Analysis: What ails Cambodia's mental health system?

Skulls on display at Tuol Sleng Genocide Museum, where more than 12,000 prisoners were interrogated, tortured and killed (Photo: David Longstreath/IRIN)

PHNOM PENH, 12 March 2012 (IRIN) - In Cambodia, the psychological fallout from one of the world's heaviest bombing campaigns, genocide and two decades of conflict, coupled with chronic poverty, have left a heavy mental health burden that medical services are ill-equipped to handle, say experts.

Lack of funding, human resources, national vision and leadership, as well as poor coordination of groups working in mental health, are among the biggest challenges.

Sareth Mon, 58, takes anti-anxiety medication regularly, obtained from the public hospital Preah Kossomak in the capital, Phnom Penh.

Soon after the Khmer Rouge took power in 1975, Sareth's one-month-old baby died in her arms as she was no longer able to breastfeed. Her three-year-old daughter died from illness. "There was just no medicine available then," she told IRIN. "I brought them into this world, but could not protect them long enough to keep them alive."

Mental Health Crisis Strains Cambodia

Cambodian psychiatrist Sotheara Chhim, from non-profit group the Transcultural Psychosocial Organization - Cambodia (Photo: VOA - A. Belford)

Aubrey Belford, VOA
Kampot, Cambodia 15 April 2010

Cambodia is a country with a more traumatic past than most. Recent decades have seen civil war, followed by genocide and more civil war. Despite a growing economy and rapid development, mental health workers say the psychological scars have yet to heal.

Cambodia suffers from high rates of mental illness, and very little treatment.

Psychiatrist Sotheara Chhim, who heads the Cambodia office of Dutch aid group, the Transcultural Psychosocial Organization, or TPO, says the country's dark past bubbles up in an exceptionally high rate of mental illness.

"In my opinion I think the past plays a very important role in attributing to the problem…. I think every Cambodian is like a glass carrying some water, meaning the traumatic past. If more water is put in, the glass fills easier than an empty glass," says Chhim.

A study by TPO found 35 percent of Cambodians suffer from some kind of psychiatric problem, from mild disturbance to full-blown illness.

The legacy of past conflict means more than a quarter of the population shows signs of post-traumatic stress disorder, and over 10 percent suffer major depression, even though most of the population is too young to remember the darkest years.

But there is little treatment. Only one percent of the government's health budget goes to mental health. For a population of 14 million people, there are about 40 psychiatrists, and only around 10 of them outside the capital Phnom Penh.

At the mental health ward at a hospital in the southern town of Kampot, Dr. Kim Vutha complains of a shortage of funds and medications.

He says Cambodians, particularly in rural areas, usually seek out mainstream treatment as a last resort after trying temples and traditional healers. In villages, it is quite common to find the seriously ill chained to posts or kept in makeshift cages.

Satya Pholy, a counselor in Phnom Penh, says that despite the prevalence of mental illness, many Cambodians simply do not want to acknowledge the problem.

"There's a stigma in Cambodian society," he said. "If someone talks to a counselor or goes to a psychologist or psychiatrist, 'Oh he's crazy, what's wrong with him?'"

He says traditional culture often plays a role in how mental illness is address.

"It goes back to animism and Buddhism and Hinduism, where most illnesses come from the unbalance of the wind, the soil, the fire and the water. Also, if you offended the spirits of the mountains or of the trees, you know, then the spirit will try to get you back, have revenge, make you sick," he explains.

Foreign aid organizations can not fill the gap. Sotheara Chhim says the economic crisis has meant less money for his organization, which travels around the country doing mental health outreach.

"I think mental health gets less attention, left behind in Cambodia. [The] Ministry of Health used to say keep saying mental health is one of the priorities but I don't think it's a priority," he said.

Sotheara says donor cuts forced him to fire 50 employees late last year.

Among the small government efforts to deal with the crisis, 10 new psychiatrists are being trained every year. But people working in the field, such as Sotheara, say this is still not enough.

‘Jungle Girl’ settles into family life [-She's back with her family after disappearing for a few days]

Rochom P'nhieng was fed by her mother when she was first discrovered in January 2007
Rochom P'nhieng (R) stands next to her mother (L) in this photo from January 2007

Rochom P’nhieng case highlights need for improved mental health services

BY CAT BARTON AND CHEANG SOKHA
Phnom Penh Post, Issue 17 / 03, February 8 - 21, 2008

No sooner had the battalions of Western press corps emblazoned long-lost Rochom P’nhieng onto the world’s consciousness, than they forgot her.

The days after a naked, emaciated P’nhieng wandered back into civilization on January 13 last year, having apparently spent 18 years living in the jungle, saw a blitzkrieg of foreign reporters and film crews descend on her village. Health professionals from across the world were quick to pontificate on how best to help Cambodia’s own “feral child.”

But a year on and the dusty village of Phsom in Ratanakkiri’s remote O’Yadao district is quiet. P’nhieng has now spent a year living with the family that claimed her as their long-lost daughter – although no DNA tests have been conducted – and has been forgotten by the media and health care professionals who so eagerly offered their services when she first emerged from the jungle.

“Since she came back no one has paid any attention to her,” said her father, Sal Lou.

“No government or hospital officials have come to see how she is doing.”

One person who has been paying attention to P’nhieng is Hector Rifa, a professor of behavioral research methods who works with the Spanish NGO Psychologists without Borders (PSFA). For ethical reasons, Rifa declined to discuss the details of P’nhieng’s case.

But according to her family, P’nhieng is doing well, all things considered. When she emerged from the jungle last year she was naked, malnourished and mute. Socialization has been slow but steady, Sal said.

“She can wear clothes now and she doesn’t try to take them off,” he said. “She eats a lot of rice, she has a big plate of it with her meals, but still she doesn’t speak.”

In the first few months after she returned, P’nhieng would take off the clothes her family gave her and try and leave the house. She escaped successfully once, but wandered back into the village several days later.

Now, she is content to stay at the house and has settled back into family life. P’nhieng eats her meals with her family – she has learned to use cutlery, her father said – and then goes out to the garden.

“She sits in her spot under the cashew tree,” said Sal. “She sits on her own – laughing, waving, humming or singing bits of tune.”

P’nhieng may not be able to speak but she is no longer entirely silent. Her parents say she sometimes keeps them awake at night singing or laughing to herself.

P’nhieng was lost aged nine when herding cows near the edge of the jungle in 1989. Her father was in Mondulkiri when she vanished. After two or three days, the family gave up hope of her returning.

“She was very young and we really didn’t believe that she would have survived until she came back last year,” he said. “Normally, after a few days of disappearing in the jungle they die.”

On February 14, 2008, P’nhieng is in the family garden, wearing a blue sarong and an orange pajama top. Her hair has been bluntly cut into a ragged bob. She sits on the ground between a barbwire fence and a set of wooden shelves.

She is aware of those around her – she responds with seeming pleasure when her mother brings her a small bunch of bananas and her eyes follow new arrivals with focused intensity – but her continued silence is worrying her family.

“I still believe the jungle spirits are inside her and they harm her and stop her from speaking out,” said Sal.

He is trying to raise money to cover the cost of taking his daughter to a spirit healer in Mondulkiri province who could help exorcise the jungle spirits from his daughter. The trip will cost upwards of $1000, he estimates.

Rifa declined to comment on reasons why P'nhieng remains mute a year after her return from the jungle. Like many professional psychologists, Rifa dislikes the careless use of psychological labels or people “playing psychologist,” both of which, he said, can “destroy the life of anybody.”

He cautioned the Post against contributing to “the general audience think[ing] that anybody can make psychological diagnosis by themselves,” and forcefully discouraged working on the blind assumption that P’nhieng was suffering from mental health problems.

When asked about P’nhieng’s progress, he said that “we have to work always thinking that everything is possible.”

After a year of proper food, P’nhieng has gained a noticeable amount of weight and is, according to the director of the O’Yadao operational district, Tak Bunthak, in good physical health.

“She has no physical health problems as she came in for a check up at the health center and she was fine,” he told the Post in Banlung on February 15. “We gave her some vitamins but I don’t think her current problems relate to malnutrition.”

Bunthak said that, in his opinion, if P’nhieng had faced severe malnutrition over the whole 18 years she was gone, “she would not have grown up properly or been able to stand, but when my staff inspected her they said she was fine. She is normal physically but I believe she has some mental health problems.”

But determining whether P’nhieng has mental health problems is nearly impossible in O’Yadao district because the health centers there have “no capacity” to diagnose or deal with mental health problems, Bunthak said. In Ratanakkiri province there is only one doctor and one nurse – both of whom received three months of training in Phnom Penh on “psychological issues” – to deal with the population’s mental health problems.

“We lack the buildings, the staff, the medicine,” Bunthak said. “We suspect some of the cases we see at the hospital are people suffering from moderate mental health problems, they could be treated with medicine and a little care but we can’t help them as we have no capacity here, and their relatives don’t know how to care for them either.”

The director of Banlung provincial hospital, Hing Pan Sokunthea, agreed that a lack of capacity prevented the province providing adequate levels of mental health care.

Although there is no way of knowing exactly what happened to P’nhieng during the 18 years she spent away from her family nor whether she is currently afflicted with mental health problems, her case does draw attention to the lack of mental health care capacity in Cambodia’s provinces, particularly remote regions such as O’Yadao, about three hours’ drive from Banlung.

“Mental health is not a priority in developing countries,” said Rifa, the psychologist.

“There are many provinces in Cambodia that are not attended. The government of Cambodia, through the National Mental Health Program, is making a big and successful effort but not in the province of Ratanakkiri,” he said.

PSFA, in cooperation with the Spanish Agency of Cooperation for Development, is starting a new project titled the Promotion of the Psycho-social Wellbeing Among the Indigenous Women of Cambodia, starting in Ratanakkiri province.

“We expect a better situation [in terms of mental health care] in the very near future, working side by side with the Ministry of Health,” Rifa said.

In the meantime, the burden of care for P’nhieng has fallen upon her family. They are spending more on food and have lost one income as Sal, her father, no longer goes out to work so he can stay home and watch his daughter.

“I have to look after her as a bodyguard looks after a high ranking official. I follow her all the time and I am very worried that if I leave her she will wander off on her own and not return like before,” he said.

“Even though we are now in difficulties because of looking after her I cannot throw her away – she is my daughter. She got lost when she was nine and she lived in the jungle for 18 years in great difficulty. Now I have to look after her.”