How not to get lost in translation. Going abroad to help establish education in psychiatry

Edvard Hauff
Jan 3, 2018
12 min read

Updated: 9 minutes ago

When Khmer Rouge’s terror regime in Cambodia was ended in 1979 there were no mental health psychiatrists in the country, and no mental health services. The Norwegian Council for Mental Health initiated an educational program for psychiatrists in Cambodia, which was managed by the University of Oslo in collaboration with the International Organization for Migration and the Cambodian Ministry of Health. Norwegian psychiatrists participated for six years in the training of the doctors as well as in the early establishment of psychiatric services. Which challenges did we meet? How was it possible for us to contribute in a meaningful way to the implementation of this transcultural and transnational project?

Introduction

Nearly 15% of years of life lost are attributed to mental disorders globally, and this is one of the largest causes of disability worldwide (1). Spending on mental health services is very low in low-income countries, and the training of mental health personnel is critical to build capacity in recognizing and treating persons with mental illness. The Norwegian Council for Mental Health (NORCOM, Rådet for psykisk helse) addressed this problem when they conducted a national telethon in 1992. A part of the income from the telethon was earmarked for international projects. The International Organization for Migration (IOM) was consulted in this connection, and IOM recommended NORCOM to fund psychiatric education in Cambodia. The Norwegian Ministry for Foreign Affairs (UD) and NORAD later took over the funding. The Cambodian Government had appealed to the international community for assistance in re-establishing a national health care system, which was destroyed during the Khmer Rouge reign 1975-1979. The only psychiatric hospital was closed, and probably used as a torture center (personal communication). Less than 50 out of 100 medical practitioners survived, and none of the mental health professionals. The country had an acute need for such personnel to plan and initiate mental health services. Considering this, NORCOMH and IOM decided to collaborate with a project to try assist the Cambodian government in the field of mental health. The Psychosocial Centre for Refugees at the University of Oslo (UIO) was asked to manage a project, which was called the Cambodian Mental Health Training Program (CMHTP) (2).

When Khmer Rouge’s terror regime in Cambodia was ended in 1979 there were no mental health psychiatrists in the country, and no mental health services. The Norwegian Council for Mental Health initiated an educational program for psychiatrists in Cambodia, which was managed by the University of Oslo in collaboration with the International Organization for Migration and the Cambodian Ministry of Health. Image by Unsplash.

How did we start, and what did we expect?

Previously training of psychiatrists for low-income countries had mostly been conducted in former colonial powers and in some other high- income countries. When discussing the project with WHO, IOM and other experts, a few of the experts argued that it was too early to establish such a project in this early phase of rehabilitation of the country, while the majority were supportive. However, there was also an academic discussion internationally, where some colleagues argued that such projects represented a “Western” approach to mental health which was not culturally appropriate (3). It soon became clear to us that it probably would be better to provide psychiatric training of mental health professionals in the country where they were going to practice. Medical doctors were the most established profession to prioritize, while we hoped that other professions would eventually follow. None of the Norwegian psychiatrists involved in the project had previously lived in Cambodia, but we were highly motivated to meet the challenge. However, it helped that the project manager (EH) had previously been a WHO temporary advisor in Southeast-Asia and had worked clinically with Khmer refugees living in refugee camps. Considering the positive feedback from the consulted parties, we decided to organize two planning workshops, inviting national and international participants who had relevant experience and opinions. After fruitful discussions in the workshops, it was decided to establish a training program inside Cambodia. The program should have a community mental health orientation, but the curriculum had to be developed. A professor of Psychiatry from Sri Lanka accepted to be the main external evaluator of the project.

The Cambodian Mental Health Training Program, (CMHTP) started the specialization training in psychiatry in 1994 after ten candidates were recruited the three years as planned, with nine males, and only one female.

There was a need to establish a psychiatric outpatient clinic, to provide a training ground, as well as to serve patients. it was important for us to implement it without further delay, considering the overwhelming needs in the community. A major hospital in Phnom Penh which at that time was called the Khmer-Soviet Friendship Hospital was willing to allocate space and take overall responsibility for the out-patient clinic. The name of the hospital was later changed to Preah Norodom Sihanouk Hospital. It was decided to recruit 10 physicians to join the program, hoping that some of them would manage to complete a three-years specialization course so that they could serve as the future planners and managers of a mental health, care system in the future. We prioritized younger doctors with general medical experience, from different provinces, The rationale for this was a hope that they in the future would practice in their provinces and not only in the capital. We succeeded in doing this, but one of the participants was more senior (Professor Ka Sunbaunat), working in the Faculty of Medicine, University of Health Sciences. His participation represented an important link to the Faculty, where we also hoped to include a psychiatry course in the medical school. The supervisors were senior Norwegian psychiatrists with previous international and transcultural experience. We planned that they should serve for a period of one year and be present every day in the clinic. Thus, there were challenges regarding language. The Faculty of Medicine used French as the teaching language while the daily language was Khmer. Considering that the supervisors and teachers were not fluent in any of these languages, the Faculty of Medicine supported us in using English for training purposes, and CMHTP provided a course in English for the residents to brush up their competency in English.

What was achieved?

The Cambodian Mental Health Training Program, (CMHTP) started the specialization training in psychiatry in 1994 after ten candidates were recruited the three years as planned, with nine males, and only one female. We tried to recruit more women, but we were not successful at that time. Fortunately, subsequent batches of residents included more women. It became obvious that the participants needed a small stipend to afford the training, and these were channeled through IOM. It is doubtful if the program could be completed without these moderate stipends, especially in the early phase when they had limited other income. A proposal to reduce the size of the stipends created a lot of anxiety!

The training was problem-based, and the residents started to see patients immediately. The clinical work took place in the mornings, followed by presentation and discussion of findings. In the afternoons they had lectures and self-study. The clinical activities were experiences as highly meaningful and needed. There was no referral system in the country and the patients came to the clinic by recommendations and information from other patients, and sometimes from colleagues in other fields. There was a small consultation fee for the first visit. The curriculum was based on psychiatric curricula internationally, especially from South-East Asia. It was flexible in order to include components of particular contextual importance in Cambodia, emphasizing topics that the residents found to be culturally relevant. Culturally important understanding and treatment of traumatic stress was obviously especially important, not long after the Khmer Rouge terror – addressing the consequences of the trauma on individuals, families and the society. The supervisors had expected that the residents frequently would refer to traditional healing and idioms of distress, but this was not so common. Initially they seemed primarily to use a bio-medical model for understanding of the patients’ suffering. They were obviously not used to academic discussions and critical thinking and were careful not to challenge the supervisors directly. The reductionist bio-medical approach was challenged by the supervisors when trying to understand patients from the point of view of transcultural psychiatry as well as by a bio-psycho-social and contextual understanding. They were for example aware of traditional healing practices, for example of the cultural idioms of wind imbalance, like kyol geu (3), which means wind overload. They also diagnosed spirit possession among the patients in the clinic, and this is a cultural phenomenon that the Khmer population is familiar with. However, the residents did not seem inclined to collaborate with the traditional healers, the Kru Khmer. In line with WHO’s advice, we also tried to encourage such contact, but without much success. The candidates appeared to see them as competitors and were critical about some of their practices. Considering the central belief in Karma, they frequently advised patients to go to the pagoda to receive the healing practices there, especially patients with mild to moderate depression and anxiety.

It became clear that it was difficult to manage the out-patient clinic without possibility to admit any seriously ill patients for in-patient treatment. Eventually the hospital allocated a couple or rooms for short-term treatment of in-patients. The residents obtained experience by working in this unit, but they needed more experience with in-patient treatment. This was addressed by establishing collaboration with Chao Praya hospital in Bangkok, which received the residents for a three-moth training in inpatient treatment.

There was also successful collaboration with other programs and organizations. All the residents received important clinical experience in child psychiatry by visiting a foreign NGO conducting such a program in an area not far from Phnom Penh. Considering the community psychiatry orientation of the program, we managed to establish a good working relationship with the NGO “Social Services of Cambodia (SSC)”. This NGO was working in particularly deprived areas also outside the capital, and the residents accompanied the social workers on their field trips to such villages. The residents were motivated to participate in these trips, despite presence of pockets of surviving units of Khmer Rouge in the vicinity. This was a mutually useful collaboration, since the NGO also referred persons in need of psychiatric assessment and treatment to the clinic. Furthermore, we managed to establish a psychosocial rehabilitation center near the hospital clinic. This was primarily used for patients with serious mental illness who needed to improve their social functioning and integration in their families and neighborhoods. The Municipality let us use an old wooden building and different activities were established in collaboration with SSC, such as cooking, sowing and hair dressing. With the assistance of WHO a center for the treatment of Substance abuse and the residents also received teaching in this field.

Theoretical activities

We decided to provide an element of more focused in-depth teaching by organizing three teaching blocks every year. They were full time courses of two weeks each time, and contained all the components of a psychiatric curriculum, among them psychopathology, psychotherapy, psychopharmacology and child -and adolescent mental health. After each teaching block there was an examination. These teaching blocks were quite similar to the “grunnkurs” in the residency training in Norway. The residents appeared to really appreciate the theoretical courses. In addition to the Norwegian psychiatrists, the lecturers were experienced academics and senior clinicians from the region, including Thailand, The Philippines, Malaysia and Hong Kong.

In addition, all the residents had to write a thesis which accounted for partial fulfillment of the Faculty of Medicine’s requirement to be recognized as a medical specialist. This was a major undertaking, and the residents worked hard to accomplish this, but all of them finished in time. They received supervision from the resource persons who had been teachers and supervisors in the training. Later the psychiatrists completed various academic activities. For example, one wrote an internationally acclaimed PhD (4), and another colleague became a major planner in the MOH (5).

Success factors

Since all the ten residents were able to complete their training in time indicates that the project may be described as a success. Furthermore, all the activities conducted through the project eventually were taken over by the national authorities and institutions, which was a long-term strategic goal when we started. The psychiatrists continued to share their skills and knowledge with subsequent batches of psychiatric trainees, as well as teaching mental health to other health professionals and students in the following years until now. There has been a particular emphasis on providing training in mental health for primary health personnel, and 296 medical doctors and medical assistants as well as 627 nurses, have been trained, (2020 figures). There was an additional new program after the CMHTP called the Cambodian Mental Health Development program (NMHP) which was managed by IOM in collaboration with the University of Oslo. This program focused more on developing mental health services in different parts of the country. Thereafter the government took more responsibility for country-wide treatment and training in mental health and psychiatry and established a national program (NPMH) in 2004. A department of mental health and substance abuse was established in the Ministry of Health in 2014. Now the education of psychiatrists in Cambodia is completely managed by the university and national authorities. According to the MOH there were 97 psychiatrists in the country in 2022 (5). In retrospect the initial program thus gave rise to a wide variety of activities where the psychiatrists had a leading role. They were willing and able gradually to expand their models of understanding to a more diversified model with integration of community psychiatry with more explicit transcultural aspects.

Theme: Lost in translation

When Khmer Rouge’s terror regime in Cambodia was ended in 1979 there were no mental health psychiatrists in the country, and no mental health services. The Norwegian Council for Mental Health initiated an educational program for psychiatrists in Cambodia, which was managed by the University of Oslo in collaboration with the International Organization for Migration and the Cambodian Ministry of Health. Norwegian psychiatrists participated for six years in the training of the doctors as well as in the early establishment of psychiatric services. Which challenges did we meet? How was it possible for us to contribute in a meaningful way to the implementation of this transcultural and transnational project?

Introduction

Nearly 15% of years of life lost are attributed to mental disorders globally, and this is one of the largest causes of disability worldwide (1). Spending on mental health services is very low in low-income countries, and the training of mental health personnel is critical to build capacity in recognizing and treating persons with mental illness. The Norwegian Council for Mental Health (NORCOM, Rådet for psykisk helse) addressed this problem when they conducted a national telethon in 1992. A part of the income from the telethon was earmarked for international projects. The International Organization for Migration (IOM) was consulted in this connection, and IOM recommended NORCOM to fund psychiatric education in Cambodia. The Norwegian Ministry for Foreign Affairs (UD) and NORAD later took over the funding. The Cambodian Government had appealed to the international community for assistance in re-establishing a national health care system, which was destroyed during the Khmer Rouge reign 1975-1979. The only psychiatric hospital was closed, and probably used as a torture center (personal communication). Less than 50 out of 100 medical practitioners survived, and none of the mental health professionals. The country had an acute need for such personnel to plan and initiate mental health services. Considering this, NORCOMH and IOM decided to collaborate with a project to try assist the Cambodian government in the field of mental health. The Psychosocial Centre for Refugees at the University of Oslo (UIO) was asked to manage a project, which was called the Cambodian Mental Health Training Program (CMHTP) (2).

When Khmer Rouge’s terror regime in Cambodia was ended in 1979 there were no mental health psychiatrists in the country, and no mental health services. The Norwegian Council for Mental Health initiated an educational program for psychiatrists in Cambodia, which was managed by the University of Oslo in collaboration with the International Organization for Migration and the Cambodian Ministry of Health. Image by Unsplash.

How did we start, and what did we expect?

Previously training of psychiatrists for low-income countries had mostly been conducted in former colonial powers and in some other high- income countries. When discussing the project with WHO, IOM and other experts, a few of the experts argued that it was too early to establish such a project in this early phase of rehabilitation of the country, while the majority were supportive. However, there was also an academic discussion internationally, where some colleagues argued that such projects represented a “Western” approach to mental health which was not culturally appropriate (3). It soon became clear to us that it probably would be better to provide psychiatric training of mental health professionals in the country where they were going to practice. Medical doctors were the most established profession to prioritize, while we hoped that other professions would eventually follow. None of the Norwegian psychiatrists involved in the project had previously lived in Cambodia, but we were highly motivated to meet the challenge. However, it helped that the project manager (EH) had previously been a WHO temporary advisor in Southeast-Asia and had worked clinically with Khmer refugees living in refugee camps. Considering the positive feedback from the consulted parties, we decided to organize two planning workshops, inviting national and international participants who had relevant experience and opinions. After fruitful discussions in the workshops, it was decided to establish a training program inside Cambodia. The program should have a community mental health orientation, but the curriculum had to be developed. A professor of Psychiatry from Sri Lanka accepted to be the main external evaluator of the project.

The Cambodian Mental Health Training Program, (CMHTP) started the specialization training in psychiatry in 1994 after ten candidates were recruited the three years as planned, with nine males, and only one female.

There was a need to establish a psychiatric outpatient clinic, to provide a training ground, as well as to serve patients. it was important for us to implement it without further delay, considering the overwhelming needs in the community. A major hospital in Phnom Penh which at that time was called the Khmer-Soviet Friendship Hospital was willing to allocate space and take overall responsibility for the out-patient clinic. The name of the hospital was later changed to Preah Norodom Sihanouk Hospital. It was decided to recruit 10 physicians to join the program, hoping that some of them would manage to complete a three-years specialization course so that they could serve as the future planners and managers of a mental health, care system in the future. We prioritized younger doctors with general medical experience, from different provinces, The rationale for this was a hope that they in the future would practice in their provinces and not only in the capital. We succeeded in doing this, but one of the participants was more senior (Professor Ka Sunbaunat), working in the Faculty of Medicine, University of Health Sciences. His participation represented an important link to the Faculty, where we also hoped to include a psychiatry course in the medical school. The supervisors were senior Norwegian psychiatrists with previous international and transcultural experience. We planned that they should serve for a period of one year and be present every day in the clinic. Thus, there were challenges regarding language. The Faculty of Medicine used French as the teaching language while the daily language was Khmer. Considering that the supervisors and teachers were not fluent in any of these languages, the Faculty of Medicine supported us in using English for training purposes, and CMHTP provided a course in English for the residents to brush up their competency in English.

What was achieved?

The Cambodian Mental Health Training Program, (CMHTP) started the specialization training in psychiatry in 1994 after ten candidates were recruited the three years as planned, with nine males, and only one female. We tried to recruit more women, but we were not successful at that time. Fortunately, subsequent batches of residents included more women. It became obvious that the participants needed a small stipend to afford the training, and these were channeled through IOM. It is doubtful if the program could be completed without these moderate stipends, especially in the early phase when they had limited other income. A proposal to reduce the size of the stipends created a lot of anxiety!

The training was problem-based, and the residents started to see patients immediately. The clinical work took place in the mornings, followed by presentation and discussion of findings. In the afternoons they had lectures and self-study. The clinical activities were experiences as highly meaningful and needed. There was no referral system in the country and the patients came to the clinic by recommendations and information from other patients, and sometimes from colleagues in other fields. There was a small consultation fee for the first visit. The curriculum was based on psychiatric curricula internationally, especially from South-East Asia. It was flexible in order to include components of particular contextual importance in Cambodia, emphasizing topics that the residents found to be culturally relevant. Culturally important understanding and treatment of traumatic stress was obviously especially important, not long after the Khmer Rouge terror – addressing the consequences of the trauma on individuals, families and the society. The supervisors had expected that the residents frequently would refer to traditional healing and idioms of distress, but this was not so common. Initially they seemed primarily to use a bio-medical model for understanding of the patients’ suffering. They were obviously not used to academic discussions and critical thinking and were careful not to challenge the supervisors directly. The reductionist bio-medical approach was challenged by the supervisors when trying to understand patients from the point of view of transcultural psychiatry as well as by a bio-psycho-social and contextual understanding. They were for example aware of traditional healing practices, for example of the cultural idioms of wind imbalance, like kyol geu (3), which means wind overload. They also diagnosed spirit possession among the patients in the clinic, and this is a cultural phenomenon that the Khmer population is familiar with. However, the residents did not seem inclined to collaborate with the traditional healers, the Kru Khmer. In line with WHO’s advice, we also tried to encourage such contact, but without much success. The candidates appeared to see them as competitors and were critical about some of their practices. Considering the central belief in Karma, they frequently advised patients to go to the pagoda to receive the healing practices there, especially patients with mild to moderate depression and anxiety.

It became clear that it was difficult to manage the out-patient clinic without possibility to admit any seriously ill patients for in-patient treatment. Eventually the hospital allocated a couple or rooms for short-term treatment of in-patients. The residents obtained experience by working in this unit, but they needed more experience with in-patient treatment. This was addressed by establishing collaboration with Chao Praya hospital in Bangkok, which received the residents for a three-moth training in inpatient treatment.

There was also successful collaboration with other programs and organizations. All the residents received important clinical experience in child psychiatry by visiting a foreign NGO conducting such a program in an area not far from Phnom Penh. Considering the community psychiatry orientation of the program, we managed to establish a good working relationship with the NGO “Social Services of Cambodia (SSC)”. This NGO was working in particularly deprived areas also outside the capital, and the residents accompanied the social workers on their field trips to such villages. The residents were motivated to participate in these trips, despite presence of pockets of surviving units of Khmer Rouge in the vicinity. This was a mutually useful collaboration, since the NGO also referred persons in need of psychiatric assessment and treatment to the clinic. Furthermore, we managed to establish a psychosocial rehabilitation center near the hospital clinic. This was primarily used for patients with serious mental illness who needed to improve their social functioning and integration in their families and neighborhoods. The Municipality let us use an old wooden building and different activities were established in collaboration with SSC, such as cooking, sowing and hair dressing. With the assistance of WHO a center for the treatment of Substance abuse and the residents also received teaching in this field.

Theoretical activities

We decided to provide an element of more focused in-depth teaching by organizing three teaching blocks every year. They were full time courses of two weeks each time, and contained all the components of a psychiatric curriculum, among them psychopathology, psychotherapy, psychopharmacology and child -and adolescent mental health. After each teaching block there was an examination. These teaching blocks were quite similar to the “grunnkurs” in the residency training in Norway. The residents appeared to really appreciate the theoretical courses. In addition to the Norwegian psychiatrists, the lecturers were experienced academics and senior clinicians from the region, including Thailand, The Philippines, Malaysia and Hong Kong.

In addition, all the residents had to write a thesis which accounted for partial fulfillment of the Faculty of Medicine’s requirement to be recognized as a medical specialist. This was a major undertaking, and the residents worked hard to accomplish this, but all of them finished in time. They received supervision from the resource persons who had been teachers and supervisors in the training. Later the psychiatrists completed various academic activities. For example, one wrote an internationally acclaimed PhD (4), and another colleague became a major planner in the MOH (5).

Success factors

Since all the ten residents were able to complete their training in time indicates that the project may be described as a success. Furthermore, all the activities conducted through the project eventually were taken over by the national authorities and institutions, which was a long-term strategic goal when we started. The psychiatrists continued to share their skills and knowledge with subsequent batches of psychiatric trainees, as well as teaching mental health to other health professionals and students in the following years until now. There has been a particular emphasis on providing training in mental health for primary health personnel, and 296 medical doctors and medical assistants as well as 627 nurses, have been trained, (2020 figures). There was an additional new program after the CMHTP called the Cambodian Mental Health Development program (NMHP) which was managed by IOM in collaboration with the University of Oslo. This program focused more on developing mental health services in different parts of the country. Thereafter the government took more responsibility for country-wide treatment and training in mental health and psychiatry and established a national program (NPMH) in 2004. A department of mental health and substance abuse was established in the Ministry of Health in 2014. Now the education of psychiatrists in Cambodia is completely managed by the university and national authorities. According to the MOH there were 97 psychiatrists in the country in 2022 (5). In retrospect the initial program thus gave rise to a wide variety of activities where the psychiatrists had a leading role. They were willing and able gradually to expand their models of understanding to a more diversified model with integration of community psychiatry with more explicit transcultural aspects.

Emblem of the Ministry of Health of Cambodia (MOH). The collaboration with MOH was excellent throughout the project period, and the ministry stated that they saw Norway as the leading provider of mental health assistance in Cambodia.

Considering all these factors, this teaching program may be seen as an early contribution to the rehabilitation of medical services and the development of general professional manpower in the society. After war, terror and hunger the country was in the process of modernization and integration in the international community. We had the impression that Norway was recognized as a small peace-loving country without a colonial past, and this may have contributed to the positive attitudes to the program in the MOH, hospital leadership and the university. The preparatory conferences with international mental health professionals and national leaders were very useful and helped to obtain consensus and provide an anchoring of the program. There was a discussion if it was too early to start such a program in and early phase of rehabilitation. However, there was agreement to introducing psychiatry early as one of the major medical specialties. The national authorities were apparently of the same opinion. It was also of great importance to have a collaboration with the International Organization for Migration (IOM). They provided logistical and administrative support, and IOM was particularly helpful in the interaction with the Norwegian funding bodies.

Why did we start with an education specifically of psychiatrists? This was a strategic decision considering medical doctors’ position and influence in the society, as well as the scarcity of other formal mental health practitioners. However, there was a pronounced need for educational programs for other health professionals as well. Before this training, the nurses in the out-patient clinic primally functioned as secretaries who e.g. distributed medication. Fortunately, it was later possible to establish a training program for psychiatric nurses as well, supervised by experienced Norwegian psychiatric nurses. A course in psychiatry was further included in the medical school as planned. In addition, the psychiatric candidates gradually increased their teaching efforts for clinical staff in hospitals and health centers in other parts of the country. At the same time there were several NGOs which provided psychosocial services and non-specialist training. The MOH created a sub-committee of mental health under the leadership of Prof. Ka Sunbaunat which coordinated the programs, and this was useful for the collaborative efforts between the programs. The collaboration with MOH was excellent throughout the project period, and the ministry stated that they saw Norway as the leading provider of mental health assistance in Cambodia.

Conclusion

Before the start of the program, we had some experience from working as clinicians and advisors in Southeast Asia, but no detailed experience from working in Cambodia. Still, it was possible to implement the program as described, which in many ways may be seen as a success. How was this achieved? It is obvious that this had not been possible without the high motivation and continued commitment of the residents, both the first batch and the subsequent batches. It is quite remarkable, considering that they were survivors of the Khmer Rouge terror, and having been incarcerated in concentration camps during the Khmer Rouge reign. They have continued practicing psychiatry in psychiatry until they now are approaching retirement age, filling roles as clinicians, teachers, researchers, managers and planners. Another main factor is the willingness of the Ministry of Health to continue the education after foreign support was ended, and the willingness of the University of Health Sciences to continue the specialist training in psychiatry for medical doctors and integrating psychiatry in the undergraduate teaching.

The long-term funding by Norwegian authorities was also a crucial factor. Their funding of these projects was rather unique, both regarding content and the long duration of the funding. In such a complex project it is useful to have continued leadership and the project’s strategy was in line with the other main actors. Similar projects in other countries in the future would probably need such a long-term funding to achieve comparable results. The decision to provide small stipends was probably a wise decision and ensured that all the residents completed their training. IOM’s willingness to take responsibility for the subsequent program (NMHP) ensured continuity. Furthermore, the foreign experts involved provided important professional input and support, not the least in the preparatory conferences and the teaching blocks. We are convinced that the assistance from professionals in region was very important and contributed to the completion of the project. The project was also an opening door for other Norwegian colleagues who later conducted workshops and supervision in the country. The psychiatrists and other mental health professionals involved in these projects in Cambodia probably have provided an important stimulation and contribution to the development of transcultural psychiatry and mental health in Norway. Thus, the project may be described as having a South-North, a North-South and a South-South dimension. □

References by request:

Arias, Daniel et al. (2022) Quantifying the global burden of mental disorders and their economic value Clinical Medicine, Volume 54, 101675

Hauff, E. (1996). The Cambodian mental health training programme. Australasian Psychiatry, 4(4), 187.

Bracken, Patrick J.; Giller, Joan E.; Summerfield, Derek (1995). "Psychological responses to war and atrocity: the limitations of current concepts" (PDF). Social Science & Medicine. 40 (8): 1073–1082.

Hauff, E (2001) Kyol Goeu in Cambodia. Transcultural Psychiatry, 38 (4):468-473

Chhim, S. (2017). Mental Health in Cambodia. In: Minas, H., Lewis, M. (eds) Mental Health in Asia and the Pacific. International and Cultural Psychology. Springer, Boston, MA.

Department of mental health and substance abuse (2023) Mental health strategic plan 2023-2032 — Emblem of the Ministry of Health of Cambodia (MOH). The collaboration with MOH was excellent throughout the project period, and the ministry stated that they saw Norway as the leading provider of mental health assistance in Cambodia.

Considering all these factors, this teaching program may be seen as an early contribution to the rehabilitation of medical services and the development of general professional manpower in the society. After war, terror and hunger the country was in the process of modernization and integration in the international community. We had the impression that Norway was recognized as a small peace-loving country without a colonial past, and this may have contributed to the positive attitudes to the program in the MOH, hospital leadership and the university. The preparatory conferences with international mental health professionals and national leaders were very useful and helped to obtain consensus and provide an anchoring of the program. There was a discussion if it was too early to start such a program in and early phase of rehabilitation. However, there was agreement to introducing psychiatry early as one of the major medical specialties. The national authorities were apparently of the same opinion. It was also of great importance to have a collaboration with the International Organization for Migration (IOM). They provided logistical and administrative support, and IOM was particularly helpful in the interaction with the Norwegian funding bodies.

Why did we start with an education specifically of psychiatrists? This was a strategic decision considering medical doctors’ position and influence in the society, as well as the scarcity of other formal mental health practitioners. However, there was a pronounced need for educational programs for other health professionals as well. Before this training, the nurses in the out-patient clinic primally functioned as secretaries who e.g. distributed medication. Fortunately, it was later possible to establish a training program for psychiatric nurses as well, supervised by experienced Norwegian psychiatric nurses. A course in psychiatry was further included in the medical school as planned. In addition, the psychiatric candidates gradually increased their teaching efforts for clinical staff in hospitals and health centers in other parts of the country. At the same time there were several NGOs which provided psychosocial services and non-specialist training. The MOH created a sub-committee of mental health under the leadership of Prof. Ka Sunbaunat which coordinated the programs, and this was useful for the collaborative efforts between the programs. The collaboration with MOH was excellent throughout the project period, and the ministry stated that they saw Norway as the leading provider of mental health assistance in Cambodia.

Conclusion

Before the start of the program, we had some experience from working as clinicians and advisors in Southeast Asia, but no detailed experience from working in Cambodia. Still, it was possible to implement the program as described, which in many ways may be seen as a success. How was this achieved? It is obvious that this had not been possible without the high motivation and continued commitment of the residents, both the first batch and the subsequent batches. It is quite remarkable, considering that they were survivors of the Khmer Rouge terror, and having been incarcerated in concentration camps during the Khmer Rouge reign. They have continued practicing psychiatry in psychiatry until they now are approaching retirement age, filling roles as clinicians, teachers, researchers, managers and planners. Another main factor is the willingness of the Ministry of Health to continue the education after foreign support was ended, and the willingness of the University of Health Sciences to continue the specialist training in psychiatry for medical doctors and integrating psychiatry in the undergraduate teaching.

The long-term funding by Norwegian authorities was also a crucial factor. Their funding of these projects was rather unique, both regarding content and the long duration of the funding. In such a complex project it is useful to have continued leadership and the project’s strategy was in line with the other main actors. Similar projects in other countries in the future would probably need such a long-term funding to achieve comparable results. The decision to provide small stipends was probably a wise decision and ensured that all the residents completed their training. IOM’s willingness to take responsibility for the subsequent program (NMHP) ensured continuity. Furthermore, the foreign experts involved provided important professional input and support, not the least in the preparatory conferences and the teaching blocks. We are convinced that the assistance from professionals in region was very important and contributed to the completion of the project. The project was also an opening door for other Norwegian colleagues who later conducted workshops and supervision in the country. The psychiatrists and other mental health professionals involved in these projects in Cambodia probably have provided an important stimulation and contribution to the development of transcultural psychiatry and mental health in Norway. Thus, the project may be described as having a South-North, a North-South and a South-South dimension. □

References

Arias, Daniel et al. (2022) Quantifying the global burden of mental disorders and their economic value Clinical Medicine, Volume 54, 101675
Hauff, E. (1996). The Cambodian mental health training programme. Australasian Psychiatry, 4(4), 187.
Bracken, Patrick J.; Giller, Joan E.; Summerfield, Derek (1995). "Psychological responses to war and atrocity: the limitations of current concepts" (PDF). Social Science & Medicine. 40 (8): 1073–1082.
Hauff, E (2001) Kyol Goeu in Cambodia. Transcultural Psychiatry, 38 (4):468-473
Chhim, S. (2017). Mental Health in Cambodia. In: Minas, H., Lewis, M. (eds) Mental Health in Asia and the Pacific. International and Cultural Psychology. Springer, Boston, MA.
Department of mental health and substance abuse (2023) Mental health strategic plan 2023-2032