As a boy in Battambang province, Chhit Sophal watched as Khmer Rouge soldiers rounded up villagers to witness an execution.
“I know many people who were about my age. We experienced a lot of trauma,” said Chhit Sophal, now a program assistant for the National Mental Health Program. “The man died, and we watched them chop his chest. It was very cruel.”
Chhit Sophal, part of a generation who experienced three decades of war, genocide and civil unrest, says he has kept in touch with people from his village, and no one has shown symptoms of post-traumatic stress disorder. Not yet, at least.
But a study conducted by the Transcultural Psychosocial Organization Cambodia estimates 2 out of 5 Cambodians suffer from some form of stress-related mental disorder, 28 percent of which have PTSD, said Chhim Sotheara, managing director of TPO.
Triggered by a traumatic event, PTSD usually manifests itself in symptoms of anxiety, fear, nightmares and lack of sleep, he said. But Chhit Sophal says the TPO figure might be too high, adding that only about 2 percent of patients treated at national facilities are diagnosed with the disorder, while more than two-thirds of patients are diagnosed with depression and anxiety.
Chhim Sotheara says that the disjoint in PTSD diagnosis is because many patients “mask their [PTSD] with depression and anxiety.”
Scott Cowcher, NMHP supervisor, agrees that sometimes the current system forces mental health services to look at “what’s the problem right now?” Busy hospitals sometimes force health workers to “deal with the immediate issue and backtrack from there,” said Cowcher.
Chhit Sophal is one of only 20 psychiatrists in Cambodia. Later this week, six more doctors and 11 psychiatric nurses will graduate, bringing the number of psychiatrists to 26, and the total number of nurses to 40.
A Norwegian-funded program, implemented by the International Organization for Migration, trains doctors and nurses in clinical practice, psychiatric theory, medicinal treatment, psychotherapy and counseling, said Andy Siegman, IOM resources management officer.
In Cambodia, treatment from psychiatrists is currently available in five provinces, and 11 other provinces offer services from general practitioners who have basic knowledge of mental illness. But most of these services are limited to cities, said Chhit Sophal.
NGOs such as Social Services of Cambodia offer a “psychosocial” approach to mental health care. Trained counselors visit more than 200 patients for regular sessions at their homes in villages in Kompong Speu and Oddar Meanchey provinces.
Ellen Minotti, director of SSC, says the group trains counselors to provide services to people with issues like relationship distress and substance abuse.
Minotti says social issues from the Khmer Rouge era might influence any number of psychosocial disorders, but she warns that mental illness in Cambodia can’t be attributed to Pol Pot alone.
“[He] adds a special dimension to mental illness in Cambodia,” she says, “but we can’t measure that very well.”
Minotti points out that many Cambodians do not want to talk about past traumas.
“People don’t like to wake up the tiger,” she said.
Counselors from SSC spend their first week of training coming to terms with their own emotional health and discussing issues that might affect their ability to advise patients.
In 2002, both Minotti and Chhim Sotheara worked with the Ministry of Health to develop an ambitious 20-year National Health Care Plan. The plan’s opening pages describe the psychological wounds of a nation that has experienced high levels of stress and personal as well as collective trauma.
So far, the plan has not been approved or implemented, said Chhit Sophal. “Our master plan is very long; in some parts of the plan, it does not fit the Ministry of Health,” said Chhit Sophal. “We wanted to train social workers, but the Ministry of Health does not have that kind of funding.”