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Welcome to the Dark Side: Depression in Cambodia

By: Bronwyn Sloan Posted: November-16-2009 in
Bronwyn Sloan

Originally published on Expat advisory On February 7th 2008, following several requests we have lifted the article to our current pages.

Hi. My name is Bronwyn, and, like up to 15 percent of the population, I suffer from depression. Unfortunately for me, although there is a group for recovering alcoholics in Cambodia, and even a group for recovering drug addicts, there is no 12-Step Sad Sacks Anonymous. I have a medical certificate that says I am not crazy, I have been assured by experts that I am not delusional, I am certainly not ashamed and I know I am not alone. Expats and Cambodians alike share dark days like I do, but few people talk about it.

When you become an expat, your traditional support mechanisms are sometimes just not there anymore. At home, I used to go to St Mary's and light candles, or go for long walks by beautiful, beggar-free Sydney Harbor before catching a ferry to a wonderful acupuncturist who spoke my language. Here I go to the pagoda or walk on the river, but it isn't the same because it isn't my childhood, and when you look for sadness in Cambodia, there is no shortage of it.

You can find yourself a long way from family and friends, and life in any culture, let alone a different one, can be stressful.

Cambodian days sometimes start with a sea of cheekbones and bewildered dark eyes staring up at you, and a smiling chorus of: "Yes. (long pause) Cannot." Some boss from a developed country is on the phone yelling that it simply IS NOT POSSIBLE that your staff have ALL gone off to lunch together simultaneously and will not return for three hours, nor that there has been no electricity for the previous three hours, and there is a guy on your doorstep you are positive you don't know inviting you to his wedding, which you will have to pay for with money you don't have. On the way to a lunch you don't want, someone in a Tico with military plates thinks it's ok to turn left from the right lane on a red light if they smile and for some reason the police then stop you.

And no, the story of the working single mother coming home and finding her toddler sticking the cat to the wall with superglue while the nanny laughs and explains "he play" is not apocryphal. Cambodian child care notions are sometimes radically different to ours.

When I first explained to my Cambodian partner that I had dark days when just getting out of bed seemed pointless and my body felt like it was made of lead, he was angry. He had seen his entire family die in various and increasingly gruesome ways at the hands of the Khmer Rouge by the time he was 13, he said, and he copes. Of course, he doesn't - he still fights the Khmer Rouge in his sleep and cries out to ghosts, but to a Khmer man, even making negative comments about his wedding tackle is less insulting than questioning his mind.

There is always a degree of guilt with depression - why should I feel like this when I have so much more than so many people? In Cambodia, with such a bloody history, that guilt can intensify into a terrible aloneness.

For a very spiritual people, Khmers seem to have an overwhelming need to make mental anguish physical. Like most Asian cultures, they don't face mental health issues easily. Better to moxy-suction a whopping great black circular spot on your forehead than admit to stress. You might look a bit silly at Sundowners, but at least you don't have to talk about it.

I have to admit I feel frustrated that I have such trouble communicating the concept of depression to Cambodians. The response is always "Don't think too much", but like many Cambodian suggestions, they have just given you the solution without providing the steps to reach it.

When I returned from a visit to the clinic this week the women of the house informed me the girl next door had just committed suicide. She had shown no symptoms of sadness - how could she in this culture? Her family was in complete shock. When they heard what was wrong with me, the women immediately began lighting a flurry of incense and planning a trip to the pagoda for a cleansing. I was, apparently, either contagious or infected.

There have been days that I physically could not answer my phone or touch a computer. Because any city in Cambodia is a village - even Phnom Penh - the gossip mill can also be hurtful. As a female journalist, I find my stories being judged in tandem with my looks on local blogs ("yes, I saw that story, and doesn't she look haggard/fat/old!"), and hard-won investigative pieces which happen to involve another woman being denigrated as mere cat fights.

But being a woman has its positives, too. I find it easier to talk through my problems than most men. I have supportive female friends, many of whom also see the dark and admit to it. As a single mother, I can afford wonderful staff here to carry some of the burden when it seems too hard to go on, and I have found a wonderful Cambodian man who has gradually opened and shared his amazing life with me.

Expat communities can sometimes be spiteful, but for me the most important part of healing has been overcoming that fear and reaching out. If you don't have a friend you feel you can confide in, go to an embassy-recommended clinic and get a confidential consult from a doctor. But whatever you do, don't think you have to suffer in silence and solitude.

I have found good rapport with a female GP, but there are a range of options and languages available at several good clinics and everyone responds differently to different people. Sometimes all you need is a shoulder to cry on and someone to tell you it's ok in your native language, but most modern prescription anti-depressants are available over the counter here if necessary. A good clinic can even order them in, and it is reassuring (and wise) to have a qualified person overseeing dosage and ensuring the medicine is genuine.

The problem is, the doctors available are mainly GPs with experience of your problem but no specialist knowledge. There are few qualified psychiatrists here, and most of them are Khmers geared to the cultural sensitivities and treatment of Khmers. The Soviet Friendship Hospital runs an excellent outpatient clinic, the country's most prominent psychiatrist, Ka Sunbunaut, has a clinic near the Russian Market which is listed in the Yellow Pages, and there is an inpatient hospital in Takhmao, but few non-government organizations deal with this massive problem so many Cambodians also struggle with.

For organizations, which work on five-year plans and quantifiable results, mental health is just too difficult. TPO is one of the few organizations here (perhaps the only one) which helps Cambodians cope with their past and future.

For expats, there are qualified counselors who can compliment a regime of medication or simply walk us through our problems in a confidential and compassionate way. They are most easily reached through the clinics, which can recommend a variety of selections so you can find a person who suits you. Most counselors do not advertise, but they are there.

The website Mind Gym has also been recommended. It's a self-help behavioral change site that has worked for some friends. I am one of those people who can't deal with that sort of interactivity when I'm down and feel no need to do it when everything seems rosy, but it is certainly an option.

Then there is the expat (and Khmer) tendency to self-medicate. Drugs like Xanax and Valium are easily available, and booze is cheap. It all helps to kill the pain for a while. Bars are full of expats and Khmers talking about anything but their feelings. My advice from bitter experience is, don't - instead admit to yourself that you have a valid health problem and reach out to a professional, or at least seek the advice of a friend, because in the long run it's cheaper and more effective, but pot, kettle, black. We all need to learn and cope in our own ways.

I have friends who have healed themselves just by talking things through with a counselor here. Somebody who understands the same day to day challenges telling you it's not the end of the world is sometimes all the medicine you need, although if your problem is clinical and has needed careful professional monitoring in the past, you need to understand the safety net is limited in Cambodia.

The point is, there are healthy, sensible options available here which can work. Some of my strongest friendships have been formed in Cambodia, and I often rely on these friends now to get me through, because sometimes only another expat can understand. A friend once told me the first six years in Cambodia are the toughest, but after that it gets easier because you stop trying to make sense of it. Cambodia can feel like you are running on quicksand, or just caught in a particularly bad scene of some kind of demented ethnic Days of Our Lives episode. It's nothing to be ashamed of.

 

Depression. This is an important and often misunderstood topic.

Depression. This is an important and often misunderstood topic.

Depression is high on the list of reasons people seeking counselling services at the Phnom Penh Counselling Centre (established in 1998). As well as depression Bronwyn seems to be talking about signs of secondary traumatic stress, which a process by where we are psychologically affected by other people’s traumatic experiences. Secondary traumatic stress (STS), also known as vicarious trauma or compassion fatigue, exhibits the same symptoms of traumatic stress, acute stress disorder and post traumatic stress disorder. STS is not the result of a one-off or several traumatic events; it is a process; we are porous and soak up the trauma that lurks in the environment. Nothing has actually happened as such, but we become reclusive, have disturbed sleep, and avoid the news broadcasts, news papers and violent films. We are easily startled and become hyper-vigilant, whilst snippets of those awful things we hear about pop uninvited into our minds as thoughts and pictures, even when we are not thinking about them. We don’t want to get out of bed in the morning, feel oppressed, depressed, and experience guilt for feeling so awful when those around them have suffered so much.

Bronwyn mentions services for Cambodians as being few and far between, offering TPO as perhaps the only service available. At the Phnom Penh Counselling Centre we have several qualified Khmer counsellors and a subsidy to help Khmer clients who cannot afford pay for services, but attracting Cambodians has consistently proved difficult; such services are there if you are ‘crazy’, and no one wants to be labelled as such. Most of our work within the Cambodian community is crisis work and once the crisis is over they do not return. There appears to be a lack of understanding of the concept of longer-term counselling to deal with conditions such as depression, anxiety and traumatic stress.

Bronwyn also, rightly, refers to a lack of group support for depression sufferers. The Phnom Penh Counselling Centre would be willing to facilitate such a group (which would not be called Sad Sacks Anonymous) if that’s what people would like. Depression can be a dark and lonely road that is misunderstood by those who have not suffered from it. Depression sufferers can experience mild, moderate or severe symptoms such as fatigue, tearfulness, sleep disturbance, sadness, lack in interest in daily activities, suppressed sexual interest, reclusiveness, and more. Any underlying depression (or any other psychological conditions) you had before coming to Cambodia is likely to come to the fore and be exacerbated by living in this environment.

Depression, traumatic stress, secondary traumatic stress and the associated conditions such anxiety, phobias, relationship difficulties, self esteem issues, etc., are treatable and Phnom Penh is fortunate in having psychological resources available, including psychologists, counsellors and an expat psychiatrist, who offer services in several languages at affordable rates. Those in other developing Asian countries often have to travel out of country to obtain these services. Choosing the right therapist is really important. Not every client-therapist relationship works and choice is important. Unlike many Asian cities, Phnom Penh has choice so take your time your selection. Ask around, find out – we are all listed in the Yellow Pages, and make sure the therapist you choose is able to provide verification of their professional credentials and is receiving clinical supervision. You can self-refer or be referred by your doctor.

Thank you Bronwyn for submitting your piece and Expat Advisory for re-publishing it; this topic will never be out of date.

Jane Lopacka, MA

Director of Phnom Penh Counselling Centre
Senior Counsellor and
Clinical Supervisor
Trauma Specialist
www.ppcounselling.org

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