The Provision of Psychiatric Care in a Post-Conflict Setting

The multitude of mental health problems caused by living on the verge of death and starvation--both during the khmer rouge and afterwards during the vietnamese occupation--are tremendous and overwhelming. So many khmer still react to things with base emotions, and this is a central reason for sudden fits of violent rage, acid attacks, alcoholism, etc.

I've met and worked with both Dr Chak Thida and Prof. Ka Sunbonat. Both are quite dedicated doctors who have taken the enormous responsibility of organizing the National Mental Health Programme and providing therapy to even just a few of the hundreds of thousands (if not millions) who could greatly benefit from such therapy.

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

by Seth MeixnerTue Sep 4, 9:30 AM ET

"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."