Discussion: Ethics in Cross-Cultural Research

Chapter 3

The Concept of Posttraumatic Growth in a Cambodian Sample A Grounded Theory Study

Skultip (Jill) Sirikantraporn, Grant J. Rich, and Nashaw Jafari

Studies have documented that people do report growth or positive outcomes as a result of their struggle to cope with trauma or stressful life events (Bonanno, 2005; Calhoun & Tedeschi, 2006; McMillen, 1999). The term “posttraumatic growth” (PTG) was developed to conceptualize the phenomenon. Most Western studies have suggested that the core elements of PTG include improved relating to others, seeing new possibilities in life, spiritual change, and increases in personal strength and appreciation of life (Tedeschi & Calhoun, 1996). More recently, the concept of PTG has begun to be investigated across cultures in both quantitative and qualitative studies. For instance, relevant research includes samples from Australia (Shakespeare-Finch & Copping, 2006), Japan (Taku, Calhoun, Tedeschi, Gil-Rivas, Kilmer, & Cann, 2007), Bosnia (Powell et al., 2003), and China (Ho et al., 2013), and from cancer survivors across cultures (Diaz, Cordova, & Spiegel, 2012). The cross-cultural findings suggest that the five dimensions of PTG (personal strength, appreciation of life, relating to others, spiritual change, and new possibilities; Tedeschi & Calhoun, 1996) may or may not vary across cultures, especially for cultures in which the self is defined as individualistically oriented, compared to collectivistically oriented (Helgeson, Reynolds, & Tomich, 2006; Yang, 2003). This indicates that more in-depth examinations for different cultures are warranted.

Since the end of the horrific and tragic era of the Khmer Rouge, which peaked between 1975 and 1979, and which killed approximately two million people, a quarter of the whole Cambodian population at that time, from execution, disease, starvation, and overwork (Chandler, 2007; Hinton, 2004; Kierman, 2008), Cambodia continues to be plagued by the trauma and cycles of violence and victimization due to ongoing political and social instability, high rates of poverty, and limited access to resources (Jarl, Cantor-Graae, Chak, Sunbaunat, & Larsson, 2015). A recent survey of nearly 3,000 adults from 9 of the 25 provinces in Cambodia found that an estimated 31 percent of women and 18.4 percent of men suffer from probable anxiety disorders and 19.7 percent of women and 10.2 percent of men suffer from probable depressive disorders. This survey also found that of those who experienced the civil war, 92.3 percent experienced at least one traumatic event, with a mean of seven events, and that among younger participants who did not experience the civil war, 70.2 percent experienced at least one traumatic event (RUPP, 2012). Discussion: Ethics in Cross-Cultural Research

Living in the posttraumatic era after the experience of the atrocity of the genocide, Cambodians have had to find ways to cope with the psychological impact. Throughout the past decades of research, many cultural studies, including work in medical anthropology, have examined the cultural meanings of trauma and trauma responses among Cambodians as a result of the Khmer Rouge (Becker, Gay, Beyene, & Ken, 2000; Hinton et al., 2009; Hinton, Howes, & Kirmayer, 2008; Ratliff, 1997; Van Schaack, Reicherter, & Chhang, 2011). However, to understand the complete picture of trauma study in cultural context, it is also important to explore cultural meanings of growth and positive changes after trauma. This study, therefore, aimed to investigate the concept of PTG among a Cambodian sample from both etic and emic perspectives of cultural psychology. Discussion: Ethics in Cross-Cultural Research

Trauma studies in Cambodia have evolved in their attempts to understand the effects of trauma on Cambodians’ psychological and cultural health. A trauma-based cultural syndrome was defined as the set of salient culturally specific trauma-related symptoms of survivors of the Khmer Rouge, and include kyol goeu (wind overload), which causes one to become unconscious, fall to the ground, turn pale, and sweat (Hauff, 2001), sleep paralysis (“the ghost pushes you down”), nightmares, and panic attacks (Hinton, Pich, Chhean, & Pollack, 2005). Another important Cambodian trauma phenomenon is “broken courage” or “baksbat,” which overlaps to some degree with posttraumatic stress disorder (PTSD) (Chhim, 2013). Baksbat is the idiom of distress experienced by Khmer persons as a lack of trust in others, submissiveness, feeling fearful, and being “mute and deaf” (Chhim, 2013). The interpersonal nature of many of the above symptoms, such as sleep paralysis and baksbat, may partially explain why healing practices found to be important for Cambodian trauma survivors are interpersonal by nature. Some of these identified practices among Cambodian trauma survivors are making merits to the deceased, holding a festival for loved ones, and healing the wider community (Agger, 2015).

The struggle of Cambodians over the past few decades has been further complicated by the intergenerational effects of trauma (intergenerational transmission of trauma) to the younger generation Cambodians. Often the adverse effects of intergenerational transmission of trauma are referred to as “unspoken trauma.” Although the young Cambodians experienced their own suffering acquired from post-genocide effects, coupled with the direct damage done to the country’s current human and socioeconomic development, these effects and impacts on the country’s youth have been under-acknowledged (Rich, 2015). One proposed path of transmission is through family interactions. Such a pathway suggests that the enduring effects of violence experienced by the survivors of the genocide have significantly impacted the ability of their children and young adults to form a stable sense of security and attachments. A study of Cambodian mothers, who experienced the Khmer Rouge, and their daughters confirmed and expanded this path by revealing that the mother’s PTSD was predictive of her daughter’s anxiety (Field, Muong, & Sochanvimean, 2013). In addition, the mother’s role-reversing parental style mediated the relationship (Field, Muong, & Sochanvimean, 2013). Discussion: Ethics in Cross-Cultural Research

Another path of transmission of effects is through lingering effects of socioeconomic issues stemming from the Khmer Rouge, which have kept Cambodia in severe poverty decades after the genocide. Corruption and abuse of power in the government and military present during the Khmer Rouge era have continued to affect the post-genocide country’s poor research infrastructure and accessibility as well as have led to mistrust in the government among young-generation Cambodians (Hinton, 2002). These effects of intergenerational trauma have caused many young Cambodians to continue to suffer from trauma stemming from the Khmer Rouge era despite the fact that they were not even there themselves.

The focus of the above studies in Cambodia has been on the negative outcomes of trauma, which is understandable, because it enables researchers and practitioners to establish culturally appropriate diagnosis and treatment. However, a more complete, culturally appropriate understanding of recovery from trauma, and of growth after trauma, is also necessary to cultivate ways of coping and thriving after any type of trauma. The purpose of the present study is to fill a gap in the existing Cambodia trauma studies by exploring the concept of PTG to conceptualize this term from within the culture. Thus, a primary goal of the current study was to identify specific factors associated with PTG in the Cambodian context, examining whether more universalist and Western assumptions in the preexisting PTG literature apply to the present sample. Discussion: Ethics in Cross-Cultural Research

METHODS

Participants

Twelve participants participated in the in-depth interview. These participants were drawn from a larger mixed-methods study of 70 participants (mean age = 20.86) conducted in Phnom Penh, Cambodia’s largest city (Rich, 2015). There were six female and six male participants in the qualitative portion of the study. Most identified as single (83 percent), and as from mid-level socioeconomic status (SES; 75 percent). Most reported they had completed high school (66 percent) and were currently students (75 percent) and self-identified as Buddhist (91 percent). All of them reported having experienced at least one traumatic experience.

Data using the life events checklist (Gray, Litz, Hsu, & Lombardo, 2004) from the larger quantitative sample found that 97 percent endorsed at least one type of trauma, and 84 percent endorsed 5+ types of traumas (Sirikantraporn, Rich, Jafari, & Chandhok, 2016). The most frequent number of traumas endorsed by the quantitative sample was 9 (17 percent of the sample). The most frequently endorsed types of traumas were: (1) transportation accident, 90 percent; (2) natural disaster, 86 percent; and (3) severe human suffering, 73 percent. To protect participant confidentiality, researchers are not able to link specific qualitative interviewees to specific quantitative measure responses. Discussion: Ethics in Cross-Cultural Research

Measures

Semi-structured Interview Guide

An interview guide included 20 open-ended questions in the Khmer language and aimed to explore in-depth experiences and understanding of the concept of PTG. The questions were based on recent research and clinical literature on PTG and on cultural literature on the Khmer culture and society (e.g., Chandler, 2007; Ratliff, 1997). Discussion: Ethics in Cross-Cultural Research

Data Analysis

Grounded theory was suitable for this study because the study proposed to examine the phenomenon of PTG from the point of view and insight of the local people, a topic and approach which has not yet been explored in-depth within the Cambodian context. Grounded theory was used to generate an emergent theory through the discovery of themes (Glaser & Strauss, 1967). Theoretical sampling was used to increase the maximum variable sampling (Maykut & Morehouse, 1994). The sample size was determined by the concurrent process of data collection and coding procedures until the saturation point was met, the point at which no new categories were forthcoming (Maykyt & Mayhouse, 1994). Constant comparative analysis through three stages of coding (open

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coding, axial coding, and selective coding) was used to discover emerging themes and an overarching theory (see Glaser & Strauss, 1967). There were several strategies utilized to increase trustworthiness of the study findings. First, peer scrutiny of the research project was used, where three coders independently coded the data and compared emerging categories and themes until the final version of categories and themes were agreed upon. Second, an audit trail and journaling among researchers was utilized to increase researchers’ reflexivity and progressive subjectivity (Lincoln & Guba, 1985) to minimize the intrusive influence of the researchers’ own biases on the research procedures and findings. Discussion: Ethics in Cross-Cultural Research

Procedure

This research was a collaborative project between Alliant International University and the American University of Phnom Penh (AUPP). This chapter focuses on the qualitative portion of a mixed- methods study; the quantitative portion of the study includes data utilizing such measures as the life events checklist (LEC), PTG inventory (PTGI) scale, and the Adult Resiliency Measure (ARM) (Sirikantraporn, Rich, Jafari, & Chandhok, 2016). The Institutional Review Board (IRB) approval was obtained from both institutions. This was the first research project conducted at AUPP, a new university founded in 2014. AUPP created an IRB specifically to facilitate our work, and this IRB included faculty as well as student board members. Thus, the timeframe for approval was somewhat extended and the IRB approval process began in early Autumn 2014, and approval was received in Winter/Spring 2015. The voluntary nature of student participation was emphasized. Planning for data collection was involved, especially as summer student schedules were only finalized around time of the researcher’s arrival to Cambodia from the United States. Because student schedules were very full, extra credit for research participation was not permitted, and since several field trips for summer classes conflicted with previously arranged data collection schedules, multiple data collection sessions were conducted. Two bilingual Khmer English student teaching assistants (TAs) arranged and conducted the interviews. At the end of the data collection period, a debriefing session was held by one of the faculty coauthors with the student TAs also present, and all students were invited; the session was well attended and students demonstrated an interest both in social science research methods and in the work’s relevance and potential value for Cambodia. Discussion: Ethics in Cross-Cultural Research

RESULTS AND DISCUSSION

Overall, the model of PTG proposed by Tedeschi and Calhoun was supported in this Cambodian qualitative sample (N = 12. 50 percent female). This section presents exemplary quotations (F means the quotation was from a female participant and M means the quotation was from a male participant) that capture the major categories found, together with their major themes; discusses the themes of PTG that emerged from the data by the Grounded Theory method; and compares these themes with previous literature on Tedeschi and Calhoun’s model of PTG. Four categories and ten themes emerged from the data (see Figure 3.1). Discussion: Ethics in Cross-Cultural Research

Figure 3.1 Construction of PTG in the Present Cambodian Sample.

Category 1: Personal Growth

Personal growth is defined as personal strengths and positive personal aspects of growing as a result of one’s struggle to cope with trauma. This category was made up of three themes (i.e., self- efficacy, acceptance, and self-actualization). Discussion: Ethics in Cross-Cultural Research

First Theme: Self-efficacy

Reported by 66 percent of the participants (8 out of 12), self-efficacy, which refers to one’s belief in one’s ability to successfully execute behaviors necessary to produce specific performance attainments (Bandura, 1986), is reflected in the selective code by the catch phrase, “I now know I can overcome future stressful events.” The experience is seen as a turning point at which the person feels a sense of independence for having been able to cope with and survive the event because they have done so with the last trauma. This theme has also been found in an Australian sample (Shakespeare-Finch & Copping, 2006), and it can be considered in line with the increased personal strength dimension of the five-factor Tedeschi and Calhoun model that found that individuals have a strong belief in one’s ability to face life problems after enduring a stressful life event. Some of the responses to illustrate this theme are:

At the end it makes me stronger, but before it [the trauma] makes me stronger it…it kind of destroys me a little bit until I knew that I shouldn’t be there because it’s not going too good for me, then I got stronger. But I always got stronger after everything that happened. (F)

Like I’m the most important person who can makes me a better person and also the one who can keep myself going so… I have a feeling that everything is possible if I want it to happen. (M)

I am able to pick myself up and start over, like not dwelling on some uh, bad experience in the past that hinders me from achieving other things that I want in life. (M)

Second Theme: Acceptance The second theme refers to personal growth that stems from the ability to accept the situation and to accept the good and not-so-good qualities of life, of self, and of others, and to recognize that “no one and no family is perfect.” This theme was mentioned by 66 percent of the participants (8 out of 12), and is exemplified by the quote, “so it changed about my life—[xxx] no one is perfect and people have their own flaws” (M). More responses to illustrate this theme include:

Learned to accept that you are not perfect and you still have something to improve. (F)

For anything or about anything it’s just kind of whatever happens, happens, whatever doesn’t, doesn’t … sometimes things happen for a reason. (F)

I feel like open to that be more accepting. And I’m more willing to try to accept other peoples’ flaws but I also at the same time am more close and accepting about my own feelings. (M)

While this theme was not explored and measured in the original five-factor model of Tedeschi and Calhoun’s PTGI (1996), it was viewed later by the authors as a precursor (and not an outcome) of growth (Tedeschi & Calhoun, 2004).

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This theme was also found to be a salient PTG theme in the Australian sample (Shakespeare-Finch & Copping, 2006). While Acceptance is viewed as a precursor and not an outcome of growth when Tedeschi and Calhoun explained that valuing the event itself can be a catalyst for growth (Tedeschi & Calhoun, 2004), in this study’s sample, acceptance implied not only accepting what happened but also accepting different qualities (positive and negative) in oneself and others, which suggests that acceptance may function as both a precursor and an outcome of PTG. After trauma, a less extreme and more balanced way of viewing the world has also been found in a longitudinal PTG study of tsunami survivors to be serving as a coping resource after the disaster, in which both positive and negative experiences are integrated (Siqveland, Nygaard, Hussain, Tedeschi, & Heir, 2015). Discussion: Ethics in Cross-Cultural Research

Third Theme: Self-actualization

Self-actualization is defined in this study as increased self-knowledge and self-realization of one’s life priorities and one’s capabilities (Heylighen, 1992). This theme, found in 75 percent of the participants (9 out of 12), appears to be more related to inner satisfaction of self and self-awareness, rather than outward satisfaction in career or intellectual achievements. The self-actualizing process has been believed to potentially be interrupted and “forfeited” in trauma sufferers (George & Sar, 2006). As the person learns to confront and grow from trauma, this process may resume and become available to survivors again (Dass-Brailsford, 2007). This supports the notion in the PTG literature that self-actualization is an outcome of one’s acceptance and confrontations of the trauma (Joseph & Linley, 2005). Exemplary quotes of this theme include:

I don’t think it has affected, like I said earlier, what I wanted in life is still what I want in life, just I improve on that goal, improve on the, on the process of how I want to achieve it. Instead of just wanting it, I know I have a better idea, a clearer idea in order to reach that goal. (M)

I know that I’m strong and I can focus on what is important to me and my goals. (M)

Self-efficacy, acceptance, and self-actualization emerged as three salient and interconnected themes that appear important for the participants’ sense of increased personal strength.

Category 2: Interpersonal Growth

The second category, interpersonal growth, is defined as the growth-promoting factors that are related to one’s interpersonal relationships as a result of trauma. Two major themes were identified as supporting interpersonal growth: (1) increased appreciation for social support and (2) increased empathy and altruism.

First Theme: Increased Appreciation for Social Support

Eighty-three percent of the participants (10 out of 12) reported the importance of support from family, friends, and community. This support can be in the form of having at least one person to think of when they experienced high stress. One participant captured this dimension by stating, “without such support, I wouldn’t have been where I am today.” Social support has been identified as one of the essential dimensions of growth after trauma (Tedeschi & Calhoun, 2004), and further studies suggested that the relationship between social support and growth may be the perceived availability of emotional support (Schroevers, Helgeson, Sanderman, & Ranchor, 2010), which allows successful cognitive coping and recovery after trauma (Tedeschi & McNally, 2011). Discussion: Ethics in Cross-Cultural Research

In addition, this theme illustrates the closer and warmer interpersonal relationships that often exist post-trauma in comparison to prior to the trauma. These findings strongly support the literature of PTG, which highlights the warmer, more intimate relations with others after a stressful life event. One important quality of closer interpersonal relationship among this sample is good listening, which was reported by 58 percent of the participants, such as is reflected in this quote: “My friends and family help me a lot because they are good listeners” (M). This finding potentially expands the PTG literature by clarifying that good listening from one’s social support person(s) is one of the important qualities of a good relationship, and such supportive listening may help one feel better as one struggles to cope with stressful life events. While this dimension of good listening has not be directly explored in relation to PTG, Woodward and Joseph (2003) indicated that having relationships where the traumatic individuals can feel nurtured and validated and experience genuine acceptance from others through “active, attentive, and compassionate listening” may not only help them recover, but also foster PTG. As the finding from this study suggested, this person may be anyone, including a close friend, family member, spiritual leader, and/or mentor. Some of the exemplary quotes for this theme are:

I, first of all, I didn’t realize that he was that sick. I just don’t know what, and then, after his recovery, I realized how much he meant to me and I really appreciate it. Every single day I tell him I love him and take care of him more and we’ve become much closer. (F)

Friends and family help me a lot. They keep encouraging me to go on and live happily. (M)

I learned, like, people in the fear factor, people are like, frightened. So, we all know that most, mostly when we are frightened, we are frightened and feeling down. So, I learned that we should encourage each other to stand up. (M)

Second Theme: Empathy and Altruism

After the stressful life experience, 66 percent of the participants (8 out of 12) reported that they have become more considerate and aware of the impact of their actions on other people and how other people feel when facing difficult situations. Half of these participants also reported their desire to help others who are facing life challenges. Based on the PTG study on Asian communities, Yang (2003) found that the way to actualize in collectivist cultures, such as in some Asian cultures, may be via self-correction and self-examination to develop such qualities as altruism, kindness, and conscientiousness, to uphold the ultimate goal, personal-social harmony. The findings of this study support the notion that factors related to growth among this Cambodian sample may be related to the collectivistic aspect of self and relationships with others. Discussion: Ethics in Cross-Cultural Research

Quotes from participants to illustrate this theme include:

I mean, sometimes because actually I room with others, and sometimes they know about my problems and I am not the only one—[xxx] people are having harder lives than me and they can still do it, and then some people will just come out and talk about their difficulties too, and it makes me feel better—people have difficult things in life. (M)

I think I learn I learn how to know what the other people are thinking when I’m with them. Instead of just doing what I want and not really taking into consideration how the other people may felt by it. Yeah. (M)

You don’t want other people to feel the same thing [hopeless and fearful]. I learned to give people advice and help, so they don’t have to feel the same thing that I went through. (F)

Category 3: Transitions that Facilitate Growth

Transactions that facilitate growth refer to factors that are significant in helping them grow from trauma. There are three emerging themes in this category (i.e., moving from fear to courage, modifying priorities, and opening to new experiences).

First Theme: Moving from Fear to Courage

Sixty-six percent of participants (8 out of 12) reported this change. Fear is a prime emotion involved in trauma and traumatic experience, and it plays a role in PTSD by triggering mind and body to avoid certain feared situations/persons that are a reminder of the trauma (Morey et al., 2015). This theme suggests that the increased personal strength in one’s ability to overcome future adversity may stem from the conscious shift from fear to courage among this sample. This shift appears to be highly relevant to the Cambodian population and the PTSD-idiom of broken courage (baksbat; Chhim, 2013). Some relevant quotes from the qualitative sample include:

It made me more brave after the loss. (F)

I learned that even I’m look stronger, but once in a fear events or frightened events, I’m a bit of a coward. But, with the encouragement of my friends and family, I’ll evolve to stand up, to be strong. (M)

Actually when I first encountered that event, I felt very frightened, covered, and just, scared (laughs). I didn’t move anything, but after that it taught me a lot about being courageous. (F)

I am not fearful now, but I’m just more cautious with what I do. (F)

I became more courageous. I mean, it didn’t really impact my goal, it just made me more conscious about something that happened. (F)

Second Theme: Modifying Priorities

Fifty-eight percent of the participants (7 out of 12) stated that the way they value things in life has been different from before the stressful event. This shifting in priorities has been documented as an important change after trauma among those who experience growth. Changed philosophy of life, however small, is a highlighted element in Calhoun and Tedeschi’s (1996) model. Shifts in priorities are often considered the outcome of trauma that facilitates growth in PTG among cancer patients (Cordova, Cunningham, Carlson, & Andrykowski, 2001; Sears, Stanton, & Danoff-

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Burg, 2003; Widows, Jacobsen, Booth-Jones, & Fields, 2005). This seems to be congruent with this present study’s participants, who reported that after the stressful life experience, they realized what is more important and meaningful in life that they had before taken for granted. With regards to the modifying priorities theme, some illustrative quotes from the qualitative sample include:

at first I wanted to go as far as possible, but right now when I learned about problems with my parents I don’t want to go that far, I want to be with them more, and before, all it means to me to be successful in life was to be successful academically and with my career, but right now it comes to both- family and career. (M)

Before, I focused on other people and what they think, but now I’m focusing on my goals and on what I want to accomplish. (F)

Third Theme: Opening to New Experiences

Ninety-nine percent of the participants (11 out of 12) reported that they became more open to new experiences in life. A study of the Big Five personality traits and PTG found that people who are more open to new experiences appear to be more likely to benefit from PTG (Almedon, 2005; Tedeschi & Calhoun, 2004). These studies suggest that the openness to new experiences may enable people to be more likely to seek social support, search for necessary and adaptive information, and cognitively process the information in helping them cope, find meaning, and thrive after trauma.

This speculation was supported by a more recent study on PTG and coping, which found that the appreciation of life and the new possibilities of PTGI subscales showed positive associations with six adaptive coping strategies (active coping, planning, positive reframing, turning to religion, using emotional and instrumental support) (Alexander & Oesterreich, 2013). Quotes that relate to the opening to new experience theme include the following examples from the qualitative sample:

Because I see things differently, before…I used to be really closed minded about things, but after that, I actually see things more wide and clear. (F)

More cautious to new experiences with new people but more open to new experiences in general. Yeah. (F)

It helped me be more open to people and new things. (F)

In sum, three emerging themes that support the category of transitions that facilitate growth after trauma in terms of Tedeschi and Calhoun’s (1996, 2004) model were: (1) moving from fear to courage, (2) modifying priorities, and (3) opening to new experiences.

Category 4: The Role of Religion/Spirituality

This category entails responses that detail the role of religion and spirituality on positive changes as a result of trauma. Two themes emerged to support this category: (1) a shift in religious/spiritual understanding and (2) a change in the role of karma.

First Theme: Shift in Religious and Spiritual Understanding Seventy-five percent of participants (9 out of 12) reported that their religious beliefs decreased after trauma and/or played no role in their trauma and recovery to begin with. Sixty-six percent of participants’ responses (8 out of 12) may potentially be understood within the realm of increased spirituality through feeling more connected with others and increasing personal faith in accepting and overcoming life stress. Discussion: Ethics in Cross-Cultural Research

Religion and spirituality have played a significant role since the conception of the term “PTG” (Shaw, Joseph, & Linley, 2005). Research, however, has shown different results when it comes to its negative or positive role on PTG. While religious coping may help explain increased PTG after trauma (Schultz, Tallman, & Altmaier, 2010), there are also studies suggesting poor mental health outcomes associated with negative religious coping and with religious rigidity (Chan & Rhodes, 2013; Harrison et al., 2001; Pargament, Smith, Koenig, & Perez, 1998). These findings suggest that it may not be religion itself, but rather it is the positive use of religion and openness to changes in a person’s religious belief and spirituality that matter more in terms of PTG (Calhoun, Cann, Tedeschi, & McMillan, 2000). One study described spiritual growth as stronger spiritual orientation related to worldview, goals, relationships with others, and sense of self, dimensions which are positively related to PTG (Cole et al., 2008). Exemplary quotes for this theme include:

Having good friends and family of course, and yeah being able to spend time with them, you know, especially after a long and tiring day at school you know, go grab something to eat. (M)

Just that you know sometimes things do happen for a reason and maybe in the long run things will play out the you know the way they are meant to play out so. You don’t always get what you want but that’s for a reason. (F)

But my faith in religion has been decreasing ever, ever…the older I get the lesser faith I have in religion,” “I learned that myself is pretty strong. Like that I’m gonna face in life, that’s a way for me. After that event, when I also experience like harsh things in life after that I’m not as devastated as the first time cause I know it’s just something that I can overcome. (M)

Second Theme: Change in the Role of Karma The majority of the participants (75 percent) reported that they did not believe that karma played a role in their suffering and/or their recovery. A few of the participants (33 percent or 3 out of 12) shared that they now see karma as a guide for their future actions by believing that their future is determined by their own actions. When discussing karma, one participant stated, “If I want to succeed or do something, I can do it myself.” Others also expressed complex views of karma:

I try my best to do good, but I mean, like, it doesn’t necessarily mean you get any good. So … yeah. But I keep on doing it anyway; maybe there’s a part of me that believes it. (F)

I don’t know if it will or not, but if I have a choice, I wouldn’t want it to because I want to make my own choices in life. I don’t want something that has already been set up by, uh super natural something like that, that will gonna happen even if I don’t want it to happen; I don’t believe in that. I believe I always have a choice. (M)

I don’t really believe in karma. No, I mean I believe in karma, but when I’m in my hard times, I don’t really think about karma or anything because I am thinking about ways to solve it. (F)

The concept of karma is an essential one to explore, as it is a central component in Khmer Buddhism, referring to the cause-effect of one’s actions, and that one deserves things that happen to them because of one’s past actions, including in past lives (Smith-Hefner, 1999). After the atrocities of the Khmer Rouge, many studies have attempted to understand the role of karma in individuals’ healing and explanations for life events (e.g., Coggan, 2015; Harris, 2008; Ratliff, 1997). Some found that Khmer people stray from using the traditional way of understanding karma in their healing journey (Ledgerwood, Ebihara, & Mortland, 1994). The finding of this theme may suggest that an example of these shifts is a shift of the focus of Khmer Karma from past actions to present actions to determine future results. Discussion: Ethics in Cross-Cultural Research

CONCLUSION

In conclusion, data reveal that participants developed a maturing perspective, including a sense of increased personal strength, and a shifting from a powerless to an empowered sense of identity. In addition, data indicate increased and enriched connections with others, and an activated desire to help others. Finally, connection to an ability to find meaning in suffering in a future-oriented manner aided PTG after life hardships. Such data help evaluate assumptions from the existing cross-cultural literature on PTG—such as the assumption that PTG is universally experienced—that have been difficult to evaluate, given the preexisting state of information, notably the lack of data on this issue with a Cambodian sample. In particular, the Cambodian data show that many features of the PTG model described with Western samples are confirmed by the Cambodian data. These data are also important as help-seeking behaviors and options for most Cambodians differ from behaviors and options of many needing similar help in the United States and other Western nations. For instance, when seeking help for mental health issues, 50 percent of a national Cambodian sample approached family, 28 percent monks, 24 percent a medium, and 21 percent traditional healers, but only 3.9 percent approached doctors and 24 percent a pharmacy (RUPP, 2012). In addition, psychiatric medications, even when and where available, are very expensive, a year’s supply often costing more than the annual salary of the average Cambodian (Rich, 2015). Understanding coping styles and PTG experiences in this sample thus may suggest interventions that are effective and feasible, given current local financial and service provider realities, and may serve as a caution to well-intentioned international groups who plan to simply attempt to apply Western models to the current situation in Cambodia.

The Cambodia data do largely support the model of PTG proposed by Tedeschi and Calhoun (1996; 2004) and which was examined in a number of studies with Western samples. The model and results carry potential significance for development of clinical interventions and applications. The findings help to enrich understanding of these issues by revealing more in-depth points of view than offered through use of only numeric questionnaires developed originally for use in Western nations. Such results provide particularly valuable information, given the extensive prevalence of exposure to traumatic events both in those who experienced the civil war in Cambodia and in younger participants in the contemporary Cambodia of today (RUPP, 2012). Unfortunately, the RUPP study (2012) did not examine PTG, but it did examine PTSD and trauma, finding similar scores between urban and rural populations. Discussion: Ethics in Cross-Cultural Research

One specifically local issue that merits detailed future study is the role of religion and spirituality (including karma) with respect to PTG in the Cambodian context. Given the tragic history of Buddhism during the Khmer Rouge era, when most of the monks were killed or driven out of the country, and many temples and libraries destroyed, it is likely that there are many unique features to the experience of religion and spirituality today in Cambodia, especially as religious and educational institutions reemerge. Since the present research utilized an urban sample, future research also should explore how PTG may manifest itself in rural Cambodian samples as well as nonstudent samples, as social support systems, financial and intellectual resources, and worldviews may

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differ in such groups. The present data may serve both current and future researchers well in terms of providing data on various contemporary subgroups in Cambodia (college students, employed, urban) that may be utilized to help evaluate why subgroups may vary or not vary with respect to traumatic experiences. Additionally, the present study is particularly valuable as it examines a subgroup of Cambodians that were born after the end of the Pol Pot era, yet who experienced traumatic events at similar rates as those who directly experienced the civil war in the 1970s (97 percent in the current sample of students, 92.3 percent for the RUPP (2012) sample that personally experienced the civil war). Future researchers may find it valuable to examine what is universal, or at least held in common by several groups, in the trauma experiences of these subgroups, and what may be more specific to a certain cohort and historical context. Discussion: Ethics in Cross-Cultural Research

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