From depression to addiction and anxiety, it’s all too easy for it to seem that life is slipping out of control. Ellie Dyer looks at the state of Cambodia’s 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 York’s 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 Cambodia’s 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 Cambodia’s 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 RUPP’s 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”.

mental-Health-Cambodia-2Trauma 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 people’s 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 out-patient 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 hospital’s 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 don’t 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, it’s quite new. I think that, so far… they still [do] not understand what psychology is,” she says. “There’s 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 expat’s 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 it’s kind of like a playground that they get lost in. The sandbox swallows them up, so to speak,” he says.

mental-Health-Cambodia-3“Some go through the phase and come out unscathed, and that’s 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 don’t 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 they’re in control. You remind them that ‘we’re your friends, and we care about you. You might not see this, but we’ve noticed lately that you’re 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 don’t often know whether what you’re 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 hasn’t 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, TPO’s executive director, at a project launch attended by many members from Cambodia’s psychological community.

“There is huge work that needs to be done,” he tells the audience. “So a small group of mental health professionals — I don’t think you are able to deal with all the work… you will be burnt out with all the problems.”

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