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Voices from the Field: A Cambodian-led Approach to Mental Health

Lucy Gamble

One day, one of my Cambodian colleagues greeted me with a smile and exclaimed, exuberantly and with joy, ‘You have put on weight’. My reaction was to become self-conscious and make a note myself to lay off the condensed milk in my coffee. In fact, his comments had nothing to do with my weight; he was trying to find a way to welcome me back warmly and tell me that he thought I looked well on my return from a few days off. Having grown up during the Khmer Rouge time, and subsequent years where food was scarce and many people were malnourished, this comment was intended as a compliment and reflected a perception of wellbeing.

Culture denotes how people understand and experience the world around them. It is transmitted through lived experience and is felt and experienced largely on an unconscious level. If a person lives in, and is a part of, a dominant culture, it can be hard to become aware of its influence. They are enveloped in it, like the fish in water. Stepping into another culture, an opportunity arises to become aware of the difference and edges between the guest and the host. Many factors start to come in to play that will influence the level of awareness of this difference: comprehension of the host country’s language, power dynamics, sense of professional certainty, and the expectations placed on others and self, to name but a few.

Within psychiatry, the Diagnostic and Statistical Manual and the International Classification of Disease diagnostic systems organize how

L. Gamble (*)

NHS Greater Glasgow & Clyde, Glasgow, UK © The Author(s) 2017

R.G. White et al. (eds.), The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health, DOI 10.1057/978-1-137-39510-8_22

symptoms are clustered and interpreted. The language and concepts drawn from these manuals are now used in countries with very different cultures to those in which they were initially developed, for example, the development of post-traumatic stress disorder (PTSD) within the USA for veterans of the Vietnam War (Young 1997). There is some evidence to suggest this is altering what is perceived as mental illness (Watters 2011). Academic journals (Errebo et al. 2008) and popular media (BBC News 2005) have documented the delivery of interventions developed within Europe and America, for example, cognitive behavioural therapy (CBT), to low-income countries as a way of supporting mental health programmes, or to provide emotional support to those who have been caught up in natural disasters such as the 2004 Tsunami. The Mental Health Atlas (WHO 2011) has facilitated comparisons of mental health resources and workforces between high- and low-income countries. The mhGAP (WHO 2008, 2010) initiative has called for the scaling up of mental health services within low-income countries. Underpinning this is a reliance on concepts being translatable of perceptions of health and wellness being similar to support the idea that models of mental health care can be ‘adapted’ and then rolled out in different countries. However, there are two questions that are particularly apposite here:

  • 1. What are the implications of more of the same?
  • 2. Are we assuming that these countries have not developed systems of understanding and intervention to support mental and emotional wellbeing over the centuries they have existed?

Kirmayer and Pedersen (2014, p. 764) have pointed out that ‘local responses to suffering are embedded in cultural systems of meaning and healing that are part of the religious, spiritual, and moral fabric of communities and societies’. As such, mental health is expressed at a cultural level. Without an understanding of this, it is possible to wander into a minefield of misunderstandings, whether it be a superficial misunderstanding of a greeting, or on a more serious level, well-meaning but misjudged interventions. It has been argued that there is a creeping process of globalization occurring in mental health that is homogenizing perspectives (see Higginbotham and Marsella 1988). This has consequences in terms of the development and support of people’s mental health and wellbeing for everyone. The homogenization of perspectives within mental health may lead to different perspectives and approaches being missed that could offer an alternative, or at least complement how psychiatry addresses the challenge of mental ill health and lack of wellbeing within the West. The adage ‘If the only tool you have is a hammer, everything will look like a nail’ seems appropriate here. Countries such as Cambodia challenge professionals and researchers to understand and approach mental health differently. Openness to this enables a more collaborative approach that will be of more benefit both there and for a wider understanding of mental health in general.

In 2002, I moved to Cambodia to work as a clinical advisor for a nongovernment organization (NGO), the Transcultural Psychosocial Organization (TPO) Cambodia.1 Two years before I joined them, they had decided to become independent of TPO International that had been instrumental in starting the project in 1995 and to become a Cambodian-led organization. Rather than continuing a pattern of foreign experts visiting for periods of time, they decided they could be better supported by identifying people with the skills and knowledge they wanted and for those people to become TPO staff, living and working alongside them. I spent just over two years with them and have remained in contact since this time as the field of mental health has evolved in Cambodia. TPO has now been working in the field of mental health for two decades. Dr Chhim has been their executive director for the last 13 years.

Drawing on my experience of working for TPO, and continued contact with them, this chapter aims to explore four areas: firstly, Cambodian conceptualizations of mental health, in particular trauma; secondly, offer an outline of core components of TPO’s programmes; thirdly, consider challenges that can occur when mental health professionals and concepts from the East and West come into contact; and lastly, reflect on the wider implications of issues raised within this chapter for Global Mental Health.

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