Caged and chained:

Cambodia's mentally ill video

FRIDAY 19 DECEMBER 2014
In a country where mental illness is blamed on bad luck, karma and ghosts,
sufferers are often shackled and afraid - forced to live in the shadows.
Warning: this film contains disturbing images.

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MENTAL HEALTH CARE

CAMBODIA

ASIALIFE JANUARY 2, 2013

From depression to addiction and anxiety, its all

too easy for it to seem that life is slipping out of control. Ellie
Dyer looks at the state of Cambodias mental health system and
discovers what is available for those seeking help. Photography
by Conor Wall.
Fast forward to 2030 and the World Health Organisation forecasts that depression will be the
single largest contributor to the burden of disease worldwide.

Despite such warnings and the estimated 450 million people currently suffering from mental
health disorders, the subject remains shrouded in stigma in many societies including Cambodia,
where some people with severe mental health problems are locked in cages or chained up by
their families.
Mental health is like leprosy 2,000 years ago. Everyone is scared of it, one health practitioner
is quoted as saying in a 2012 study on Cambodian mental health, published by two experts
from the Leitner Centre for International Law and Justice at New Yorks Fordham Law School.
Such issues which can include major psychiatric disorders such as schizophrenia and bipolar
disorder, psychosocial problems such as mild anxiety disorders, and also intellectual disabilities
caused by conditions such as Down Syndrome can touch us all. A local expert estimates that
at least five percent of people suffer from a psychological problem.
Such concerns are of particular importance to Cambodia which, due to a combination of
factors, is seen as a country that contains significant risk factors for poor mental health.
A recent survey by the Royal University of Phnom Penh (RUPP) estimates that Cambodias
suicide rate was 42.35 per 100,000 people in 2011, compared to a worldwide average of around
16. Anxiety and depression are also measured at well above average.
Many point to Cambodias traumatic history as a factor. An entire generation was touched by
decades of unrest, especially during the brutal Khmer Rouge regime of 1975 to 1979, during
which up to two million people died. Numerous studies document high levels of Post Traumatic
Stress Disorder in the country, and experts say trauma can trickle down through generations.
Everyone had family before the war, and after the war everyone lost a member they did not
give us enough to eat, they pushed us to work like a prisoner they killed people in front of
you, and you became traumatised, explains Sek Sisokhom, a regime survivor who now heads
RUPPs psychology department.
Those who were suffering from that time, now they are mothers and parents. They did not get
any treatment, and issues continue from them to the young generation.
Using attachment theory as an example, she says those who experienced food shortages during
the regime may still save meat for fear that
supplies will run out. Families may also want
their children to stay at home, due to concerns
over safety, which can make the young feel as
if they have no freedom.
Trauma is not the only influence on mental
health. A 2011 essay by international experts
and Youk Chhang, from the Documentation
Centre of Cambodia research institute, points
out that the current life conditions of most of
the people with mental health problems in
Cambodia are not conducive to psychological
recovery.
Domestic violence and substance abuse
continue to be factors in peoples day-to-day
lives, while some argue poverty also has an
effect.
Common mental disorders are about twice as

frequent among the poor as among the rich, explains World Health Organisation representative
Steven Iddings to a recent psychology conference in Phnom Penh. Evidence indicates that
depression is 1.5 to 2 times more prevalent among the low income groups of a population.
Despite the risk factors, psychological and psychiatric services remain limited in Cambodia. In
2010, just 35 trained psychiatrists and 45 psychiatric nurses were catering for the entire
country, according to the Leitner report.
Though Cambodia has two psychiatric in-patient units in Phnom Penh and additional outpatient services, mental health workers are still overloaded with patients. Dr Chak Thida, of the
Khmer-Soviet Friendship Hospital, was quoted in the report as saying that the hospitals mental
health services see 200 to 300 people a morning, which averages at 30 to 40 patients per doctor
per day.
A lack of knowledge can also affect potential patients. Some dont know where to go and Sek
says people can turn to traditional healers, relatives, monks and pharmacists before considering
mental health services.
Psychology for Cambodian people is quite young, its quite new. I think that, so far they
still [do] not understand what psychology is, she says. Theres a lot that needs to be done in
the future.
Without receiving the necessary support, families can quickly become overwhelmed, especially
when treatment options are limited and cases severe. Some believe that their loved ones are
possessed by bad spirits, studies indicate.
Health professionals, cited in the Leitner report, estimate that between 10 and 40 percent of
those suffering from severe mental disabilities are chained up or locked in cages. One mother
recalls that she had locked her daughter in a bamboo cage for several years before
professionals provided her treatment for psychosis.
Generally, in the community, people like my son are looked down on, called crazy, beaten, a
father of a mentally disabled child tells researchers.
Nevertheless, for locals and expats alike who are suffering from mental health issues or feel
their lives are spinning out of control, a range
of services are available.
One organisation offering psychological
services in Phnom Penh is Indigo. American
counsellor Boyd Bergeson says that his mostly
Western clients are commonly dealing with
issues such as anxiety, depression, money
management or former drug use. Phnom Penh
is also place where everything is available in
a higher concentration than in many expats
home countries.
This is kind of like the Las Vegas of Asia. A
lot of us had already gone through that phase in
our college years but [for] some Westerners,
this is their first stop and its kind of like a
playground that they get lost in. The sandbox
swallows them up, so to speak, he says.
Some go through the phase and come out

unscathed, and thats great. Other people get addicted to methamphetamines, other people get
addicted to prostitutes. Some people start beating their girlfriends, and it needs to be dealt
with.
Counselling can help, but if someone is not receptive to professional help, friends can consider
staging an intervention.
You dont want to surround the person and shine a spotlight in their face, Bergeson says. It
has to be done in a very peaceful, gentle approach where the person feels like theyre in
control. You remind them that were your friends, and we care about you. You might not see
this, but weve noticed lately that youre a little depressed, or been drinking a lot more than
usual, and we want to help you.
Support services born out of personal experiences have also been set up to deal with pressures
associated with working in isolated, challenging environments. It was such an experience in
Nanning, China, that sparked Australian Weh Yeoh to help found a pilot scheme to support
development workers, whose careers can involve living and working in remote locations.
The isolation is the one that gets to you, it gets to anybody really, and you feel that very
strongly. But also at work you dont often know whether what youre doing is right you
need someone to bounce ideas off, says the development worker, now based in Cambodia.
In a bid to help workers seeking similar support, he along with three counterparts and with
advice from a careers coach and a clinical psychologist runs a peer-coaching service through
an online forum called WhyDev. It matches up workers in the hope that the pairs can provide
emotional and professional support to one another via Skype, email or, if they are located close
by, face to face contact.
People are increasingly more willing to open up about talking about some of these issues, but
traditionally it hasnt always been the case, Yeoh says, emphasising that the service has
limitations and users can be referred on to counsellors. Having somebody who understands
what you are going through and maybe has experienced the same thing is invaluable.
And, as calls for increased mental health funding in Cambodia are made, programmes are also
underway to train people to provide mental support. RUPP offers masters and bachelor
programmes in psychology. Masters students need to work on 100 cases and write a thesis in
order to complete their programme.
NGOs are also branching out. Last month, the Transcultural Psychosocial Organisation
Cambodia (TPO), which offers counselling as well as psychological support to the Khmer
Rouge Tribunal, launched a new training scheme called Mental Health First Aid.
The pilot scheme will provide local health and Cambodian Red Cross volunteers with the
necessary knowledge to enable them to listen, assess, support and advise people who could be
suffering from psychological strain in the community, providing a front-line service for mental
health concerns.
We know that mental health professionals are lacking in every part of the world, and
Cambodia is one of the countries that is also lacking, explains Sotheara Chhim, TPOs
executive director, at a project launch attended by many members from Cambodias
psychological community.
There is huge work that needs to be done, he tells the audience. So a small group of mental
health professionals I dont think you are able to deal with all the work you will be burnt
out with all the problems.

See related article on mental health care on

AsiaLIFE HCMC