Knowledge of psychology in Cambodia: Exploring the relationships to demographics,psychopathology,and idioms of distress

Abstract

Rates of mental health disorders in Cambodia are markedly higher than in other low- or middle-income countries. Despite these high rates, mental healthcare resources remain scarce and mental health stigma is pervasive, particularly for vulnerable populations of young women and individuals of low socioeconomic status. To address this gap, teaching Western mental health treatments and using a mental healthcare framework are recommended within the Cambodian context. However, Western frameworks do not address cultural syndromes or idioms of distress and operate from an individualistic perspective that does not address cultural values and beliefs. The present study employs a mental health literacy framework in an exploratory analysis of rates of psychological knowledge in a nationally representative sample of Cambodian adults (N = 2,690). To address recommendations for increasing mental healthcare, we designed a survey to investigate Cambodians’ knowledge about mental health constructs. Results indicated that only 18.9% of Cambodians knew about psychology, and chi-square analyses revealed that women, individuals in rural areas, and individuals with significant distress due to cultural symptoms and syndromes reported knowing about psychology significantly less than their male and non-distressed counterparts. Additionally, those who reported higher income and higher levels of education indicated significantly higher rates of psychological knowledge, as did those with clinically significant rates of PTSD, at a rate of knowledge approaching significance. Implications for this study include the need to tailor interventions and resources to vulnerable populations, to assess the fit of current recommendations for the Cambodian context, and to further emphasize the need for culturally responsive interventions that address all presentations of Cambodian distress and align with understandings of mental health within the nation.

Keywords

Cambodia idioms of distress mental health literacy psychology

Years of civil war and genocide coupled with pervasive poverty and governmental corruption have resulted in Cambodians suffering numerous traumatic experiences (Chhim, 2017). These and other stressors have impacted mental health through heightened rates of psychopathology including depression, anxiety, and posttraumatic stress disorder (PTSD; Seponski et al., 2019). In response, an influx of Western-based mental health training and services has entered the nation, with recommendations to increase mental healthcare services given by global agencies and Western institutions (Miller et al., 2019). While more Cambodian nationals are currently being trained as therapists or psychologists, mental healthcare infrastructure remains lacking and therapists report experiencing myriad challenges in delivering mental health services (Seponski et al., 2020). Additionally, Western mental healthcare models often do not incorporate Cambodian beliefs or understandings of distress and wellness (Janus, 2010). As current recommendations for training and delivery of mental healthcare remain centered on Western modalities, this study offers an exploratory analysis of psychological knowledge among Cambodians to elucidate the extent to which the population is aware of the Western constructs that underlie mental healthcare.

We employ a Western mental health literacy framework to evaluate the landscape of mental healthcare that has been shaped by Western influences (Jorm et al., 1997), seeking to understand rates and correlates of mental health literacy through the broad domain of psychological knowledge on a national Cambodian scale for purposes of promoting care responsive to local culture and vulnerable populations. As part of this examination, we explore cultural symptoms, syndromes, and idioms of distress, exploring how understandings of Western mental health relate to experiences of distress as defined and expressed by local cultural beliefs.

Conceptual framework: Mental health literacy

Mental health literacy is defined as “knowledge and beliefs about mental disorders which aid their recognition, management, or prevention” (Jorm et al., 1997, p. 182). This inherently Western construct is important to consider within the Cambodian context as Western organizations (i.e., NGOs) and mental health models (i.e., Eye Movement Desensitization and Reprocessing) have influenced the landscape of Cambodian mental health education and treatment for the past two decades (Chhim, 2017; Seponski et al., 2020). The World Health Organization (WHO, 2010) has advocated for continued mental health resources to be implemented across the nation. Mental health literacy aids in the evaluation of current mental health treatments, recommendations, and resources, and in the development and implementation of treatments that are responsive to the local community, including bolstering non-professional forms of mental health aid (Jorm, 2000).

Heightened mental health literacy carries implications for decreasing stigma, as lack of psychological knowledge is related to increased prejudicial views and behaviors, while those with higher mental health literacy are more likely to understand mental health disorders as illnesses, not personal weaknesses (Reavley et al., 2014). Despite these findings, research is mixed on how having a mental illness impacts mental health literacy, with some findings indicating lower mental health literacy among those with psychopathology (e.g., Kim et al., 2015), or no association between mental health literacy and psychological symptoms (e.g., Naal et al., 2020), which may limit health-seeking and increase self-stigma for those presenting with symptoms of psychopathology and distress.

While mental health literacy is grounded in a Western lens (Kirmayer & Pedersen, 2014), this study assesses trends in mental health literacy to underscore the current state of knowledge among the Cambodian population to assess Cambodians’ awareness of Western psychological constructs that are being promoted as a prominent course of treatment and model for understanding distress throughout the nation. This study seeks to consider the first aspect of mental health literacy—knowledge of mental health disorders—engaging in an exploratory analysis of demographic factors and distress to establish a foundational understanding of trends in mental health literacy throughout the nation.

Literature review

Cambodian mental health

Rates of mental health disorders in Cambodia are higher than in other low- to medium-income countries, with previous findings from the current study indicating elevated national rates of psychopathology, including anxiety (27.4%), depression (16.7%), and PTSD (7.6%) (Seponski et al., 2019). Cambodian women who are younger, single, and uneducated are at even greatest risk for mental illness (Saxena et al., 2007), and previous findings of this study indicated that Cambodian women experiencing depression and PTSD, as well as cultural symptoms or syndromes, are at heightened risk for attempting suicide (Armes et al., 2018). Socioeconomic status (SES) affects mental health among the Cambodian population, with individuals in financial debt experiencing significantly higher rates of anxiety, depression, and PTSD (Seponski et al., 2019). Cambodian mental health and poverty are cyclically tied, as the harsh conditions of poverty negatively affect mental health, exacerbating socioeconomic instability (Seponski et al., 2014).

Cambodian mental healthcare

Throughout Cambodia, 56 psychiatrists and 44 psychiatric nurses currently practice out of a population of approximately 16 million citizens (Chhim, 2017). These numbers are drastically lower than the number of mental health professionals working in most Western countries and even neighboring countries such as Thailand or Vietnam (WHO, 2014). Such mental healthcare resources, while already lacking in number, are concentrated in urban areas and available mainly to those of higher SES, rendering services inefficient and unequally distributed (Saxena et al., 2007). While the WHO (2010) has encouraged integration of mental health treatment into primary healthcare to provide more accessible care, such changes have not been implemented and mental health providers remain limited. While Cambodia has recently developed a department within the Ministry of Health for mental healthcare and substance abuse, no funds have been officially budgeted explicitly for mental health services, limiting education, and accessibility of mental healthcare (Chhim, 2017). Two of the authors on this article who work in the Cambodian mental health field and train local psychologists noted increased efforts to provide awareness to Cambodian society about psychology and mental health, as more individuals are seeking care at hospitals where the integrated care recommendations have been given. Efforts to provide education have occurred with high school and university students, as well as in trainings offered to primary and secondary teachers (Phoeun et al., 2019).

Much of Cambodian mental healthcare is Westernized, with many resources coming from international non-governmental organizations (NGOs) and mental healthcare training programs stemming from North American or European institutions (Chhim, 2017). While there are benefits to the provision of mental health training and services, culturally responsive treatments are lacking, compromising the effectiveness of such resources (Janus, 2010). For example, the aforementioned interplay of poverty and mental health is often unaddressed within Western therapeutic models (Miller et al., 2019), hindering treatment efficacy for clients experiencing socioeconomic hardship. Western medical models of mental health treatment are individually focused, contrasting with Cambodia's communally-oriented culture (Miller et al., 2019). Few integrative measures have been taken to incorporate Cambodian beliefs into Western mental health practices, limiting the scope of treatment for practitioners working with Cambodian clients who do not have a Western view of mental health (Janus, 2010).

Not only are there mismatches between Western modalities and the Cambodian culture, but Cambodian therapists report numerous challenges to providing mental health treatment. In a study of the experiences of Cambodian therapists, clinicians reported that a lack of understanding about psychology hindered their ability to practice and furthered mental health stigma, as well as fostered difficulties in recruitment and retention of clients (Seponski et al., 2020). Mental health stigma includes negative stereotypes and beliefs of social undesirability regarding those who have mental illnesses, often resulting in discriminatory or oppressive acts that co-occur across ecological levels, which inhibit individuals from seeking mental healthcare and negatively affect clinicians in the field (Ng, 1997).

Cultural concepts of distress

Cambodian understandings of mental health and wellbeing often lie within the contexts of physical, spiritual, and relational health, resulting in cultural concepts of distress. Cultural concepts of distress include idioms of distress, or “particular ways … members of sociocultural groups convey affliction” based on cultural norms, traditions, and values (Hinton & Lewis-Fernández, 2010, p. 210), cultural syndromes, and cultural explanations of distress (Lewis-Fernández & Kirmayer, 2019). Cultural concepts of distress may include physical symptoms with shared cultural meanings, and syndromes that are formalized and named (Hinton et al., 2013). These syndromes and symptoms reflect cultural understandings and local knowledges of stress, life threat, and panic as being held within the body. For example, after a distressing event, Cambodians may experience “baksbat,” or “broken courage.” Symptoms of baksbat highlight the interconnected nature of Cambodian health with mental (avoiding fearful thoughts), physical (muteness, digestive issues), emotional (fear, anger), spiritual (fear of losing one's soul), and relational (withdrawal from community) components (Chhim, 2013). Additional syndromes within Cambodian culture manifest due to bodily wind, including khyal (wind) attacks and kyol goeu (“wind overload”), both of which denote feelings of panic from a disruption in the internal wind throughout the body (Hinton et al., 2010). Somatic symptoms of dizziness, tinnitus, or blurry vision are also frequent among Cambodians, often in response to stress or traumatic events, (Hinton et al., 2013).

Researchers have highlighted correlations between cultural symptoms and syndromes and biomedical constructs; for example, Cambodians who experienced anxious-depressive distress (Hinton et al., 2019) and PTSD also endorsed an increasing number and greater severity of cultural symptoms and syndromes (Hinton et al., 2013), though concerns about the risk of pathologizing normal cultural idioms have been raised (Kidron & Kirmayer, 2019). When Cambodians experience these varied forms of distress, they may engage in traditional healthcare practices, such as coining or cupping, or seeking help from a monk or medium (Chhim, 2017). If these health-seeking practices do not relieve the distress, Cambodians may seek mental healthcare as a last resort, by which time symptoms are exacerbated and treatment is less effective (Seponski et al., 2020). To examine mental health literacy, we consider both psychopathology and cultural symptoms and syndromes to consider how, if at all, distress is related to mental health literacy (see Table 1).

Table 1.
Cambodian Symptom and Syndrome Addendum (CSSA).

Somatic symptoms Syndromes

1. Weakness

1. Weak heart

2. Standing and feeling dizzy

2. Wind hitting up from your stomach

3. Cold hands and cold feet

3. Wind attacks

4. Dizziness

4. Thinking too much

5. Tinnitus

5. Sleep paralysis

6. Neck soreness

7. Blurry vision

8. Sore arms and legs

Source: Hinton et al., 2019.

To understand psychological knowledge among the Cambodian population, the following research questions guided our analysis: (1) What is the level of psychological knowledge within the Cambodian population? (2) Are there significant differences in knowledge of psychology based on demographics including sex, urban or rural location, education level, or income in Cambodia? (3) Do levels of psychological knowledge significantly differ between those who report clinically significant symptoms of anxiety, depression, or PTSD, as well as those who report significant distress due to cultural symptoms and syndromes?

Method

Procedures

Data were collected in 2012 as part of the first nationally representative survey on mental health in the nation of Cambodia. Adult participants (N = 2,690) were recruited in multiple stages through cluster sampling with probability proportionate to size (PPS). Through this technique, two of Cambodia's four regions were selected for sampling, with two provinces per region, plus the capital of Phnom Penh, being selected via the PPS method. Provinces were separated into districts, of which 50 were selected. Communes (n = 100) from selected districts were stratified into urban and rural communes from which 270 villages were identified. Households (n = 10) were selected per village, resulting in 2,700 households identified for survey across the nation, 2,690 of which participated in the study. The Kish grid technique was employed to select which member of the household over the age of 21 would participate in the interview (Kish, 1949). Surveys were completed via structured interview to account for high illiteracy rates throughout the nation, conducted through a team at the Royal University of Phnom Penh (RUPP).

Measures

Participants were asked sociodemographic questions regarding age, sex, location, education level, and monthly income as well as questions developed by the research team to address mental health knowledge. Participants were asked, “Do you know about psychology?” in Khmer, where psychology was defined and translated based on the Western construct. This question was translated and back-translated for accuracy by multi-lingual speakers on the research team and cross-checked by native Khmer speakers for accuracy. Dichotomous yes/no answers were recorded to assess rates of psychological knowledge as a function of mental health literacy.

Harvard Trauma Questionnaire (HTQ)

The HTQ is a measure of PTSD symptomatology consisting of 23 Likert-scale questions that have been validated for use with the Cambodian population, assessing distress from 1 (not at all) to 4 (extremely) (Mollica et al., 2004). The mean score of all items was taken and assessed against the cutoff for probable PTSD, which was set originally at 2.5 and more recently at greater than or equal to 2.0, the latter of which was employed in this study (Mollica et al., 2004). For this sample, the HTQ had strong internal reliability with a Cronbach's alpha = .91.

Hopkins Symptom Checklist-25 (HSCL-25)

The HSCL-25 measures symptoms of anxiety and depression through 25 Likert-scale questions, employing the same 4-point scale as the HTQ (Mollica et al., 1987). Ten items measured anxiety symptoms; 15 items measured depressive symptoms (Mollica et al., 1987). All items have been previously validated for the Cambodian population. The mean score for each subscale was compared to the previously determined cutoff scores of 1.75 per subscale, with scores at or above 1.75 indicating probable depression or anxiety (Mollica et al., 1987). The HSCL-25 has been previously shown to have strong reliability with the Cambodian population, confirmed in this study with a Cronbach's alpha of .86 for both subscales (Mollica et al., 1987).

Cambodian Symptom and Syndrome Addendum (CSSA)

Developed to assess Cambodian symptoms and syndromes, the CSSA is comprised of two subscales: culturally salient somatic symptoms (8 items) and cultural syndromes (5 items) common in Cambodian culture (see Table 1; for descriptions of symptoms and syndromes, see Hinton et al., 2019). This measure has been shown to have strong face validity for each item, good internal consistency (Cronbach's alpha symptom subscale = .84 and syndrome subscale = .89), and strong test-retest reliability (r_symptom = .91 and r_syndrome = .89; Hinton et al., 2019) (for more information on the development of the CSSA, see Hinton et al., 2013). Items assessed how bothered the participant had been by each somatic experience in the past month, with responses ranging from 1 (not at all bothered) to 4 (extremely bothered) (Hinton et al., 2019). Hinton et al. (2019) determined the following cutoff scores for identifying significant distress caused by cultural symptoms and syndromes among the Cambodian population, termed distress caseness: ≥ 1.80 for the somatic subscale and ≥ 1.70 for the syndrome subscale, to which mean scores were compared.

Data analysis

Numeric data were analyzed using SPSS 25. Frequency distributions and descriptive statistics identified sample demographics including age, sex, marital status, and region, as well as rates of psychological knowledge. Correlations were conducted to examine relationships between psychological knowledge, cultural symptoms and syndromes, and probable anxiety, depression, and PTSD. Chi-square analyses were run to examine bivariate differences in perceived psychological knowledge between men and women, rural and urban located participants, income brackets, education levels, individuals with and without clinically significant rates of psychopathology, and with and without distress due to cultural symptoms and syndromes.

Results

The majority of survey participants were female (67.4%) and married (77.8%), with 50 percent of the sample comprised of married females. Over half of all participants lived in rural provinces as opposed to urban cities. The majority of respondents were over age 37 (65.7%), indicating that more than half of all participants were alive during the Khmer Rouge regime that enacted genocide against the people of Cambodia. Regarding our first research question, only 18.9% of participants indicated having knowledge of psychology. Table 2 presents detailed information on participant characteristics.

Table 2.
Participant demographics.

Variable n %

Age M = 44.13

Range = 21–86

Sex (N = 2,686)

Male 873 32.5

Female 1,813 67.4

Marital status (N = 2,677)

Married 2,084 77.8

Single 199 7.4

Divorced 51 1.9

Widowed 343 12.8

Region (N = 2,676)

Urban 858 32.1

Rural 1,818 67.9

Monthly income (N = 2,249)

<$100 1,074 47.6

$100–$300 975 43.4

$300–$500 150 6.7

>$500 50 2.3

Education (N = 2,685)

No education 486 18.1

Primary school 1277 47.6

Secondary school 583 21.7

High school 269 10.0

University or higher education 70 2.6

Psychology knowledge (N = 2,254)

Yes 426 18.9

No 1,828 81.1

Bivariate analyses indicated positive associations between distressing experiences of cultural somatic symptoms and syndromes and psychopathology (Table 3), with the strongest relationships existing between somatic distress and anxiety. This association indicates that increased distress due to somatic experiences is associated with heightened levels of anxiety. Similarly, moderate to strong relationships between somatic distress, depression, and PTSD were present, indicating associations between idioms of distress and psychopathology. These findings reflect previous research on the association between cultural syndromes and psychopathology, as has been described by Chhim (2013) and Hinton et al. (2019), underscoring the complex expression of distress among the Cambodian population that includes both features of Western mental illness and culturally specific symptoms. Moderate to strong, positive correlations were present between probable anxiety, depression, and PTSD, underscoring relationships between psychopathologies.

Table 3.
Correlations of psychopathology and somatic symptoms.

1. 2. 3. 4. 5.

1. CSSA Symptom

2. CSSA Syndrome
.763* .

3. Depression
.641* .659* .

4. PTSD
.567* .560* .779* .

5. Anxiety
.738* .711* .723* .634* .

Note. * = p < .01.

Overall, in response to our second research question, male participants indicated significantly higher rates of psychological knowledge than female participants, as did participants in urban areas when compared to participants in rural communes (Table 4).

Table 4.
Chi-square test of psychology knowledge with demographics, psychopathology, and distress.

Psychology knowledge χ2 Φ

Yes No

Sex

Male 29.9% 70.1% 85.677* −0.195

Female 13.6% 86.4%

Location

Urban 29.1% 70.9% 73.677* −0.181

Rural 14.0% 86%

Monthly income

<$100 12.6% 87.4% 67.377* 0.173

$100–$300 22.8% 77.2%

$300–$500 31.3% 68.7%

>$500 40.0% 60.0%

Education

No education 2.2% 97.8% 441.551* 0.443

Primary school 11.6% 88.4%

Secondary school 25.2% 74.2%

High school 48.1% 51.9%

University or higher education 84.8% 15.2%

Anxiety

Probable 17.6% 82.4% 0.970 −0.021

Not probable 19.4% 80.6%

Depression

Probable 21.0% 79.0% 1.260 0.024

Not probable 18.5% 81.5%

PTSD

Probable 23.6% 76.4% 2.966 0.036

Not probable 18.3% 81.7%

CSSA somatic

Distress caseness 15.9% 84.1% 8.548* −0.062

No distress caseness 20.9% 79.1%

CSSA syndromes

Distress caseness 14.6% 85.4% 13.698* −0.079

No distress caseness 21.2% 78.8%

Note. * = p < .001.

Rates of psychological knowledge were significantly higher for those in higher monthly income brackets as well as those with higher levels of education. Regarding our final research question, clinical caseness did not significantly relate to psychological knowledge, although those with probable PTSD indicated more psychological knowledge than those without PTSD at a rate approaching statistical significance (p = .08). Those without cultural syndromes or idioms of distress expressed knowledge of psychology significantly more frequently than those with significant levels of cultural syndromes and somatic distress caseness.

Discussion

The findings of this study highlight the current state of mental health literacy in Cambodia. Only 18.9% of Cambodian adults reported knowing about psychology, one of the primary components of mental health literacy. This relatively low rate of psychological knowledge is consistent with findings from other developing countries, underscoring the need for increased mental health literacy globally as low rates of mental health literacy hinder not only the identification, but also the treatment, of mental health disorders (Furnham & Swami, 2018).

This study adds to the literature by underscoring the gender disparity in mental health literacy in Cambodia. While women generally have greater mental health literacy globally (Furnham & Swami, 2018), Cambodian men in this study were significantly more likely to report knowing about psychology than women. This contradictory finding may stem in part from social desirability, particularly among men as traditional keepers of knowledge, to indicate knowledge of psychology within the frame of a mental health survey. This disparate finding may be the result of social structures within the Cambodian culture, as men are allowed to hold knowledge while women are seen as intellectually inferior, requiring women to seek knowledge and services through their male counterparts (Houn, 2014). With this social hierarchy, women who did know about psychology may not have revealed their knowledge to maintain traditional cultural norms limiting expression of psychological knowledge. This knowledge disparity remains salient as Cambodian women are more likely to suffer from a mental health disorder (Saxena et al., 2007), highlighting Cambodian women as a vulnerable population for both developing psychopathology and having low knowledge of the psychological bases for such disorders. Low mental health literacy rates for this vulnerable population may leave women suffering from mental illness at risk for increased stigmatization and without much-needed treatment; young women or women of lower SES suffering from mental illness may be at risk of not receiving necessary services and experiencing the effects of stigma (Furnham & Swami, 2018). As such, Cambodian women may benefit most from education interventions aimed at increasing mental health literacy and the implementation of mental health resources that encourage self-help, family support, or formal mental health treatment.

Consistent with the dispersion of mental health resources throughout the nation (Saxena et al., 2007), those in urban areas identified significantly higher rates of psychological knowledge when compared to participants in rural areas. Individuals may move to urban areas for mental health treatment, while others may have increased mental health knowledge due to the higher prevalence of NGO resources and institutions that train mental health professionals in urban districts (e.g., RUPP; Chhim, 2017). Those in urban locations are often of higher SES, holding increased financial resources that improve access to mental healthcare, and thus to psychological knowledge (Furnham & Swami, 2018). Urban location and higher SES are related to higher levels of education, indicating a confluence of location, income, and education that has been previously found and confirmed in this study to affect rates of mental health literacy (Furnham & Swami, 2018).

Conversely, due to geographic and financial constraints as well as potential lack of access to higher education, individuals in rural communities are more likely to seek out local, religious leaders and healers than mental healthcare, leaning on spiritual and cultural knowledges regarding the somatization of distress, as discussed below (Olofsson et al., 2018). Olofsson et al. (2018) thus recommend providing mental health education opportunities to healers in rural districts to promote culturally integrated mental health treatments that minimize stigma while elevating accessible, traditional health-seeking methods across the nation.

Participants with clinically significant psychopathology did not report increased mental health literacy when compared to those who did not meet clinical cutoffs. Low mental health literacy rates among clinical populations have significant implications, including a lack of professional help-seeking and lack of detection of psychopathology when seeking treatment (Jorm, 2000), which can hinder the efficacy of treatment as well as the acceptance of mental healthcare when presented in integrated healthcare settings (Seponski et al., 2020). The lack of heightened mental health literacy among those with probable mental illness may be due to the number of idioms of distress that provide somatic or supernatural explanations for distressing symptoms. Unsurprisingly, those who identified significant levels of distress due to cultural symptoms and syndromes were less likely to know about psychology compared to those who did not indicate culturally related distress. These findings are consistent with studies in other low-income countries that suggest that the somatization of distress is associated with lower levels of mental health literacy, influencing conceptions of the origin of symptoms as well how they are treated (Furnham & Swami, 2018). As Hinton et al. (2019) underscored, psychopathology and cultural idioms of distress are highly connected within the Cambodian population. As such, continued assessment of all features and attributions of Cambodian distress is essential to create and tailor interventions that treat the full symptom expression of Cambodian suffering.

Limitations

While this study began to examine Cambodian mental health literacy, only the dimension of mental health recognition, assessed through psychological knowledge, was considered. The mental health literacy dimensions of mental health management and prevention must be assessed to specifically tailor culturally responsive education and intervention. The dichotomous nature of this question does not allow for nuance regarding what is known about psychology among the Cambodian population, but provides a baseline for future mental health literacy research. The income variable employed in this study does not account for the number of individuals per household or average monthly expenditure. Further consideration of the implications of SES and income should be assessed as related to mental health literacy. Finally, the tested data is cross-sectional in nature; there is a need to account for the changing landscape of mental health in Southeast Asia and around the world, particularly as mental health literacy is studied globally.

Conclusion

This study adds to the literature by assessing the current state of mental health literacy in a representative sample of Cambodian adults, identifying vulnerable populations with significantly lower mental health literacy. The findings indicate that although an increasing number of mental health resources may be available to help those in need (particularly those provided by Western entities and through training programs that import Western models of psychotherapy), the local Cambodian population, including those most vulnerable to mental illness and stigma e.g., women and individuals of low SES, are largely unaware of Western psychology. Future research should further explore the additional factors of mental health literacy, including beliefs related to mental illness and its effects on stigma and health-seeking behaviors throughout the nation. The creation of culturally responsive measures to ascertain the level of mental health literacy in Cambodia along its many dimensions is crucial (see Reavley et al., 2014 for examples of recently developed measures).

This study's findings on the mental health knowledge of the Cambodian population provides a basis for future studies of interventions designed to meet the needs of the local population, including those who do not hold psychological knowledge. While mental healthcare is continually supported by Western institutions and, more recently, the Cambodian government, the need to consider knowledge and beliefs about Cambodian distress, symptomatology, and healing is great, and recommendations for culturally responsive care must include critical considerations of local cultural health knowledge and beliefs (Kidron & Kirmayer, 2019). Future research on Cambodian wellbeing and distress should integrate local knowledges and healing practices, to examine whether and how a mental health framework can encourage healing among those in need throughout the nation.

Somatic symptoms	Syndromes
1. Weakness	1. Weak heart
2. Standing and feeling dizzy	2. Wind hitting up from your stomach
3. Cold hands and cold feet	3. Wind attacks
4. Dizziness	4. Thinking too much
5. Tinnitus	5. Sleep paralysis
6. Neck soreness
7. Blurry vision
8. Sore arms and legs

Variable	n	%
Age	M = 44.13
	Range = 21–86
Sex (N = 2,686)
Male	873	32.5
Female	1,813	67.4
Marital status (N = 2,677)
Married	2,084	77.8
Single	199	7.4
Divorced	51	1.9
Widowed	343	12.8
Region (N = 2,676)
Urban	858	32.1
Rural	1,818	67.9
Monthly income (N = 2,249)
<$100	1,074	47.6
$100–$300	975	43.4
$300–$500	150	6.7
>$500	50	2.3
Education (N = 2,685)
No education	486	18.1
Primary school	1277	47.6
Secondary school	583	21.7
High school	269	10.0
University or higher education	70	2.6
Psychology knowledge (N = 2,254)
Yes	426	18.9
No	1,828	81.1

	1.	2.	3.	4.	5.
1. CSSA Symptom
2. CSSA Syndrome	.763*	.
3. Depression	.641*	.659*	.
4. PTSD	.567*	.560*	.779*	.
5. Anxiety	.738*	.711*	.723*	.634*	.

	Psychology knowledge	χ2	Φ
Sex
Male	29.9%	70.1%	85.677*	−0.195
Female	13.6%	86.4%
Location
Urban	29.1%	70.9%	73.677*	−0.181
Rural	14.0%	86%
Monthly income
<$100	12.6%	87.4%	67.377*	0.173
$100–$300	22.8%	77.2%
$300–$500	31.3%	68.7%
>$500	40.0%	60.0%
Education
No education	2.2%	97.8%	441.551*	0.443
Primary school	11.6%	88.4%
Secondary school	25.2%	74.2%
High school	48.1%	51.9%
University or higher education	84.8%	15.2%
Anxiety
Probable	17.6%	82.4%	0.970	−0.021
Not probable	19.4%	80.6%
Depression
Probable	21.0%	79.0%	1.260	0.024
Not probable	18.5%	81.5%
PTSD
Probable	23.6%	76.4%	2.966	0.036
Not probable	18.3%	81.7%
CSSA somatic
Distress caseness	15.9%	84.1%	8.548*	−0.062
No distress caseness	20.9%	79.1%
CSSA syndromes
Distress caseness	14.6%	85.4%	13.698*	−0.079
No distress caseness	21.2%	78.8%

Footnotes

Acknowledgements

We are grateful for the support of our colleagues, Dr. Bunnak Poch, Channika Pot, Laura Bebra Saupe, Hema Nhong, Dr. Luise Ahrens, Dr. Kevin Conroy, and Sek Sisokohm.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

Data collection was funded by GIZ (Gesellschaft für internationale Zusammenarbeit), Maryknoll, and Catholic Relief Services (CRS).

ORCID iD

Amber N. Kelley

Amber N. Kelley, M.MFT, is a PhD candidate in the Human Development and Family Science department at the University of Georgia, with a focus on marriage and family therapy. Her research explores the mental health outcomes, behaviors, and services of populations historically impacted by systemic trauma. Currently, her work examines the cross-cultural implementation of Western psychology and psychotherapy models in non-Western populations and the mental and physical health of Cambodian elder refugees, as well as an emphasis on theoretical conceptualizations of systemic and intergenerational traumatic stress.

Desiree M. Seponski, PhD, LMFT, is an Associate Professor in the Department of Human Development and Family Science, Marriage and Family Therapy Program at the University of Georgia, visiting faculty at the Royal University of Phnom Penh, Cambodia, and President-elect of the International Family Therapy Association. Her research focuses globally on culturally responsive therapeutic intervention with immigrant and historically marginalized families. Her current work explores the implementation of Western based therapy models in Southeast Asia, mental and relational health in Cambodian families (US and abroad), complex trauma, and the use of photovoice and mixed methods.

Sareth Khann, PhD, is a lecturer in psychology in the Department of Psychology at the Royal University of Phnom Penh in Cambodia where he also serves as coordinator of their master's program in Clinical and Counseling Psychology. His published works focus on mental health, with current projects exploring the relationship among culturally specific syndromes, depression, anxiety, PTSD, and functional impairment in Cambodian young adults.

Cindy Lahar, PhD, is Professor and Program Coordinator for Psychology at the University of South Carolina Beaufort. She was named a Carnegie Scholar by the Carnegie Foundation for the Advancement of Teaching and has received two Fulbright awards to conduct research and teach in Cambodia. She continues work in Southeast Asia consulting with the Department of Psychology at the Royal University of Phnom Penh. Her research background is in cognitive and developmental psychology, with a current focus on cross-cultural training initiatives aimed to enhance psychology training in Cambodia and projects that focus on the scholarship of teaching and learning.

Sovandara Kao, PhD candidate, is a lecturer in psychology in the Department of Psychology at the Royal University of Phnom Penh in Cambodia where he also serves as operator of the master's program in Clinical and Counseling Psychology. His published works focus on mental health and education, with current projects exploring the impact of self-esteem, enabling family relations, and school social climate on future aspirations of high school students in Cambodia.

Tanja E. Schunert, MD, is a specialist in psychiatry and psychotherapy for adults as well as for children and adolescents. She is currently head of a psychiatric-psychotherapeutic day and outpatients clinic in Northern Germany. From 2010 to 2012, she was a lecturer in traumatology and trauma therapy at the Department of Psychology at the Royal University of Phnom Penh in Cambodia. Funded by GIZ, she established the master's program in Clinical and Counseling Psychology, including the nationwide collection of data for the Cambodian National Mental Health Survey. Her published works focus on mental health, with projects exploring the relationship among culturally specific syndromes, depression, anxiety, PTSD, women’s mental health, and suicide attempts in Cambodia.

References

Armes

S. E.

Somo

C. M.

Khann

Seponski

D. M.

Lahar

C. J.

Kao

Schunert

(2018). Mental health indicators of suicide in Cambodian women. Asia Pacific Journal of Public Health, 30(1), 7–18. https://doi.org/10.1177/1010539517751349

Chhim

(2013). Baksbat (broken courage): A trauma-based cultural syndrome in Cambodia. Medical Anthropology, 32(2), 160–173. https://doi.org/10.1080/01459740.2012.674078

Chhim

(2017). Mental health in Cambodia. In H. Minas & M. Lewis (Eds.), Mental health in Asia and the Pacific: Historical and cultural perspectives (pp. 135–144). Springer Science + Business Media.

Furnham

Swami

(2018). Mental health literacy: A review of what it is and why it matters. International Perspective in Psychology: Research, Practice, Consultation, 7(4), 240–257. https://doi.org/10.1037/ipp0000094

Hinton

D. E.

Lewis-Fernández

(2010). Idioms of distress among trauma survivors: Subtypes and clinical utility. Culture, Medicine and Psychiatry, 34(2), 209–218. https://doi.org/10.1007/s11013-010-9175-x

Hinton

D. E.

Kredlow

M. A.

Pich

Bui

Hofmann

S. G.

(2013). 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 (SSI). Transcultural Psychiatry, 50(3), 347–370. https://doi.org/10.1177/1363461513481187

Hinton, D. E., Pich, V., Marques, L., Nickerson, A., & Pollack, M. H. (2010). Khyâl attacks: A key idiom of distress among traumatized Cambodia refugees. Culture, Medicine, & Psychiatry, 34(2), 244-278. https://doi.org/10.1007/s11013-010-9174-y

Hinton

D. E.

Seponski

D. M.

Khann

Armes

S. E.

Lahar

C. J.

Kao

Schunert

(2019). Culturally sensitive assessment of anxious-depressive distress in the Cambodian population: Avoiding category truncation. Transcultural Psychiatry, 56(4), 643–666. https://doi.org/10.1177/1363461519851609

Houn

(2014). Gender inequality among men and women in Cambodian society [PDF file]. Kitakyushu Forum on Asian Women. http://www.kfaw.or.jp/

10.

Janus

N. G.

(2010). West meets East: The current state of mental health services in Cambodia. East-West Connections, 10(1), 63–80. link.gale.com/apps/doc/A299760669/LitRC?u=uga&sid=bookmark-LitRC&xid=b5f6d28e

11.

Jorm

A. F.

(2000). Mental health literacy: Public knowledge and beliefs about mental disorders. British Journal of Psychiatry, 177(5), 396–401. https://doi.org/10.1192/bjp.177.5.396

12.

Jorm

A. F.

Korten

A. E.

Jacomb

P. A.

Christensen

Rodgers

Pollitt

(1997). Mental health literacy: A survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166(4), 182–186. https://doi.org/10.5694/j.1326-5377.1997.tb140071.x

13.

Kidron

C. A.

Kirmayer

L. J.

(2019). Global mental health and idioms of distress: The paradox of culture-sensitive pathologization of distress in Cambodia. Culture, Medicine and Psychiatry, 43(2), 211–235. https://doi.org/10.1007/s11013-018-9612-9

14.

Kim

J. E.

Saw

Zane

(2015). The influence of psychological symptoms on mental health literacy of college studetns. The American Journal of Orthopsychiatry, 85(6), 620–630. https://doi.org/10.1037/ort0000074

15.

Kirmayer

L. J.

Pedersen

(2014). Toward a new architecture for global mental health. Transcultural Psychiatry, 51(6), 759–776. https://doi.org/10.1177/1363461514557202

16.

Kish

(1949). A procedure for objective respondent selection within the household. Journal of the American Statistical Association, 44(247), 380–387. https://doi.org/10.1080/01621459.1949.10483314

17.

Lewis-Fernández

Kirmayer

L. J.

(2019). Cultural concepts of distress and psychiatric disorders: Understandings symptom experience and expression in context. Transcultural Psychiatry, 56(4), 786–803. https://doi.org/10.1177%2F1363461519861795

18.

Miller

J. K.

Platt

Nhong

(2019). Psychological needs in post-genocide Cambodia: The call for family therapy services and the implications for the “majority world” populations. Journal of Family Psychotherapy, 30(2), 153–167. https://doi.org/10.1080/08975353.2019.1613610

19.

Mollica

R. F.

McDonald

L. S.

Massagli

M. P.

Silove

D. M.

(2004). Measuring trauma, measuring torture: Instructions and guidance on the utilization of the Harvard Program in Refugee Trauma’s versions of the Hopkins Symptom checklist-25 (HSCL-25) & the Harvard Trauma Questionnaire (HTQ). Harvard Program in Refugee Trauma.

20.

Mollica

Wyshak

de Marneffe

Khuon

Lavelle

(1987). Indochinese versions of the Hopkins symptom checklist-25: A screening instrument for the psychiatric care of refugees. The American Journal of Psychiatry, 144(4), 497–500. https://doi.org/10.1176/ajp.144.4.497

21.

Naal

Tavitian-Elmadjian

L. R.

Yacoubian

H. A.

(2020). Predictors of mental health literacy in a sample of university students in Lebanon. International Journal of Mental Health, advanced online copy, 1–23. https://doi.org/10.1080/00207411.2020.1838239

22.

C. H.

(1997). The stigma of mental illness in Asian cultures. Australian and New Zealand Journal of Psychiatry, 31(3), 382–390. https://doi.org/10.3109/00048679709073848

23.

Olofsson

Sebastian

M. S.

Jegannathan

(2018). Mental health in primary health care in a rural district of Cambodia: A situational analysis. International Journal of Mental Health Systems, 12(7), 1–13. https://doi.org/10.1186/s13033-018-0185-3

24.

Phoeun

Nguyen

A. J.

Minh

D. H.

Nam

T. T.

Weiss

(2019). Assessing the effectiveness of teachers’ mental health literacy training in Cambodia: A randomized controlled trial. VNU Journal of Science: Education Research, 35(3), 100–144. https://doi.org/10.25073/2588-1159/vnuer.4279

25.

Reavley

N. J.

Morgan

A. J.

Jorm

A. F.

(2014). Development of scales to assess mental health literacy relating to recognition of and interventions for depression, anxiety disorders and schizophrenia/psychosis. Australian & New Zealand Journal of Psychiatry, 48(1), 61–69. https://doi.org/10.1177/0004867413491157

26.

Saxena

Thornicroft

Knapp

Whiteford

(2007). Resources for mental health: Scarcity, inequity, and inefficiency. The Lancet, 370(9590), 878–889. https://doi.org/10.1016/S0140-6736(07)61239-2

27.

Seponski

D. M.

Lahar

C. J.

Khann

Kao

Schunert

(2019). Four decades following the Khmer Rouge: Sociodemographic factors impacting depression, anxiety and PTSD in Cambodia. Journal of Mental Health, 28(2), 175–180. https://doi.org/10.1080/09638237.2018.1466039

28.

Seponski

D. M.

Lewis

D. C.

Bermudez

J. M.

Sotelo

J. M.

(2020). Cambodian therapists’ perspectives of western-based psychotherapy models: Addressing the challenges for service providers. Journal of Family Psychotherapy, 31(1–2), 36–55. https://doi.org/10.1080/08975353.2020.1759018

29.

Seponski

D. M.

Lewis

D. C.

Megginson

M. C.

(2014). A responsive evaluation of mental health treatment in Cambodia: Intentionally addressing poverty to increase cultural responsiveness in therapy. Journal of Global Public Health: An International Journal for Research, Policy, and Practice, 9(10), 1211–1224. https://doi.org/10.1080/17441692.2014.947302

30.

World Health Organization (WHO). (2010). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialised health settings. WHO.

31.

World Health Organization (WHO). (2014). [Interactive map and dataset] Mental health: Psychiatrists and nurses working in mental health sector (per 100,000 population). http://www.who.int