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LITERATURE REVIEW
Currently, there is a lack of literature exploring the dimensions of social isolation
and depression among the Cambodian elderly. For the purpose of the study, this literature
review will be: (1) a general account of the traumatic Cambodian experience during the
years of the holocaust in the mid ‘70s; (2) issues relating to mental health and
acculturation; and finally, (3) an exploration of the dimensions of social isolation and
depression among other ethnic groups as it relates to the Cambodian elderly.
The Cambodian Experience
Cambodian refugees suffered and survived the atrocities of the Cambodian
holocaust under the communist Pol Pot’s Khmer Rouge regime between 1975 and 1979.
When Vietnam overthrew the Khmer Rouge, many survivors fled to refugee camps along
the Thai-Cambodia border and retold their traumatic experiences to researchers of mass
violence. Among the most prominent of these researchers, Cheung (1993) documented
this Cambodian refugee experience. During the onset of the Khmer Rouge regime,
Cambodian civilians were forced to evacuate their cities to live in the rural areas of
Cambodia. There, hundreds of thousands of civilians were subjected to work in labor
camps while other civilians were executed, died of starvation, or disease. Cheung further
explained that the primary agenda of the Khmer Rouge was to destroy the previous
Cambodian government and rid the country of western influences. Carlson and
Rosser-Hagan described this agenda as a master plan to “eradicate the intelligentsia and
begin a new classless society” (Carslon & Hagan, 1993, p. 223). Hence, civilians who
were, or even appeared to be educated, westernized or affiliated with the
military/government were automatically murdered. At the end of Pol Polt’s regime, the
Khmer Rouge had killed between one to two million civilians out of the country’s seven
million population (Kinzie, Fredrickson, Ben, Fleck, & Karls,1984).
After the Vietnamese military invaded Cambodia and brought down the Khmer
Rouge regime in 1979, many survivors fled to nearby countries of Vietnam and Thailand
where they were exposed to additional traumas before arriving to the United States. Their
journeys to nearby countries were often dangerous. Those who survived the trip to
bordering countries were forced to live in refugee camps where they were exposed to
overcrowded and unsanitary conditions (Uba & Chung, 1991).
In refugee camps, Uba and Chung (1991) reported and categorized the survivors’
traumatic past when they were separated from family members who were either lost or
murdered, witnessed acts of violence and/or were forced to commit violence themselves,
sometimes to their own family members. Additionally, during the war, they were victims
of starvation, rape, and other physical acts of atrocities.
Similarly, during interviews with Cambodian refugees, Mollica et al (1998)
numerically categorized the traumatic experiences of refugees under the Khmer Rouge
regime. She found 85% of Cambodian civilians lacked food, water, shelter, medical
care, and experienced brainwashing and/or forced labor; 54% were reported as having
witnessed the murder of a family member or friend; 36% experienced torture; 18%
experienced head injury; and 18% experienced rape or sexual abuse.
Furthermore, during Mollica and colleagues (1998) survey of 993 Cambodian
adults in a Thai refugee camp, they reported the refugees’ experiences of 20 traumatic
events in the order as follows:
Torture, rape, knifing or axing, beatings to the head, beatings to other parts
of the body, near drowning, near suffocation with a plastic bag, murder of
a family member or friend, combat situation, forced evacuation under
dangerous conditions, shelling or grenade attack, imprisonment,
brainwashing, being lost or kidnapped, forced labor, forced marriage,
extortion or robbery by armed bandits, lack of food or water, lack of
shelter, and ill-health without access to medical care, and witnessing
murder of a stranger, torture, rape, knifing or axing, beatings to any parts
of the body, suicide attempt, near drowning, and near suffocation with a
plastic bag. (p. 482).
During Pol Pot’s genocidal reign, Cambodian elderly were subjected to the same
cruel treatment as the younger adults. But being particularly vulnerable, the elderly were
among the first to perish from disease, starvation, or hard labor. After the Vietnamese
invasion, the fortunate among those who survived the holocaust were able to reunite with
their family members or relatives and relocate to other countries as refugees.
The U.S. Experience and Mental Health Issues
After being refugees during the 1980s, Cambodian immigrants experienced the
further difficulties of adjusting to their new life in the United States. They were
psychologically burdened by their traumatic past while at the same time experiencing the
stress and demands of acculturation in the U.S.
Before their arrival to the U.S., many Cambodian refugees experienced severe
traumas during the Khmer Rouge regime. A research study found Cambodians to be the
least educated, most physically ill, and most depressed group among all Southeast Asian
refugees in the U.S. (Meinhardt, Tom, Tse, & Yu, 1994). Another study suggested that
stress is a post-emigration factor among Southeast Asian refugees, created by learning a
new language, seeking employment, establishing social supports, and redefining roles
(Nicholson, 1977). Due to the severity and duration of stressors, many developed the risk
of serious mental health problems (Kinzie, et al, 1984) such as depression, anxiety, and
posttraumatic stress disorder (PTSD). Among Southeast Asian refugees, Cambodians
show much higher rates for depression (80%), anxiety (88%), and PTSD (86%) (Carlson
& Rosser-Hogan, 1993). Kinzie and Fleck (1987) also suggested that Cambodians are the
most traumatized and are at the greatest risk for future mental health problems among
Southeast Asian refugees in the U.S.
In addition to health problems, many Cambodians experience financial difficulty
which may impact their physical well-being (Rambaut, 1985). Bach (1979) reported that
among Indochinese refugees, Cambodians have the highest rate of unemployment. Uba
and Chung (1991) studied non-clinical samples of Cambodians and found that over 40%
had experienced trauma during the Khmer Rouge regime. The authors strongly suggested
that pre-migration stresses affect the quality of life and results in unemployment, low
income, and poor health. Furthermore, Uba and Chung, (1991) hypothesized that
traumatic experiences predict the financial status of Cambodians in the U.S. due to
spending much time and effort coping with their trauma. This may also result in poor
physical health and psychosomatic disorders.
Even after ten years as residents in the
U.S., many refugees are still suffering from significant mental distress and they do not
seek mental health treatment (Carlson & Rosser-Hogan, 1993). Gong-Guy and
colleagues (1991) reported that mental health services that are available in the U.S. rarely
offer services in the refugees’ native language. Carlson and Rosser-Hogan (1993) also
found that the mental health services serving these refugees are geared towards helping
them to gain employment and establish financial sufficiency. However, the service lacks
psychological treatment and health professional staff who are culturally and linguistically
competent to treat this population.
Among Southeast Asians, there is a strong stigma attached to mental illness
(Westermeyer, Vang, & Neider, 1983a). Laderman and Esterik (1988) suggested that this
association is related to physical manifestation of uncontrolled emotions that are
considered to be pathological and humiliating. Mental illness is perceived as being in the
state of “madness” for many Cambodians, and requires long-term placement in a
psychiatric institution (Kleinman, 1977).
Frequently, Cambodians perceive mental health problems as indicative of
“madness” “craziness” or sometimes possession by implacable spirits. Physical health,
on the other hand, is regarded as important and is associated with food and the physical
body (Tseng, 1975). Tseng argued that as a result, many are conditioned to think and
worry about their problems in a somatic way. For example, they may complain of bodily
pain/numbness, feeling fatigue, having headaches, or experiencing insomnia. Cheung
and Lau (1982) also suggested that the reason of somatization among Cambodian
refugees results from the influence of the Chinese medical concept of differentiating
between mind and body, or between psychological and somatic symptoms.
Cambodian patients frequently will not accept being labeled as suffering from
psychological illnesses, but rather, they believe that they are suffering from a medical
condition (Chueng, 1993). Chueng also proposed that Cambodians hold this view due to
their fatalistic beliefs towards existence and their cultural upbringing, which encourages
them to suppress their affect and to tolerate suffering. The suppression of affect and
emotion hinders the expression of their emotional suffering from traumatic experiences.
They may be reluctant to articulate their emotional symptoms ( Mollica, Wyshak, &
Lavelle, 1987).
Cambodian patients often minimize their traumatic past and associated
symptoms due to guilt and shame (Kinzie, Boehnlein, Leung, Moore, Riley, & Smith,
1990). Kinzie and collegues (1990) further reported that they also tend to associate life
events and phenomena with “animistic” or “super-naturalistic beliefs”; therefore the
western concept of a doctor or care provider being able to treat their emotional symptoms
is regarded as strange and foreign to them.
Currently, the youngest of the Cambodian elderly are generally sixty-five years
old. During the Cambodian holocaust of the mid ‘70s, these groups were at least
forty-five years old. The Cambodian elderly who are 65 years or older are entirely
dependent on their family members or paid non-relative caretaker. They continue to
experience lack of mental health care access due to their language and cultural barriers.
Clearly, there is a significant lack of research study of the Cambodian elderly with
regards to depression. Further research study in regards to depression among the
Cambodian elderly is needed to help health-care providers to understand and to better
serve this vulnerable population. The researcher predicts that the Cambodian elderly will
be found to experience the effects of depression and social isolation.
Dimensions of Depression
The existing body of knowledge regarding depression among the Cambodian
elderly is scant. Therefore, the primary literature review of depression in this work will be
a comparison between the researcher’s knowledge of depression among Cambodian
elderly and other ethnic elderly, specifically Chinese immigrants and White elderly in the
United States. Additionally, this literature review will include the current literature of the
theoretical dimensions of depression among the elderly in the U.S.
Depression is considered to be the most common mental disorder among the
elderly (Snowden & Donelly, 1986; La-Rue et al., 1986; Finalyson & Martin, 1982; Hyer
& Blazer, 1982; Blazer et al., 1987). Some of the most salient risk factors of depression
among ethnic elders include poverty, lack of education, failing physical conditions, as
well as high rates of family dysfunction or disruption (Ross & Huber, 1985). Other risk
factors that may be associated with depression include female gender, lack of financial
resources (Rogers, 1999), living alone (Mui, 1993), and lack of personal choice (level of
responsibility) and social resources (Reker, 1997).
Along with risk factors of depression, many researchers (Blazer et al., 1987;
Chappell & Badger, 1989; Haug et al., 1984; Revicki & Mitchell, 1990; Rogers, 1999)
suggest that physical impairments are associated with depression. Mui (1993) also
suggested that the symptoms of depression are natural responses to physical illnesses.
Likewise, Reynolds and colleagues (1994) explained that depression can worsen a
patient’s existing medical problem and has been found to be associated with long term
disability among patients. As a result of depression, the patient may lack the ability to
cope with daily life stressors. Another result of depression is dementia among the elderly.
Buntinx and colleagues (1996) found a significant relation between old age and dementia
among elders who are 50 years old or more. Prevalent symptoms of depression among
the elderly are sleep difficulties, hypochondriasis, and cognitive impairment (Blazer &
Houpt, 1979; McGie & Russell, 1962; Mortimer, 1983; Zung, 1967).
There is little substantial knowledge of the dynamics of depression among ethnic
elderly in the U.S. due to the lack of empirical research within this population (La Viest,
1995). The author further reported that the availability of empirical research among
White and Black elderly populations was substantial enough to conduct significant
statistical analysis, respectively. However, among Asian Americans and other ethnic
elderly groups, there is no significant research data to support meaningful analysis for
depression.
Cambodian elderly share some similar cultural backgrounds with Chinese elderly
in the United States, such as cultural values and religious practices. Hence, the risk
factors for depression among Chinese elderly may also apply to Cambodian elderly. In a
study conducted by Zhang and colleagues, it was hypothesized that the risk factors of
depression among Chinese elderly in China were “stressful family situations,
socio-demographic status, poor physical health, high financial pressure, and less healthy
lifestyles” (Zhang, Yu, Yuan, Tong, Yang, & Foreman, 1997, p. 201). The results of the
study showed that 47% of 350 elderly subjects (65 years or older) were depressed due to
social status, poor physical health and family disruption. Also, 13% were depressed due
primarily to stressful family disruption. Similarly, the results found in China were
reported (Woo et al., 1994; Krause & Liang, 1993; Krause et al., 1993; Hasegawa, 1985)
to be consistent with the results among Chinese elders in the U.S. Specifically, these
results for risk factors of depression were socioeconomic status, physical health,
functional ability, and social relationships.
The above mentioned studies concerning Chinese elderly help to hypothesized
that many Cambodian elderly are significantly depressed due to similar life stressors.
And similarly to the Chinese in the U.S. and China, the risk factors of depression among
Cambodian elderly are suggested to be poor physical health, family situation, social
relationships, and financial stress or the ability to meet basic financial needs. The studies
also help to suggest that the symptoms of depression among Cambodian elderly are
similar to most symptoms among the Chinese elderly population in the U.S. For
example, such symptoms may include sleep difficulties, hypochondriasis of the
gastrointestinal system, headaches or dizziness, numbness of specific body parts, and loss
of appetite.
The nature of the symptoms among Cambodian elderly is associated with
socio-cultural factors. Like the Chinese, the majority of Cambodian elders experienced
depression somatically rather than cognitively. In a study of neurasthenia in Hunan,
China, Kleinman (1982,1986,1988) argued that the nature of depression depends on the
socio-cultural construct of a population group. In this particular study, the author argued
that depression and its symptoms derive from the cultural living experience in a
socio-cultural environment. For example, as part of the Cambodian socio-cultural
environment, the family cultural value is the central focus of family structure. Some of
these values include behavior rules of financial support and maintenance of a relationship
of devotion and dignity for family members. These cultural values are similar to the
Chinese Confucian concepts of “loyalty”, “piety”, “benevolence”, and “righteousness”
which requires that parents must be considerate of their children and, in return, their
grown adult children will care for them (Zhang et al., 1997). Along the line of Chinese
family value, Xu and Wu (1984) suggested that it is a common cultural belief to consider
family life as the center of an individual’s life, especially among the elderly. Thus, within
this socio-cultural context, if the concept of cultural family value is disrupted or
unfulfilled, it is expected that the elderly may experience psychological distress, which
may manifest itself into depressive symptoms.
Other studies reported (Burnette & Mui, 1994,1996; Mui, 1996a; Mui &
Burnette, 1996) that Chinese immigrants experience depressive symptoms due to the
psychological distress of immigration and acculturation process (such as language and
cultural barriers), poverty and physical or mental illnesses, social isolation, lack of family
support, residential changes among children, and arrangements for a new-born or new
family members from abroad.
The psychological distress among Cambodian elderly may, likewise, stem from
immigration and acculturation factors relating to past war-refugee experience and
adaptation to life in the U.S. Additionally, poverty is a significant factor of depression
among the Cambodian elderly. Chung and Bemak (1996) found a high percentage of
Southeast Asian refugees who are dependent upon welfare after being in the United States
for up to five or six years. Among these Southeast Asian refugees, Cambodians between
the ages of 18-68 years are among the highest group of welfare dependents.
The
Cambodian refugees face other risk factors of poverty living in the city of Long Beach.
Most refugees are concentrated in the poor urban areas of Long Beach where gang
violence or other violent acts occur on a daily basis and unsanitary/overcrowded living
conditions is the reality of their daily lives. These living conditions of poverty may
further exacerbate the psychological distress and ultimately cause depression among the
elderly. Another aspect of poverty the elderly refugees face is financial burden. Mendes
De Leon and colleagues (1994) suggested that financial strain is the cause of daily life
worries and may result in deterioration of mood and poor physical health.
The factors of mental/physical illness, social isolation, and lack of family support
are strong contributors of psychological distress among the Cambodian elderly. As
mentioned before in the above literature, many Cambodians experienced the Cambodian
genocide and suffered significantly, both mentally and physically, from its aftermath. The
factors of social isolation and lack of family support may worsen the mental/physical
conditions of the elderly and contribute to a future in which they may experience a high
mortality rate and low quality of life.
Social isolation among the Cambodian elderly may include lack of public
support/intervention or a lack of personal family support. The elderly may lack both
supports, but the lack of family support is a critical factor of depression. Zhang and
colleagues (1997) suggested that lack of expected care and consistent financial requests
from family members are factors that are likely to lead to depression among Chinese
elderly, considering that the central concern is focused on family life. Zhang and
colleagues (1997) further suggested that the Chinese elderly are also susceptible to
depression because the experience of family conflict or disruption strongly opposes their
strong traditional beliefs of family values. Since little is known about the Chinese elderly
mental health problems, depression in this population goes largely unrecognized and
untreated. If left untreated they are at risk of committing suicide (Mui, 1991). As a result
of depression, Chinese American elderly have a higher rate of suicide than white
American elderly (Yu, 1986).
Since Cambodian elderly share common cultural and traditional family values
with the Chinese elderly discussed above, their problems remain unrecognized and
untreated as well due to the lack of access and underuse of community healthcare. Other
factors concerning these problems are due to health service barriers between patients and
health-care providers, and the lack of financing to establish health-care
services/organizations (Gottlieb, 1991). The ultimate result of undiagnosed and untreated
depression in late life is not only insurmountable distress among the elderly, but also to
their families and society (Allen & Blazer, 1991). The rate of suicide associated with
depression among the Cambodian elderly in the U.S. currently remains unknown due to a
lack of empirical study among this population.
Gelfand and Yee (1991) suggested that depression is frequent among elderly
immigrants because of limited economic resources and material losses due to migration
and current stressful life events. Furthermore, the authors suggested that these life
stressors of immigration and acculturation are additional risks for “situational stress” and
“somatic symptoms,” especially when there is lack of family support. This may also be
especially true among the Cambodian elderly. The common situation among the
Cambodian elderly includes financial burden, language and cultural barriers, and family
disruption. Depression and anxiety may also manifest as somatic symptoms. Due to their
somatic symptoms and other factors discussed above, they often erroneously seek medical
services rather than mental health services. Medical doctors frequently do not find their
physical complaints (e.g., dizziness, headaches, and bodily aches and pain, or numbness)
as a significant medical diagnosis. In addition to complaints about their physical-related
problems, the Cambodian elderly frequently express their problems with their current
situation such as spousal abuse and problems with their children such as failing in school
and involvement in criminal activities.
Due to their current situational stress (i.e., poverty, family disruption, and
financial burden), and their traumatic past experiences, the Cambodian elderly are likely
to develop various mental health problems. Depression is a current and common mental
health problem among them. They are at greater risk than the mainstream society to
develop physical and mental ailments. Mui (1991) claimed that these problems can be
addressed based on cultural values and cultural expectations. Additionally, health
providers should focus and observe clients’ “self-perceived health, their living situation,
and their level of satisfaction with help from family members” (Mui, 1991, p.643). This
observation, Mui further suggested, is important to plan and design a culturally sensitive
mental health agency/program.
The Cambodian elderly are in need of a culturally appropriate mental health
service in the community of Long Beach due to the unique Cambodian experience and
cultural background. The mental health service should draw from Mui’s (1991) model
for a culturally sensitive mental health provider. This would enable care providers to
address the Cambodian elderly’s perception of their own health condition, their living
situation, and the perceived level of help from their family members. The combination
of this approach may help them to not only prevent further mental health problems, but
also help them to ease into the process of acculturation and, thereby, help them to become
self-sufficient in terms of achieving better health and quality of life.
Dimensions of Social Isolation
Social isolation is a concept that has many definitions and characteristics. As a
result of this disparity, research findings concerning social isolation remain inconclusive
and inconsistent. Another research barrier hindering the study of social isolation is the
measurement of research findings, which varies among researchers, and the fact that the
concept is not instrumental to survey research (Lumpkin & Johnson, 1987). Like social
support, the current concept of social isolation has generated inconsistent research
findings due to the lack of conceptual and methodological clarity. (Mitchell & Trickett,
1980; Rundall and Evashwick, 1980; Barrera, 1981). The conflicting findings of social
isolation are an additional barrier in terms of forming definite conclusions. This may be
due to the many variables of social isolation (Silverstone & Miller, 1980), such as age
group. Overall, the concept and term of social isolation does not have uniformity and
lacks consensus in terms of its causes and consequences (Adams, Kaufman, & Dressler,
1989).
Despite this discrepancy, social isolation is generally defined as the negative
change in health and well-being of individuals or the change in status and situation, and
the loss of emotional and physical contact of individuals or groups. Silverstone and
Miller (1980) refer to social isolation as the detachment of individuals or groups from
general experiences such as “interaction”, “communication”, “cooperation”, and “social
and emotional involvement.” Monk (1988), on the other hand, defines social isolation
specifically to that situation in which the aged find themselves in as the result of
“mandatory retirement policies”, “relationships”, “mobility of children”, “deaths of
spouse, relatives, and friends”, and “losses of organizational memberships.”
Other definitions of social isolation refer to the lack of emotional interaction with
other individuals and feelings of loneliness. For example, Bennett considered social
isolation as basically “the absence of specific role relationships which are generally
activated and sustained through direct personal face-to-face interactions” (Bennett, 1980,
p. 15). Weiss (1973) suggests that social isolation is the disconnection from social
network, which manifests itself by the individuals’ feelings of “fear”, “anxiety”,
“apprehension”, “abandonment”, “boredom”, “aimlessness”, and “marginality.”
Some authors define social isolation as a complex phenomenon, which involves
the individuals’ interaction, psychological consequences, and various stages and
dimensions of social isolation. Townsend (1968) argues that social isolation is an
objective phenomenon relating to the individuals’ lack of social interaction from which,
the social and psychological consequences stems. A more sophisticated term of social
isolation states isolation as “a multistaged”, “multidimensional”, and “cumulative
process” (Rathbone-McCuan & Hashimi, 1982). They further claim that the cause of
isolation occurs within four dimensions: (1) physical (physical problems such as sensory
loss); (2) psychological (e.g., phobias, depression, fear and anger); (3) social (e.g., change
in work or family structure); and (4) economic (e.g., lack of financial means may deter
individuals from social activities).
Similar to its term, social isolation as a measuring concept lacks clarity and
consensus among researchers as well. For example, Tec and Granick (1960) based their
study on a “3-point scale,” which includes the variables: no contact with relatives, no
living children, being unemployed for 10 years or more, and living alone. Alternatively,
Coe and colleagues (1985) based their study of social isolation upon one variable: persons
who have no family in a specific metropolitan area. Lowenthal (1976) measured social
isolation as having only casual or no contact with others for a two-week period prior to
the interview, whereas Weeks and Cuellar (1983) measured social isolation in terms of
degree of contact with family and friends. Hyman (1972) included the measurement of
both objective and subjective aspects of social isolation such as loneliness, alienation, the
number of reliable persons to depend upon, and living arrangements.
The research methodology, conceptualization, and terminology of social isolation
remains unclear and inconclusive. Current study to update the study of social isolation is
needed to further explore its origin and effects among the elderly. For the purpose of this
study, social isolation is defined in terms of the subjects’ life experiences and the level of
social contact with their current spouse, children, friends, and their community.
Additionally, this study will explore and compare the subjects’ life experiences between
their lives in Cambodia and current lives in the United States.
The cause and characteristics of social isolation lacks uniformity and clarity as
well. Research findings varies in terms of complex demographic factors (Ellis, 1996)
such as age group, economic resource, location, lifestyle, and health status. For example,
in a research study of social isolation among rural elderly widows, Arling (1976)
suggested that social isolation may result from health deterioration and financial resource.
Arling further reported that widows who have more social interaction tend to be more
educated and interact with friends and neighbors. Similarly, in a longitudinal study,
Maddox (1966) reported that less socially active elderly tended to be “older”, “in poorer
health”, “economically disadvantaged”, and “of lower intelligence.” In a more recent
study of isolated and under-served elderly, Ellis (1996) proposed that the problems
related to isolated elderly are “marital problems”, “divorce adjustment”, “health
problems”, “widowhood”, “loneliness”, “anxiety or fear”, “grief”, and “economic
difficulties.” Ellis also suggested that these are probable risk factors toward depression
and psychological impairments.
With regards to the factors of isolation among the elderly, it should be observed
that the primary cause is depression due to loss of close members and health, loneliness,
isolation, feelings of hopelessness and uncertainty, and loss of mastery (Solomon &
Zinke, 1991). Other factors which sometimes cause social isolation are personality
dysfunction due to difficulties with interpersonal relationships (Kosberg & Garcia, 1987).
The forms of social isolation may have various forms among the elderly. Ernst and
colleagues (1977) suggested such forms as: (1) emotional (withdrawal into apathy and
rejection of future relationships); (2) social (decrease of primary networks of friends and
relatives duet to loss from deaths, relocation, or retirement); and (3) physiological
(decline of the senses and ability to ambulate, which limits social contact). These
research findings (Ernst, Badash, Beran, Dosovsky, & Kleinhauz, 1977) show variations
between subgroups that older respondents who are in poorer health, were unmarried, and
have lower income and education are at a greater risk of experiencing the negative effects
of social isolation than their counterpart.
A more recent and complex study of social isolation, Kaufman and Adams (1988)
argued that the study of social isolation should focus on three areas: (1) structural
attributes of social networks; (2) interactional patterns between subject and individuals of
social networks; (3) psychological consequences (structural and interactional patterns of
subjects’ social network). Future study of social isolation should be toward various areas
of concern (Rubinstein and colleagues, 1994). For example, Rubinsteins’ area of
concern in terms of social isolation and social support is “ethnic diversity”, “social
support”, and “social isolation.” This area of concern obviously fits well with the study
of social isolation among the Cambodian elderly. Under this concern, the author further
suggested that the quality of social support existed from traditional and cultural structures
as well as mainstream social institutions of support. Additionally, Rubinstein cited that
the “effects of racism, exploitation, financial stress, lack of opportunity, ethnic
misunderstanding, changing identities, distinctive family configurations, and generational
differences are to be felt” (Rubinstein, Lubben, & Mintzer, 1994, p. 71) among the
diverse ethnic groups in the U.S.
As suggested under the area of ethnic concern, the Cambodian elderly are
challenging their traditional and cultural structures against the change in circumstances
and environment. For example, the Cambodian elderly are struggling against the barriers
of acculturation, language, generational differences (with their children), and a traumatic
past as refugees of war. These barriers are high risk factors toward social isolation and
the under-utilization of mainstream institutions such as senior citizen centers or the
utilization of medical/mental health professionals in their community.
Research findings support the argument that there is a relationship between the
physical and mental health of the elderly and the level and quality of their social network
(Cohen et al., 1985; Ernst et al., 1978; Rumsey & Justice, 1982). Likewise, Larson
(1978) has reported a significant relationship between the level and quality of social
activities/social interactions and their subjective sense of well-being. In a study of 800
randomly selected elderly, Hale and Libowitz (1974) found a strong and consistent
relationship between social isolation and mental impairment. Similarly, in their field
survey research, Cummings and Henry (1961) concluded that there is a biological cause
for the act of social isolation among the elderly: increasing disabilities and the realization
of impending death may both cause the progression of social disengagement. The risk of
social isolation and loneliness may also result in the decrease of mortality rates (Monk,
1988).
Several researchers contend that there is a significant biological risk stemming
from social isolation. Creecy and colleagues (1985) reported that the consequences of
loneliness among the elderly may include medical problems such as diabetes, coronary
disease, arteriosclerosis, peptic ulcer, and respiratory aliments. Fry (1986) reported the
occurrence of suicide among the elderly as the result of loneliness. With reference to
social isolation, Wells (1975) suggested that the major problems among the elderly are
“faltering contact” with their surroundings and the “gloom of isolation.” As a result, he
further suggested, “apathy takes over” and then the decline of perceptions such as sight,
hearing, smelling, touch, and taste entails. To further support Wells findings, O’Neil
(1975) reported a clear correlation between sensory loss and senility among the aged in
the State of New York’s nursing home residents. Additionally, Arie (1973) linked
dementia among the aged to impaired mobility and sensory deprivation such as deafness
and/or blindness. Also, dementia with depression and anxiety tends to cause
hallucination and apathy among the elderly.
Silverstone & Miller (1980) suggested that social isolation among the elderly is an
unnecessary imposition. In order to alleviate the burden of isolation and its harmful
effects, there must be “accessible housing”, “access to readily available transportation”,
“access to recreational facilities”, “prosthetic supports”, and a “barrier-free environment”.
Additionally, all the above mentioned supports may help to alleviate the process of
socialization and create sufficient financial resources to make all this possible for the
elderly.
Sub-populations of the elderly in the U.S. may experience varying degrees and
effects of social isolation (Ernst et al., 1978). In order to mitigate the problem, Ernst and
colleagues (1978) suggested that professional health-care providers need to be sensitive to
the harmful effects of social isolation among these different elderly sub-populations. In
light of this awareness, mental and physical health providers must be sensitive and
competent in terms of understanding the Cambodian elderly in the U.S. This
comprehensive understanding includes acquiring the knowledge of the Cambodian and
U.S. experiences. Their traumatic past and current cultural barriers are high risk factors
toward the harmful effects of social isolation.
Summary
The theoretical dimensions of Social Isolation and Depression were applied to the
Cambodian elderly in the U.S. Their traumatic war experiences and current living
situation were addressed to better understand their background, cultural values, and
difficulties of acculturation. In sum, Cambodian elderly are vulnerable to serious risk
factors of social isolation and depression due to their traumatic past, living situations, and
cultural barriers. This study explored the level of both social isolation and depression
among fifteen Cambodian elderly in Long Beach, California.
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