Cambodia's dark past clouds minds

A young boy sits next to the body of former Khmer Rouge military chief Ta Mok after it was brought to the northern Cambodian city of Anlong Veng, July 22, 2006. Though only about a third of the 14 million Cambodians alive today lived through the Khmer Rouge, its dark legacy still affects the population at large. (Chor Sokunthea/Reuters)

One of the worst mental health crises in Asia gets precious little attention and money.

March 18, 2010
By Aubrey Belford
Special to GlobalPost

PHNOM PENH, Cambodia — Psychiatrist Sotheara Chhim has given more thought than most to the mental burdens carried by Cambodians.

Pointing to a glass of water on his table, he describes how the legacy of decades marred by war, genocide and enduring poverty still help push so many here over the edge.

“I think every Cambodian is like a glass carrying some water, meaning the traumatic past,” he said. “If more water is put in, the glass fills easier than an empty glass.”

In many ways Cambodia appears to have turned a corner from its dark past, with big cities booming and millions of foreign tourists visiting the country every year. A flood of foreign aid has even seen scourges such as HIV/AIDS finally under control and uneven progress made against poverty.

Cambodia, however, labors under the burden of one of Asia’s worst mental health crises, driven by the ghosts of its history and the stresses of living in a rapidly changing but still desperately deprived country. And unlike so many other problems in a country flooded with foreign NGOs and international organizations, the issue gets little outside attention, and precious little money.

Comprehensive figures are thin on the ground, but those that are out there point to a grim situation. A study by the Holland-based Transcultural Psychosocial Organization (TPO) found 35 percent of Cambodians suffer from some kind of psychiatric problem and 45 percent suffer from “psychosocial problems” — a broad term embracing everything from grief to stunted emotional development.

At the same time, the country suffers from a dearth of treatment. Only 1 percent of the government’s health budget goes to mental health and only 0.1 percent of the population access mental health services every year.

Cambodia is home to 14 million people, 5 million of whom are survivors of the 1975-1979 reign of the Khmer Rouge, in which up to 2 million died. For that whole population, there are only about 40 psychiatrists, and only around 10 of them outside of the capital.

The results can be seen in Cambodia’s impoverished villages, where the severely mentally ill are often found tethered and caged in hidden recesses beneath stilt houses.

Kevin Conroy, an American Catholic priest who teaches psychology at the Royal University of Phnom Penh, carries in his cell phone the photo of one such woman, a 45-year-old recently found north of the capital.

“It was the smell of urine, feces, all that stuff. That’s the part you don’t get from the picture, it’s the smell that’s there,” Conroy said.

“It sounds inhumane in some ways to people but, in a way, what other alternatives do the people have for somebody that’s having difficulties, screaming and running around and things like that? There’s not a treatment center for people like that,” he said.

Even when there is treatment, many Cambodians rarely seek it out, opting instead for temples and traditional healers.

“There’s a stigma in Cambodian society. If someone talks to a counselor or goes to a psychologist or psychiatrist, [then people say] ‘Oh he’s crazy, what’s wrong with him?’” said Sathya Pholy, a counselor at the Phnom Penh Counseling Center, a service run mostly by, and for, foreigners.

Apart from stigma there is also the fact that most Cambodians don’t see mental health through the prism of Western science. It’s a factor that cuts both ways, affecting both when and how Cambodians see themselves as sick and the effectiveness of treatments developed to deal with illnesses — from schizophrenia to depression — originally defined in a Western cultural context.

“[Cambodian culture’s conception of mental illness] 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,” Sathya Pholy said.

“Also, if you offended the spirits of the mountains or of the trees, then the spirit will try to get you back, have revenge, make you sick.”

Amid such a grim situation, most of the burden of treatment falls on foreign-funded NGOs. Even the government, which aims to train 10 new psychiatrists every year, freely admits it relies on foreign funding.

The global recession, and the relative obscurity of mental health issues, means much of that money is drying up. Sotheara Chhim, who runs TPO’s local affiliate doing mobile outreach in Cambodia’s villages, said funding cuts from donors including the Dutch government forced him to fire 50 staff members late last year.

“I think mental health gets less attention, gets left behind in Cambodia,” he said with visible exasperation.

“There is no funding, I think, I don’t know why. The government has no funding and not many donors are interested in mental health.

“If I try to get funding from donors to provide mental health services, no one will give it.”

Cambodia's long look backwards; doctors struggle to heal a troubled country

Cambodian mental health patients wait to see a doctor at a hospital in Phnom Penh, on 16 Aug. "I always have nightmares about being chased by something black, a shadow," says doctor Sotheara Chhim, describing the aftermath of peering into the dark places that most Cambodians are trying to forget.

PHNOM PENH (AFP) — "I always have nightmares about being chased by something black, a shadow," says doctor Sotheara Chhim, describing the aftermath of peering into the dark places most Cambodians are trying to forget.

"It is not something clear, but it is probably relevant to the Khmer Rouge," says Chhim, one of only 26 psychiatrists providing care for a rising tide of Cambodians who are no longer able to cope with the damage caused by the brutalities of the past.

"I listen to so many stories. I dream about being in a kind of trap, a cage," says Chhim, himself a survivor of the apocalypse that engulfed Cambodia in the late 1970s, explaining the personal toll exacted by confronting, again and again, other people's demons.

Chhim, who directs the Transcultural Psychosocial Organisation (TPO), one of the country's few mental health facilities, warns that worse could be yet to come as a genocide tribunal forces Khmer Rouge victims to re-live atrocities inflicted by the regime.

But the psychological fallout of the trials only highlights a much broader need for mental health services in one of the region's most traumatised countries.

"The incidents of mental illness are getting higher from year to year, but still a lot of psychological problems are not being cared for," says Dr Ka Sunbaunat, dean at the University of Health Sciences and director of the National Programme for Mental Health.

Some 30 percent of Cambodia's nearly 14 million people reportedly suffer from a debilitating mental condition -- from anxiety and chronic unexplained physical pain to unpredictable mood swings or sudden eruptions of rage.

Millions more are thought to be plagued by less profound problems, but the true extent of mental illness in Cambodia -- caused as much by today's crushing poverty, neglect and abuse as by past upheavals -- is unknown.

What is clear to Chhim and other healthcare providers is that Cambodia is woefully unprepared to address this issue, with one psychiatrist for every half a million people.

"At the government mental health clinics, one psychiatrists sees over 30 patients a day -- you would be exhausted. I can see only three or four a day in order to provide good care," he says.

As many as 100 people line up each day outside Phnom Penh's municipal referral clinic, where the government established a psychiatric ward two years ago, one of 61 now open throughout the country.

They wait for a chance to speak with the psychiatrist on duty, or perhaps to see one of a handful of medical residents drafted from the nearby university.

"Sometimes we have problems. With mental patients you have to spend time and when we're overcrowded like this there is not enough time," says Dr Chak Thida, walking briskly amidst the dozens of mostly middle-aged men and women arriving one recent morning at the clean and, for Cambodia, well-equipped clinic.

But even with facilities such as this, Chak Thida says, "we need more resources ... we need more psychological education for the public. People don't know that they are ill".

-- Cambodia's unwanted peace dividend --

A decade of peace following the country's long civil conflict has ironically led to an eruption of mental health problems, as Cambodians, freed from the daily traumas of war, have time for perhaps unwanted reflection, stirring sometimes devastating memories, doctors say.

"After the Khmer Rouge the trauma was still going on -- people were struggling to survive. Somehow even if they felt pain, they put it aside," Chhim says.

"For Cambodia the fighting stopped less than 10 years ago, so the people have just started getting on with their lives and that pain is starting to come back."

But many do not understand the cause of that pain, and a majority of mental health cases are often un-diagnosed or mis-treated.

As many as 80 percent of Cambodians going to see general practitioners are actually suffering from psychological trauma, Ka Sunbaunat explains.

"They don't believe they have psychiatric health problems -- they believe this is normal for everybody after the war," he says.

Doctors say they are battling ignorance or heavy social stigmas that often associate mental problems with witchcraft or sorcery.

"There is no recognition of mental health, most of the people we meet never come to us straight away -- they go to traditional healers, they think that their problems are caused by black magic," Chhim says.

Chhim's TPO is engaged in an ambitious public education campaign that he says reaches as many as 10,000 people a year.

The group trains traditional village authority figures such as monks to recognise the symptoms of mental trauma, and organises counselling sessions for alcoholics or victims of domestic violence. Substance abuse and physical attacks are the most common causes and affects of mental trauma today, Chhim says.

"To help people deal with trauma, a lot of things have to be involved, we need a holistic approach bringing in things like religion and social justice," he says.

"We are purely community-oriented. We train the stakeholders, especially the traditional healers, the monks, the nuns, those who help the people in the communities with their problems so that they are able to recognise these problems and provide support."

Ahead of the Khmer Rouge trials, TPO is preparing a campaign to deal specifically with mental issues that are expected to arise as a result of dredging up the blackest chapter in Cambodia's modern history.

Chhim says the group plans to distribute leaflets detailing the symptoms of post traumatic stress syndrome and other related illnesses, a well as provide counselling for those directly involved in the trials as witnesses.

"The tribunal can trigger memories," Chhim says. "The people who experienced these terrible events will (re-live) the experience when they hear about investigations or crimes. It will reactivate the traumatic memories."

Up to two million people died of starvation and overwork, or were executed by the communist Khmer Rouge which took over the country in 1975 and set about erasing modern Cambodia and trying to create an agrarian utopia in its place.

Millions were exiled to vast collective farms, while money, schools and religion were outlawed. The educated, including doctors, were systematically hunted down and killed.

Khmer Rouge leaders called the first year of their rule "Year Zero".

For most Cambodians it was simply the end of the world -- the fall of the regime in 1979 was followed almost 20 years of famine and conflict, the effects of which still echo today.

"Some people say the Khmer Rouge (regime) was so long ago that maybe the Cambodian people forgot," Chhim says. "But actually we don't forget. People have not had the chance to deal with this."

While some healthcare experts hope the trial will bring into sharp relief the failings of the current system, others are less optimistic.

"From the beginning people believed the tribunal had some miraculous healing power, when in fact it does not," says Ka Sunbaunat.

"My parents died. After a year of trial my parents remain dead -- how can I feel better? We should think about what Cambodian people are really suffering from.

"People who are victims (of the Khmer Rouge) suffer more from the poverty and hardship in their daily lives."

Mental Health Phenomenon Among Oversea Cambodians

15-03-2007
Source : Center for Social Development
By : Pongsathya Pholy

There are approximately 30,000 Cambodian Americans who called Lowell, Massachusetts their home. It is the third largest of Cambodians concentration outside of Cambodia and Long Beach, CA. Overall, there are approximately 200,000 Cambodians residing in the U.S. (U.S. Census Bureau, 2000). It has been over 30 years since the Cambodian people went through one of the worse human tragedy under the Khmer Rouge Regime. Approximately, 2 million Cambodians and about a quarter of the Cambodian population were perished.

The process of healing and national reconciliation for the Cambodian people has been an unusually slow. There are a number of reasons that contribute to the challenges of getting the Cambodian people to get on their feet again. Presently, in the U.S., the lack of human resources continues to be a problem. The majority of Cambodians are still illiterate both in Khmer and in English. Comparatively to other ethnic minority groups in the U.S., Cambodian Americans still continue to struggle when it comes to socioeconomic and sociopolitical.

Many Cambodians are headed by single-parent household. A large number of Cambodian Americans are still dependence on government financial assistance. The rates of unemployment are high due to insufficient of needed skills and expertise. Many Cambodians are working at minimum wages ($5-$8/hr) depending on their location. There are alarming rates of domestic violence, gambling, school dropout, and youth delinquency. Many Cambodians are addicted to licit and illicit substances such as alcohol and/or opiate.

So what is the phenomenon behind all of these challenges and struggles among the Cambodian people oversea? As mentioned above, the process of healing from the physical and psychological trauma has been rather sluggish. According to many studies, approximately 50 percent of Cambodian Americans still manifested symptoms of psychological trauma such as posttraumatic stress disorder (PTSD), major depression, and conversion disorder. Thus, many Cambodians do not seek psychological services. And access to competence mental health providers and psychological services proved difficult. Furthermore, Cambodians do not comprehend the concept of psychological trauma nor seeking psychotherapy. And due to the culture of submission and concern of losing face for admitting their problems, prevent many Cambodians from seeking health and mental health services.

Additionally, many Cambodians are facing daily discrimination from the mainstream community.

Extracted from: Searching Bulletin of the Center for Social Development, Vol.13, # 134, November-December 2006, p16.