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.”