Mental health services in Cambodia

STARTTS counsellor, Meng Eang Thai fled from Cambodia with his father in 1979 due to the massive social disruptions occurring there at the time.

Almost 20 years later, Meng has revisited Cambodia accompanied by STARTTS sessional psychiatrist, Professor Derrick Silove. Together they visited a new mental health clinic in Siem Reap Hospital as independent observers for a Harvard University training program.

Meng discusses his recent experience in Cambodia in an interview with Helen Basili.

Q. What were your first impressions of Cambodia when you returned?

I’ve been influenced by the idea of democracy in the Western world so I was concerned that going back to Cambodia and seeing the lack of democracy and oppression could aggravate my feelings. Also, the connection with my past was something I had to be aware of. I wondered about my ability to adjust to the society.

When I first got there it touched my heart to be back in my homeland for the first time in 20 years. But it brought back some traumatising feelings in terms of leaving the during the reign of the Khmer Rouge and my time there as a student.

Apart from that, I felt happy to see that people have the freedom to move around. Certainly, I haven’t had much connection with local social and political issues but people gave the appearance of being able to move freely. I noticed there were soldiers present in the streets although they weren’t behaving in a threatening way.

Q. How has Cambodia changed in the 20 years since you left?

Compared to the period before 1970, before the war had started, it was like two different worlds. Cambodia was so peaceful then and the cities were so organised. But compared to when we left, which was a very traumatic period, and now, I think there has been some improvement in terms of standards of living.

The people have freedom to move around and start businesses and many of the schools have re-opened. The arts have been revived. There is a new wave of talent with painting, writing and all those things, which are a valuable asset to the culture. The temples have opened up again.

It has come to the point where they can regenerate and rebuild the damage done in the time of the Khmer Rouge. I have to stress very clearly though, that I have not explored the social structure or social policy in depth.

About 80% of schools have re-opened but they are in a deteriorated condition. It is still not much, because if you look at the education system, the students only go to school for half a day and half a day isn’t enough to study properly. Also the teachers don’t get paid properly. Not only the teachers, all professional people in the public service. It leads to the point where the people don’t see those professionals as having a value for society. They only see things that increase the economy as important. The economy is the dominant force in society.

In the long run there is a need for education and to rebuild a strong social structure.

Q. What was your purpose for going to Cambodia?

The purpose was for me to find out about the changes in the country but also to observe the new techniques of introducing primary mental health care to the community. My desire was to see how they deal with mental health issues because there is a huge need in Cambodia for mental health care and mental health services.

On this occasion we went to do an independent evaluation of the Harvard University training program for mental health workers. Harvard University in the United States has sponsored a program to train Cambodian G.Ps and counsellors to become the primary health care givers who can diagnose and treat the mental health problems of Cambodian people.

The training centre was located in Siem Reap, in the northern part of the country and the second group of G.Ps and counsellors were just completing their training. I was impressed with how the program fits in with the culture. It’s a crucial part of the program and treatment that a cultural component is included. They try as far as possible to integrate the beliefs of the locals in the program.

I stayed in Siem Reap for nine days. Every day we were involved in training at the clinic at Siem Reap hospital. We learnt about the work of the clinic and the work of the trainees when they get out in the field to work. We met with a Buddhist monk who is involved with the treatment program and we met with the patients themselves. We met with other organisations like the UNDP [United Nations Development Program] who are also involved.

Q. What did you learn about the service for torture and trauma survivors in Siem Reap?

I found that primary mental health care interventions are the best way to develop the treatment for torture and trauma survivors. Providing the basic knowledge and techniques to the G.Ps and counsellors appears to give them a lot of encouragement and confidence to develop appropriate ideas to adapt to their environment for further down the track. Following the training, they can assess their own needs and evaluate the first stage of their learning experience. I see it as very positive initiative.

I have been arguing with people to acknowledge that Cambodians have had the concept of counselling for a long, long time but most of the Western practitioners have disagreed. In Cambodia, the trainees came to me and said ‘we do have counselling in our culture’. I feel very good to know that I have some people who agree with me. We have to acknowledge that although the Cambodian idea of counselling is different from the Western tradition, it still exists. It’s a matter of integrating the two into one form.

Q. Who funds the service at Siem Reap?

The service is funded by US Aid through Harvard University. Part of the grant comes from Japan as well.

Q. How effective is the service at Siem Reap?

It is very effective indeed. There has been a high success rate in terms of patient recovery. Some patients went from a state of psychosis to the functional stage where they could go back to work and get along with their life. They did this with minimal medication.

Q. What sort of programs do they have for clients?

They use medication and counselling but also they look at the practical needs of clients. In Cambodia, when one member of the family falls ill the whole family is effected and the income of the family starts is reduced. In that sense, they work with a welfare program to supply food to the family of the sick person.

The UNDP is also involved and provides some career training and education after they recover. Attempts are made to place them in jobs or help them establish their own business.

Where necessary, a monk is involved to provide spiritual support. They really take a holistic approach.

Q. How many clients do they have?

Each counsellor has about 30 clients and there were eight counsellors. The clients are from all over Cambodia. Sometimes the counsellors go to the eastern parts of the country and do outreach.

The program has become well known to the local community. They do community development work such as providing education to the villages about mental health and treatment but they also try to encourage the traditional approach to treatment as well.

All the counsellors and doctors at the service are Cambodian. They were trained by a group from Harvard University. In that group of trainers there were two Cambodian people who now live in the US. The training program included guest speakers who spoke about topics like counselling intervention, medication and diagnosis. They have a year of training altogether.

The clinic has provided treatment to patients from remote regions of the country near the Vietnamese border. The patients come and stay for short periods of treatment from four to eight weeks.

Q. What were the most pressing needs of the Cambodian service?

What we found out from the doctors and the counsellors was that they need further advanced training in terms of professional development.

The counsellors also need more training on stress management otherwise they won’t be able to cope.

The medication they have over there is not the sort of medication that tends to be used in developed countries. It is not enough. They need more varieties of medication to make the treatment more effective.

They also need to have a follow-up team to work with doctors and monitor the person during treatment.

We would like to see this type of program included in the curriculum of the School of Medicine in Cambodia in the future. This would allow the new G.Ps that graduate from the School of Medicine to have an understanding of the mental health program and treatment. It could also assist the G.Ps to identify mental health problems at an early stage before they become too severe.