Treating the Tormented : In an Asian Refugee Camp, Pilot Mental Health Program Seeks to Ease the Despair

On a hot and steamy night last November, as the muffled booms of artillery shells echoed in the distance, the pressures of life in this refugee camp turned one man into a monster.

Angered that his wife and 6-year-old daughter had gone for an evening walk against his wishes, Touch Chamleakana began drinking heavily. When they returned, he savagely attacked them with an ax. Both died instantly.

“A devil came into my head, it was magic,” said the brooding, 35-year-old Cambodian, as he sat manacled in a jail cell two days later. “I want my family back. But I do not want to live here anymore. This camp, it is not a normal place to live.”

Site 2, where Chamleakana and 145,000 other refugees live, is a bamboo slum ringed by barbed wire less than 2 miles from the front lines of a bloody civil war. It is a camp without hope, a place where even the strongest spirits can shatter.

Covering less than 4 square miles, Site 2 is the world’s largest Cambodian city outside of Phnom Penh. It has no electricity, fresh food or water supplies of its own. Police protection is minimal and there is no defense against the artillery shells launched by enemy troops.

Ever since the camp opened in 1985, large families have been crammed into rows of tiny huts that offer no privacy. Raw sewage runs in open ditches. Refugees, many of whom fled to the border expecting a better life, have little to do during the day and live on a diet of low-grade rice and canned fish supplied by the United Nations.

For the Khmer, as Cambodians are known, Site 2 has been a virtual prison.

But now, it is about to become a testing ground for the first-ever mental health program launched by the United Nations in a refugee camp. If successful, the program could become a model for other Cambodian border camps in Thailand and for U.N. hot spots throughout the world.

Proponents say the program will help Site 2 refugees, many of whom lost children and other family members to the murderous Khmer Rouge. Pol Pot and his henchmen slaughtered more than 1 million Cambodians in the 1975-79 genocide, and advocates say it would be inhumane not to provide counseling and support for the survivors.

But critics question whether any kind of mental health effort is possible in a filthy, overcrowded camp where residents fear for their lives.

“If you or I lived in Site 2, we would be crazy,” says Father Pierre Ceyrac, a missionary who has worked with the border Khmer since 1982. “There is no future here and there are no human rights here. There is only despair.”

In the last two years, camp residents like Chamleakana have begun cracking under the strain of long-term confinement. Murder, rape and assault are increasing, and the suicide rate has doubled, according to U.N. statistics.

Bandits from nearby villages break into the camp at night, hurling hand grenades at those who protest. Brothels and gambling dens attract thousands of men who have deserted their families. Many have taken second and third wives.

Camp officials are especially concerned about the children who have grown up in Site 2 and know little about their homeland. More than 53% of the population is under 14, and although many youngsters are enrolled in school, few can read or write. For those nearing adulthood, the future is bleak.

“In my heart, I am sad about living here,” says Kheama Oum, a 19-year-old girl who fled to the border with her parents in 1987. “I cannot get married, because this is a very bad place to raise children.”

Oum, whose two older sisters were murdered by the Khmer Rouge, journeyed 50 days on a path strewn with land mines to reach Site 2 and saw scores of dead bodies along the way.

“I still have bad dreams,” she says. “I cannot forget.”

In light of these problems, it is not surprising that thousands of camp residents are demoralized, and that many have developed profound emotional problems, says Andy Pendleton, senior camp officer for the United Nations Border Relief Organization (UNBRO), a branch of the United Nations that provides food and water to the residents of Site 2.

“You can’t escape the conclusion that a mental health crisis is at hand here, because people were not meant to live like this,” he says. “It’s time for the world to recognize that in this camp, mental health and human rights are as much of a problem as food, water and shelter.”

But change comes slowly to Site 2. Although it is controlled by the Thai government, the camp is administered internally by the Kampuchean People’s National Liberation Front, a U.S.-backed resistance group that is one of three factions fighting the Vietnam-backed Cambodian government.

Guerrilla leaders restrict refugees from leaving the site and have opposed efforts to move the camp farther away from the front lines. UNBRO officials privately estimate that no more than 20% of the residents support the resistance and that most would leave the camp if they could.

Yet that is an impossibility, given the Thai government’s refusal to classify the Khmer as refugees. Instead, they have been labeled “displaced persons,” a status that entitles them to only minimal standards of care and all but rules out their emigration to a third country.

Meanwhile, tensions continue to rise. During a recent week at Site 2, a 3-year-old girl was raped by a teen-age boy, according to UNBRO statistics. An 18-year-old girl hanged herself, after an argument with her mother. Bandits broke through the fence, plundered the homes of several residents and injured 19 innocent bystanders with hand grenades.

“The top priority at Site 2 should be making life safer for these people and enabling them to go home,” says Pendleton. “But something also has to be done to help them cope with the pressures of living here.”

For years, relief workers at Site 2 have been lobbying U.N. officials to provide mental health services, as part of an overall campaign to guarantee human rights. Although the camp has three medical hospitals and a clinic to deal with “depression” among Khmer refugees, there are no programs dealing specifically with psychiatric problems.

Thai and U.N. officials have delayed acting on such proposals, hoping that the Cambodian war would end and that the border camps could be closed. But action also has been delayed by the “uncomfortable link” between mental health and human rights issues, according to Roger Fordham, a Bangkok-based refugee specialist who coordinates relief groups working on the border.

“This (mental health) is a touchy matter, because it leads you to tough political questions,” he says. “Why isn’t the camp moved to a safer place, away from shelling? Why isn’t there a higher level of security?”

There are no easy answers, given the politics of the Cambodian situation. Thailand, for example, does not want a massive influx of Khmer and insists that refugees stay where they are. Guerrilla leaders frown on Westerners entering the camp after dark, when most of the crime takes place.

The United States and other Western nations have done little to challenge these policies, since they actively back the Cambodian resistance, a coalition that includes Site 2’s rebel leaders, former Prince Norodom Sihanouk and the Khmer Rouge. As a result, UNBRO officials say that their hands are tied and it would be difficult to move the refugees to another site.

Last October, however, the political logjam eased somewhat. After Paris peace talks collapsed among the various Cambodian factions, U.N. officials gave the green light for an experimental mental health program at Site 2.

The preliminary plan would blend Western psychiatrists and specially trained Khmer practitioners and focus on severely disturbed residents. Counseling also would be offered to those burdened by traumatic Khmer Rouge memories.

The impetus for the program came from several U.S. physicians, including Christopher Elias, a Seattle-based doctor who has spent many years working with the border Khmer, and Richard Mollica, a Harvard Medical School psychiatrist and Indochinese refugee expert.

Mollica, who runs a psychiatric clinic for Southeast Asians at St. Elizabeth’s Hospital in Boston, says the push for mental health services at Site 2 is a logical extension of the clinical work that he and other Cambodian specialists have been doing for years in the United States.

“In dealing with Khmer men and women, we see a population that has been exposed to extraordinary trauma, far more than the average person in our society,” he says. “It seemed obvious that we would find even greater unhappiness in a camp where people live in daily fear for their lives.”

Mollica and a team of experts visited Site 2 in 1988 and again last year to lay the groundwork. Although they did not compile firsthand data, the group conducted numerous interviews with Khmer officials and estimated that symptoms of hopelessness and despair may affect up to 85% of the camp population, with hundreds needing immediate care.

Cambodian women in particular were found to have deep anxieties about their safety and the well-being of their children, according to reports issued by the group under the aegis of the World Federation for Mental Health, a nonprofit, non-governmental organization.

A key recommendation was that camp officials improve security and move the refugees to a safer area. The study team plans another visit in April to gather data, and a final decision is expected this year by U.N. officials.

Mollica’s proposal has drawn a largely favorable response from Khmer medical officials at Site 2 and relief agencies. But others say the program may run into trouble because there is too great a gulf between Cambodian culture and Western psychiatry.

“I don’t know how you can get people who have suffered from Pol Pot to simply open up,” says Robert Brandts, a physician who has worked on the border since 1980. “I worked with a tough Khmer woman for six years before I learned that five of her children had been killed by the Khmer Rouge.”

Others say the U.N. should focus more on human rights issues.

“I just don’t think it’s possible to provide effective mental health services in the middle of a war zone,” says Mary Skully, a Connecticut-based psychiatric nurse who has worked with Cambodian refugees in the United States.

“Even the army takes its own people off the front lines when it offers them counseling. Until we provide more security for these people, the idea of mental health is beside the point. It may even be a hoax.”

Mollica acknowledges the criticism, but says his program deserves a chance, even if larger political goals are not immediately met.

“We may not be able to solve the human rights problem overnight, but that is no reason to let conditions at Site 2 fester,” he says. “If you’re bleeding badly, even a Band-Aid is better than nothing.”

When Khmer Rouge leaders were driven from power by Vietnam’s 1979 invasion of Cambodia, the world was stunned to learn of the genocide they had carried out. But their most lasting legacy may be the broken spirits of those Cambodians who somehow survived the killing fields.

For these people, much like the victims of Auschwitz, the weight of traumatic memory can be a lifelong burden, according to James Lavelle, a Boston-based social worker who is a member of Mollica’s team.

“What the Khmer Rouge did was abhorrent, and we in the West probably can’t imagine what it must be like to live through that kind of upheaval,” he says. “If you talk to people at Site 2, each one of them can tell a story that is so horrible, you may not even believe it the first time you hear it.”

Hem Soeurn, a 49-year-old Site 2 resident, is a case in point. On the surface, he seems to be at ease in his new life as an assistant director of the Khmer People’s Depression Relief Center. Sitting at a table in the quiet, bamboo building, he offers a visitor a cup of tea and smiles.

Along with his wife, Phaly Nuon, Soeurn and other refugees are trying to ease the mental tensions that plague their countrymen. The center, which opened in 1988, combines Western-style counseling with the traditional healing herbs that have been a part of Khmer culture for thousands of years.

Asked about his background, Soeurn tells a harrowing story. When the Khmer Rouge came to power, he was stripped of his job as an accountant with the Shell Oil Co. in Phnom Penh and thrown into jail. His Khmer Rouge guards beat him savagely with metal bars, sometimes for hours at a time.

During the next few weeks, Soeurn was told that his wife had been taken to a work camp, and he later learned two of his six children had been killed by the Khmer Rouge. From his prison cell, he saw scores of Cambodians slaughtered with axes and then dumped in mass graves.

Soeurn survived only because he was able to fix rice-cleaning machines, and he spent weeks in captivity before being released to a work camp. After the Vietnamese invasion, he was reunited with his family.

The story is told in a flat, dull monotone. But when the middle-aged man discusses his torture and the death of his children, he laughs.

That reaction is a troubling problem among camp residents, according to Svang Tor, a Pol Pot victim who works with Mollica’s team.

“When the Khmer Rouge took power, they turned Cambodians against each other, turned children against their families, and everyone was afraid to speak,” she said during a recent visit to Site 2.

“They created what we call Tiing Moong, or the dummy personality. Someone who has no emotions, no thoughts, someone who wants only to survive and would do whatever (his masters) asked.”

Today, the signs of Tiing Moong are evident throughout Site 2. Khmer refugees are isolated from one another and do not trust even close family members. When memories become unbearable, many of them laugh.

“The Cambodians have a saying that they have cried so much, they have no more tears. So they laugh,” says Pendleton. “The pain is something they try to suppress.”

Sometimes, it erupts in violence, as with Chamleakana. But for others, the traumas of Pol Pot and Site 2 produce nothing but silence. On a recent drive through the camp, Pendleton visited a man in his hut who had not spoken for one year.

Neighbors said that the 47-year-old former soldier, known only as Ghea, lost a leg when he stepped on a land mine in battle. The man seemed to be adjusting to life in the camp but was greatly embarrassed 13 months ago when a radio he had borrowed from a friend was stolen.

Social workers sensed his loss of face, a catastrophe in many Asian cultures, and replaced the radio. But Ghea was shattered, and he has not spoken a word since. He spends his days staring at the dirt floor, oblivious to the cries of his wife and children.

“That man needs psychiatric care, today,” says Pendleton as he leaves Ghea’s hut. “But every time somebody tries to take him to a hospital miles from here, he fights them off fiercely. We need some kind of care that could help him immediately, right in this camp.”

At Site 2, volunteer physicians and Khmer medics provide a level of care higher than that in Cambodia itself. But they do not offer comprehensive psychiatric services. Instead, severely disturbed people are referred to specialists in a refugee camp 20 miles away.

The Mollica team found, however, that the mental health problems of many Site 2 residents are not properly diagnosed. For example, patients suffering from depression and suicidal tendencies are treated for medical disorders, such as upset stomachs, and then released, the group concluded.

Much of this is traceable to the Khmer themselves, who are reluctant to seek out counseling. But Mollica also believes doctors and other medical workers should be trained to spot such cases.

“We have to find a way to reach all of these people, but it has to be on their terms. A Western psychiatrist can’t just walk into Khmer society and tell people how to live. It’s got to be a delicate blend.”

In a darkened hut at Site 2, Phaly Nuon sits with a woman who has recently fled her home to escape a drunken, abusive husband. With her children in tow, she has come to the depression relief center in search of safety.

Only a handful of women at Site 2 have used the shelter, and Nuon suspects that many others are suffering in silence. Still, the center is an example of the mental health care that Mollica and others would like to see expanded.

When the battered woman sought help, she also was offered the use of traditional healing herbs. For thousands of years, Cambodian folk doctors known as Krou Khmer have created powerful concoctions from plants that relieve symptoms ranging from upset stomachs and headaches to hypertension.

“I don’t know how the Krou Khmer do it, but the Cambodians believe in it, and that’s what’s most important,” physician Brandts says. “If we’re going to work with them, we have to respect that tradition.”

In addition, the center offered the woman “spiritual” counseling sessions to discuss her problems. Traditionally, Cambodians bring their personal problems to elders or Buddhist monks. Yet Barnabus Mam, a center employee, says talking about personal problems may catch on at Site 2.

“We have suffered just like the people who now can come to see us,” says Mam, who lost his parents, a brother and two sisters to the Khmer Rouge. “We understand them very well, you see, because we have all had the same nightmares.”

To combat mental health problems in Site 2, Mollica’s proposal would blend all of these ingredients--folk healing, religious consultation and Western-style counseling--in a program relying heavily on the Khmer themselves.

A key component would be the training of Cambodian mental health experts. These practitioners would spot telltale signs of emotional disturbance among patients and help prescribe remedies. They would be assisted by Krou Khmer healers, Buddhist monks and members of the depression relief center.

“It might take 6 to 8 months before (a patient) speaks her mind,” Mollica told an audience of Krou Khmer, center workers and Buddhist monks during a recent visit to Site 2. “But you have to be patient and be a compassionate listener. This is how we can begin to solve the problem.”

Will the mental health program make a difference?

Marybeth McCarthy, a longtime relief worker who directs a recovery program for Site 2 alcoholics, says that any effort is welcome, regardless of its shortcomings. Looking back on a recent week of camp violence, including Chamleakana’s murder of his wife and daughter, she shakes her head sadly.

“All of these people are suffering because we have been ignoring their psychological problems for too long,” McCarthy says.

“That murder is just one story out of 140,000 in this place. One day, all of these stories will come out, including thousands we don’t know about yet. And when they do, God help Cambodia.”