West meets east: the current state of mental health services in Cambodia.

Janus, Nancy G.

Introduction

Cambodia is a country whose history is shaped by thirty years of conflict, from genocide to civil war to ordinary street violence. Its people still deal with the psychological scars of losing friends and relatives as well as the professional elite that guided the political and educational systems before the Khmer Rouge period. The result is that now there is heavy dependence upon foreign aid to rebuild the country economically, educationally and socially. There is significant reliance on organizations such as the World Bank for economic support, and on some 200 to 300 international NGOs for social and educational reconstruction (Martonova et al).

Poverty is a major problem in Cambodia, with women and children being the most affected. According to Dr. Sotheara Chhim, the confluence of poverty and Cambodia's violent past yields a significant number of mental health problems within the country and contributes to a dearth of trained professionals to address them. (1) A review of the websites of numerous NGOs working on human rights issues relating to women and children reveals that nearly all of these NGOs claim to be providing some form of counseling or social rehabilitation. This raises the question of how this counseling is being accomplished, by whom and with what training. Furthermore, since most counseling theory has been postulated by Western mental health specialists, how is it being modified for effective use with Cambodian clients, if at all? This article tries to address these questions and further examines the particular issues of working with Cambodian clients within their culture.

During the summer of 2009, this author traveled to Cambodia to interview Western and Cambodian mental health specialists to understand better how the psychological needs of Cambodia's women and children are being addressed. She visited 14 NGOs in Phnom Penh and Siem Reap, interviewing counselors and social workers. She also visited the Department of Psychology at the Royal University of Phnom Penh to ascertain how undergraduate and graduate training of mental health specialists is being done.

History of Mental Health Services in Cambodia

Prior to 1975, there was only one psychiatric hospital in Cambodia. After the Khmer Rouge period in 1979, there were no hospitals, and the small number of psychiatrists who had worked previously had been killed. It was not until 1988 that the mental health needs of Cambodians were once again addressed, but this time only those Cambodians who found themselves living in the refugee camps along the Thai border were served. At that time 57 family and child mental health counselors received training from the Harvard Program in Refugee Trauma. This training evolved into an important resource, the Harvard Guide to Khmer Mental Health (Lavelle et al).

In 1993 the Cambodian National Health Plan made psychiatry a high priority along with general health improvement. However, without Cambodians educated to provide either the services or the training to implement the priority, international organizations had to step in.

In 1994 the Transcultural Psychosocial Organization International (TPO), based in Holland, began a mental health program in Cambodia "to help Cambodian people overcome the psychological consequences of the trauma they experienced in the last three decades of war, socio-political upheavals and the genocidal Pol Pot's regime in the country" (Chhim 2). TPO exists to this day, based in Phnom Penh with four satellite offices in other cities in Cambodia. This organization provides direct services to Cambodians with mental health problems and is also involved in training initiatives for Cambodians working for other NGOs in the country.

In the same year the Dutch recognized the need for mental health agencies in Cambodia, the Norwegians did as well. The Norwegian government funded the Cambodian Mental Health Development Program to offer three years of training for 10 Cambodian physicians interested in specializing in psychiatry. Several years later, 10 more Cambodian psychiatrists were trained (Savin1). As of 2006, a total of 26 psychiatrists were trained in this program along with 40 psychiatric nurses. Today there are a total of 30 Cambodian psychiatrists in the country, primarily based in Phnom Penh.

After the Pol Pot period in Cambodia, the need for mental health services was strong, and the training of psychiatrists alone would not meet it. Recognizing that paraprofessional counselors might be trained to provide services in the villages, a group of Cambodian-American social workers began a program in 1992. Village volunteers were trained to provide direct social work services to their troubled neighbors in the villages. Training expanded to cover more than 600 staff of the Ministry of Social Affairs. This program evolved into a still-existing NGO, Social Services of Cambodia (SSC), which continues to offer social work skills training to NGO employees throughout Cambodia. (Minotti 1).

In recent years, other international groups have come to Cambodia to provide counseling and social work training to NGO staff. Currently there are training programs at and through TPO in Trauma Focused Cognitive Behavior Therapy. Staff from NGOs working with traumatized children and young adults are being trained in this model, which, in the West, has proved effective in alleviating the symptoms of Post Traumatic Stress Disorder.

The Nature of the Cambodian Mental Health Problem

Due to it's violent past and grinding poverty, there are a number of predictable mental health problems manifest in Cambodia. Of 1400 adults measured by the Household Survey of Psychiatric Morbidity in Cambodia in 2001, 42 percent met criteria for depression, 53 percent for anxiety, and 7 percent for post-traumatic stress disorder. Twenty-five percent of the respondents felt that their symptoms were sufficiently intrusive to make them socially impaired (Dubois et al 181). These problems contribute to, or are exacerbated by, the many serious social and economic difficulties in Cambodia today.

Cambodia continues to be a violent place, and the violence takes many forms. Domestic violence is rampant both in villages and urban areas and receives a high level of social acceptance both from men and women (Surtees 32). According to Joseph Mussomeli, "In a society soaked in violence for more than thirty years, and with a lack of trust in the judicial system, Cambodians, and men in particular, believe that aggression is an appropriate tool to control and dominate others. There is no compunction against being violent to women, children, and one another" (Mussomeli 1).

Related to domestic violence is human trafficking: many young people are being sold by their impoverished families to enter a violent world of prostitution. Significant numbers of street children form gangs and engage in urban crime. Homelessness is a reality for many Cambodians who are evicted from their land. Finally, the killing of so many Cambodians in the late 1970's has resulted in the disruption of extended family supports on which the people had relied in time of need (Lee 55). Given the extent of these problems, numerous international NGOs have stepped in to help. Most offer counseling and social work services that have been copied from Western models of service delivery.

Cambodian Help-Seeking Behavior

Cambodians are not averse to seeking help for mental distress. However, they prefer to be seen by traditional Cambodian healers before they seek Western-style counseling. There is a deep tradition of spiritual healing in Cambodia and a belief system that incorporates folk medicine as the most viable healing alternative. According to Soeurn Hem,

   Besides medicines, folk healers use religion, magical incantations,
   tattooing, burying magical objects under the skin, pouring holy
   water, inscribing handkerchiefs with magical scriptures, making raw
   threads to be worn around the waist, spitting chews of betels and
   areca nuts, calling souls with magic formulas and other such
   practices.

   Traditional healers also use pinching the skin, coining, glass
   suction, herbal steaming, massage, bed heating and other
   treatments. Finally, Cambodian folk healers treat patients by
   making offerings to the ancestors or spirits, appeasing angry
   ghosts, ghouls, or the devil. They may use mediums to contact the
   water spirits, the male spirit, or others. Sometimes they use
   magical Pali words to "tie" the spirits. They may also "whip" a
   spirit through the patient's body in order to chase out the illness
   caused by evil spirits or the devil. (16)

Specifically, there are several categories of traditional healers in Cambodia. The Kruu Khmer is a sort of sorcerer. He may provide traditional medicine or he may offer magic. Lang describes the Kruu Khmer as a "practitioner of magic who has a number of talents. He is believed to be able to inject supernatural power into an amulet by drawing on his secret magic formula. He can also prescribe traditional herbs, roots and folk remedies" (Lang 60). The Kruu Khmer typically does not become possessed by a spirit when he works with a Cambodian client, but other spiritual healers called Chol Rup Arak do. This spirit possession allows the healer to communicate with the spirits that are seen to be infecting the client. The Achar Wat is able to communicate with the spirits without becoming possessed himself. Typically it is only the seriously mentally ill who see the Achar Wat or the Chol Rup Arak and, according to Sotheara Chhim, (2) it would be unusual for a client suffering from depression or anxiety to go to such a healer. What is essential to understand about these traditional healers is that they are able "to apply a consistent template based firmly on Cambodian cosmology and drawing on its entire biological, psychological, social, and ecological canvas" (Eisenbruch 9).

Cambodians will often choose to see a monk for mental health problems. They believe that if a monk prays for them and helps them to be on the best Buddhist path, they will be healed. Buddhist prayer helps the client to feel empowered to address his or her problems with greater strength. Unfortunately, most monks in Cambodia are not trained in counseling or psychology and do not have skills to address the help-seekers beyond prayer. One exception is the Salvation Center of Cambodia where Buddhist monks have received basic training in Western counseling skills in order to work directly with clients who have HIV/AIDS. However, eschewing the Western approach, Venerable San Pon, director of the Salvation Center explained that the counseling process used with these clients is first prayer, followed by the application of holy water and finally review of the Buddhist teachings called the dharma. (3)

Cambodians are not averse to seeing Western mental health professionals or to engaging in traditional verbal counseling with them. However, certain criteria are expected. First of all, confidentiality is of the utmost importance. As a people, Cambodians do not typically complain or tell their personal stories. Consequently, they are particularly sensitive to the notion that the story might be shared. According to Dr. Sotheara Chhim, it can be hard to get Cambodian clients to talk at all, and it often takes several visits before they will open up and tell the true story. In the interest of saving face, they may fabricate a story or hide key details of it. (4)

Secondly, Cambodian clients expect that the counselor will have a thorough understanding of their cultural traditions. The counselor must "have an in-depth understanding of the patient's values, experiences, behaviors and feelings" (Mam 28).

Finally, the counselor must be empathic, accepting and non-judgmental.

Any professional trained in the mental health disciplines of the West will have no difficulty understanding the criteria of confidentiality, empathy and taking a non-judgmental stance. However, awareness of deep cultural perspectives is more difficult for Westerners.

Differences between Western and Cambodian Clients

Most counseling theory has evolved from Europe and America, and Western assumptions about the mentally healthy person may actually have little applicability in the Cambodian context. As a Theravada Buddhist country, Cambodians believe strongly that suffering is a normal part of life. In the WWest, counseling is oriented toward the removal of suffering. For the Cambodian client, counseling is about coping with suffering. "The religion teaches people to take what comes, that they are not responsible for their lot in life, that outside forces control their fate" (Coates 148).

The belief that people's problems are determined by past life behaviors does not permeate most Western thought, but it is very important to Buddhist belief. Steinberg explains that

The doctrinal formula of Theravada Buddhism can be restated as follows: that which a man is, is the fruit of what he has been. Each malicious deed or intent--or for that matter, the failure to gain adequate merit in this life--carries a seed which germinates into misfortune in a later existence. Similarly, each adversity or misfortune encountered in the present life can be traced to some misdeed committed in an earlier one. (Steinberg 61)

Most Western counseling theory is predicated on the notion that the individual can take charge of his or her own life and come to a solution for its problems. The assumption that those problems may stem from mistakes in a previous life can breed passivity among Cambodian clients. The Western counselor needs to understand that the idea of taking charge in this life to bring better outcomes in the next life provides effective leverage for change in the client.

Another Buddhist construct that makes Cambodians different from Western clients is the unity of body and mind. Mental distress is quickly somaticized into physical distress. The Cambodian client is more likely to seek help for the somatic complaint and consequently may resist the notion that his or her problem should be dealt with through counseling. The client is also more likely to anticipate a medical model fix. That is, the expert listens and immediately proposes a solution to the problem.

The notion of expertise is deeply rooted in the Cambodian belief about hierarchy. Cambodia is a fiercely hierarchical society, with social hierarchy determined by intellectual status, age, gender, urban vs. rural dwelling, etc. This is an issue in counseling since Western theory supports the notion that the client and counselor work together as partners rather than in a hierarchical arrangement. If the Cambodian client anticipates a quick fix by the expert, and the counselor anticipates the unveiling in partnership of the problem and the client's arrival at his or her own solution, they may be at cross-purposes with one another.

The hierarchical arrangement of family, along with the Buddhist precept that the child owes a debt to his or her parents for birthing him or her, make counseling especially difficult when the etiology of the problem is in past or present family relationships. Some Western counseling approaches invite the counselor to explore the client's past and to discuss familial injuries. According to one mental health professional currently working in Cambodia, Cambodians simply will not look at the role of parents in their problems. "Their parents cannot make mistakes." (5) This is in part because of the expectation that one lower in a hierarchy always shows respect for those above him or her. For women it is clearly spelled out in the Chbab Srey or women's behavior code (Mal). The code states that the woman must always treat her parents with respect and deference and follow the path that they laid out for her. The Western client is more likely to examine the role of parents in his or her problems with objectivity, while it is culturally inappropriate for the Cambodian client to do so.

Generally Western counseling advocates for the recognition of and sharing of feelings in counseling sessions. However, emotional expression is different for Cambodian clients than for Western ones. For one thing, Khmer is a language that does not have a lot of words to express emotion. This is particularly the case for the negative emotions such as sadness. In order to communicate a feeling state, the Cambodian does so in subtle, indirect ways and only with people who are especially trusted. According to Fitzgerald, et al,

The problem goes beyond language, however, because the whole process involves transferring from one way of thinking about conceptualizing emotions to another.

This is especially the case if this translation is from a language with a limited affective vocabulary to one with an extensive vocabulary where each term carries different, often subtle, shades of meaning. (Fitzgerald et al 56)

Current Practice in Cambodia

At the present time in Cambodia there is a lot of activity in the counseling field. While the number of psychiatrists is still very limited, and the formal training program for psychologists at the Royal University of Cambodia is quite young, there has been considerable training of paraprofessional counselors who are now working with the human-rights based NGO's throughout Cambodia. The two principal training agencies are Social Services of Cambodia and the Transcultural Psychosocial Association. Additionally, some Western-based NGO's such as World Vision and Friends International bring their own trainers over from the United States on short-term assignments. Sometimes the model is to train the Cambodians in counseling skills that they then teach to their colleagues, and sometimes the practicing counselors receive training directly.

One issue noted by this author in discussing counselor education with numerous Cambodian practitioners is the difficulty of integrating the training models with Cambodian cultural belief. The Royal University of Phnom Penh addresses this in two cultural competence courses. However, the number of Masters-level graduates in Cambodia is still very small. The vast majority of counselors in Cambodia are trained in workshop formats that last from one week to periodically over six months.

Client-centered Counseling

Social Services of Cambodia (SSC) has trained 300 Cambodian counselors, most of whom have been women. (6) This organization teaches a client-centered model of counseling, stressing careful listening and eliciting of the client's story. Posted on the wall of the center is a list of the steps of their model: 1. Build the relationship; 2. Explore the problem; 3. Identify the client's needs and strengths; 4. Make a plan using the strengths; 5. Implement the plan; 6. Follow up and review.

The client-centered model is very different for the Cambodian client who is accustomed to giving and receiving advice. Ellen Minotti, the director of SSC, explained that the biggest impediment to the use of the client-centered model is the hierarchical structure of society in Cambodia. Cambodians attribute expertise to the counselor, placing him or her on a higher level in the social hierarchy. Consequently they expect advice from him or her, and counselees struggle with the notion that the solution to the problem lies within him or herself. Minotti goes on to explain that the translation of the word "counseling" in Khmer is "to give advice." (7)

Despite their initial discomfort with the client-centered model of counseling, Cambodian clients frequently do open up and reveal their stories in detail. The critical factor is whether the client comes to trust the counselor. Dr. Denis Nicolay, a Belgian psychiatrist working in Cambodia, states that the most difficult problem with counseling Cambodians is establishing trust and helping them to understand confidentiality. (8) Dr. Sotheara Chhim adds that they fear that their story will be spread throughout the community, and that they will lose face if others know about their personal weaknesses. (9)

Building a relationship with a Cambodian client can take a long time. Dr. Chhim states that it may take up to five counseling sessions before the client will share his or her true story. He hypothesizes that this reluctance to share may stem in part from the Pol Pot history wherein people who spoke honestly were often brutally killed. He also reports that listening is not the Cambodian way. "I have the same story as you, so why are you telling me yours. Just forget it." is how Chhim conceptualizes the Cambodian listening style. (10)

Client-centered counseling, the non-judgmental listening to clients, may be awkward for Cambodians who, as they reveal their story, may begin to cry. Dr. Chhim points out that crying is not tolerated in Cambodian society, and that even if a child cries, the parent's response may be "stop that or I'll beat you." (11) On the other hand, many Cambodians really need the opportunity of having a committed listener. According to Pennebaker, "holding back or inhibiting our thoughts and feelings can be hard work. Over time, the work of inhibition gradually undermines the body's defenses. Like other stressors, inhibition can affect immune functions, the action of the heart and vascular systems, and even the biochemical workings of the brain and nervous systems" (Pennebaker 2).

This author had the opportunity of talking with various counselors who had received training in client-centered counseling through Social Services of Cambodia. While they seem to understand theoretically how to utilize the model, in practice the Cambodian way seems often to take over. Counseling quickly becomes advice-giving, and non-directive approaches become directive. Most NGOs do not pay for their employees to receive ongoing supervision from Social Services of Cambodia. So if left on their own, many counselors apparently go back to what they know best.

Trauma-Focused Cognitive Behavior Therapy

Along with Social Services of Cambodia, the Transcultural Psychosocial Organization has been the second important training resource for counselors in Cambodia. Beginning in 2000, TPO has been the beneficiary of training through the Trauma Healing Initiative of the Minnesota-based Center for Victims of Torture. The CVT has used a train-the-trainers approach to teaching the skills of Trauma Focused Cognitive Behavior Therapy (TF CBT) to Cambodian clinicians. This is a step-by-step model developed for use with children and families who have had traumatic experiences, and as such it is being applied in Cambodian NGOs that have client bases who are victims of trauma. This author spoke to clinicians working with victims of human trafficking and domestic violence specifically about their work with TF-CBT.

"TF-CBT is a components-based hybrid approach that integrates trauma-sensitive interventions, cognitive-behavioral principles, as well as aspects of attachment, developmental neurobiology, family, empowerment, and humanistic theoretical models in order to optimally address the needs of traumatized children and families" (Cohen, Mannarino and Deblinger 32). At least in the early stages, the components are largely educational, teaching clients about the impact of trauma and normal reactions to it, and, in the case of child clients, teaching their parents skills for living with traumatized children. Then the treatment teaches particular skills, including relaxation and appropriate emotional expression. Clients learn that there are strong links between thinking, feeling and behaving, and the counselor helps them to recognize and modify dysfunctional thoughts about their trauma. Finally the client is led to recount the trauma in detail, first to the counselor and subsequently to the parent or family members. If the client is in danger of re-victimization, the counselor works with him or her to develop a safety plan.

There are elements of the TF-CBT model that are quite consistent with Cambodian expectations of the counselor. This model is highly directive, particularly in the early stages of counseling. The counselor acts as a teacher to the client, thereby fulfilling the "expert" expectation that goes with the hierarchical model of Cambodian society.

When it comes time to teach about the nature of trauma and the links between dysfunctional thinking and feelings and behavior, it is essential for the counselor to have in-depth understanding of the Cambodian client's cultural beliefs. For example, in Cambodia women are in an inferior position to men in virtually all arenas. Consequently it would not be unusual for a female victim of domestic violence to accept it. "Women themselves are socialized to obey their husband and to tolerate his anger" (Gormon, Dorina & Kheng 33). The Western counselor would see this acceptance as stemming from dysfunctional thinking, while a Cambodian would find it consistent with cultural perspectives on gender relations.

TF-CBT is a model that requires a longer training ramp-up than client-centered counseling. Cambodian counselors have first to learn the listening skills taught in the client-centered model in order to be able to develop the trust relationship with their clients and to reach the point at which the client is willing to talk about his or her actual traumatic experiences. Subsequently they have to be taught the educational material which accompanies the early stages of TF-CBT; the impact of trauma on people, relaxation and stress relief, affective expression and cognitive coping skills. Cambodians are accustomed to didactic approaches that invite memorization and mastery, but the educational system of Cambodia does little to prepare them to analyze and apply the material that they learn. "They copy and memorize, not question" (Grossman 181).

In interviewing Cambodians using TF-CBT with their clients, this author noted that the model had indeed been well-memorized and the counselors were able to restate the necessary steps. However, when asked for more detailed or specific explanations, their level of understanding seemed limited and they were quick to explain how they offered advice and direction to their clients. The problem may be that most NGO counselors receive training but little follow-up supervision. An exception is Hagar, an anti-trafficking agency. According to Sue Taylor, Children Department Manager, the Cambodian counselors are using the strategies of TF-CBT effectively and are seeing progress. (12) However, Taylor herself is able to provide ongoing training and supervision to those counselors, trainers from Boston University are directly involved, and she has created a 10-step manual for them to use in their work.

TF-CBT was developed for use with children and their families, but it has been extended by Cambodian practitioners for use with adult clients as well. Steps such as teaching parenting skills have been eliminated, and in the final step of sharing the trauma story, the client is able to choose with whom they would like to share rather than being required to share with a parent or family member.

Skeptics in Cambodia suggest that TF-CBT is too complex for Cambodian counselors to master truly. It requires a high level of self-awareness for the client to be able to identify his or her dysfunctional thoughts. This author heard from several Western counselors practicing in Cambodia that Cambodians are not awareness-focused and are unfamiliar with exploring their internal world. Chhim explained that TF-CBT is more effective with "white-collar workers" than with the uneducated masses. The less educated, he explains, just say to the counselor, "I don't know, it's up to you." (13)

Group Counseling

There are efforts to offer group counseling through some of the NGOs in Cambodia. Group counseling can be an economical way to address the needs of numerous clients. However, in Cambodia group counseling seems to be a misnomer for what actually occurs. In Western countries, group counseling serves to build a sense of sharing around a similar problem or issue. Openness and honesty on the part of group members is expected. However, in Cambodia, such open sharing would lead to a loss of "face" and would not find the cooperation that it does in Western societies. What actually seems to occur in "group counseling" in Cambodia is largely didactic. While clients might have the same problem, such as being victims of domestic violence, human trafficking or HIV/AIDS, they do not discuss it among themselves. Rather, group sessions may serve to provide information about legal or medical services available to them, or to teach them life-skills such as hygiene and money-management. (14)

Moving Ahead

So far the book has not been written that integrates traditional Cambodian beliefs and cultural constructs with Western models of psychology. Efforts to teach Western models in Cambodia appear to be working during training programs, but they seem to lose their focus in application. The Cambodian counselors employing them are indeed products of their own culture, and as such return easily to giving advice and short-term, quick-fix solutions for their clients. The majority of Cambodian people still prefer traditional healers to Western-trained counselors and consequently they seek the counselors out in situations of desperation when traditional healing has not worked. Higher levels of success in reaching Cambodian clients with Western approaches seem to occur in NGO settings where the clients are already connected rather than with individuals who seek counseling on their own. When ongoing clinical supervision is a part of the counseling program, the application of Western approaches seems to have a greater hold.

In order to render the practice of counseling most effective in Cambodia, there needs to be greater integration with cultural practice. Happily, the Royal University of Phnom Penh includes a course entitled Cultural Competence-Partnership with Local Resources designed to teach students about " ... the types of folk and professional healers who work in Cambodia and the manner in which they help people overcome mental suffering and psychosocial distress. The aim is to equip students in their future work as psychologists in Cambodia, to utilize Buddhism and local culture and to augment the capacity of the monks, traditional healers and mainstream psychology to collaborate in community mental health" (Hema 2).

As mental health service delivery becomes more universal in Cambodia, which it surely will in response to modernization, it will be interesting to see how the traditional means of healing might become collaborative with Western counseling practice. Will mental health centers develop in districts that include both types of helpers working in dialog with one another? It seems logical that the credibility of the counselor would be enhanced if he or she were in a referral relationship with a traditional helper. Might clients of the kruu Khmer be referred to the counselor for further mental health support when needed and vice versa? The key would seem to be in the development ofhigh-level understanding between both of them.

Perhaps the helping role of the monks in Cambodia could be enhanced by specific training in the methodologies of Western counseling. In a form of Buddhist pastoral counseling, prayer, recognition of Buddhist precepts and the use of holy water could be combined with client-centered listening skills and willingness to hear the "whole story" from the client.

The creative therapies may also have a place in mental health service delivery in Cambodia. In a culture in which talking about problems is not the norm, expression through art, drama and music has strong potential. Cambodians love to dance, sing and play; and fun, laughter, story telling and role-play are important parts of the creative therapies. (15) Approaches such as these mitigate against the fierce hierarchy and create less distance between the client and the counselor. Already some efforts are being made to use art therapy with children in Cambodia with good success. (16)

Conclusion

At this time in its history, there is considerable interest in providing mental health services in Cambodia. Various Western-educated specialists are offering training for Cambodian nationals to provide counseling and social work services. While Cambodians are very interested in these training programs, it seems that in practice they do not apply the skills learned and rather revert to approaches that are more culturally consistent. The cultural values of authoritarian hierarchy, subservient gender roles,and client defenses against "loss of face" all tend to erode the building of counseling relationships that match Western expectations inherent in the theory and training of counselors.

While better-educated, urban Cambodian clients may be comfortable with counseling models that involve high levels of self-disclosure, less educated and rural clients much prefer the help of traditional healers such as the kruu Khmer. Their methods depend upon ritual and magical practices that are little understood by Western counselor-trainers, and self-disclosure plays a minor role in the application of those rituals and practices.

Although it has been recognized for nearly twenty years that collaboration between Western counselors and traditional monks and healers would be a good thing, there are very few examples of such collaborations occurring at this time in Cambodia. How will such collaboration be promoted and designed? Perhaps an integration of the healing models is not to be, but at least there needs to be increased respect between them. As Cambodian trainees reach levels of understanding deep enough to become counseling trainers, their own appreciation for their culture and its worldview may bring about the link that seems currently to be missing between training and practice.

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(1) Sotheara Chhim (Director, Transcultural Psychosocial Organization) in discussion with the author, June 2009

(2) Chhim, discussion.

(3) Venerable San Pon (Director, Salvation Center of Cambodia) in discussion with the author, July 2009.

(4) Chhim, discussion.

(5) Tina Franke (social worker, Social Services of Cambodia) in discussion with the author, June 2009.

(6) Ellen Minotti (Director, Social Services of Cambodia) in discussion with the author, June 2009.

(7) Minotti, discussion.

(8) Denis Nicolay (Consultant Phnom Penh Counseling Center) in discussion with the author, June 2009.

(9) Chhim, discussion.

(10) Chhim, discussion.

(11) Chhim, discussion.

(12) Sue Taylor (Children's department manager, Hagar) in discussion with the author, June 2009.

(13) Chhim, discussion.

(14) Oem Phally (Director, Program Against Domestic Violence, Siem Reap) in discussion with the author, July 2009.

(15) Nicolay, discussion.

(16) Kim Son Sok (social worker, Anjali House) in discussion with the author, July 2009.