They lead to under-utilisation of services, higher
prevalence rates, treatment dropouts, misdiagnosis and mismanagement. Doctors and
other service providers may become reluctant to refer Karen patients for mental
healthcare for fear of mismanagement and harm to patients. Karen patients may also
be offended, as depicted in the following quotation:
The psychologist [at Centrelink] asked so many questions: “Do you want to harm
yourself? Please tell me if you want to commit suicide”. He [the Karen refugee
client] was shocked! I was the interpreter and he said to me “Why do they ask me so
many silly questions? I am a normal person” … The man [Karen client] said “I feel
you insult me; I can cope with that kind of situation, no problem. I spent twenty
years in a refugee camp. Don’t worry about me”. (Key informant – Mr J)
13.5 Reflections
The cultural mismatch fuelling the negative encounters experienced by Karen
refugees attending Australian mental health service providers was aptly conveyed in
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an early study by Frye and D’Avanzo (1994) who compared and contrasted Khmer
and Western psychotherapeutic approaches to healing. They observed that:
Western scientific medicine tends to approach the resolution of painful
psychological experience with a confrontative approach. Identification and
dissection of the psychological trauma is encouraged, and introspection is
expected to be followed by verbalization. Somatization is considered
maladaptive and is not rewarded. Confrontation of the psychological pain is
considered courageous by the patient and skillful by the therapist. (p. 94)
Frye and D’Avanzo’s (1994) conclusion that these particular aspects of Western
psychotherapy contrasted sharply with the healing approaches of Khmer refugees is
uncannily relevant to the situation of Karen refugees. The present research findings
have demonstrated that a confrontative, verbal approach to psychological suffering
and trauma is antithetical to Karen culture. Like the Khmer, the Karen perceived the
act of confrontation as rude. Introspection was part of the symptomatology of hso
k’moe tha (thinking too much). Somatisation was an expected part of suffering. The
outpouring of feelings was not encouraged nor rewarded. Social contact, participation
and support were thought to be integral to healing. These findings, and those of other
refugee mental health researchers, imply that prevailing Western mental health
discourses must be re-examined. Moreover, these combined findings imply that
professionals must give attention to the possibility that Western “therapeutic”
treatments may indeed be unhelpful, offensive and even harmful for refugee
populations.
Western healers tend to rightly favour evidence-based interventions but unfortunately
non-Western alternatives are overlooked or dismissed as nonsense often simply
because they have not been researched. As J. P. Wilson and Drozdek (2007) argue:
“[the] opportunity to do scientific research is a privilege of rich societies” (p. 379).
Patient harm and marginalisation of indigenous knowledge systems are further risks
associated with the use of Western mental health interventions with refugee
populations (Stubbs, 2010). The full ramifications of transmitting Western psychiatric
models and treatments are, as yet, unknown. Watters (2010) argues that indigenous
experiences and expressions of distress and mental illness could indeed be critically
changed:
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How a people in a culture think about mental illnesses – how they categorize
and prioritize the symptoms, attempt to heal them, and set expectations for
their course and outcome – influences the diseases themselves. In teaching the
rest of the world to think like us, we have been, for better and worse,
homogenizing the way the world goes mad. (p. 2)
Demonstrating further exactly how Western models of mind are imposed onto a
population at a time of upheaval, Watters (2010) points out that the pharmaceutical
industry has funded trauma-oriented training for health professionals in post-disaster
settings. Moreover, PTSD research is often combined with aid relief and clinical care
and thus may become a kind of currency for refugees seeking help (Summerfield,
2010). Individuals in such circumstances are likely to engage in Western programs
and mental health interventions not because such programs align with their experience
or perspective of their emotional world but as a strategy to obtain other forms of
assistance and maintain relationships with those who retain the power, money and
access to resources. My research findings add to Watters’s concerns and suggest that
even resettled refugees engage with services that they perceive to be useless or
offensive in an attempt to access needed resources and because they lack the skills
and confidence to disengage from contact with these organisations.
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Chapter 14
Implications for Practice and Future Research
14.1 Introduction
This chapter addresses the major implications and recommendations of the findings
for (a) generalist HSS service providers, (b) mental health service providers, and (c)
future research.
14.2 Implications and recommendations for generalist HSS service providers
Drawing upon the research findings presented in Chapters 8 and 12, this section
provides concise recommendations for Australian resettlement service providers as
well as policy makers and researchers interested in refugee resettlement in Australia.
Recommendations are grouped according to areas of service provision and key topics
of concern.
14.2.1 Case management and resettlement orientation
a) Evaluate the effectiveness of HSS services and the duration and consistency of
the case management services provided to new arrivals. In particular, the
needs and availability of services for recipients of the Women at Risk visa
subclass should be further investigated.
b) Assess the availability and efficacy of DIAC’s Australia – a new home DVD
(DIAC, 2009a) and Beginning a life in Australia booklet (DIAC, 2010b).
These information sources were both available free of charge and in Karen,
and provided information on many of the environmental mastery issues
identified in this thesis (e.g., banking systems, housing, parenting, Australian
law and healthcare). However, no participants in this study mentioned having
or using them.
c) Investigate humanitarian entrants’ needs in relation to housekeeping and home
safety in Australia. Women lacked environmental mastery in these areas and
were stressed by these issues (see Section 8.3.4) but there is a paucity of
research on this topic. The findings from this study support those of a recent
Australian study of case managers perspectives about home safety (Campbell
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& Turpin, 2010) and suggest that intervention programs and further research
on this issue is warranted.
d) Investigate alternative means of providing orientation or settlement support
during the resettlement period in Australia which tap into existing cultural
approaches to education, support-seeking and information sharing (see
Chapter 10).
14.2.2 Non-Karen speaking service providers
a) Ensure that handouts and information provided to Karen are in Karen and are
heavily based on visual communication of ideas.
b) Independent empirical research should investigate the interpreting services
available to refugees. This research should explore the broad issues affecting
the interpreter scenario including intra- and inter-ethnic mistrust (e.g., within
the Karen community, and between Karen and Burmese) and service
providers’ lack of cross-cultural competency and familiarity with the Karen
people (e.g., assuming they speak Burmese or misunderstanding them and
their language to be Korean).
c) Assess the feasibility of innovative solutions to interpreter problems such as
the implementation of designated days when on-site interpreters are available
for specific ethnic groups to attend social services and health clinics11. Such a
solution is likely to reduce the distress caused by negative interactions,
improve efficiency and decrease staff frustration for organisations. Clinics
could be mobile outreach vans or medical centres in Western Sydney.
Appropriate interpreters and bilingual, bicultural health workers could be
booked in advance of regular ethnic clinic days to ensure that Karen (and
other) patients are able to adequately understand their interactions with
healthcare providers. An added benefit of designated ethnic clinic days is that
transport and childcare problems would likely be reduced for patients as
parents could carpool (or use public transport together) and share childcare
arrangements. Moreover, another positive side effect would likely be the
11 At the time of writing these research findings and recommendations were being utilised by a working
group comprised of Karen service providers, staff from New South Wales Refugee Health Service and
the researcher.
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provision of another collective, group-oriented activity. A clear finding
throughout this research is that Karen women enjoyed, and benefited from,
group activities with other Karen women (see Section 10.3). Rather than
organising and attending healthcare appointments in isolation, Karen women
are likely to enjoy undertaking such activities as a collective.
14.2.3 Adult Migrant English Program
a) Develop ways to harness the motivations of refugee communities, understand
and sensitively negotiate cultural customs, and take into account the effects of
culture, gender and context on student learning.
b) Investigate how candidates for the Special Preparatory Program are identified
and seek to understand why and how some women slip through the cracks.
c) Education programs must do no harm and a basic level of cross-cultural
respect and understanding must be a prerequisite for all encounters between
teachers and learners. Women’s encounters with their teachers did not always
meet this basic level of care and instances of discrimination and poor service
provision were noted. As humanitarian arrivals encounter human rights,
possibly for the first time, their experience with resettlement service providers
must reinforce the dignity and respect for all persons that underpin these
rights.
d) Develop further opportunities for informal, practical and visual learning
(Maher, 2006).
e) Teachers should teach English in English and refrain from using other
languages not spoken by all students (except where teaching in the students’
native language).
f) Provide greater access to bilingual assistants in classes where teachers do not
speak their students’ native language and when students’ are not competent in
basic level English. Auerbach (1993) has argued that “bilingual options are not
only effective but necessary for adult ESL students with limited L1 literacy or
schooling” (p. 9).
g) Bilingual English language assistants should be supported in obtaining
educational qualifications to enable them to become teachers. Bilingual
interpreters are often also qualified teachers (or hold other tertiary
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qualifications) in their country of origin and the recognition of their
qualifications, fully or partially, needs to be facilitated (McKay, 2009; United
Nations Educational Scientific and Cultural Organization, & International
Institute for Education Planning, 2009).
h) Independent program evaluation research should explore the level of English
proficiency acquired by humanitarian entrants following completion of current
service provisions and situate findings within an international context.
i) Best practice guidelines should be developed for teachers and organisations
providing AMEP services in Australia. Until 2009 DIAC funded the AMEP
Research Centre to provide research and professional development services to
AMEP providers. There is currently no research centre or best practice
guideline informing AMEP service providers. Some of the research findings
from this study can form a foundation for guiding best practice.
14.2.4 Poverty and housing
a) Refugee poverty and housing should be priority issues at all levels of
government. These problems were pertinent sources of stress for Karen
women and negatively affected their wellbeing. This is unsurprising as
poverty itself is known to adversely effect mental wellbeing (Marmot, 2005).
The mental health of refugee communities cannot be adequately addressed
without removing their realistic fears of homelessness.
b) Regular and independent monitoring of HSS providers is needed to ensure that
refugees receive appropriate and adequate assistance from contractors. Some
participants’ homes were in states of disrepair and the women experienced
considerable difficulty securing adequate (affordable and appropriate)
housing. Findings from this study and other recent reports (DIAC, 2011q;
Ernst & Young, 2011) demonstrate the need for urgent monitoring.
c) Food security issues amongst refugees in Australia should be further
researched and addressed (Gallegos et al., 2008).
d) Settlement service providers should develop further strategies for equipping
Karen refugees with budgeting and home-management skills. The research
findings indicated that women’s home-management and financial management
problems intersect with additional challenges including gambling and gender
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role beliefs and practices. Future research and interventions should address
these related issues also.
14.2.5 Employment support services
a) Job Services Australia should monitor and review staff interactions (see
Section 8.3.2) and ensure that services are provided in a respectful manner.
b) Staff should be provided with adequate cultural competency training to alert
them to the cultural differences and needs of refugee clients.
14.2.6 Parenting
a) Investigate and address refugee parenting issues. Women’s parenting
difficulties resonated with those of other resettled refugee families in Australia
(Atwell et al., 2009; Lewig et al., 2010). The intervention recommendations of
Lewig et al. (2010) seem applicable here. These researchers question the
appropriateness of Western models of social work for refugee parents and call
for closer collaboration between social workers, refugee elders, refugee
communities, schools and police to address parenting issues.
14.3 Implications and recommendations for mental health service providers
This section draws on the research findings to provide recommendations for mental
health service providers. In formulating these recommendations, I frame them within
the principles of the ecological model for refugee mental health (Miller & Rasco,
2004) and the Ottawa Charter for Health Promotion (World Health Organization,
1986). The recommendations are summarised below and then expanded in subsequent
sections.
Recommendations for service providers
Prioritise (a) prevention over treatment and (b) issues that are of concern to the
community. Address the material and systemic sources of suffering.
Build individual and community capacity and self-efficacy.
Work with existing community strengths and integrate interventions into
existing support networks.
Address gender and work with women.
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Engage communities in critical reflection.
Enhance staff cultural competency training.
Improve access to bilingual, bicultural and gender-matched staff.
Evaluate intervention and service provider efficacy.
Utilise practice-based evidence.
Design culturally congruent mental health interventions.
14.3.1 Prioritise (a) prevention over treatment and (b) issues that are of
concern to the community
Much of women’s distress was caused by a mismatch between the demands of
resettlement life and women’s resources to meet those challenges. Preventative and
relevant interventions for Karen women should focus on addressing their most
pressing concerns of (a) English language proficiency, (b) communicating with
service providers (e.g., interpreter-related problems), (c) employment, (d) parenting,
and (e) environmental mastery.
14.3.2 Build individual and community capacity and self-efficacy
The research brought to light the pervasive and complex effects of low self-efficacy
or agency and loss of identity, which might be targeted as part of preventative
interventions. These problems seem to have arisen from Karen refugees’ current
social circumstances, cultural context and prior experiences. A thorough and
theoretical understanding of these issues, such as that provided by the current study
(see Sections 8.6, 12.8 and 14.4.4) could be of interest and use to mental health policy
makers and service providers.
Interventions that extend the dependency fostered in refugee camps are harmful and
should be avoided. Rather, interventions should focus on (a) building community
capacity, (b) strengthening existing support networks, (c) establishing individual and
collective ownership, and (d) enabling Karen women to achieve improved efficacy in
their lives. Moreover, services built by and for refugee communities are more likely to
be utilised and perceived as effective than the provision of services by mental health
professionals (Miller & Rasco, 2004).
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14.3.3 Work with existing community strengths and integrate interventions
into existing support networks
A central theme throughout this thesis has been the critical importance of Karen
collective and intracommunity support. Service providers need to harness this
community strength and interventions should (a) be integrated into existing networks,
and (b) replicate emic support networks. Policy makers and service providers should
seek to work with community leaders, harness their energy and determination, and
rethink mutually beneficial strategies for structuring service provisions to use their
skills in a sustainable way.
Existing settings such as organisations that provide language training, vocational
training and other services are likely to be ideal sites to provide interventions
(Jaranson & Bamford, 1987). Such an approach would likely be convenient for clients
and would also minimise shame and stigma associated with attending the intervention
(Tribe, 2002). Practitioners seeking to integrate interventions into existing community
activities must become familiar with local leaders and work with them to integrate
information or skills training into existing community events.
The research findings suggest that group-based, communal interventions are likely to
be most relevant and effective for Karen women. Health service providers could assist
the community in creating and facilitating support groups for members with shared
experiences or problems (e.g., single mothers experiencing parenting problems). To
avoid stigmatisation, groups could be based around activities such as gardening,
sewing, poetry, cooking or craft activities. For individuals whose experiences or level
of distress lie outside of the collective group’s understanding, facilitators could
provide help to seek assistance from specialists (pastors, community leaders, healers,
therapists or doctors). Karen women should also be empowered to form their own
collective support groups to provide emic healing strategies (e.g., prayer, sharing of
experiences and altruism).
14.3.4 Engage communities in critical reflection
Refugee communities should also be assisted in making sense of their unique
struggles in the resettlement environment. Moreover, they should be supported in
overcoming the harmful risks associated with particular cultural practices or
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characteristics whilst also respecting and maintaining their culture. Their capacity to
interact and “adapt effectively” (Miller & Rasco, 2004 p. 35) to existing supports and
environments must also be enhanced. One intervention and empowerment model that
seems applicable here is Chan’s (2010) Assertiveness Communication Training
Program.
14.3.5 Address gender and work with women
The research findings demonstrated the gendered aspects of Karen women’s
suffering. Service providers should work with communities to address gender
ideologies that are harmful and limit women’s participation in life. Women expressed
a desire for “improved communication” within the Karen community as well as
greater flexibility and unity across gendered, political and religious divisions.
Gendered and intracommunity divisions are complex matters. However, as a female
Karen key informant suggested, women leaders are important for creating unity. She
described the present Karen community as characterised by a “top-down” approach
largely controlled by men and suggested a more “grass-roots approach” in which
women united to form forums and address issues. Service providers should help
Karen women to facilitate such forums and empower them with skills to address the
issues of concern to them. One approach might be to empower respected and senior
Karen women to mobilise community supports, liaise with service providers and
provide information and support.
14.3.6 Enhance staff cultural competency training
Staff should receive adequate training on the sociocultural and political backgrounds
of their refugee clients and be sensitised to cultural differences in expression of affect.
Mental health practitioners should seek to gain a thorough understanding of their
refugee clients’ EMs of mental illness to avoid mistaking culturally appropriate
expressions of distress for manifestations of psychopathology. They should also
become familiar and competent in working with interpreters (Tribe, 2002, 2007,
2009; Tribe & Lane, 2009). The conceptualisations, terms and idioms of distress
described in this thesis provide rich data for this particular group of Sgaw-speaking
and (primarily) Christian Karen refugees from the Thailand-Burma border. However,
the umbrella term “refugees from Burma” encompasses several ethnic subgroups with
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vastly different religious and political perspectives. Muslim Rohinga refugees from
the Burma-Bangladesh border may hold very different conceptualisations of distress
as “ethnic composition influences ethnopsychological models significantly” (Kohrt &
Hruschka, 2010, p. 345). It is necessary to emphasise that idioms of distress must be
explored anew within different settings and populations of refugees from Burma.
14.3.7 Improve access to bilingual, bicultural and gender-matched healthcare
staff
Service providers should seek to provide refugee communities with greater access to
bilingual, bicultural and gender-matched staff. Research suggests that ethnic minority
patients prefer bilingual, bicultural therapists and respond better to treatment provided
by ethnically matched therapists (Griner & Smith, 2006; Walton, Berasi, Takeuchi, &
Uehara, 2010; Ziguras, Klimidis, Lewis, & Stuart, 2003). The recently released
Refugee Health Plan (2011–2016) aims to ensure accessible, culturally and
linguistically competent health services (New South Wales Department of Health,
2011). Many of the strategic priorities and actions in the plan address concerns and
recommendations arising from this study. In particular, the planners aim to recruit and
train bilingual community educators to provide health education and information and
recognise that “Bridging the language barrier is clearly fundamental to effective
communication” (p. 27). Findings from this study support the urgent need for these
changes and bring attention to the importance of addressing communication from a
gender perspective also.
14.3.8 Evaluate intervention and service provider efficacy
Monitoring and independent audits of generalist HSS services for refugees appear to
be warranted. There is also a distinct lack of available evaluative reports from
services in relation to refugee mental health and the efficacy of specialist services for
refugees should be urgently examined. Some existing programs (e.g., the Karen
Community Housing Cooperative and the Haven Australian community garden plot
described in Chapter 8, Sections 8.3.3 and 8.3.4) were viewed positively by the
community and also appeared to build community capacity and enhance self-efficacy.
However, typical of interventions with refugee communities (Miller & Rasco, 2004),
these interventions lacked formal evaluation.
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14.3.9 Utilise practice-based evidence
Mental health practitioners are advised to challenge their professional bodies to
address institutional biases and draw upon a wider field of empirical knowledge to
guide interventions with refugee communities. This recommendation resonates with
Birman et al.’s (2008) call for policy makers, researchers and practitioners to better
utilise “practice-based evidence” (p. 122) to explore interventions that already exist
and occur in the real world. Their study of the International Family, Adult, and Child
Enhancement Services for refugee children in America provides a framework for
further efforts in this field.
14.3.10 Design culturally congruent mental health interventions
The current findings do not mean that adapted forms of talk-oriented approaches to
healing are always unwarranted for refugees (de Jong, 2002). Researchers van de Put
and Eisenbruch (2004) found that despite the lack of a cultural framework for talking
about one’s problems, Cambodian women reported finding relief from sharing their
history of war-related suffering in a group therapy settings.
In my study, some healthcare key informants reported that their Karen clients had
benefited from mental health services including individual interventions based on
Western psychological therapies (e.g., CBT techniques such as relaxation, activity
scheduling for pleasant events and cognitive restructuring of traumatic events).
However, these key informants also reported that, generally speaking, their Karen
clients did not wish to talk about their traumatic experiences, did not understand the
benefit in doing so, and more commonly found support for their wellbeing through
community interaction and addressing resettlement challenges (such as
unemployment).
The findings concerning women’s approaches to healing call for therapeutic pluralism
(Tribe, 1999b) rather than a “one size fits all” approach to enhancing the wellbeing of
Karen refugee women and echo Jacobs’ (2007) caution to:
Beware of those who advocate that something is better than nothing and who
wish to forge ahead with interventions that have not been well planned and
prepared with the local community. (p. 934)
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Not only do therapeutic modalities need to be reconsidered, but the inappropriateness
of the Western model of the professional sixty minute consultation with a stranger
also needs to addressed. Karen women are more likely to benefit from healing
approaches that are appropriate to their needs, and cultural beliefs and traditions.
While understanding and providing (or enhancing) culturally relevant supports is
complicated (Bemak et al., 1981), it is likely to result in services that are better
utilised and more helpful.
The research findings raise the paradox of how Karen women valued support yet also
valued concealment of emotional distress and stoic silence (see Chapter 10). This
presents challenges for service providers but other findings related to coping suggest
several suitable approaches (e.g., group-based interventions) and flag some potential
pitfalls for health professionals. These findings can be used to create or adapt
interventions to align with women’s perspectives.
Women’s main psychological coping strategies (e.g., self-control, distraction and
acceptance) (see Section 10.2) are strikingly similar to the approach taken in
mindfulness-based CBT (Cayoun, 2011), which suggests that culturally adapted CBT
and particularly mindfulness-based approaches (Cayoun, 2011; Lau & McMain,
2005) might be acceptable and relevant to this population.
Mindfulness-based interventions are informed by a philosophy that espouses the
acceptance of suffering and an interrelated conceptualisation of body and mind. They
teach cognitive behavioural techniques to decrease isolation and harmful behaviour
patterns, increase pleasant and interpersonal activities, and observe thought patterns.
This approach normalises and validates emotional suffering at the same time as
employing strategies to improve one’s situation. Karen women’s emphasis on
understanding and accepting the ubiquity of human suffering is a central tenant in
mindfulness-oriented interventions. It seems that the cognitive reappraisal strategies
espoused in mindfulness therapies (e.g., acceptance) are also possibly better suited to
the Karen cultural and political context than cognitive reappraisal techniques
emphasised in other psychotherapies (e.g., reframing negatives to positives and
decreasing the personal importance of events). These latter strategies have been
associated with negative psychological functioning among oppressed populations
(Perez & Soto, 2011). D.E. Hinton, Pich, Hofmann and Otto (2011) have recently
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published treatment guidelines and case studies advocating mindfulness and
acceptance-oriented CBT interventions with refugee populations. Further research in
this field, and with Karen refugee populations, should be undertaken.
14.4 Implications and recommendations for future research
The implications and recommendations of the findings for future research are
summarised below and then expanded in subsequent sections.
Recommendations for future research
Use explanatory models to further explore mental health topics with refugee
women.
Work sensitively with refugee communities and strive to access emic
perspectives.
Explore notions of power(lessness), use(lessness), dependency and identity.
Investigate the strengths, limitations and pathways of emic coping strategies,
particularly acceptance, stoic silence and shared experiences as well as both
material and spiritual approaches to coping.
Explore pathways and patterns of refugee adjustment to resettlement overtime.
14.4.1 Use explanatory models to further explore mental health topics with
refugee women
In the refugee mental health literature that I reviewed, this study was unique in its
combined use of vignettes with an EM interview framework. The findings suggest
that the use of case vignettes is well suited to understanding refugees’ EMs of mental
illness. The vignettes provided a way of portraying Western psychiatric categories
without using technical language and participants appeared comfortable discussing
the topics in a group environment. Vignettes may be a promising research technique
for accessing refugee women’s experiences, expectations and beliefs about health and
other topics. Future studies could explore a greater range of psychiatric constructs or
diagnoses including psychoses and substance abuse and longitudinally explore mental
health literacy (Goldney, Fisher, Dal Grande, & Taylor, 2005).
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14.4.2 Work sensitively with refugee communities and strive to access emic
perspectives
In this study, Karen women’s experiences and perceptions, particularly those of
service providers in Australia, were not always transparent and easily accessible. This
experience demonstrates that researchers, evaluators and planners must be sensitive to
the cultural and socio-political context that may limit the information obtained
through survey and interview methods. It is important for such future research to use
sensitive research methods to access the “backstage” (Miller, 2004, p. 217) opinions
of refugee communities rather than superficial positive endorsements reminiscent of
their reluctance to criticise or complain. This study has demonstrated several useful
approaches to address these concerns. These include the triangulation of multiple
perspectives as well as ethnographic data collection methods.
14.4.3 Investigate the roles and challenges of refugee community leaders
The research findings concerning burnout of elders and community leaders (see
Section 12.9) warn of the negative flipside to a strong community network and
warrant further investigation. The findings from the present study suggest that current
settlement service provisions do not make the best and most sustainable use of these
existing community support people. Further research is necessary to ensure that this
important resource is supported and maintained in Karen and other refugee
communities.
14.4.4 Explore notions of power(lessness), use(lessness), dependency and
identity
The interconnected issues of power(lessness), use(lessness), dependency and identity
were critical factors affecting women’s wellbeing but these concerns are rarely
discussed in refugee mental health literature and future research seems warranted. The
research findings on these issues share features with several Western theoretical
models, namely Bandura’s (1977) theoretical framework of self-efficacy (see Section
8.5), Seligman’s (1975) model of learned helplessness and conceptualisations of
demoralisation (Frank & Frank, 1991, 1996; Kissane, 2001; Kissane et al., 2001) (see
Section 9.5.3). These frameworks might be useful for future research.
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Why might self-efficacy, helplessness, defeat, entrapment and demoralisation be
useful concepts from which to understand refugee mental health issues? As we have
seen, a lack of personal and collective autonomy, control and self-determination
characterised the entire refugee journey for Karen women. One could argue that
everyday life for most refugees is characterised by defeat or lack of accomplishment
of one’s desired outcomes and (for those in camps) entrapment. Indeed, Karen
refugees on the Thailand-Burma border have been described as “birds inside a cage”
(Fuertes, 2010, p. 20). Refugees by definition do not wish to leave their homes – they
are forced. Those who seek refuge do not wish to live in camps but have few choices.
As we saw in Chapter 2, over five million refugees have lived in a state of limbo for
five or more years. In several conflict situations, including Burma, camps have
housed populations since the 1980s. For those who spend decades in camps it seems
likely that most will neither believe nor experience that they can do much to influence
the major outcomes in their lives. Moreover, their problems are colossal and,
according to Bandura (2001), the “magnitude of human problems also undermines
perceived efficacy to find effective solutions for them” (p. 18). With regard to
refugees, Abdi (2005) has argued that self-worth is destroyed by the dependency
fostered in camps. It seems that more so in camps, than during initial flight, human
defensive manoeuvres are rather futile. There is nothing to master except adjusting to
daily camp life, nothing much to escape from (relative to fleeing inside Burma) and
nothing to attack.
14.4.5 Investigate the strengths, limitations and pathways of emic coping
strategies
Acceptance, stoic silence, shared experiences and the division of support systems into
material and emotional or spiritual ones respectively dominated Karen women’s emic
approaches to coping. The current findings highlight the urgent need for studies
exploring these emic pathways to healing.
Interestingly, there are some important parallels between the coping processes
described in this study and conceptual models of social support described in Western
literature. House (1981) described the following four aspects or types of supportive
social interactions:
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1. Emotional: verbal and nonverbal communication of love, empathy, trust, care
and sense of belonging.
2. Informational: provision of advice or guidance to problem-solve a difficulty.
3. Instrumental: provision of tangible, material goods or physical assistance
completing a task (e.g., translating a document).
4. Appraisal: communication for self-evaluative (rather than problem-solving)
purposes (e.g., constructive feedback, affirmation and social comparison).
House’s (1981) operational framework of social support has since been applied to a
range of populations (Helgeson & Cohen, 1996; Langford, Bowsher, Maloney, &
Lillis, 1997) and his model may provide a useful lens through which to understand
and further explore social support in refugee communities.
The notion of appraisal support (also referred to as affirmational support) (Kahn &
Antonucci, 1980) seems analogous to the key notion of the shared experience which
was central to Karen women’s help-seeking encounters. When women sought help
from their peers and leaders, the tacit knowledge or open discussion of their shared
experiences appeared to provide them with reassurance and a source of social
comparison and opportunity for self-evaluation. Women appeared to seek and obtain
emotional and appraisal types of support solely within the Karen community.
Informational and instrumental support was also predominantly sought within the
community, especially in relation to problems that were more culture-specific in
nature (e.g., adapting to parenting in the Australian context). However, in relation to
information and instrumental support, Karen women did also access and utilise
service providers.
Across Karen women’s approaches to coping, the importance of the shared
experience was apparent. There is sparse mention of the concept of shared experience
(in relation to help seeking and coping) in refugee mental health literature and
seemingly none exploring the mechanisms by which a shared experience is helpful,
nor the potential implications for service provision. The processes outlined by Thoits
(1986) (see Section 10.6.2) could serve as a lens through which to understand and
further research coping strategies among refugees. Women’s division of emotional
and practical support also shares similarities with the Western emotion- and problem-
focused coping framework (Agaibi & Wilson, 2005; Lazarus & Folkman, 1984) (see
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Section 10.6.1) and this model could be useful for furthering refugee mental health
coping research.
The research findings highlight the need for a cautious approach to investigating the
strengths and weaknesses of emic coping strategies. On the one hand Karen women’s
coping strategies such as acceptance and stoic silence might, from a Western
perspective, be considered maladaptive, passive, victim-like or even pathological
(Basoglu et al., 1997). Indeed, some Karen key informants interpreted these strategies
as potentially harmful and noted the potential for these practices to become warped
into unconditional acceptance, apathy, idleness and helplessness in the context of
persecution and protracted camp confinement. As noted, this perspective shares
similarities with Seligman’s (1975) theory of learned helplessness, Bandura’s (1977)
theoretical framework of self-efficacy and conceptualisations of demoralisation
(Frank & Frank, 1991, 1996; Kissane, 2001; Kissane et al., 2001). Thus it seems that
cultural practices and traditional coping strategies may, in certain circumstances,
actually predispose people to experience low self-efficacy and learned helplessness.
In contrast, as we saw in Chapter 10 (see Sections 10.2.4 and 10.3.1), acceptance and
normalisation of suffering was also associated with the ability to tolerate and survive
hardship and was seen to have its origins in venerated cultural and religious beliefs
and values. It is perhaps harmful to label these approaches disordered. Literature also
supports Karen women’s claims that acceptance and normalisation was, for them,
helpful and effective in reducing distress (Sachs et al., 2008). These discussions are
largely absent in mainstream mental health literature and these findings suggest that
researchers should work to better understand other emic coping strategies as well as
the role of these variables within different cultural contexts. At present, there is
insufficient research on suppression, acceptance and other emic approaches to healing
in refugee populations to make statements on their functions and effects. Future
research is warranted as the findings from this study suggest that these areas of
inquiry may help refugee mental health service providers to better understand the
experiences and needs of refugee communities.
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14.4.6 Explore pathways and patterns of refugee adjustment to resettlement
overtime
Finally, this study has highlighted the centrality of post-migration factors to Karen
women’s wellbeing. Most psychological research with refugees has focused on
trauma, but given the apparent importance of post-migration resettlement factors
future research should also explore how refugees cope with the demands of
resettlement including their pathways and patterns of adjustment overtime. The
current literature lacks dedicated research in this field. Several models have been
proposed and each has received modest attention. Berry’s (1992) model of
acculturation provides one potential framework. Gonsalves (1992) proposed the
application of C. L. Grove and Torbiorn’s (1985) model for cultural sojourners. S. D.
Ngyuen’s (1982) three-stage model of refugee adjustment might also be useful.
Longitudinal studies could helpfully explore the process of resettlement and
contribute to the development of models appropriate to refugee communities.
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Chapter 15
Conclusions
15.1 Introduction
In concluding this thesis, it is pertinent to firstly revisit the study’s overall aims which
were to (a) explore Karen refugee women’s experiences and perceptions of suffering
and distress, (b) analyse the women’s major psychosocial needs within the Australian
context, and (c) frame recommendations for action by community organisations and
services.
This original study contributes to knowledge in a number of ways. Firstly, it
contributes to an empirical understanding of Karen refugee women’s experiences and
conceptualisations of mental wellbeing. This contribution is significant and necessary
as, to the best of my knowledge, there are no previously published investigations of
Karen refugee women’s psychosocial wellbeing. By not imposing a pre-determined
psychiatric framework on Karen women’s experiences of distress and wellbeing, the
findings add to (and enhance) academic knowledge of refugee mental health issues
and prompt a reconsideration of existing theories and models. The findings contribute
to the field of psychological and medical anthropology, particularly in adding to the
body of knowledge concerning cultural idioms of distress and EMs. From a practical
perspective, this study provides a foundation for public and mental health
professionals to develop more culturally appropriate ways of addressing the mental
health of Karen refugee women.
15.2 Women’s conceptualisations of distress and the transferability of Western
theories
The prevailing discourse of refugee mental health research and practice has
emphasised the importance of traumatic war experiences. However, the findings
presented here have brought to light a clear disparity between prevailing trauma-
focused approaches and Karen women’s conceptualisations and EMs of their distress.
The findings strongly indicated that, for Karen women adjusting to life in Australia,
single adverse life events were of less relevance to their overall wellbeing than the
chronic daily stressors they encountered after resettlement. Women conceptualised
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their psychological suffering as, in large part, caused by their social circumstances
including poverty, persecution, social disharmony, unemployment, exclusion and
discrimination and gender role pressures. They highlighted the suffering caused by
their inability to communicate effectively and thus navigate life in Australia, as well
as their ongoing grief and uncertainty about loved ones who remain in their homeland
or who are scattered across refugee camps. Their idioms of distress were embedded in
the physical, spiritual, gendered and socio-political circumstances of their lives.
Moreover, the mental health impact of feeling useless dominated their descriptions of
both individual and collective suffering.
No conceptually equivalent term for PTSD or even trauma existed in Sgaw Karen.
Indeed, a PTSD-like construct (as distinct from other terms) was not present in the
women’s discussions or conceptualisations of suffering. PTSD may not be an
appropriate illness construct for Karen refugees and is somewhat incongruent with
their conceptualisation of mind, body, environment and self in relation to others.
Karen women attributed different meanings, values and causal attributions to
symptom constellations similar to those of PTSD according to a broader framework
of personal, social and spiritual suffering.
However, these findings should not be taken to suggest that symptoms of traumatic
stress are not present among Karen women. Women did grieve, feel angry and have
nightmares as a result of past traumatic experiences. Indeed, women’s narratives
vividly illustrated that they experienced many of the symptoms indicative of PTSD.
For example, they described re-experiencing, avoidance and hyper-arousal symptoms
which they associated with traumatic as well as other social stressors. The
preponderance of trauma-focused refugee mental health research would appear to
indicate that such “symptoms” of traumatic stress are the most pressing concerns for
refugee communities. However, Karen women’s discussions of psychological distress
strongly suggest that psychological trauma was not among their most urgent concerns
in Australia. Further, not all people who experienced symptoms of traumatic stress
found their symptoms distressing. Moreover, the presence of such symptoms does not
necessarily appear to imply impaired functioning. The research firmly indicates that
the mere identification of PTSD symptoms amongst the Karen does not necessarily
lead to an accurate understanding of their experiences or needs, nor to an indication of
302
appropriate interventions. The observation of PTSD symptoms in this population
could lead mental health professionals towards a category fallacy (Kleinman, 1980),
that is, the false belief that a category has coherence and validity in a new setting
simply because its constituents can be observed. The findings of this study therefore
may help mental health professionals to provide more culturally competent care for
Karen women in Australia.
Women contextualised suffering within their cultural and sociopolitical milieu and
generally understood their distress to be a normal response to their unenviable
experiences (see Chapters 9 and 10). Their conceptualisation of the normality of
psychological suffering after forced migration raises some rather radical questions.
What is a normal response to human suffering on such a grand scale? Is normality the
absence of PTSD symptoms such as nightmares, recollections of the past,
hyperarousal and fear of one’s surroundings? Would it be normal to be “symptom”
free following the experience of fleeing a burning village, witnessing torture and
learning about disappearances? Would it be normal to remain free of anxiety and
depression whilst members of your family remain in refugee camps where they are
hungry, vulnerable and facing an uncertain future? When psychiatric disorders such
as depression and PTSD are applied uncritically to refugees these important questions
are avoided. Key informants identified sponsored dependency, fear of authority,
disempowerment, mistrust, absolute compliance and apathy, tolerance or acceptance
of hardship as the collective “trauma” suffered by the Karen community, and
experienced again by individuals in relation to resettlement stressors encountered in
Australia. These findings fit with Kleinman’s (1995) argument that “collective
trauma” (p. 177) might better encapsulate the experiences of refugee communities
rather than medicalised and individualised psychiatric frameworks such as PTSD.
The findings concerning Karen women’s discourse of stress, loss and trauma (see
Section 9.3.2) also provide further evidence that the impact(s) and experience of
traumatic events are mediated by the meaning assigned to them (Hagengimana &
Hinton, 2009; Park, Mills, & Edmondson, 2012; Sachs et al., 2008; Terheggan,
Stroebe, & Kleber, 2001), and support the notion that cultures differ in the events they
perceive to be traumatic (D. E. Hinton & Lewis-Fernandez, 2010a). For Karen
women, traumatic events with serious and long-lasting social ramifications were
303
amongst the most pertinent of trauma-related sufferings. Non-trauma-related
destruction of social networks and social capital appeared to be viewed as similarly
severe. Karen cultural and religious conceptualisations of a world where suffering is
normal may have mediated the effects of their traumatic experiences. Moreover, in
the Karen context, the long-running civil war and decades of persecution may have
provided them with realistic (to their context) beliefs about unfairness and injustice
such that individual traumatic encounters did not substantially violate their
worldviews. Such cultural, religious and socio-political psychological preparation
may have served to buffer or protect them from the impact of traumatic experiences.
Taken together, these findings strongly suggest that Western mental health
practitioners should reflexively explore prevailing discourses concerning traumatic
suffering and healing.
Finally, as we saw in Chapters 9 and 11, women’s idioms for, and conceptualisations
of, distress describe a trajectory or continuum of human emotional and mental
suffering. In contrast, Western psychiatric constructs are based on dichotomies and
taxonomies that distinguish between categories of disorder or disease. Despite this
major difference there were also several important similarities between Karen
women’s conceptualisation of distress and those found in both Western popular
culture and academic literature. The findings suggest that the concepts of neurosis and
common mental disorders (see Section 11.7.1) align with Karen women’s
conceptualisation of emotional and mental distress along a related continuum rather
than as discrete states of suffering. It appears that a continuum of distress may be a
more accurate model of the range of variation in emotional and mental states found in
everyday life, not only for the Karen, but for other cultures (including Western
societies) also.
15.3 Risk, resiliency and wellbeing in social, cultural and political context
In terms of addressing the question of what issues affect Karen women’s wellbeing,
this study has raised some important issues. The findings strengthen the growing
literature (Carswell et al., 2011; Laban, Gernaat, Komproe, van der Tweel, & de Jong,
2005; Miller & Rasmussen, 2010; Porter & Haslam, 2005; Steel, Silove, Bird,
McGorry, & Mohan, 1999) suggesting that post-migration difficulties are key
determinants of mental health difficulties for resettled refugee populations and may
304
mediate the effects of pre-migration trauma. Much of this literature has been
quantitative whereas the current study adds emic and qualitative evidence to the body
of knowledge. Moreover, this study adds a new dimension by demonstrating how pre-
migration culture, refugee-specific migration experiences, post-migration difficulties
and wellbeing were linked through the interconnected issues of power(lessness),
use(fulness) and identity – all of which must be understood within a cultural and
historical context.
As we have seen (see Sections 3.3.2 and 8.5), compliance with rules, containment (or
suppression) of distress, respect for authority and avoidance of confrontation appear
to be central to the Karen “national character”. They also appear to have socio-
political origins and probably served adaptive functions for the Karen throughout their
experiences of persecution. Such behaviour may have aided survival and prevented
violence and conflict, as non-compliant and confrontational individuals (and villages)
would quickly meet the heavy hand of the military junta. These traits also probably
served to maintain social cohesion and encourage tolerance of hardship during crises.
Quiet endurance of suffering contributes to risk as well as resilience when, through
repeated experiences of powerlessness, it extends to demoralisation, fear of authority,
apathy, submission, dependency and fatalistic tolerance of hardship (see Section 8.5).
Powerlessness was a central component of the refugee journey. Refugees have been
powerless in effecting their desire to remain in their homes and country of origin.
They have often been powerless in protecting not only their material possessions but
also their loved ones from persecution or death. Many have been powerless to alter
the undesirable experience of living in a confined camp where, as leaders suggested,
capacity and identity were stripped away. As the leaders noted, camps deny self-
sufficiency and create dependency. In a word, they are dehumanising. Camp
dependency disables opportunities for building self-efficacy and perpetuates a cycle
of reliance on others. It effectively paralyses initiative and confidence to succeed in
one’s own endeavours. In short, it teaches helplessness.
Beliefs, behaviours and mannerisms associated with Karen culture and the warped
manifestations of these practices in response to protracted persecution exacerbated
resettlement stressors in Australia, particularly when service providers took Karen
people’s compliant and shy behaviour at face value and overlooked their needs and
305
difficulties. People who are both fearful of and dependent on authorities are unlikely
to thrive in Australia’s competitive and individualistic culture. Although certain
problems, such as low rates of health service use, may be common to many resettled
refugee communities, cultural characteristics of the Karen place them at further risk of
neglect by service providers. Figure 6 schematises a possible model for use in
understanding this Karen context. It demonstrates, using five concentric circles, the
layered process by which individual features, cultural characteristics, pre-migration
experiences, prolonged refugee camp confinement and post-migration resettlement
factors interconnect and manifest as issues of powerlessness, identity and uselessness.
306
Individual
CulturalTraits /Values
Defined genderroles
Pre-MigrationExperiences
ProtractedCamp Life
Resettlement
Shy / quiet
Fear of authority
Fear of people & environment
Failure / useless
Respect authority
PhysicalPhysical / Social / Cultural/ Social / CulturalContextContext
Negative Mental /Negative Mental /Emotional ContextEmotional Context
Useless & wasted
C o m p l i a n c y
Mistrust
Fear offreedom
Powerlessness
C o m p l a c e n c y
Demoralisation
Confusion
Sponsoreddependency
DeathDestruction
DisappearancesPersecution
Poverty
Lack of: safety, healthcare &opportunities (education /
employment)
Limbo
Poverty
Relative SafetyGreater Safety
Poverty
Culturechange:
gender andparenting
Discrimination
Religious
Language & lackof environmental
mastery
Identity / roleloss
Helplessness
Accept suffering
Strengths &weaknesses
Apathy
Figure 6: Karen social, cultural and political context and associated negative psychosocial sequela
307
The model indicates a broadening of the theoretical base guiding refugee mental
health research. Using the sociological frameworks of Bourdieu (see Section 2.4.4) it
is possible to deconstruct the prevailing psychiatric narrative(s) concerning refugee
mental health and present and analyse responses from refugees themselves in regard
to their individual and collective experience and perspective. It is possible to marry
together an understanding of large social issues central to the refugee experience (e.g.,
power) with the daily experiences, behaviour patterns and emotional experiences of
Karen women.
Women who grew up in Karen villages or in refugee camps learnt and internalised a
set of practical cultural competencies, beliefs and embodied dispositions. They
acquired a social identity within that space and mastered living in that environment.
As Bourdieu (1990) states:
The practical mastery of the logic or the imminent necessity of a game – a
mastery acquired by experience of the game, and one which works outside
conscious control and discourse (in the way that, for instance, techniques of
the body do) [sic]. (p. 61)
It seems that getting “a feel for the game” of the Australian lifestyle was problematic
for many Karen women. They lacked knowledge of systems, procedures, laws, rights
and responsibilities, cultural norms and patterns of interpersonal communication, as
well as tools and physical objects. They also lacked experience, and confidence, to
interact effectively with service providers. Much of their knowledge of the world,
even their practical skills (such as how to wash clothing), was irrelevant in their new
environment. The research to date has been insufficient in recognising and accounting
for these social and physical processes and their impact on wellbeing.
The concept of habitus serves to “connect the biologic being with the social world via
physical and psychic embodiment” (Carrington & Luke, 1997, p. 101). This is
especially salient in the field of refugee mental health, as most non-Western cultures
experience the emotional world in a more somatic manner (Kleinman & Kleinman,
1985). The notion of habitus also provides a framework for understanding physical,
practical challenges of resettlement such as adjustment to an urban spatial orientation
as well as to appliances, furniture and technical equipment and services. For example,
308
Karen women’s traditional bodily habitus is significantly different from the physical
postures and movements assumed in an Australian classroom.
The habitus is developed in a broader structured social space or “field” characterised
by certain rules, class systems, and systems of power and domination affecting access
to resources. Bourdieu exemplified the concept of habitus through pointing out how
the politics of gender amongst the Kabyle peoples of Algeria are embodied in ways of
talking, walking and speaking. Similarly, Karen women’s embodiment of gender and
their traditional pattern of social relationships were remarkably different from the
gendered social relationships, expectations and experiences they encountered in
Australia. Their culturally accepted gender rules and logic did not necessarily transfer
easily to their post-resettlement environment. This was partly conveyed through Mu
Htòh’s description of Karen women as having previously been “living in the kitchen”
rather than attending school or engaging in paid work. This accepted field of gendered
behaviour was one of the first to be disrupted in Australia, where all adults, including
women, were expected to attend English language classes and seek employment. Here
too research to date has failed to adequately address the embodiment of gender
amongst refugee women and the implications for their wellbeing and resettlement.
15.4 Coping: the commonsense, complex and contradictory
Karen women had their own strategies for coping with stress and mental health
problems (see Chapter 10). They sought practical and informational support to
manage situations when they believed that they (or someone else) had the capacity to
influence or resolve the stressor. When women were faced with situations they could
not (or believed they could not) influence (e.g., the death of a child) they sought
emotional support from others with shared experiences and used coping strategies
such as prayer, distraction and self-control. Across interpersonal approaches to
coping, a mutual shared experience appeared to be a critical ingredient to women’s
perception and experience of a help-seeking encounter as beneficial. This feature of
help-seeking is likely to have origins in cultural traditions that value and respect the
experience and wisdom of elders. These findings have implications for service
providers (see Chapter 14).
309
Karen women’s EMs espoused a strong connection between mind, body and
behaviour. They described the ability of the mind-self to observe and overcome
unhelpful cognitive patterns as central to wellbeing. Acceptance, stoic silence, self-
control, minimisation and normalisation of distress were emic practices, expressions
and manifestations of distress and coping that featured heavily in the research
findings. Aspects of these practices do, of course, share features with popular
approaches to managing and expressing distress in various Western populations
including the notion of the British stiff upper lip (Fraser, 1992). Normalisation of
emotional suffering is also a practice actively encouraged in the West as a means of
destigmatising mental illness (Hinshaw & Cicchetti, 2000). However, from the
perspective of mental health professionals, individual coping strategies such as stoic
silence and minimisation have been largely deemed unhelpful and even pathological.
Western psychiatric literature has typically associated emotional suppression with
negative social and psychological outcomes (Gross & John, 2003). The findings from
this research, as well as other cross-cultural studies of refugee mental health (Sachs et
al., 2008; Perez & Soto, 2011), indicate that the relationship between psychological
coping strategies (e.g., expression of emotion, introspective analysis and cognitive
reappraisal) and psychological functioning is moderated by culture and context.
Western mental health literature has, as yet, failed to sufficiently explore the role,
function and implications of such stoic silence, minimisation and other associated
practices in non-Western (and possibly Western) populations. This study with Karen
women has contributed to filling this gap.
As discussed throughout this thesis (see Sections 8.5, 10.2.4, 10.3.1 and 10.6.3) the
findings from this study have demonstrated that the practices of acceptance, stoic
silence, minimisation and normalisation have complex origins and multifarious (as
well as sometime contradictory) implications for Karen women’s wellbeing. Women
found solace through accepting and normalising distress as a universal feature of
human life, as well as through minimising the circumstances of their suffering in
relation to their peers and others. However, as discussed in Chapter 12 (see Sections
12.7.2 and 12.8), we have also seen how these practices appear to contribute, in the
context of protracted persecution and forced migration, to a worsening of
psychosocial problems and become hindrances to effective resettlement. There has
310
been a general failure to consider the complex pathways and interactions between
these practices and wellbeing.
15.5 Paradigm clashes and practical problems
Women positioned community-based social supports as more salient to their
emotional and mental health needs than outside agencies. Of external support
services, those that addressed women’s most pressing concerns and assisted them in
developing skills to adapt effectively and feel effectual in their lives in Australia were
perceived to be most helpful. However, women’s ability to access and benefit from
health and social support services was limited by several persistent inadequacies and
problems within service provisions (see Chapters 12 and 13). Most notably, women’s
interactions with service providers were plagued by communication problems. A
further problem was culturally incongruent methods and models of service delivery.
Most Karen women did not see Western psychotherapy as relevant to their needs in
large part because (a) they believed it could not solve their most pressing problems,
(b) they did not relate to talking to strangers, and (c) there was too much focus on
things they did not want to talk about. Various other cultural mismatches (or
paradigm clashes) also appeared to act as barriers to Karen women accessing and
benefiting from mental health services. Some participants also believed that Western
mental health services and diagnoses were potentially limiting and unhelpful to the
Karen community. They argued that these approaches weakened the strength of
individuals and the community as a whole and viewed the trauma discourse as
contributing to apathy, dependency and helplessness amongst community members.
Practitioners are advised to do no harm and yet, paradoxically, their therapeutic
strategies may do just that. Service providers have largely addressed interventions
from an ethnocentric and monolithic view, using “therapeutic” strategies with refugee
populations for whom those strategies were not developed. The research findings,
particularly those discussed in Chapter 13, suggest that prevailing Western mental
health discourses should be re-examined and professionals must give attention to the
possibility that Western “therapeutic” treatments may indeed be unhelpful, offensive
and even harmful for refugee populations. Strategies that are beneficial for Western
populations enjoying a period of political peace are not necessarily helpful – and
311
indeed may be harmful – for Asian (or other) populations experiencing conflict,
oppression and persecution, and forced migration. Individualistic models of therapy,
particularly those that emphasise the importance of recounting and analysing past
traumatic experiences, are unlikely to meet the complex somatopsychosocial sources
and expressions of suffering experienced by Karen women. An understanding of the
importance of the shared experience in Karen women’s approaches to coping may
help to explain some of the difficulties experienced when Karen community members
attended Australian mental health services.
The implications of the paradigm clashes were many and most obviously involved
Karen patients avoiding or merely superficially entertaining mental health service
providers, for example, politely attending appointments but without truly engaging or
agreeing with the necessity of the visits. Participants often regarded psychotherapies
as irrelevant or useless but did not tend to describe them as harmful. The effect of
misaligned cultural perspectives between mental health practitioners and Karen
community members occasionally resulted in frustration and offence. Apart from Dr
G’s account (see Section 13.4), in which he had to intervene and stop a patient
attending counselling, there were no other direct allegations of harm caused to Karen
patients. However, these findings still point towards the need to ask: “Are trauma
counseling services as beneficial, or even as harmless, as they seem at first sight?”
(Argenti-Pillen, 2003, p. 10). The findings discussed in Chapter 13 suggest that they
are not.
15.6 Final reflections
The findings strongly suggest that refugee mental health needs to be viewed through a
social determinants of mental health framework such as that recommended by Barry
and Jenkins (2007) who divide these determinants into the individual, community and
structural.
As individuals, Karen (and other) refugees have demonstrated their personal
resilience and ability to deal with stress. Many have managed to survive situations of
unimaginable suffering. They have demonstrated their will to live through their
persistence and their fight to survive. They have resettled in Australia because they
have hope. They are agents, immensely resourceful, and extremely wilful. It is not
312
easy to plunge into the unknown of resettlement even when the known is a dark and
dangerous place. Their communities are strong, and they continue to place a high
value on social support and community cohesion.
Whilst most Karen refugees enjoy a strong sense of belonging within their own ethnic
communities, the same cannot necessarily be said for the sense of inclusion and social
participation afforded them within the broader Australian context where structural
factors act as barriers to their wellbeing. Indeed, privileged societies are becoming
increasingly intolerant and unwelcoming towards refugees at a time when 44 million
displaced people do not wake up each morning feeling safe.
In Australia the issue of humanitarian entrants is a politically loaded topic attracting
heated public debate (Mares & Allotey, 2003). Media-fuelled public resistance
towards “boat people”, “queue jumpers” and “economic migrants” has created an
atmosphere of distrust, resistance and discrimination towards all humanitarian entrant
populations (Murray, Davidson, & Schweitzer, 2008; Refugee Council of Australia,
2011a). They are often conveyed as vulnerable hapless victims in need of assistance,
or as sneaky asylum seekers and economic migrants threatening to take jobs from
Australians. Highly qualified humanitarian entrants face often insurmountable barriers
to getting their skills recognised in Australia. Many of those with tertiary
qualifications are not even asked about their skills (Refugee Council of Australia,
2011a). Those with adequate English struggle to gain jobs let alone meaningful
employment. Those without English are marginalised on the fringe of Australian
society and face discrimination when seeking adequate housing. The structural
determinants of health including poverty and discrimination are weakening the
capacity and wellbeing of individuals and communities from refugee backgrounds.
The research findings from this study with Karen women demonstrate the need for
political and civic social action to address the complex and systemic factors affecting
the wellbeing of refugees in Australia. Moreover, the current study clearly emphasises
the need for a strength-based, culturally congruent community development approach
to both service provision and research. They reiterate Minas’ comments, made over
20 years ago, in The Health of Immigrant Australia: A Social Perspective:
313
The maintenance of good mental health requires, amongst other things,
freedom from injury, poverty and discrimination, the opportunity for
productive work, education and leisure … Bringing about change in such
noxious circumstances is clearly a political process. (Minas, 1990, p. 280)
314
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Appendices
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Appendix A: DSM-IV criteria
Diagnostic criteria for posttraumatic stress disorder (American Psychiatric
Association, 2000, pp. 467–468)
A. The person has been exposed to a traumatic event in which both of the following
were present:
1. the person experienced, witnessed, or was confronted with an event or events
that involved actual or threatened death or serious injury, or a threat to the
physical integrity of self or others
2. the person’s response involved intense fear, helplessness, or horror. Note: In
children, this may be expressed instead by disorganised or agitated behaviour
B. The traumatic event is persistently re-experienced in one (or more) of the
following ways:
1. recurrent and intrusive distressing recollections of the event, including images,
thoughts, or perceptions. Note: In young children, repetitive play may occur in
which themes or aspects of the trauma are expressed.
2. recurrent distressing dreams of the event. Note: In children, there may be
frightening dreams without recognisable content.
3. acting or feeling as if the traumatic event were recurring (includes a sense of
reliving the experience, illusions, hallucinations, and dissociative flashback
episodes, including those that occur upon awakening or when intoxicated).
Note: In young children, trauma-specific re-enactment may occur.
4. intense psychological distress at exposure to internal or external cues that
symbolise or resemble an aspect of the traumatic event
5. physiological reactivity on exposure to internal or external cues that symbolise
or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by three (or more) of the
following:
1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. efforts to avoid activities, places, or people that arouse recollections of the
trauma
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3. inability to recall an important aspect of the trauma
4. markedly diminished interest or participation in significant activities.
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings)
7. sense of a foreshortened future (e.g., does not expect to have a career,
marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as
indicated by two (or more) of the following:
1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one
month.
F. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or less
Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.
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Diagnostic criteria for Acute Stress Disorder (American Psychiatric Association,
2000, pp. 471–472)
A. The person has been exposed to a traumatic event in which both of the following
were present:
1. the person experienced, witnessed, or was confronted with an event or events
that involved actual or threatened death or serious injury, or a threat to the
physical integrity of self or others
2. the person’s response involved intense fear, helplessness, or horror
B. Either while experiencing or after experiencing the distressing event, the individual
has three (or more) of the following dissociative symptoms:
1. a subjective sense of numbing, detachment, or absence of emotional
responsiveness
2. a reduction in awareness of his or her surroundings (e.g., “being in a daze”)
3. derealisation
4. depersonalisation
5. dissociative amnesia (i.e., inability to recall an important aspect of the
trauma)
C. The traumatic event is persistently re-experienced in at least one of the following
ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of
reliving the experience; or distress on exposure to reminders of the traumatic event.
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts,
feelings, conversations, activities, places, people).
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping,
irritability, poor concentration, hypervigilance, exaggerated startle response, motor
restlessness).
F. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or impairs the individual’s
ability to pursue some necessary task, such as obtaining necessary assistance or
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mobilising personal resources by telling family members about the traumatic
experience.
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and
occurs within 4 weeks of the traumatic event.
H. The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition, is not better accounted
for by Brief Psychotic Disorder, and is not merely an exacerbation of a pre-
existing Axis I or Axis II disorder.
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Appendix B: Interview guide for Karen key informants
Demographics
Date:
Name of community spokesperson:
Role of person:
Educational / professional background:
Sex:
Age group:
Length of stay in Australia:
Other info:
General orientation
1. I would like to know a little bit about their current situation. What is life in
Australia like for most of the Karen women that you know?
Note: check English skills, employment, visa status
2. Would you say it is a close community or are there many people who do not
have contact with other Karen?
3. Are there social clubs and other organisations that bring people together? Are
they well attended?
4. What language or languages are regularly spoken at home and at social
functions?
5. How do Karen women view Australian society? What aspects do they like
about Australia? What are the common complaints about Australian culture,
institutions or people?
6. Are there any services or businesses which are used regularly by Karen
women?
Services
I’m interested in how Karen women cope with their stress and emotions. I’m
especially interested in how the family, community and services can do a better job in
giving them the help and support they need.
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7. In many ways mental and emotional health problems are not much different
from other health and social problems. I was wondering which health services
Karen women use? For example, do they go to particular doctors or clinics, do
they use special ethnic services?
8. What are the good things about the services that they use?
9. What are some of the complaints about these services that you have heard?
10. Are there specific problems that this group face in accessing services when
they are experiencing mental health problems? What are they?
11. In your opinion what are the main mental health issues facing the community?
12. What do you think should be done to help these problems?
13. Would you be willing to help me on this project by helping me get into contact
with people with these problems?
How did / does the community consider and react to mental health problems?
Has this changed in Australia?
Do people ask for emotional support / psychological support when they need it?
If yes, how are they seen by the their community?
Please describe the ways conflicts and disagreements are dealt with by people in the
current situation?
Optional prompt
Give a description of a hypothetical person with psychological symptoms…
(identified in interview).
Name and provide a detailed description of all the locally recognised syndromes such
a person might have.
Name and describe all the problems that these symptoms might represent.
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Appendix C: Interview guide for service providers
Service background
1. First I would like to learn a little bit more about your service. Would you
please briefly describe your service.
Note:
o How long has it been operating?
o How is it funded and managed?
o How many staff and facilities does it have?
o What services are provided?
o How many people use the service?
o Has the number of people serviced or the type of services offered,
changed in the past 3-4 years? If so, what has been the change and why
did it occur?
2. My project is focusing particularly on Karen refugee women. Does this
service ever see Karen women?
3. Do other refugee communities from Burma use this service?
General questions re. Karen women’s background and experiences
What is life in Australia like for most of the Karen women that you know or are aware
of (note check re. English skills, visas etc.).
1. Are there some general observations that you can make about the differences
between the Karen women attending your service and Anglo-Australians?
And other ethnic groups?
2. Would you say it is a close community or are there many people who do not
have contact with other Karen?
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3. Are there social clubs and other organisations that bring people together? Are
they well attended?
4. How do Karen women view Australian society? What aspects do they like
about Australia? What are the common complaints about Australian culture,
institutions or people?
5. Are there any services or businesses which are used regularly by Karen
women?
6. I was wondering which health services Karen women use? For example, do
they go to particular doctors or clinics, do they use special ethnic services?
Karen women and this service
Thank you for answering all of these questions. Now I would like to learn about your
experiences with Karen women (or other refugee women from Burma) in terms of
coming to this service.
1. What are the most common reasons Karen women (or other refugee
women) attend your service?
2. How are Karen women (or other refugee women) usually referred to your
service?
3. Which services do you usually offer to Karen women (or other refugee
women)?
4. For which of the services is there the greatest demand?
5. Are there services which you think are desirable, but which are not popular
with clients?
6. Are there services which clients ask for that this service cannot provide?
7. As far as you know, have staff at this service received any training in
cross-cultural issues? If yes, in what ways was the training helpful? If no,
in what ways do you think that such training would be helpful?
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8. Does the service have any bilingual workers? If yes, what are their
responsibilities? What are the advantages of having them attached to your
service? Are there any disadvantages?
9. Does the service ever use an interpreter service? If yes, have you found
them to be effective? Have there been any problems? If not, how do you
deal with communication problems when they arise?
Mental health
In this project I am interested in how Karen women cope with stress and emotions. I
am especially interested in how the family, community and services can do a better
job in giving them the help and support they need.
10. In the course of regular work, is there ever any contact with Karen women
(or other refugee women) with mental health problems? If yes, what are
some typical examples?
11. In your opinion, what are the main mental health issues facing Karen
women?
12. Do you believe Karen women are more or less likely to experience mental
health problems than other refugee women? Than other Australians?
13. Do you believe that the mental health problems of Karen women are more
likely to go undetected?
14. Do you believe that they mental health problems of Karen women are
more likely to be inadequately treated?
15. Are workers in this service trained to recognise mental health problems. If
yes, what is the content of the training?
16. Is there anyone in your service with counselling or other mental health
skills?
17. Are people who may have mental health problems told about other
services? If yes, which services? Is there regular feedback and
communication between that service and this organisations? If not, are
workers aware of services which are available?
18. What are the good things about the services that they use or that are
available for them to use?
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19. What are some of the complaints about these services that you have heard?
20. Are there specific problems that this group faces in accessing services
when they are experiencing mental health problems? What are they?
21. What do you think should be done to help these problems?
Would you be willing to help me on this project by helping me get into contact with
organisations or people familiar with these problems and issues?
397
Appendix D: Interview guide for Karen women
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402
403
Appendix E: Participant information and consent form (English version
only)
HREC 08338
THE UNIVERSITY OF NEW SOUTH WALES
PARTICIPANT INFORMATION STATEMENT AND CONSENT FORM
A study of the emotional wellbeing and problems experienced by Karen refugees.
Study Description
This research is being conducted to explore how Karen women in Sydney feel about and experience the
impact of displacement. Many Karen people have experienced oppression due to decades of political
conflict in Burma. We hope to learn about the emotional and social impact from the perspective of
Karen people who are refugees in Australia. This study will be important in the sense that it will gather
ideas and expressions that come directly from the Karen people themselves.
You were invited as a possible participant in this study because you are a member of the Karen refugee
community in Sydney.
Taking Part In This Study
Interviews
If you decide to participate, we will ask you to participate in up to two individual or group interviews.
These interviews will take up to approximately two hours. Interviews will be conducted in your chosen
language and an interpreter will be made available.
Confidentiality
All information gathered during this study will be kept confidential. Your name will not be included or
mentioned on any published data.
404
Reimbursement
You will be provided with a $20 food voucher as a token of our appreciation.
Your consent
Your decision whether or not to participate will not prejudice your future relations with the University
of New South Wales. You are free to withdraw your consent and to discontinue participation at any
time without prejudice.
Feedback
When the study is complete you will be provided with a report summarising the results. In addition,
you will be invited to attend a community meeting where the results will be discussed and you may
participate in identifying research recommendations and actions to be taken.
405
THE UNIVERSITY OF NEW SOUTH WALES
Risks and Benefits
The personal benefits for taking part in this study include the chance to share and discuss your
experiences and knowledge. It is hoped that the information obtained from this study will be of use to
guide policy planning and for developing assistance programs for Karen refugees in Australia. We
cannot and do not guarantee or promise that you will receive any benefits from this study.
You may be asked about stressful situations that you have experienced and it is possible that you may
find discussing these matters distressing or upsetting. Should you feel distressed by this, you will be
assisted in seeking appropriate help.
Complaints
Complaints may be directed to the Ethics Secretariat, The University of New South Wales, Sydney
2052 Australia (phone 9385 4234, fax 9385 6648, email [email protected]). Any complaint you
make will be investigated promptly and you will be informed out the outcome.
Contact
If you have any questions, please feel free to ask us and we will be happy to answer them.
This research is being conducted by Paula Watkins, a doctoral candidate at the University of New
South Wales. She may be contacted at the School of Public Health and Community Medicine, Level 2
and 3, Samuels Building, Faculty of Medicine, UNSW Sydney 2052, Australia. Her telephone numbers
are:
9130 4880 and 0416 180 337, and her email is [email protected].
You will be given a copy of this form to keep.
406
THE UNIVERSITY OF NEW SOUTH WALES
PARTICIPANT INFORMATION STATEMENT AND CONSENT FORM
(continued)
A study of the emotional wellbeing and problems experienced by Karen refugees.
You are making a decision whether or not to participate. Your signature indicates that, having read the
information provided above, you have decided to participate.
…………………………………………………….…………………………………………………….
Signature of Research Participant Signature of Witness
…………………………………………………….…………………………………………………….
(Please PRINT name) (Please PRINT name)
…………………………………………………….…………………………………………………….
Date Nature of Witness
407
THE UNIVERSITY OF NEW SOUTH WALES
REVOCATION OF CONSENT
A study of the emotional wellbeing and problems experienced by Karen refugees
I hereby wish to WITHDRAW my consent to participate in the research proposal described above and
understand that such withdrawal WILL NOT jeopardise any treatment or my relationship with The
University of New South Wales or any organisations within the Karen Community.
…………………………………………………….…………………………………………………….
Signature Date
……………………………………………………
Please PRINT Name
The section for Revocation of Consent should be forwarded to Dr Husna Razee, School of Public
Health and Community Medicine, Level 2 and 3, Samuels Building, Faculty of Medicine, UNSW
Sydney 2052, Australia.
408
Appendix F: Group interview guide
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412
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Appendix G: Conversations with Karen: art exhibition
Media coverage
Media 1: Art shares stories of Burmese refugees (Perrin, 2011).
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Media 2: Conversations with Karen (“Conversations with Karen, 2011).
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Photos of event
Photo 1: Exhibition space
Photo 2: Dolls made by Karen women in Sydney were on display. After the
exhibition the dolls were sent to children in orphanages on the Thailand-Burma
border
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Photo 3: Group of Karen women (faces blurred to protect anonymity) visiting the
exhibition and sharing lunch
