Operation Unchain – release for the mentally ill in Cambodia

Battambang – a city in the north-western corner of Cambodia – swelters under an unrelenting sun. The dry season air tastes of dust and there seems to be no escape from the heat. Behind one of the suburban homes, a solitary figure sits on a bare bamboo bed in a shelter that consists of four wooden posts supporting a corrugated iron roof. The metal crackles as it expands in the high temperature. The low, monotone sound of the 32 year-old man’s muttering sounds like the chanting of a Buddhist monk in one of the nearby pagodas. There is an uneasy tension that is only intensified by the strange laughter that punctuates the droning of the man’s voice intermittently. Approaching the shelter, a heavy, rusted chain comes into view – one end locked to one of the posts, and the other end attached securely to an anklet around the man’s right leg.

TPO Operation Unchain
Without access to mental health services, this is how many desperate Cambodians deal with family members suffering mental illness.

This is how Yoeut Sorya has lived for the last ten years – locked up by his parents behind their family home just ten minutes’ drive from the city centre. The sad fact is that there are many more Cambodians just like Yoeut, chained or tied up by desperate family members who simply don’t know what to do with their loved ones suffering from severe mental illness, a situation that Cambodian organisation TPO is doing their utmost to change.

TPO Operation Unchain
Yoeut Sorya has been chained up for so long that the padlock has rusted shut

Cambodia is a nation with a severe lack of mental health services. Out of 1000-odd practicing physicians in Cambodia in 1975, only fifty had survived the Khmer Rouge regime by 1979, none of whom were mental health professionals. The decimated healthcare system never fully recovered – at least in the field of mental health – and as recently as 2015, there were only 49 trained psychiatrists in the entire country, of whom only ten worked outside of the capital. Even in Phnom Penh there are only two psychiatric in-patient facilities – the only such facilities in the entire country – with a total of 16 beds between them. With mental health services available in only nine of Cambodia’s twenty-four provinces, people in rural areas are often on their own when family members start to display signs of psychosis.

Enter TPO. The Cambodian NGO’s mission is to improve the well-being of Cambodians with mental illness and to help them to function effectively within their work, family and communities. Celebrating its 20-year anniversary in 2015, TPO (Transcultural Psychosocial Organization) was initially the branch of Dutch NGO TPO International, but just five years after its establishment, TPO Cambodia was registered as an independent local NGO in 2000, and is now staffed and run completely by local Cambodians. One of their more recent projects is ‘Operation Unchain’, which was initiated in 2015 to free Cambodians suffering from severe mental illnesses from being tied, chained or locked up by families unable to deal with their psychoses due to lack of awareness and insufficient access to medication and mental health facilities.

We joined Dr Ang Sody, one of the two psychiatrists responsible for 41 Operation Unchain patients across Cambodia, for two days on the job visiting patients in Battambang province. What we saw left us with an overwhelming sense of the undeniable impact a significant lack of mental health services has on a nation. We were, however, warmed by a feeling of hope that the situation could be turned around.

Dr Ang climbed down from the TPO 4-wheel drive and started down the dirt road toward the home of the first patient for the day after a couple of hours driving from Siem Reap. The doctor’s medical bag looked oversized beside her tiny figure. After surviving the days of Pol Pot, Ang was one of the first Cambodians to graduate in the post-war era with an MD from the University of Health Sciences and to complete a residency in psychiatry. A ways down the track she turned a corner and we followed. 45 year-old Ream Touch was waiting, sitting on a bamboo bed. When she saw the doctor, her face beamed.

TPO Operation Unchain
Ream Touch has responded well to Dr Ang’s therapy and medication, and her family is likely to release her from her chain soon. The final decision is always the family’s, so education for families and communities is just as important as treatment for sufferers.

Touch has been a patient of Dr Ang’s for just two months. On the initial visit, she was suffering from auditory hallucinations and was virtually unapproachable and violent toward others. She had been chained to a post by the bed by her sister Ream Ry for 3 years, as neighbours and even her own family were fearful of Touch’s violent outbursts. Traditional healers had not produced the results Ream’s mother had hoped for, and the family lived too far from any mental health services to utilise them. Looking at the woman sitting calmly next to the doctor, her eyes smiling warmly, it was hard to imagine her as a fearful force seething with anger as she had previously been described. Soon we were to hear Touch’s story.

Before her psychosis, the mother of two was happily married. The family lived a peaceful life in the village of Kampong Chhnang, but times were tough. Touch’s husband took a trip to the capital Phnom Penh in the hope of finding stable work in order to send money back to support Ream and her family, but he never reached his destination. He was involved in a fatal traffic accident shortly before reaching the city. Family members were notified, but Touch was unaware of the fate that had befallen her husband. She was asked to travel to see her husband, but had not been told that he had passed away. On seeing the body, she could not handle the shock. From that point on, she suffered severe psychosis. Touch wouldn’t eat out of a paranoia that people were trying to poison her, and she heard voices constantly.

Thankfully in Touch’s case, she and her family had a supportive community who tried to help any way they could, but they were not equipped to deal with such an intense situation. It was out of desperation that Ry chained her up. Touch and Ry’s mother felt relieved at the thought of knowing that Touch could not harm herself or others, but thought that all hope was lost until a commune leader told her about TPO.

TPO Operation Unchain
Dr Ang Sody measures out medication for Ream Touch. Medication is provided free of charge by TPO to ensure it is available to all, regardless of their financial situation.

After being contacted by Ry, Dr Ang diagnosed and medicated Touch – a service provided at no charge to TPO’s patients. At first Touch’s mother had trouble giving her the medicine due to Touch’s paranoia, but after hiding the medication in Touch’s food, she began to see a change. Two months later, and Touch is now calm and able to communicate with a lucidity that is a stark contrast to her previous state. Touch is still chained, but there is hope that her release is imminent. We wondered what a patient may be like before TPO’s intervention. It wasn’t long before we would find out.

Stepping out of the car outside Bour village a few kilometres down the road, we were instantly greeted by the babbling sound of a woman’s voice. A young woman approached Dr Ang and led her to a small wooden hut. As our eyes adjusted to the darkness inside the hut, a short-haired lady, each arm tied by the wrist to one of the walls, appeared out of the black. She spoke to us, her eyes at times pleading, at times filled with wrath and hatred, the unintelligible words tumbling out over each other in a confused and ever-changing tone. This was Dr Ang’s first contact with 54 year-old Sam Nakry – the young lady’s mother – who was forced to leave her job with CMAC clearing landmines after her psychosis set in. But Nakry wasn’t the only family member in need of TPO’s help.

TPO Operation Unchain
Sam Nakry, 54, squats in the room where she has been tied by her daughter. Without access to any mental health services, her daughter simply didn’t know what else to do to keep her mother safe and ensure she didn’t harm others.

Nakry’s daughter led us out of the hut and past chickens and pigs to a rusting iron cage suspended above the ground behind the family’s home. As we approached, the pungent smell of human waste took over the fresh rural air. A dark pile of blankets inside the cage shifted, and the naked hunched body of Nakry’s son Sok Ny emerged from under the coverings. Unlike his mother’s psychosis, which Dr Sody attributes to a genetic predisposition triggered by times of emotional trauma, Sok Ny’s schizophrenia seems to be the result of abusing the drug Yaba, which is a mixture of methamphetamine and caffeine, along with alcohol while working in Thailand.

TPO Operation Unchain
Dr Ang speaks with Sok Ny in the cage he has been locked in since his schizophrenia took hold.

The care for both Nakry and Sok Ny has fallen on the shoulders of Nakry’s daughter, who lost her left hand in a rubber factory incident some years ago. Nakry’s two other children are unable to help financially. Her other son is working in Thailand, but the construction company he is working for is withholding his income to repay an undisclosed amount for “visa processing and recruitment fees”, while Nakry’s other daughter has just recently had a child, and her husband’s meagre income is barely enough to care for the three of them.

When asked how she feels having to care for her mother and brother, she couldn’t fight the tears that welled up as she told us of her fears that if anything happened to her, nobody would be able to care for Nakry and Sok Ny. Besides the weight of responsibility for her mother and brother’s care, she also needs to care for her 14 year-old sister Sao Muy and her own 11 year-old daughter Soeum Risa. Just two visits in, and the harsh reality of the difficulties faced by everyday Cambodians with mental illness and their families had hit us with full force.

TPO Operation Unchain
Soeum Risa, 11, sits on a swing in the family’s back yard where her uncle Sok Ny lies in the iron cage that he has been locked up in for the last three years.

Over the following one and a half days, we followed Dr Ang as she visited family after family, each with their own tragic story. Brothers Sieng Sothea, 26, and Sieng Sok Khoeun, 29, had been released from their ropes after medication and therapy for their drug-induced psychoses had been effective, but Sok Khoeun had regressed after going off his meds, claiming that he had been healed. The smashed walls and television set in the family home said otherwise.

TPO Operation Unchain
Sieng Sok Khoeun holds the family’s pet cat on his bed by the television that he smashed during an episode prior to our visit.

TPO Operation Unchain
After going off his medication, Sieng Sok Khoeun has become increasingly violent. Here he is seen through a hole he punched in the wall of his home. Due to lack of resources and distances involved, TPO is not yet able to visit patients in many provinces more than once every two weeks, or even monthly.

Then there was 46 year-old At Rim, who had made good progress in the two months since TPO’s first visit, but had killed one of the family dogs by swinging it against a wooden post just days before Dr Ang’s visit. After seven years of being tied to a post by the family home, it seemed it would still be some time before the family would feel safe enough to release At.

TPO Operation Unchain
At Rim squats in the area where her family have kept her chained for the last seven years due to their and their neighbours’ fear of her violent impulses fueled by paranoid delusions.

In Toul Thnong village, Sam San’s family had sold their two hectares of land to pay for ten different traditional healers to cure her schizophrenia. Treatments included pouring holy water over her, piercing her skin with bamboo to release the evil spirits, rubbing hot chilli all over her face and body, and exorcism. After the family had run out of money and options, they heard about TPO, and within two months of free treatment Sam was released from the room she had been locked in. She no longer has paranoid fears that men will come to rape her daughter, and she has stopped beating her daughter – previously a daily occurrence.

TPO Operation Unchain
Nouk Sarim, 34, holds medication that Dr Ang has given for Nouk’s mother Sam San, who sits in a hammock outside the building she had to be locked up in just two months previously. Sam is one of TPO’s success stories, now released from forced confinement and returning to a life free from hallucinations and paranoia.

At the age of 60, Dr Ang Sody could be enjoying time with her granddaughter in her Phnom Penh home, but instead she spends four days a week on the road travelling to remote rural areas with a medicine bag and a message of hope for desperate families. With just her and Dr Chhim Sotheara to cover the entire kingdom of Cambodia, Dr Ang is saddened by just how limited the help she can provide is. While TPO works with the Ministry of Health, other NGOs, and referral hospitals to try to build a stronger network of mental health services in Cambodia, along with village leaders who participate in their monthly awareness sessions, the impact they can have is limited by available funding.

TPO Operation Unchain
Dr Ang is greeted as she makes a visit to one of TPO’s patients’ homes in Battambang province.

A donation of $5000 by King Norodom Sihanomi in 2015 was allocated to Operation Unchain, and to date, 8 people have been released since the project began in February 2015, largely thanks to the King’s donation along with another $5000 raised through the platform Global Giving, which allowed TPO to provide psychiatrists and medication free of charge to 41 families in nine provinces of Cambodia. This however, is merely scratching the surface, as the more families TPO helps, the more in similar situations come out of the woodwork, and there’s only so much two psychiatrists can humanly do.

In a nation where most communities still look to traditional religious and superstitious healers for help in cases of mental illness, and where most years, there is zero intake into Cambodian universities’ psychiatry majors, TPO has an uphill battle to fight. But looking into Sam Nakry’s pleading eyes, or seeing the restored sparkle in those of Ream Touch, we can only hope that TPO is not only able to continue Operation Unchain, but to access the resources to expand the work.

TPO Operation Unchain
Tied to a post by her family’s home, At Rim is one of a multitude of Cambodians who suffer due to a lack of mental health facilities and services, along with a lack of awareness among the communities they live in.

If you would like to help support the work TPO is doing in Cambodia, you can make a donation through the Global Giving website here.

Having seen the dedication of Dr Ang and the gratitude in the eyes of the families TPO helps, I can’t express just what a difference even a few dollars can make in these people’s lives. I’d really appreciate it if you could also share this post to help spread the word about the situation in Cambodia for people with mental illness, and to help find more support for the organisations that are working hard to change the situation there.

TPO Operation Unchain

All images ©2016 Adam Robert Young