Cambodia’s Growing Mental Health Problem

Text by Dene-Hern Chen and Chan Muyhong
Photos by Kara Fox

Phnom Penh, Cambodia – Long Ratana was a teenager when the Khmer Rouge began its brutal regime. Assigned to work in a children’s unit, the 50-year-old remembers having to labour under dire conditions with little food. She remembers the verbal abuse heaped upon her by Khmer Rouge cadres. And she remembers looking down the barrel of a gun, convinced that she was going to die.

“I had a gun pointed straight at me when Khmer Rouge cadres caught me and my friend picking beans from a farm,” Ms. Ratana recounted. “It’s a crime [to forage for food without permission] at that time, but I was hungry.”

“That experience has stayed with me. It made me feel very inferior,” she said, explaining that this feeling seeped into her daily life. “I always felt like there was a weakness inside of me.”

15b credit Kara FoxLasting three years, eight months and 20 days, the Khmer Rouge’s brief reign left a devastating impact – approximately two million people were dead when it ended on January 7, 1979. About half were executed and buried in mass graves all over the country, while others starved under slave-like work conditions.

The survivors themselves bear unseen scars. For Ms. Ratana, her problems began manifesting in her 30s, when she found herself crippled with anxiety and depression, unable to care for her children. Desperate for relief, she sought help from Transcultural Psychosocial Organization (TPO), an NGO established in 1994 that provides mental health services and counselling to locals.

Its director, Dr. Chhim Sotheara, said that roughly 40 per cent of its patients suffer from depression and anxiety, while many others have more serious problems, like psychosis and schizophrenia. Besides its clinic work, TPO provides psychosocial support to victims and witnesses testifying in the Khmer Rouge tribunal, which was set up in 2006 to prosecute those most responsible for the regime’s crimes.

“When we start the tribunal, people’s memories will resurface, and some might be traumatised by the problems. They might have difficulty sleeping and concentrating and have more fear,” Dr. Sotheara said.

He added that TPO also does “testimonial therapy,” which allows victims barred from testifying in the tribunal to have a voice in public testimonial sessions that ends in a Buddhist blessing ceremony.

“The court only selects a few number of people who have hard evidence to testify,” he said. “That means those who have also been tortured but don’t have hard evidence cannot testify, meaning that their suffering is not acknowledged.”

Despite TPO’s work, it is unclear how long the path the recovery is. With little financial resources from the government, and no official study done to survey the prevalence of mental health issues, TPO and other mental health departments in Cambodia are severely underfunded, understaffed and overworked. Dr. Sotheara said there are currently about 50 psychiatrists in the whole country – “that’s about 0.3 psychiatrists for every 100,000 people,” he clarified – and with less than 1 per cent of the national health budget allocated towards this need, the problem will only get worse.

“There is no health without mental health, and when mental health is not good, it will affect the productivity of the people and the psyche of the nation,” Dr. Sotheara said. “This would be a problem for the future.”

At the Khmer Soviet Friendship Hospital – where the country’s first psychiatry services were established in 1994 – its mental health department is inundated daily with hundreds of patients. Dr. Yem Sobotra, director of the hospital’s department of mental health and substance abuse, believes that awareness may be growing, but there remains a lack of understanding in rural areas.

“In Cambodia, mental illness is a social stigma. They believe that having mental illness and seeking out services is like going to a crazy hospital,” Dr. Sobotra said. “Sometimes they believe that it is a spirit possessing a person, so they bring them to a monk or a traditional healer.”

15c credit Kara FoxDelaying services to people afflicted with serious problems, like schizophrenia and bi-polar disorders, can be dangerous, he said. “They might delay for a month or two months or three months in the community, and it causes [the afflicted] to harm themselves or to harm other people.”

Cambodians might also be more susceptible because of its recent Khmer Rouge past, though this connection is difficult to ascertain because there have been no studies done, Dr. Sobotra said.

“Behind all the social problems, all the money problems, all the family problems, [my patients] are also somewhat traumatised by the Pol Pot regime,” he said. “Yet there is no priority for mental health; there is only priority for HIV or TB.”

For those who have been able to accept they have a problem, seeking help can be life-changing. After five years working with TPO, Ms. Ratana said that she now knows she is a person of worth, and has since gotten a job as a manager at a resort in Kep province.

“When I first came, I couldn’t even talk, I just kept crying,” she said. “I felt like I was useless before, but now I know I can achieve things.”

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