Chapter 12

Mental healthand interactions with the social environment. Given the fact that the brain, unconsciousness, and soulfunction in response to stimulation through interaction with the surrounding environment, the mind
appears to be something that does not work independently within the individual but rather is somethingthat functions only when relationships with surroundings are brought into the individual. It also
incorporates history and culture to shape itself. In other words, it is only in a dynamic interaction between
the individual and the surrounding environment or history/culture that the mind works. This aspect

Learning objectives

therefore assumes that mental illnesses/ disorders and poor health of the mind are greatly related to

You will be able to gain proper understanding and explain:issues of relationships or interactions with surroundings, or those of individual adaptation to the- The concept and development of the mind from biological, mental/psychological, and social

environment or history/culture.

aspects.

As a matter of course, these three aspects of the mind are not independent but linked to each other.

- Mental health, psychological conflicts and defense mechanisms, the mind-body relationship andThat is, the human mind, which is one phenomenon, is viewed from three aspects: the biological, mental/

the stress theory, and stressful events. And by taking these factors into account, you will also be

psychological, and social aspects. The mind has a totality that integrates at least these three aspects. This

able to consider ways to cope with stress and social support.

means that in considering mental health, issues need to be viewed comprehensively from the biological- Cambodia’s challenges in mental health and consider ways to address those challenges.

aspect, which mainly includes the growth/development of the cerebral nervous system and other body

- How to listen to children with a supportive and receptive attitude.

parts, the mental/psychological aspect, which focuses on individuals’ experiences and ways of life, andthe social aspect, which consists primarily of interactions of individuals with the social relations

This chapter provides an overview of mental health issues in Cambodia. It first describes ways tosurrounding them such as their family, school, local community, and nation, and the history/culture ofunderstand the mind and theories of the development of the mind that provide a basis for considering

their country or region.

mental health, then explains the definition of mental health by the World Health Organization (WHO),the stress theory, and contemporary mental health challenges in Cambodia.

1. Concept and development of the mind and mental
health1) Three viewpoints on the mind2) Development of the mind
(1) Mental development in the biological aspect
As in the case of the mind, we examine the development of the mind from three aspects, namely, thebiological, mental/psychological, and social aspects.
First, the development of the mind in the biological aspect is based on the growth/development of
the cerebral nervous system. Thus, it is supported by physical growth and development as well. According

What is the mind? Does the mind really exist in the first place? Is it an illusion created by the brain? We

to Dekaban and Sadowsky,1 the brain already weighs 360 g in a newborn girl and 380 g in a newborn

consider what the mind is by assuming three general aspects:

boy, as shown in Figure12.1. In one year from birth, it grows by approximately 1.6 times to 940 g for a

The first aspect sees the mind from the perspective of biomedical psychiatry and brain science.

girl and 970 g for a boy. The weight of the brain is known to reach 90% of that of an adult at around 6

This perspective views the mind as brain functions. It considers that each of the various actions of the mind

years old. After that, the growth rate of the brain decreases, with the brain size reaching almost its peakis controlled by the region that localizes it in the brain. It therefore assumes that mental illnesses/ disorders

at 19 to 21 years old. Due partly to differences in physical constitutions, brain weight differs between theand poor health of the mind are caused by damage to, or is a dysfunction of, a certain brain region.

sexes; it is 1310 g for women and 1450 g for men, indicating that men have a heavier brain than women.

The second aspect, which is adopted in some fields including psychoanalysis, depth psychology, andBrain weight starts to decrease in the late fifties as people age.

counselling, assumes the existence of “the mind” to be something that cannot be understood objectively

Meanwhile, concerning changes in synaptic density2 in the prefrontal cortex, which is responsible

or with natural science, such as unconsciousness and a soul. This view believes that the accumulation

for high-level human cognitive functions such as control of language and thinking, the density at 4 years

of individual life experiences shapes the mind as a subjective world. It therefore assumes that mental

after birth is known to reach double that of an adult. Synaptic pruning starts to progress slowly after

illnesses/ disorders and poor health of the mind are greatly related to matters of one’s way of life or lifearound 4 years old, and intensely accelerates at around 14 to 16 years during adolescence. While networks

experiences, or those of one’s subjective self-being.

of synapses used frequently remain, those not used are pruned and eliminated.

In the third aspect, the mind is understood as not only a series of functions within the individual’s

A higher synaptic density does not necessarily provide a better function; an overly complicatedbrain/central nervous system and inner self but also a series of functions in connections with people

network cannot process information efficiently as it can be imagined from a labyrinthine information

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Chapter 12

Mental health

219

(g)

1600
1400

(2) Mental development in the mental/psychological aspect

Male

1200

Although there are a variety of theories about mental development in the mental/psychological aspect,

Femaletwo theories can be presented as representatives: Piaget’s theory of intellectual development and

1000

Erickson’s life span development theory.

800

a. Piaget’s theory of cognitive development (Figure 12.2)

600

According to the theory of cognitive development by Jean Piaget (a Swiss developmental psychologist,

400

1896-1980)3,4, children aged from 0 to 2 are in the sensorimotor stage, in which the knowledge of the

200
0

world around them is limited to what they can sense and touch. As the sense of their own existence
Newborn

1 year

2 years

3 years

10-12
years

19-21
years

50-60
years

81-85
years

This figure is created based on data obtained from “Dekaban, A.S. and Sadowsky, D., Changes in brain weights during
the span of human life: relation of brain weights to body heights and body weights, Ann. Neurology, 4:345-356, 1978”

Figure 12.1 Human brain weight by gender and age

begins to grow, they start to understand that things exist even though they cannot see, and also understandcausal relationships between actions and consequences. Then, children aged from 2 to 7 are in the
preoperational stage, in which they begin to think using images, and fantasies appear in their words
and play. They enjoy using animism to think of natural phenomena such as an angry mountain. Their
thinking is still self-oriented. The period from the ages from 7 to 11 is called the concrete operational

network. Rather, as synaptic pruning progresses, information transmission becomes more efficient asstage, in which children begin to think logically and become less self-centered and able to see things

it can be imagined from networks of major roads. Because this synaptic pruning occurs through thefrom various aspects. For example, they acquire the concept of conservation, that is, the amount ofinteraction between the body and the environment, the environment in which one has spent during

water remains the same even after it is transferred from one container to another with a different shape.

adolescence is important. Adolescence, during which intense synaptic pruning occurs, is a period in

After this stage, from early adolescence, the formal operational stage, in which adult thinking iswhich the brain structure is drastically reconstructed; therefore, it is considered to be a period in which

acquired, begins. In this stage, they acquire abstract thinking and begin to think about things according

mental disease is likely to develop (susceptible period) and deviant behaviors tend to occur. It is

to visions and ideals without concrete experience. For example, they can think scientifically and make aestimated that it takes about 25 years for the frontal cortex to mature to the adult level.

hypothesis for estimation and compare the result with a fact to draw a conclusion.

Column: What are the prefrontal cortex and synapses?

The brain can be broadly divided into the cerebrum, the cerebellum, and the brain stem (a collective
term for the midbrain, the medulla oblongata, and the pons). Among these, the cerebrum is separated
into four regions: the frontal lobe (with functions primarily related to thinking, judgment, and action),the parietal lobe (chiefly perception and sensation), the occipital lobe (vision), and the temporal lobe
(hearing and memory). The prefrontal cortex is more developed in humans than in any other animal,
accounting for approximately 30% of the frontal lobe and approximately 10% of the entire brain. The
prefrontal cortex is responsible for cognitive functions necessary to live humanly, including reflecting/thinking, controlling actions and emotions, communicating, controlling memory, making decisions,solving problems, and acting with long-term goals.
In the nervous system, nerve cells (neurons) are responsible for information transmission.
Nervous cells are not linked to each other but adjoin with gaps. A connection from the end of one

220

Sensorimotor stage(approx. 0–2 years)

Preoperational stage(approx. 2–7 years)

The sense of their own
existence begins to grow.
Begin to understandcausal relationships
between actions andconsequences

Think using images.
Fantasies appear in
their words and play.
Thinking is selforiented

Concrete operational
stage(approx. 7–11 years)
Think logically.
Can see things fromvarious aspects

Formal operational
stage(from earlyadolescence)
Acquire abstract
thinking.
Can think according
to visions and ideals

Figure 12.2 Piaget’s theory of cognitive development

b. Erickson’s life span development theory

nerve cell to the next nerve cell is called a synapse. A neurotransmitter is released in this gap, andErik H. Erikson (an American developmental psychologist and psychoanalyst born in Germany, 1902-

information is transmitted from one nerve cell to another. For example, when the sympathetic nervous

1994)5 divided the period of life from infancy to maturity into eight developmental stages by characterizing

system is activated, noradrenaline is released, making the state of mind and body active, while theeach stage according to specific skills acquired and behavioral tasks achieved, or developmental tasks.

activation of the parasympathetic nervous system leads to secretion of acetylcholine, creating a

They are infancy (basic trust vs mistrust), early childhood (autonomy vs shame/doubt), preschool

relaxed state of the mind and body (see Chapter 2).

(initiative vs guilt), school age (industry vs inferiority), adolescence (identity establishment vs diffusion),
Chapter 12

Mental health221

young adulthood (intimacy vs isolation), middle adulthood (generativity vs stagnation), and senium

19th century. Infants develop their mind by interacting with their caregiver and fostering environment(integrity vs despair).

through the body.

In Erikson’s view, if the developmental tasks of each developmental stage are successfully achieved,

The environment with which they interact is, according to a model presented in Adolescent healththe person will acquire a desirable nature, but if not, the person will emerge with an undesirable

21st century7, considered to be a social ecosystem consisting of schools, families, neighbourhood, andpersonality trait. For example, a main task for children of preschool age (about 3 to 4 years old) is to “domacro society. This social ecosystem affects human health throughout the entire life course from priorthings on their own or depend on others,” and then experience developmental crises, depending on

to birth to senium. Accordingly, the development of the human mind continues to be affected by thewhether they develop autonomy, or feel shame and doubt (e.g., a crisis over autonomous evacuation). If

social ecosystem.

they can successfully achieve the task, they will acquire the spirit of independence and the sense ofcontrol, which will develop their will, but if they fail, they will lose confidence in their ability and feelashamed of themselves. A task for children of early school age (about 4 to 5 years old) is whether they3) What is mental health?

can do things on their own initiative, and they experience a crisis in which they face initiative or feelingsof guilt about their negative attitude. If they successfully achieve it, they will develop a sense of purpose

According to the WHO, mental health is more than a condition free from mental disorder; it is theand the will to try new things, but if they fail, they will develop feelings of guilt or become passive.

ability to think and learn and understand others’ emotions and respond to them, as shown in the WHO’s

Children of late school age (about 5 to 12 years old) experience a crisis in which their ability to do things

definition of health (see Chapter 1).8 In addition, mental health is a condition in which an individual’s

well is tested. After entering school, they begin to shift the focus of their social relations from the family

physical, psychological, social, cultural, and spiritual health and other related factors are balanced, andto friends and teachers. If they play with friends, learn in class, do homework, and participate in schoolin which the individual is harmonized with the environment.8 Therefore, mental health is health with aevents well, they will come to feel confidence and pride in their ability, which will develop the industry

totality that cannot be considered separately from things like physical, psychological, and social health.

necessary to work hard in school. Meanwhile, if they feel they do not do those things well enoughMoreover, it is health that is also inseparable from the environment.

compared with their friends, they will come to feel a sense of inferiority or a lack of confidence, which

The WHO also states that it is a condition in which an individual can smoothly exhibit his or her

will increase the sense of maladjustment to school life. Through these experiences, a concept of self inability, cope with various stresses in daily life, and engage in work and studies to contribute to society.

school-age children is developed. Without question, support from parents, teachers, and friends, if

The WHO emphasizes the importance of mental health by describing that mental health is the foundation

provided to address the developmental tasks of this stage, will allow children to achieve the tasks moreof abilities of groups and individuals that enables people to think humanly, communicate with eacheasily and their minds to develop even more healthily. It will also help address developmental tasks

other, earn a living, and enjoy life.9

related to the establishment of identity in adolescence.

Given all of these things, mental health is considered to be a condition in which a person has the

In adolescence (about 12 to 19 years old), children face the question of who they are and experienceability to live with independence (or sense of agency) as a human in this world and can display thatthe major challenge of establishing identity. Once they obtain their roles in society through various

ability. Thus, mental health in the developmental stage is viewed as a condition in which children canexperiences in studies, work, and social relations, they will be able to deepen self-understanding andeffectively exercise their abilities to, for example, think, learn, communicate, control behaviors andbecome clearly conscious of themselves. Those who fail to find their roles or places to which theyemotions, make decisions, and cope with stress in daily life according to their age (see the function of

belong in society may become adults with vague self-consciousness. The development during and after

the prefrontal cortex), and at the same time, it is a condition in which those abilities can be enhanced toyoung adulthood is not discussed in detail here.

the highest levels that individuals can achieve because children are in the midst of growth and(3) Development of the mind in the social aspect
Lastly, we discuss theories about development of the mind through social relations. The individual’s
self-recognition of “who I am” does not exist without the existence of others. That is because one needs

development.

4) Adolescents in the world and mental healthanother person who is different from oneself in order to confirm one another existence. For example, fordevelopment of the mind in infancy, relationships between the infant and the caregiver and fostering

The WHO estimates that 10% to 20% of the adolescents in the world have mental health issues that areenvironment are important. Rene Spitz (an American pediatric psychiatrist and psychoanalyst born inundiagnosed or untreated.10 Furthermore, young people with mental health issues are victims of a human

Vienna, 1887-1974)6 discovered hospitalism, a phenomenon in which infants who are fostered in anrights violations as a result of social exclusion, discrimination, and stigma (a negative, discriminatory

institution away from their parents for some reason experience a delay in physical, intellectual, emotional,

attitude that sees a person’s specific characteristics as something shameful, abominable, and stained),or language development because of a lack of adequate stimulation from parents, that is, a physicaland tend to have learning difficulty, show dangerous behaviors, and have physical health issues. The

contact and emotional relationship with parents; this phenomenon had already become an issue in themost common cause of mental health issues in young people is depression.

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Mental health223

2. Stress in daily life and mental health
1) Mechanism for protecting the mind

Column: Various emotions and the control of emotions

A person has various emotions. According to the classical theory of emotional development, aperson first acquires emotions of pleasantness and unpleasantness in infancy, and pleasantness is

To maintain mental health, we must continue to protect the mind by coping with various stresses anddivided into joy and affection while unpleasantness is divided into anger and hatred; a person

conflicts in daily life. The world has entered a stage in which our health is threatened by various stresses

develops more complicated emotions with age. It has been said that the basic elements of emotions

caused by social life, which came after the threat of infectious disease and the spread of lifestyle diseases.

develop by 2 years of age and emotions become as various as those of adults by 5 years of age.

This section explains about the psychological defense mechanism that enables us to cope with various

However, recent studies point out that emotions such as joy, anger, and fear emerge as early as

frustrations and conflicts inherent to human life.

infancy.

Austrian psychoanalyst Sigmund Freud first proposed the defense mechanism, and Anna Freud (aEmotions themselves cannot necessarily be classified into good and bad ones, and there is nodaughter of Freud) developed it. Freud believed that the human mind consists of three layers: superego,need to deny any emotion. Meanwhile, positive emotions such as enjoyment, joy, affection, trust,ego, and id (es, unconsciousness). The superego is a sociocultural moral code that is internalizedhappiness, and surprise are easy to accept, but negative emotions including anger, jealousy, fear,through, for example, parental discipline, and represents the mind consisting mainly of conscience,

conflict, hatred, sorrow, and shame are hard to accept. Thus, if negative emotions become excessive,

which takes actions by judging norms, morals, and right and wrong, while the id represents the mind of

they can result in problems by causing antisocial behavior such as harming oneself or others. One

instinctive desires and drives, emotions, and the accumulation of past experiences. The ego representsof the mechanisms of the mind that controls these negative emotions is the psychological defense

the defensive function of the mind that receives moral requests from the superego (e.g., prohibition,mechanism. Coping behavior, social support, mindfulness, and meditation, which are discussed

ideals, and consideration for others), and desires and drives as well as emotions from the id (Freudlater, are also psychosocial means to control negative emotions.

attached particular importance to sexual desire and drive), experiences a conflict between the superego
and the id, and seeks for reality adaptation by coordinating with the reality of the outside world.
The psychological defense mechanism is the action of the mind to mitigate unpleasant emotional
experiences such as anxiety, depression, guilt, and shame that are caused when the ego is exposed to theinstinctive desires and drives as well as emotions of the id, and is the unconscious action of the mind by

2) Relation between mind and body, and psychosocial stress(1) Hans Selye’s stress theory13

which the ego attempts to resolve the crisis and readapt to reality.11 In general, the defense mechanism

Stress is originally an engineering term that means “pressure” applied to an object. In the late 1930’s,

is the means that the ego or the self uses to protect itself from desires that it wants to reject and unpleasantHungarian-Canadian physiologist Hans Selye found that strong demand from the outside world disturbs

emotions and notions, and is a normal action of the mind that everyone experiences. However, if thehomeostasis (see Chapter 2) and causes nonspecific, physiological responses to the living body (e.g.,

defense mechanism is excessive or inadequate, it can lead to social maladjustment, causing problematicswelling of the adrenal cortex, atrophy of the thymus, spleen, and lymph node, and gastric and duodenal

behavior or impairing the health of the mind and body.

bleeding/ulcers) in experiments with rats, and published the stress theory.13 Selye’s stress theory was

The most basic example of the psychological defense mechanism is repression. It is the action of theego that unconsciously excludes desires that it wants to reject (e.g., sexual desire), unpleasant notions

soon applied to humans, and research on the relation between stimulation from the psychosocial
environment and human response began.

and emotions (e.g., hostility), and threatening experiences from consciousness and puts a lid on them so

Environmental triggers that induce stress responses are stressors, which are largely classified intothat they will not enter the consciousness.12 The id is assumed to be an unconscious space to store these

physicochemical stressors (e.g., noise, vibration, temperature, and chemical substances) andunpleasant things through repression. Although repression can give a temporary escape frompsychosocial stressors (e.g., human relations, events in school life, duties, characteristics and atmosphere

unpleasantness, the memory of a very difficult experience may enter the consciousness as an unexplainedof organizations including school, and economic conditions). In psychosocial stressors, there are acuteanxiety later, causing damage to mental health. Or it may appear as physical symptoms such as thestressors, which are stressful life events, and chronic stressors, which are daily hassles.

inability to speak, walk, or sleep, despite no physical dysfunctions.

Stressful life events refer to events that cause changes to life and require efforts to adjust life andAnother example of the defense mechanism against unacceptable notions, emotions, thoughts, andreadapt. According to the scale that measures stressful life events,14 the stress level of changes in life

memories of experiences is isolation. It is the action of the mind that attempts to separate thoseafter marriage is set at 50 as the standard, and rates the death of a spouse at 100, which is the highest

unacceptable things from oneself and keeps them away. Unbearably difficult experiences may belevel. A survey of Cambodian university students15 reported the three most common life events that they

confined so as not to be remembered, which is called dissociative amnesia.

found difficult were as follows:

Meanwhile, the psychological defense mechanism has not only unhealthy responses but also healthyor mature ones (e.g., altruism, humour, sublimation, and suppression).
224

1. Marked decrease in your or your family’s income
2. Frequent minor illness
Chapter 12

Mental health225  3. Seeing poverty in Cambodia

aspect (psychological symptoms including anxiety, depression, and irritation), and the behavioral aspect

Meanwhile, daily hassles refer to irritating or frustrating events that occur in interactions in one’s(aggression, withdrawal, tardiness/absence, and errors and accidents) (Table 12.1).

daily life. In the daily life of university students, daily hassles may be an inability to understand classwork,
excessive examinations and assignments including making reports, insufficient daily living expenses, orconcerns about securing a job after graduation. The ten most common daily hassles for Cambodian

Column: Mental health of Cambodian people

university students15 are reported as follows:

In a study of Cambodians’ psychological symptoms, conducted by Dubois, et al.16 in the Kampong

1. Too many things to do at once

Cham province, 55% of the people reported experiences of violence and poverty related to the  2. Struggling to meet academic standards

Khmer Rouge, and 42.4% had symptoms corresponding to the diagnosis of depression according

3. A lot of responsibilities

to the DSM-4 standards while 53% and 7.3% had symptoms corresponding to the diagnoses of

4. Important decisions about your future career

anxiety disorder and PTSD (Post-traumatic stress disorder), respectively. In addition, many people

5. Poor health of a friend

had multiple symptoms. The three most common stressful life events were lack of food and water,

6. Hard effort to get ahead

access to medical care, and housing. The frequency of PTSD was 28.4% in a study by De Jong, et

7. Financial burden

al. 17 and 14% in a study by Sonis, et al.,18 showing some difference due to study populations and  8. Difficulties with transportation

periods. In addition, these studies are limited by simply applying the Western psychiatry diagnostic

  9. Social conflict over smoking

categories for PTSD, depression, and anxiety disorder to the stress experiences of Cambodian

10. Social isolation

people.19

There are two ways to harm health: one is through stressors caused by events that in turn cause major

According to Nou,15 Cambodian university students’ major stressors can be classified into fivechanges to life, and the other is through stressors attributed to accumulation of daily irritations. Bothcategories, one of which is their difficulty in getting white-collar jobs after graduation, such as non-stressful life events and daily hassles vary depending on society, culture, and living conditions, and it ismanual work, specialists, or engineering/development work. Moreover, social disparities that allow

therefore necessary to consider what constitutes stressors that harm human health by taking into accountonly rich students to get good jobs have become a stressor. The subsequent stressor is changes inthe society, culture, and living conditions of each country and region (urban areas or remote mountainous

life, including the death of or separation from family members, a decrease in income, and poverty

areas), including Cambodia’s group harmony-oriented culture, which is different from Westernand the uncertain future of Cambodian society. Others inclulde changes in society; Cambodia’s

individualism.

political and social uncertainty have affected university students’ daily life. The last is malnutrition

In any case, if harmful stressors cannot be removed and exposure to them continues, stress responses

resulting from environmental pollution (dust from unpaved roads) and poverty, which is reported to(strain) occur. Stress responses appear largely in the physical/physiological aspect (physical symptoms

be a stressor that many university students suffer from. Further studies of life stressors are needed

including elevation of blood pressure, palpitation, and headache/abdominal pain), the psychologicalin the context of Cambodian life and society in detail.
The challenge of school mental health is to identify the stressors, stress responses, coping
behaviors, supportive human relations, and a sense of control in the lives of elementary school,

Table 12.1 Examples of areas and types of stress responses

Area of stress responses

Types of stress responses

Physical/physiological aspect

Elevation of blood pressure, malaise, dyspepsia, fatigability, sweating,insomnia, anorexia, palpitation, headache, abdominal pain, diarrhea, being
prone to colds, substantial change in weight

Psychological aspect

Anxiety, tension, helplessness, depression, decrease of confidence/selfesteem, irritation, difficulty in concentrating, deterioration of memory/
judgment, being passive

Behavioral aspect226

Withdrawal, tardiness/ early leaving /absence, decrease of work efficiency
and morale, increase of aggression, being pessimistic, being suspicious,
diet refusal/overeating, tics, starting or increasing the amount of smoking/alcohol drinking/drug intake, decrease of cooperativeness, change inappearance, unsanitary behavior, increase of errors and accidents, suicide
attempt/suicidal ideation/self-harmjunior high school, and senior high school students in Cambodia.

(2) Mechanism of the mind-body connection
The remarkable points about the stress theory are that it revealed that stimulation from the psychosocial
environment can induce responses in the physical/physiological aspect and cause physical diseases, andso it created the concept of psychosomatic disease.
For example, if a human relation problem such as bullying, harassment, or discrimination occurs,
people will recognize and evaluate it. If the stimulation persists and it is determined by the cognitive
appraisal to be a threat that cannot be eliminated soon, it will become a stressor, leading to various
emotional responses, autonomic nervous system excitation, transmission of this excitation throughout
the whole body via synapses, and evoking the body’s responses (see Chapter 2 for responses of theautonomic nervous system). The cognitive appraisal of a stressor causes excitation of the sympathetic
Chapter 12

Mental health227nervous system or the parasympathetic nervous system. A body’s responses vary depending on the

anxiety, depression, loneliness, and despair that result from psychosocial stressful events such as

released neurotransmitter. Representative hormones that transmit stress information are cortisol andunpleasant or disappointing events and the experience of being hurt. However, such defense will not

adrenaline, which transmit excitation of the sympathetic nervous system. If this stress condition

last long, and in fact, the person will soon be exhausted and feel seriously depressed. To avoid thisbecomes chronic, the body will soon be exhausted and unable to maintain homeostasis, resulting in thesituation, it is important to have someone reliable who will listen to and accept.

onset of disease.
However, not all stresses are necessarily harmful. Good stress is called eustress and is conceptually
distinguished from the harmful stress distress. Eustress leads to fulfillment in life and a sense of(3) Coping behavior toward, social support for, and a sense of control over stressaccomplishment and is referred to as “the salt of life.” It is a metaphor meaning that consuming it too

As a means to protect health of the mind and body from psychological conflicts and psychosocial stress,

much will do harm to health, but we cannot live without taking it.

there are coping behaviors and social support in addition to psychological defense mechanisms.

Column: Stress hormones and happy hormone

a. Coping behavior
Stress-coping behaviors are actions and skills used to reduce threats, harmfulness, and stress

Cortisol and adrenaline are major hormones released when the human body responds to stress.

responses that result from a stressor, and include emotion-focused coping that attempts to

These hormones elevate blood pressure and prepare the body for fight or flight response (seemaintain the person’s composure by controlling emotions (e.g., vent of emotions, resignation,

Chapter 2). Cortisol is a steroid hormone released by the adrenal cortex. Depending on the amountand wishful thinking), problem-focused coping that tries to solve the problem (e.g., seekingof secretion, it increases blood pressure and blood glucose levels, resulting in, for example, a decline

for information and support and implementing solutions), and cognitive appraisal-focusedin immune function.

coping that perceives the problem differently (e.g., redefinition and denial of the problem).

Meanwhile, when a joyful or good thing (eustress) happens, dopamine, which is known as “thepleasure hormone,” is released. As a result, the person is motivated to make better things happen.

b. Social support

Besides dopamine, there are serotonin (known as “the hormone of reassurance”) and oxytocin

It is support that is provided and received in social relations. Although there are several(known as “the hormone of love”).

classification methods, it can roughly be divided into emotional support, instrumental support,
and appraisal support. Emotional support includes approaches to the emotional aspect, such

Column: Psychosomatic disease

as sympathetic understanding and sharing an experience. Instrumental support further
includes support by means, i.e. aid, which is a direct intervention or support to solve thePsychosomatic disease is a physical disease, whose onset and course are affected by psychosocial

problem (e.g., lending money and giving assistance), and informational support, which isstress, and in which organic or functional abnormalities are confirmed. To understand psychosomatic

an indirect support through advice and information provision. Plus, there is appraisal

disease, the mind-body connection is important for explaining the relation between psychosocial

support, which works to change perspectives and views on stressful events, or provides a

stress and physical symptoms or physiological abnormalities. Representative psychosomatic

positive appraisal.

diseases include irritable bowel syndrome, gastric ulcer, bronchial asthma, hyperventilation

Stress coping behaviors are the actions that people take when a stressor occurs. Social

syndrome, essential hypertension, and headaches (e.g., tension-type headache and migraine). Notesupport, on the other hand, includes various types of support, such as support related to thethat physical symptoms complained of by patients with depression or schizophrenia are not included

occurrence of the stressor and support for coping with the stressful situation. Thus, socialin psychosomatic disease.

support has the effect of preventing the occurrence of stressors, reducing stress levels whenstressors occur and people feel stressed, and providing support when stress responses occur.

Column: Manic defense

Therefore, in order to maintain mental health, it is important to establish reliable relationships
with people who can provide support (e.g., family members/relatives, friends, and teachers)

There are many types of defense mechanisms that protect the ego when the person feels

and to learn about socially provided programs and services. In Cambodia, however, thepsychological stress, ranging from immature defense mechanisms (e.g., isolation of affect,

challenge is a lack of facilities, services, and programs that can provide mental health care.

rationalization, denial, and somatization) that tend to lead to maladjustment and mental healthdisorder to mature defense mechanisms (e.g., humour and suppression).20
We introduce manic defense here. It is a behavior intended to hide from others by forcing oneself
to be cheerful, to laugh, or become excited as if nothing happened, in order to divert the mind from

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Mental health229

c. Sense of control21
The key to overcoming difficult situations is to have the belief that one can overcome them

3. Mental health challenges in Cambodia
1) Externalizing problems and internalizing problems

by changing the surrounding circumstances, or the belief that one can overcome them byreceiving the surrounding circumstances and adjusting them toward a solution. These senses

According to Achenbach, et al., the most common categories describing behavior disorders inare called senses of control. These senses of control are important psychological resources to

psychopathological studies are “internalizing,” in which behavioral problems appear internally, andadapt to developmental challenges and changes in each age group, and have positive effects“externalizing,” in which they are expressed externally22. The American Psychiatric Association’son aspects of life, including health, studies, and work. The former self-initiated sense ofdiagnosis manual also explains that classifying behavior disorders broadly like this is more useful thancontrol is the primary sense of control, which is emphasized in Western societies. Meanwhile,

looking at individual behavior disorders. For example, internalized problem behaviors include anxiety,the harmonious sense of control is the secondary sense of control, which is a sense ofdepression, loneliness/sorrow, despair, suicidal ideation, physical symptoms, and withdrawal, and thesecontrol widely shared by people in East Asia. In the Asian cultural sphere, in order to cope

represent a group of behaviors that are neurotic and excessively suppressed. It has been pointed out thatwith stressful events, it is important not only to aim to change the circumstances to meet one’s

these are frequently seen among girls in elementary, junior high, and high schools and increase their

desires but also to try to adapt oneself to the circumstances to reach a solution in which bothrisks of dropping out of school, using drugs and suicide23. Meanwhile, externalized problem behaviors

are harmonized.

include destructive/aggressive/antisocial behaviors (i.e., acts of violating rules and laws, such as fights,
subversive activities, thefts, and telling lies) and hyperactive behaviors, and these represent a state in

Column: The Western mind and the Asian mind

The concepts of the mind and mental health in psychology and psychiatry have been theorized on

which behavioral suppression is insufficient24. Note that externalized and internalized problem behaviors
coexist and cannot be considered separately because anxiety or depression may be hidden behind
antisocial behaviors.23,24

the basis of traditional Western social culture and modern Western science. Careful consideration

A study of Cambodian-Americans25 states that, although the use of official mental health services asmust be given to determine whether this Western concept of the mind can universally be applied towell as guidance from parents, relatives, friends, and other people are necessary to address externalized

non-Western social cultures, such as those in Asia, India, the Middle East, and Africa. Asia is divided

problems (a 14-year-old boy’s alcohol drinking in this research) and internalized problems (11-year-old

into six areas, i.e., East Asia, Southeast Asia, North Asia, South Asia, West Asia, and Central Asia,

boy’s depression), it is effective for coping with externalized problems to administer punishment, teachand includes people who believe in religions representing various tenets of Buddhism, Islam,manners, and place children in a training facility to discipline them. This view requires attention because

Hinduism, Judaism, and Christianity; therefore, it is better to think that the concepts of the mind andit can create a foundation that allows for physical punishment. To address internalized problems, meanwhile,mental health based on Western values are different from those in Asian countries.

the study recommends letting children do what they like to do and spend their time as they please. It is

Take mindfulness as an example, which has recently been a topic of discussion. It originatesfrom sati, a Pali word used in Theravada Buddhism. In Buddhism, a Western self-centered self-necessary to develop coping methods that are effective in Cambodia by promoting the understanding of
mental health through health education while taking into account Cambodian peoples’ beliefs.

consciousness, which focuses on “me” separated from others (e.g., people and the environment), isdenied, and instead of reducing all events to their elements and viewing them separately, people
recognize that all events are mutually linked to take place and value the overall harmony. They
concentrate on “the present moment” “as it is” with an unbiased mind through specific Buddhist2) Post Traumatic Stress Disorder (PTSD) in relation to the Khmer Rougeand 2nd generation PTSD

practices, including meditation, and strive to reach “a constantly calm behavior (state) of the mind.”
The concepts of the ego and the mind in Asian Buddhist thought are different from those in the West,

It is estimated that approximately one-fifth (approx. 2 million people) of the Cambodian population diedand the healthy state of the mind also widely differs from the WHO’s concept based on a demonstration

because of torture, execution, forced labour, hunger, or disease during the Khmer Rouge era (1975–

of individuals’ abilities as described above.

1979). Even today, about 40 years later, some of the survivors and their children’s generation are still

Note that there is mindfulness as a method for reducing stress, which is separated from religious

suffering from PTSD, physical symptoms, and social maladjustment. A special tribunal, which started

significance and practiced for therapeutic effects. Nevertheless, mindfulness is something that aims

in 2006, is ongoing, and there are concerns over what influences the tribunal can have on Cambodian

for not only individuals’ inner peace but also the peace of the group or the society that surrounds

people. It is suspected that the tribunal may cause the people to reexperience past hardships, retraumatizing

individuals.

those who are seized by anger and a desire for revenge, which may lead to increasing the prevalence of
PTSD among them. In previous studies, the prevalence of PTSD widely ranges from 7% to 86% among
different studies.26

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Hinton, et al.27 created the Cambodian Symptom and Syndrome Inventory (CSSI), a questionnaire

The 2nd generation PTSD due to transgenerational trauma is a concept that considers PTSD as asensitive to Cambodian culture to measure psychological health in order to assess the influences ofresult of traumatic events experienced by parents’ generation affects their children, who did not directly

psychic trauma experiences on Cambodian refugees who fled the massacre perpetrated by the Khmer

experience those events, thus causing psychopathological symptoms. A study of Cambodian families

Rouge (Table 12.2). It is a questionnaire that asks how much they suffered from these symptoms in thehas not clarified the mechanism of PTSD transmitted between generations but has shown that the higher

past four weeks. Respondents are requested to choose from among five ratings: 0 (not at all), 1 (a little

the level of traumatic stress that a mother experienced in her life, the higher the daughter’s PTSDbit), 2 (moderately), 3 (quite a bit), and 4 (extremely). It is shown that among these symptoms, thesymptom rating. Psychic trauma experiences in the Khmer Rouge era are transmitted from mothers tosymptom of “13. thinking too much” (kut caraeum) among the “syndromes” is a key indicator of distress,

daughters, and therefore, not only caring for mothers suffering from PTSD but also providing mental

and those with higher scores of this indicator tend to have higher DSM-IV PTSD scores. People with thishealth care for their children is an important issue for Cambodia.

symptom think too much about upsetting topics, past traumatic events, and death of/separation fromloved ones. “Kut caraeum” may lead to physical symptoms such as headaches, dizziness, “wind attacks,”
depletion of bodily energy, heart weakness, and memory loss.
Table 12.2 Contents of the Cambodian symptom and syndrome inventory (CSSI)

Somatic symptoms

  1. Dizziness  2. Standing up and feeling dizzy3. Blurry vision
4. Tinnitus
5. Headache
6. Neck soreness7. Palpitations
  8. Shortness of breath
9. Chest tightness
10. Rising sputum
11. Stomach bloating/discomfort
12. Cold hands and feet
13. Numbness in the arms and feet
14. Sore arms and legs
15. Trembling of the arms and legs
16. Weakness
17. Poor appetite
18. Feeling of lightness in the bodySyndromes

Somatic-focused syndromes
1. Khyâl attacks
  2. Standing up and feeling poorly to the point you feared
fainting, khyâl overload, or heart attack
3. Neck soreness to the point you feared the neck vessels
would burst
  4. “Heart weakness”
  5. Sputum moving upward and causing you to feel you
couldn’t breathe or might have a heart arrest
6. Khyâl hitting up from your stomach, making you fear you
might die of asphyxia
  7. Fear of “death of the hands, death of the arms” (slap day
slap ceung)  8. Excessive inner hotness (kdaw khnong)
9. Having a partial or full malaria attack
10. Out of energy to the point you feared having a khyâlattack or dying from depletion
Agoraphobia/motion-sickness syndromes
11. “Poisoned by cars” (pul laan)
12. “Poisoned by people” (pul meunuh)
Emotion-focused syndromes
13. “Thinking too much”
14. Toxique
Cognitive-capacity syndrome
15. Forgetfulness/mental distraction (phluc pheang)
16. Light in the body as if your soul was not in your body
17. Fear that someone has sent an ampuu into your body
18. Fear of having low spiritual luck (rieusuy), high bad luck
(krueh)19. “Ghost pushing you down” (sleep paralysis)

This table cited from “Hinton et al., The relationship of PTSD to key somatic complaints and cultural syndromes among Cambodian
refugees attending a psychiatric clinic: The Cambodian Somatic Symptom and Syndrome Inventory (CSSI). Transcultural Psychiatry.
50:347-370. 2013.”
Copyright@2013,SAGE Publications. All rights reserved. Translated with permission.

2323) Bullying, violence, and harassment
a. Bullying
According to the 2013 Global School-based Student Health Survey (GSHS),28 the percentages of
elementary, junior high, and high school children who were bullied at least one day in the past 30 daysin Cambodia were 22.4% for those aged 13 to 15 years and 22.3% for those aged 16 and 17 years, withno marked difference between the sexes. In this study, bullying was defined as follows: “Bullying occurs
when a student or group of students say or do bad and unpleasant things to another student. It is also
bullying when a student is teased a lot in an unpleasant way or when a student is left out of things on
purpose. It is not bullying when two students of about the same strength or power argue or fight or when
teasing is done in a friendly and fun way.”
UNICEF Cambodia29 defines these three points as characteristics of bullying: an intentional(malicious) act that causes physical or psychological pain; a patterned, repeated behavior; and an attackby a stronger child. It recommends parents and teachers observe children by paying attention to thepoints below so that they will not miss any signs of bullying.
i) Physical marks such as unexplained bruises, scratches, broken bones and healing woundsii) Fear of going to school or joining school eventsiii) Being anxious, nervous or very vigilantiv) Having few friends in school or outside of schoolv) Losing friends suddenly or avoiding social situationsvi) Clothing, electronics or other personal belongings being lost or destroyedvii) Often asking for moneyviii) Low academic performanceix) Absenteeism, or calling from school asking to go homex) Trying to stay near adultsxi) Not sleeping well and having nightmaresxii) Complaining of headaches, stomach aches, or other physical ailmentsxiii) Regularly distressed after spending time online or on their phone (without a reasonable
explanation)xiv) Becomes unusually secretive, especially when it comes to online activitiesxv) Being aggressive or having angry outbursts
Chapter 12

Mental health233

substantial damage to Cambodian society35. In response, teachers have begun to receive training to learn
Recently, cyber bullying has become an issue not only in Cambodia but also around the world. The

educational methods that do not use violence in correcting children’s behaviors and managing classes

Mobile Phones and Internet Use in Cambodia 201630 reports that 48% of people access the internet or

and how to build good relationships with children. Teachers in Cambodia are strongly required to serve31

estimates that 8.86 million (54.2%) of theas mentors of children and guide them in the right direction, build relationships in which children are

country’s population (16.83 million, as of January 2021) are internet users, indicating that about half ofrespected, and understand different characteristics of children at different developmental stages (seethe total population use the internet. The spread of social media creates new forms of bullying, violence,

Chapter 3).

Facebook. In the meantime, the Digital 2021 Cambodia

and harassment. According to a five-week public-opinion poll conducted by UNICEF, 85.7% ofCambodian youths aged 15 to 25 years are exposed to the risks of online violence, cyberbullying, anddigital harassment.32 To address this situation, UNICEF has requested the Cambodian government4) Loneliness, anxiety, and depression

develop new policies for protecting children from bullying and violence using cyber means such as SNS.
In UNICEF’s study,33 the definition of cyberbullying is as follows:

According to a study of people aged 21 and older across Cambodia, conducted using the Hopkins“Cyberbullying is bullying with the use of digital technologies. It can take place on social media,

Symptom Checklist-2536 in 2011, the percentage of people with high anxiety symptom scores (referred

messaging platforms, gaming platforms, and mobile phones. It is repeated behavior, aimed at scaring,to as “anxiety”) was 18.35% for men and 31.72% for women, which represented a statistically significant

angering, or shaming those who are targeted. Examples include: spreading lies about or posting

difference between the sexes; and the percentage of people with high depression symptom scores

embarrassing photos of someone on social media, sending hurtful messages or threats via messaging(referred to as “depression”) also showed a difference between the sexes, with the percentages being

platforms, impersonating someone and sending mean messages to others on their behalf.”

10.21% for men and 19.69% for women, indicating that the percentages of anxiety and depression are

The study points out that cyberbullying has an impact on children psychologically (feeling upset,higher in women. Interestingly, in both psychological symptoms, no difference was found between

embarrassed, stupid, even angry), emotionally (feeling ashamed or losing interest in the things youurban and rural areas, but there was a difference with regards to educational background. The percentages

33love), and physically (tired (loss of sleep), or experiencing symptoms like stomach aches and headaches).

of anxiety and depression were higher in those with lower education, and among those with no education,

Although it is not easy to prevent bullying, it is important, first of all, for children to understandthe percentages of anxiety and depression were 32.51% and 20.37%, respectively. In the general“what constitutes bullying” and not to blame themselves for being bullied. Children who are being

population, women with low education are presumed to be at high risk.

bullied as well as those around them should say that bullying has occurred and tell adults. In addition,

Meanwhile, in the results of the GSHS-2013 Cambodia, which surveyed elementary, junior high,the adults and children around them need to create a safe classroom and school environment where

and high school children, 49.0% “sometimes” feel loneliness, 4.8% feel it “most of the time,” and 0.9%

bullying is not acceptable. In the current situation of most schools in Cambodia, the awareness and“always” feel it. This indicates that 54.7% of the children feel loneliness sometimes or more frequently.

support of teachers and friends is essential as there is still no school counsellor. It is important to

A comparison of this percentage with the GSHS results of the neighbouring countries Laos (32.8%) andrecognize that not only children who are being bullied but also those participating in bullying might beVietnam (44.5%) shows that the percentage of children who feel loneliness is higher in Cambodia by

suffering from mental problems and seeking help.

10%–20%. However, there was no marked difference in the percentage of those who answered that the
number of close friends is 0, which was 5.0% for Cambodia, 4.8% for Laos, and 5.5% for Vietnam.

b. Violence against children by teachers

Loneliness itself is something that everyone sometimes feels and not a mental health issue. Nevertheless,
34

The 2013 Cambodia Violence against Children Study reports increasing violence against children in

Cambodian children, who feel loneliness more frequently than their counterparts in neighbouring

Cambodia. With regard to children aged 13 to 17 years, the percentage of those who have experienced

countries, might be at higher risk of depression, anxiety, low self-esteem, sleep disorder, self-mutilation,

physical violence was 58.2% for boys and 61.1% for girls, and approximately 68% suffered violence forand suicide.

the first time between the ages of 6 and 11 years, that is, during their elementary school age. Outside

The results of the GSHS-2013 Cambodia28 also shows that 42.4% of the children “sometimes” hadhomes, violence is used by teachers. Concerning physical violence used against girls aged 13 to 17

the experience of “being unable to sleep at night because of worries,” 5.0% had it “most of the time,”years, 58.6% of the girls suffered violence from male teachers and 20.5% from female teachers; as forand 1.0% “always” had it. This distribution is similar to that of loneliness, and 48.4% of the children

boys of the same age, the percentages were 51.7% and 18.0%, respectively.

experienced sleeplessness because of worries sometimes or more frequently. In a study conducted in

Bullying mentioned above as well as violence by adults are thought to be two of the most stressful

Laos using the same items, “sometimes” was 29.9%, “most of the time” was 3.9%, and “always” waslife events to which children are exposed. UNICEF estimates that children who experience violence will

1.1%, which totaled 34.8%. This is lower than the percentage in Cambodia by approximately 15%.

be subject to long-term negative effects on their intellectual, physical, and emotional development,

These results suggest that the mental health of Cambodian children is poorer than that of their counterparts

which can result in a decline in labor power in the future and an economic loss of US$168 million

in neighbouring countries.

(accounting for 1.1% of the GDP in 2013), and points out that violence against children will cause
234

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Mental health2355) Suicide attempts, suicide

how to send out an SOS and seek help, and learning the importance of life. In addition, one possible
suicide prevention measure is to provide training for teachers so that they can learn how to listen to

Suicide not only takes the life of a person but also constitutes a public health issue that can have a deep

children and have a receptive attitude. It is also important to create a system that allows children to

influence on the family and people around the person, as well as the school and the region. The suicideconsult with adults in school, the community, and through SNS as an effort of society. At the same time,

rate (the number of people who committed suicide per 100,000 population) in Cambodia for men was

adults, including teachers and guardians, must pay careful attention to the fact that SNS may include

6.2 in 2000, which slowly increased to 8.0 in 2007 and then gradually decreased to 7.0 in 2019. The rate

information that induces suicide.

37

for women, meanwhile, decreased every year from 3.9 in 2000 to 2.8 in 2019 (Figure 12.3). The 2019

In suicide prevention measures, although individual measures are also important, the key is theglobal average suicide rates are 12.58 for men and 5.68 for women, and Cambodia’s suicide rate appears

whole school approach, in which the entire school considers the health of children as a whole andto be substantially lower than the global level. However, there is a previous study that reported a highcreates a healthy and supportive school environment (e.g., curriculums, school management policies,

suicide rate of 13–44 per 100,000 population,26 and this warrants a highly accurate epidemiologicalcaring relationships, school culture and value, and the leadership of management and teachers) as

study of suicide and statistics.

explained in Chapter 1.
28

Concerning suicidal ideation and suicide attempts of young people, the GSHS-2013 Cambodia

shows that the percentage of those who seriously considered committing suicide during the past year is6.4%, those who made a suicide plan was 8.8%, and those who made a suicide attempt was 6.7%. These
children are at high risk of committing suicide in the future.
There are many possible psychological circumstances that may push children into suicide. Suchcircumstances are as follows:

Column: Whole school approach

The whole school approach is thought to be the most effective health promotion method in whichchildren, teachers and other staff of the school, guardians, and community members collaborate at
the school in order to change the present situation of the school and improve the health and well-i) loneliness and isolation, which make them feel that they cannot trust anyone and are helpless;being of all the people. The whole school approach is characterized by, first of all, its perception thatii) a feeling of worthlessness, which makes them think it is not worth living;a school is the aggregate of many systems that depend on each other. The second characteristic is,iii) unfocused intense anger because they cannot blame anyone for their sufferings and cannot

therefore, efforts by all related people, who collaboratively participate in the process for changing

solve them;iv) an assumption that their sufferings will never end and a feeling of despair; and as a result,the school to improve the health and well-being of all the people related to the school who change
the system of the school as a whole by capitalizing on the resources and strengths of everyone.

v) psychological visual field constriction, which makes them preoccupied with suicide as the only
solution.
As measures to counter suicide, there are prevention and postvention. Prevention means building(person)

9.0

relations with those who are close to children in daily life and who notice these changes; those who talkof health room teachers (like a school nurse) and school counsellors, are not in place, and therefore, it isnecessary to train general teachers to listen to children receptively and supportively, as training to
improve the quality of teachers.
Meanwhile, because one person’s suicide can trigger a chain reaction or cluster of suicide, postvention
aims to carefully observe children who are shocked by someone’s suicide and depressed, as well as those
who are feeling guilty about someone’s suicide, and to consult with them to create an atmosphere inwhich they can easily talk. A triggering suicide is the suicide of someone such as a celebrity, like anactor, a person of the same age with the same trouble, a family member, a boyfriend or girlfriend, or aclose friend. The principal and teachers are required to deal with the family of the child who committed
suicide, and students in the same school and their guardians. In dealing with these people, it is necessary
not to glorify or criticize the suicide and to be considerate to prevent the family of the deceased from
suffering the stigma of suicide.
In school classes, health education can be provided, which includes methods for coping with stress,236

mortality rate per 100,000

In many schools in Cambodia, systems that allow children to convey their worries, including allocation

Male suicide rate

8.0

to them, and who are easy to talk to about their worries; and building relationships of trust with teachers.

7.0

Female suicide rate

6.0
5.0
4.0
3.0
2.0
1.0
0.0

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19
20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

YearThis figure is created based on data obtained from The World Bank. Suicide Mortality Rate, Cambodia.
Male:https://data.worldbank.org/indicator/SH.STA.SUIC.MA.P5?end=2019&locations=KH&start=2000&view=chart
Female:https://data.worldbank.org/indicator/SH.STA.SUIC.FE.P5?end=2019&locations=KH&start=2000&view=chart

Figure 12.3 Mortality rate caused of suicide (per 100,000) in Cambodia
Chapter 12

Mental health237

Column: Loss and grief, and grief care

physical dependence.
For information, the number of abusers of major drugs (amphetamine/methamphetamine [stimulants],

There are various events in life that may include suicide, disasters and accidents, diseases, andcannabis, heroin, and narcotics) in Cambodia is estimated to exceed 2% of the population (for theunemployment, and we may be overwhelmed by sorrow when we lose loved ones, such as family

1998–2004 period), which makes the country one with the highest drug abuser rates in the Asia-Pacificmembers or someone close to us, or things that are important to us; or when we become ill or

region, which includes Hongkong, the Philippines, Thailand, Indonesia, Laos, and Malaysia.26

disabled and lose our health. The psychological (e.g., denial, depression, anger, sorrow, anxiety, andThose who develop dependence need to receive medical care to treat their physical symptoms instead

helplessness), physical (e.g., fatigue, sleep disorder, anorexia, and autonomic imbalance), and socialof trying to cure them on their own. A self-help group, which supports mental health, is effective at(e.g., withdrawal, isolation, and increased alcohol drinking) reactions we experience when we losechanging behaviors of dependence and addiction. Therefore, Cambodia is expected to set up self-help

loved ones are called grief reactions. These are normal reactions to loss; if we suppress sad feelings,

groups on various addictions.

we will suffer from psychological difficulties for a prolonged period, making such difficulties evenharder to overcome. Grief is a long process, from the occurrence of an event to healing, and thisprocess is called grief work. In the grief care part of this grief process, the most important thing is
to respect and sympathetically listen to, as a person, the story of the person who is suffering fromtotal (i.e., psychological, physical, social, and spiritual) pain. We must refrain from easily encouraging,

4. Common mental diseases (schizophrenia and epilepsy)
1) Schizophrenia

persuading, or curing such a person.

Schizophrenia is one of the most common chronic mental diseases, affecting 7 to 10 people per 10006) Addiction and dependence

population irrespective of differences in backgrounds such as society, culture, and ethnicity, and which
can develop severe chronic psychological symptoms. The WHO estimates that 20 million people areaffected by schizophrenia around the world.38 Since no epidemiological study of schizophrenia has been

People can be dependent on various things besides alcohol. Dependence can broadly be divided into

conducted in Cambodia, the approximate number of patients, including those untreated and treated, isdependence on chemical substances (e.g., alcohol, cigarettes/nicotine, caffeine, amphetamine, narcotics,

unknown. It has been reported that due to insufficient social understanding of the disease and psychiatricstimulants, and cannabis), which is substance dependence, and dependence on behaviors (e.g., eating

care, it takes 47 months for patients to start treatment.39

disorder/overeating, gambles, games, internet, sex, and shopping/waste), which is behavioral addiction.

Disorders resulting from schizophrenia appear in thinking, recognition, emotions, language, self-

Dependence is caused by changes in the functions of the brain, mind, and body due to the habitual use

consciousness, and behaviors, and typical symptoms include delusion (e.g., being monitored byof a chemical substance, including alcohol and cigarettes, or a repetition of a behavior, such as gamblingneighbours), hallucination (e.g., hearing someone talking when no one is there), disorders of consistency

or games. Taking alcohol or engaging in a gambling activity gives the experience of enjoyment and ain conversation and behavior, lack of emotion or motivation, disorder of ego (one’s idea is known togood feeling and stimulates a circuit in the brain called the reward system that transmits pleasure. The

others), and loss of insight into disease. Therefore, in addition to the suffering of the patient, the familybrain releases a neurotransmitter called dopamine that enhances this pleasure, creating a strong desire tomembers taking care of the patient bear a heavy burden and are likely to be discriminated against by

experience this pleasure again. The desire to repeatedly experience this pleasure is satisfied, and whenpeople around them. The disease tends to manifest in a person’s late teens to thirties, and although thethe drug use behavior is repeated, resistance develops because the same stimulus will no longer haveexact cause is unknown, a study of twins reported that the probability of a pair of twins developing

the same effect as what was previously obtained from the drug or behavior. In this way, repeating drug

schizophrenia is 50%, suggesting that it may be related to heredity, the rearing environment, and sharedingestion or gambling change the functions of the brain, mind, and body, resulting in dependence.

experience of stressful events.

Therefore, in dependence, a condition in which the functions of the brain and body have been changed,
the behavior cannot be stopped by one’s own will.
There is psychological dependence and physical dependence. The former is, for example, the

The WHO points out that schizophrenia can be treated or cured, but for that, drug therapy,
rehabilitation (e.g., life skills training, social skills training), and acceptance by the community areimportant.

behavior of searching for a cigarette to get it when the person feels tempted to smoke, and the latter is,in the case of tobacco dependence, a condition in which withdrawal symptoms, such as irritation andhand tremors, occur when the nicotine concentration in the body decreases. In the case of alcohol

2) Epilepsy

dependence, autonomic nerve hyperactivity (e.g., sweating, hand tremors, elevation of blood pressure,and tachycardia) and psychological symptoms (e.g., hallucination, irritation, anxiety, and excitation) can

Like schizophrenia, epilepsy is a general mental disease, and according to the WHO,40 approximately 50

appear. Note that not all chemical substances that cause substance dependence necessarily result in

million people are suffering from the disease around the world, with 80% living in low-middle income

238

Chapter 12

Mental health239

countries without receiving treatment. The prevalence of epilepsy in Cambodia is estimated at 5.82) Counselling, mental health services

persons per 1000 population and reported to be lower than that in neighbouring countries such as Laos
(7.7/1000 persons), Vietnam (10.7/1000 persons), and Thailand (7.2/1000 persons).41

Globally, mental health issues are increasing, as are needs for counselling and mental health services.

Epilepsy is a disease characterized by recurrent “epileptic seizures” that cause a person to become

However, systems are insufficient in low- and middle-income countries, and particularly Cambodia,

unconscious and unresponsive suddenly. Symptoms are transient and subside if “epileptic seizures”

where mental health services and psychiatrists suffered devastating damage during the Khmer Rouge

disappear. However, a person may be injured depending on the place where the person collapses afterera, lagging far behind in this field. Moreover, mental health receives a lower policy priority than public

losing consciousness due to a seizure, so that it is important to reduce the frequency of seizures.

hygiene challenges such as infectious diseases and lifestyle diseases; the challenge is to give a higher

The disease is said to occur at any age but is particularly frequent in children and elderly people.

policy priority in light of the present situation of mental health in Cambodia.26

The causes of epilepsy can be identified in some cases, which include a brain tumour and a posttraumatic

Meanwhile, regarding the question of whether counselling is really effective in Cambodian society,cerebral symptom, but they are unclear in other cases. Because about 70% of the afflicted can lead ait has been pointed out that building a healing relationship between an individual and a counsellor

normal social life by receiving a proper diagnosis and taking antiepileptics, there is no need to excessively

through “talking and listening” is effective in Cambodia as well. For counselling and mental healthrestrict school attendance and work. Despite this fact, many people suffering from epilepsy are subject

services to be in place, the challenges need to be addressed first, which includes the spread of education

to stigma and discrimination.

and knowledge on mental health, the human resource development of professionals (i.e., psychiatrists,
nurses, clinical psychologists, and social workers) and subprofessionals (e.g., general practitioners,

5. Mental health care
1) Help-seeking behavior

teachers, and community/health workers), as well as the improvement of the quality of training, and theimprovement of the quality of mental health services as well as the elimination of the gap between urban
and rural areas.26
Counselling basically requires active listening skills, the ability to reflect on one’s own thinking andemotions, and the power to accept human diversity. Listed below are the 11 points that teachers should

According to a survey of 391 high school students in Grades 10 and 11 in Phnom Penh and the Prey

keep in mind support children with a mind adequate to counselling. Nevertheless, teachers are not

Veng province, which investigated help-seeking behavior, the person(s)/information source(s) frommental health professionals and should fully understand their limitations.

whom/which they most frequently seek help to cope with their personal and emotional problems were,i) Do not try to elicit a solution or answer to the problem.

as a whole, their mothers (74.4%) and friends (73.9%), followed by fathers (51.4%), other relatives orii) Create a receptive and relaxed atmosphere, and accept the child’s feelings.

family members (38.9%), internet chat rooms (29.9%), teachers (28.9%), their boyfriends/girlfriendsiii) Ask open questions. Do not interrogate.

(19.2%), and information on the internet (18.7%). Mental health professionals, doctors, and telephoneiv) Wait for the child’s answer as long as possible, and endure silence.

counselling were around 8 to 11%, indicating that these are not as accessible as informal informationv) Use the child’s words to convey the message that you “understand” them.

sources. Religious figures were also chosen by about 10% of the students as persons from whom theyvi) Express a positive interest in the child.

seek help.

vii) Show a natural, reasonable empathy.

This result shows that family members, students, and teachers are likely to be chosen as persons toviii) To clarify the feelings of the student, use or appropriately paraphrase the child’s words.

whom they talk about their mental health problems, including anxiety and depression, and therefore,ix) To organize issues, summarize the story.

efforts for mental health education in communities and schools are important. In addition, since they usex) Look at the problem from the child’s perspective and seek meaning from that perspective.

the internet to search for information about mental health and persons from whom they seek advice,xi) Believe in the child’s abilities to grow and solve problems.

creating an internet website that provides accurate information about mental health is also a goal. (SeeTPO Cambodia, https://tpocambodia.org/tips-for-good-mental-health/, etc.)
High school students’ help-seeking behaviors differ between the sexes and among regions. It is

Exercises for further thought and research

noteworthy that boys are more likely to use internet chat rooms and websites to seek information and[12-1] What does it mean to have a healthy mind?

help than girls are, and that high school students in rural areas seek advice from teachers more frequently[12-2] Research the defense mechanism of the mind by referring to resources such as Britannica: Defense

than those in urban areas do. This suggests that teachers play a greater role in rural areas with poor

mechanism (https://www.britannica.com/topic/defense-mechanism). Discuss what kind of

mental health resources and thus are required to receive education/training on counselling.

defense mechanism is commonly used in Cambodia. Research mature psychological defense
mechanisms in particular.
[12-3] What is a mechanism by which the mind and the body are mutually affected?

240

Chapter 12

Mental health241[12-4] What influence does stress have on mental health?
[12-5] What are challenges in mental health in Cambodia? Discuss how they should be addressed.
[12-6] Give examples of internalized and externalized problem behaviors. Summarize what you think
about how to respond if a child seeks advice on such mental health problems, and discuss this
topic in a group.
[12-7] Discuss the reasons for and the backgrounds behind teachers’ use of physical punishment in the
education of children. How can you guide children without relying on physical punishment?
Exchange ideas for alternatives.
[12-8] Consider the person you will seek for help first when facing a personal problem, and why you
chose that person.
[12-9] Reflect on your experiences of being asked by your friends and family members about how theyshould address their problems, and review whether you practiced the points for supportive
listening.

16 Dubois V, Tonglet R, Hoyois P, Sunbaunat K, Roussaux J-P, et al., Household survey of psychiatric morbidity in Cambodia.
International Journal of Social Psychiatry. 50:174-85. 2004.
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postconflict settings. Journal of American Medical Association. 286:555-562. 2001.
18 Sonis J, Gibson JL, de Jong JTVM, Field NP, Hean S, et al. Probable posttraumatic stress disorder and disability in Cambodia:
associations with perceived justice, desire for revenge, and attitudes toward the Khmer Rouge trials. Journal of American Medical
Association. 302:527-536. 2009.
19 Agger I. Calming the mind: Healing after mass atrocity in Cambodia. Transcultural Psychiatry 52:543-560. 2015.
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23 Liu J, Chen X, Lewis G. Childhood internalizing behavior: analysis and implications. Journal of Psychiatric and Mental HealthNursing. 18: 884–894. 2011.
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25 Deley TC. Beliefs about treatment of mental health problems among Cambodian American children and parents. Social Science andMedicine. 61;2384-2395, 2005.
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