Working in Cambodia

In the UK, I worked in a regional neurosciences centre with paediatric neurological clients and then moved to a community child development setting. My training and experience is in assessment and intervention for developmental problems, and research/ service development. I had always wanted to see the world and, becoming a bit fed up with NHS bureaucracy and nine-to-five routine, I decided to travel. Cambodia was my first stop. I was excited and terrified and I loved it and thought constantly about how I could return and be more than just a visitor: in the end I just never went home.

Setting up
I landed in Phnom Penh and started finding out what was going on in Cambodian psychology. The internet was not much help since local organisations don't rely on it: I couldn't find another psychologist for weeks, largely because there aren't many. Word of mouth is the main information source in the city, and

I soon met people and listened to their advice. Slowly people started to trust me and I began to get referrals; my private practice was on its way. Cases or projects were initially few and far between, so those months backpacking helped me get by as an newcomer in a foreign land with very little money!

A lack of psychological regulation or monitoring means anyone can claim to be anything. People want to wait a while until they know you are sticking around before they get involved. Doing a bit of work for a couple of weeks while you're on your travels isn't viewed favourably by locals. You need the cultural knowledge you get from sticking around for a longer period. Experience confirmed what people said: that it would take months to build the trust of schools and other professionals and establish a referral base. I spent the early days building up this knowledge about the country and its people.

Two and a half years after arriving I have a successful psychological services clinic and am working as a consultant to NGOs. I established the clinic with two expat partners who specialise in adult work. Our combined skills and experience, coupled with the team of expat and Khmer clinicians, means we can cope with a wide range of referrals from foreign and Cambodian populations.

Challenges
There are many challenges; here are a few of them.

Isolation
I am the only child psychologist in the country. There are no social services, so when a child is in danger or has social needs, we can liaise with NGOs, but we can do nothing unless parents cooperate. The police may or may not be helpful depending how much money they think they can make out of it.

Money
There's a huge income gap (a few hundred dollars a month for a middle-class Cambodian to several thousand for an educated expat and even more for the Cambodian elite), so it is impossible to charge a fixed fee. We do not work for free as we have to be sustainable and we don't work directly with poor Cambodians: there's too great a language and cultural divide. We therefore work predominantly with expat families and more educated Cambodians who are at least vaguely familiar with what we do. Most of these clients can afford to pay,  it's just not immediately clear how much.

Understanding
It is incredibly difficult to explain developmental assessment to someone who does not have the same concept of child development, and is used to visiting a doctor and receiving pills, or a priest or shaman who prescribes offerings at a pagoda or buffalo sacrifice. Developmental problems are poorly understood: the concept of karma in Buddhism is sometimes used to explain them, which has negative connotations for the family. This can lead to parents treating their children very badly, not out of lack of care but from a fear of losing face.

Expectations
These traditional models seem to offer a quick fix, and Cambodians don't understand why I cannot 'cure' their child immediately. Collaborative processes are totally alien. Most Cambodian families have nannies, so parents do not always spend a great deal of time with their children. Some families disengage because they think we are wasting their time (and money) or because they do not see immediate results. It is hard to gauge informed consent because of a culture which values assent.

Families will sometimes not accept their child has difficulties and can become angry when an assessment does not find an external cause, for instance the school. This can lead to simply hiring more tutors rather than addressing the real issues. Reports have to be worded carefully. One family tried to pay me to write a favourable report. It's a loss of face for reasons I can't really understand.

Plagiarism
I am also involved with the new Master's in Clinical Psychology course at the Royal University of Phnom Penh. The country desperately needs well-qualified home-grown staff who can deal with the cultural issues that bemuse foreigners. However, developing this group is a long process. The Cambodian education system is fraught with challenges. It is believed that the act of paying for a course means getting the qualification, regardless of attendance. Blatant plagiarism is widely practised, and it took me a while to understand why. I failed a student's assignment because he had copied his answer entirely from my lecture notes. He explained that he had always been taught in a rote way and was told to always write exactly what the teacher thought. He has handed in a pretty good resubmission now I've told him that I want to read his ideas too.

Teaching
A lack of suitably qualified teachers is also an issue. The course relies heavily on foreign staff but here the cultural difficulties emerge again – the course has to be in English and many of the students have problems with my accent! The other part of my work is consultancy for NGOs. This is where I get to see grass-roots Cambodia.

It is incredibly difficult to do research and evaluations, as this imposes a totally alien scientific structure. Poor people in the provinces focus on survival, not on how services could be better, how they feel about things, or what parenting techniques to use. Whenever they are asked about how a project is affecting them they give examples of material support, rather than the feedback we're looking for about processes and impact.

I am writing this in a cafe by the Mekong in Kampong Cham province where I am reviewing a Save the Children project with two Australian colleagues. We are interviewing around 80 stakeholders and beneficiaries, as well as collecting  quantitative data. At 5am on Monday we piled into a 4x4 with our translators and driver, travelling to villages around the region. We have to stay in the provinces as the roads in Cambodia are so bad it takes ages to get anywhere. Yesterday I was interviewing the district Deputy Governor when a cow walked into the room. We also had the honour of being the first foreign visitors to a small remote village where the school is a dilapidated three-room wooden hut supposedly catering for 600 children. There was one pen for every three children; some of the children were wearing rags and sometimes the teacher has to stop classes in case a storm demolished the classroom. Today, we met teachers and government officials, and tried to discriminate between useful answers and those which assume (wrongly) that we can get them more funding or which result from the Cambodian belief that it is not polite to criticise anything.

All of this highlights the constant ethical challenge to accept that I have to do a 'good enough' job with the scarce resources available, rather than meet the high standards I was trained in.

These issues might sound negative but they're challenging, and it's still a privilege to meet such different people and learn a different culture. My assumptions are being challenged. That's stimulating. There are other benefits of working here. When demand is lower I love having a glass of wine by the river or taking a scuba-diving trip. The variety and flexibility of working independently whilst seeing a different way of life and a whole different psychological make-up is wonderful.

People say to me 'you're so brave, I wish I could do something like that', but it's not true, it's so much easier than people think. My advice is to give it a try.