Modern Mental Health Care Slowly Unshackles Patients in Cambodia

The woman roamed the streets of her village for 13 years, yelling insults at strangers, chasing her family with sticks and attacking neighbors.

At night, the mother of four was chained by her relatives to a pole to prevent rampages that they feared would injure herself or others.

Chaining the mentally ill is widespread in Cambodia, a country with no psychiatrists and one of the world’s most traumatized populations from decades of war, genocide and loss of home and family.

But the slow introduction of modern mental health care is beginning to make tiny inroads.

The troubled mother was badly battered by five villagers in the central province of Kompong Speu in May. She was taken to an outpatient clinic for mental health at Sihanouk Hospital in Phnom Penh and diagnosed with schizophrenia.

The medication she now takes makes her feel dizzy and drowsy, but it has brought relief from the wild ravings that plagued her and her family for years. She can now cook, look for firewood and care for her children.

“It is very common in our country to see the mentally ill tied with chains,” said Ka Sunbaunat, a psychotherapist at the Sihanouk Hospital clinic, the country’s largest mental health facility.

“People do not mean to maltreat or torture the patients,” he added. “But it’s often a way to keep them safe, preventing them from hurting themselves or others.”

Cambodia has no inpatient facilities for the mentally ill, and equipment and drugs are lacking. Chaining people up has been the only choice many families have--a solution used in much of the West until this century.

But relatives of people suffering mental ailments are beginning to use other options. Since opening in May 1994, the Sihanouk clinic has provided more than 13,000 consultations and received 2,000 patients.

Still, that is only a start in a nation where virtually everyone has suffered the traumas of war.

About 2 million Cambodians died under the Khmer Rouge regime from 1975 to 1979, about a quarter of the population. Only 49 doctors--none of them psychiatrists--survived.

A decade of civil war between a Khmer Rouge-dominated resistance and Vietnamese-backed Communists who ruled in Phnom Penh during the 1980s killed tens of thousands more. At least 150,000 Cambodians were forced from their homes.

“Loss is the most universal experience here,” said Ellen Minotti, field administrator of Project Reach, a program aimed at helping the mentally ill in the provinces. “Loss of family, life, limb, loss of society as it was, loss of occupation--loss, loss, loss.”

Eighty percent of Cambodians eke out a subsistence existence in the countryside, and the cities aren’t much better. With per capita income less than $260 a year, the struggle to survive leaves many with no time to ponder why they feel severely depressed or ill.

“Some say that when things are really settled here, when people are more secure, we will see more symptoms of mental illness,” Minotti said.

Some poor Cambodians who do receive medical attention find they cannot afford the luxury of treating their problems.

One man treated at the Sihanouk clinic suffered from deep depression and paranoia. He burned down his house, attacked his wife with an ax, and regularly cursed and beat his six children before he was taken to the clinic for treatment.

Medicine brought temporary relief, but adverse side effects prevented him from working in the rice fields--the only means he had to support his family of seven. He soon stopped taking the medicine, and social workers fear a relapse.

Cambodia is starting to rebuild its mental health care structure. The health ministry established a mental health subcommittee in 1992 and the main medical school adopted a mental health curriculum for third- and fourth-year students.

Nurses and volunteers in one province are receiving training to provide services to adults and children, and a hospital in another has opened a psychiatric ward for children under 15.

Ten candidates for doctorates in psychology are scheduled to graduate by early 1998, new psychotherapists are being trained at Sihanouk Hospital, and several nongovernmental organizations are reaching out to the mentally ill.

But Ka Sunbaunat, the clinic psychotherapist, said more must be done.

“In most countries mental health has less priority among different disciplines of medicine, but in Cambodia it should not be this way,” he said.