Developing countries’ high needs for mental health care, skeletal mental health infrastructures, and lack of training opportunities result in significant treatment gaps (1). Videoconferencing can effectively deliver psychiatric services, clinical teaching, and supervision to resource-poor settings (2–17). The ability to traverse geographical and socioeconomic barriers may make telepsychiatry especially useful internationally (18–20). To bridge worldwide disparities in mental health services, academic centers in Western countries have partnered with developing countries (1, 21, 22). Clinical teaching and supervision provided via telepsychiatry may offer alternatives to training abroad and might help stem “brain drains” of young professionals from resource-poor countries (22–25). Furthermore, compared with face-to-face contacts, telepsychiatry requires modest investments in time, energy, and finances. Despite these potential advantages, few centers have initiated such efforts (26).
This paper describes a collaboration between the Departments of Psychiatry at the University of Colorado School of Medicine and the University of Health Sciences Cambodia (UHS) that augments the training and supervision of Cambodian psychiatry residents via Skype. This paper traces the development of this collaboration within the larger context of the Cambodian mental health history; it highlights cross-cultural, linguistic, and technical challenges and illustrates key teaching points.
From 1975 until 1979, the Khmer Rouge regime devastated and traumatized Cambodia and effectively destroyed its health and mental health care systems (27). By 1979, only 43 of the country’s 450 pre-Khmer Rouge physicians remained, none of whom was a psychiatrist. In 1992, a Cambodia Mental Health Sub-Committee was formed, but infrastructure development was hindered both by difficult economic conditions and by the Civil War that continued until 1998. A Norwegian-funded program helped the UHS train Cambodia’s first 20 psychiatrists: the first 10 psychiatrists graduated in 1998 (28), and the next 10 in 2005. Since then, UHS’ independent training program has graduated an additional 25 psychiatrists and 40 psychiatric nurses. Also, 175 general practitioners and 175 registered nurses received training in basic mental health care.
In 1998, author DS, previously employed as a psychiatrist at a Cambodian refugee camp, spent several months as a clinical supervisor with the Norwegian-funded program. He subsequently returned to Cambodia for brief periods approximately every 2 years to teach psychiatry. In 2006, DS, Sunbaunat Ka (SK; director of psychiatry residency training and Dean of UHC Faculty of Medicine), and Thida Chak (TC; vice-training director) developed a 2-week elective rotation in Cambodia for University of Colorado psychiatry residents. Three 4th-year residents have completed this elective, during which they have shadowed Cambodian psychiatrists and taught psychiatric topics of interest. In 2006, DS suggested piloting a telepsychiatry case conference. The Cambodians approved, and a Skype-based monthly case conference began in 2007.
Cambodian faculty articulated four objectives for these consultations: 1) to increase trainees’ knowledge regarding standard psychiatric assessment and treatment; 2) to connect with American psychiatrists; 3) to stimulate a culture of critical thinking and open discussion among their residents; and 4) to improve trainees’ English competencies. They also desired a long-term collaboration to further develop Cambodian psychiatry on a larger scale.
Before each monthly conference, Dr. SK reviews one resident’s written case evaluation. The resident then e-mails the case to Colorado. For confidentiality, the evaluations include no personally identifiable information. Cases are discussed during 90–120 minute sessions. From 2007–2009, bandwidth was limited, and video quality unpredictable: therefore, most consultations used voice only and e-chatting. By 2010, greater bandwidth facilitated the current videoconferencing model. On average, 10 Cambodian residents from all 3 years of training participate. Also, one or two of the following Cambodian faculty attend: SK, TC, and BP (outpatient director). DS leads these conferences from Colorado. One or two American residents who are interested in learning about international and cross-cultural psychiatry often participate, as well.
Discussions center on diagnosis and treatment, often with emphasis on cultural issues. Discussion is conducted in English, the language Cambodians use for medical records. Verbal English proficiency varies from beginner-level to fluent. DS is moderately fluent in Khmer, the Cambodian language.
This project has required limited funding. The University of Colorado and UHS provide free use of computers and the Internet. Minor technological improvements were paid for privately.
During 5 years of operation, we completed approximately 50 consultations. A total of 29 Cambodian residents and 4 American residents have participated. The following case examples illustrate key issues.
“Ms. ST,” a 20-year-old, single, unemployed Buddhist woman, brought to the clinic by her father, complained of fear of ghosts, associated with difficulty breathing, insomnia, heightened startle response, and intrusive thoughts of the following episode witnessed 3 months earlier: two men had attacked her cousin with a knife as he rode his motorbike home from work. In the ensuing struggle, one attacker was killed, and her cousin was seriously injured.
Cambodian residents initially focused on a primary diagnosis of phasmophobia, or fear of ghosts. DS pointed out, however, that the patient did not meet one key diagnostic criterion for specific phobia: “The person recognizes that the fear is excessive or unreasonable.” The patient believed that the ghosts were real. Traditional Cambodian culture holds that, after one has offended an ancestral spirit, ghosts may appear. When DS initially asked the Cambodian residents about their personal beliefs concerning ghosts, most replied that such beliefs were “superstitions.” However, after some discussion, one resident admitted having been taught to believe in ghosts as a child. Others echoed his experience. They acknowledged how, after starting to study science, their views shifted to disbelief; but during religious celebrations and memorial services, their beliefs in ghosts sometimes transiently resurfaced.
After this discussion, the group agreed that ST did not meet criteria for phasmophobia because these cultural beliefs are held by large segments of Cambodian society. Still, fear of ghosts closely related to her PTSD symptoms. The team recommended integrating traditional Cambodian treatments, including conversation with a Buddhist monk, regarding ways to appease the spirits. The patient was taught deep breathing and encouraged to resume Buddhist meditation. She was shown how her current fears connected to her past traumatic events. Low-dose amitriptyline (available on their limited formulary) was prescribed for insomnia.
Patient #2: Domestic Violence
“Ms. SR,” a 33-year-old Buddhist woman, came to the clinic after overdosing with diazepam. As the family’s economic conditions deteriorated during the previous year because of a poor rice harvest, her husband used their limited savings for alcohol and increasingly stayed away from home with a suspected girlfriend; she developed sadness, sleep disturbance, decreased libido, rumination, and decreased appetite. Visiting a monk and a traditional healer, she was treated with prayer, chanting, spiritual water, and traditional medicine. The treatments helped temporarily. At a private clinic, she was prescribed diazepam, which helped her insomnia, but not her depression. The day before the overdose, the couple’s 10-year-old son asked his father for money to pay for English tutoring. Outraged by this request, the father struck his son. When SR came to his defense, her husband hit her, left home, and returned intoxicated the next morning. The diazepam overdose followed.
Two male Cambodian residents initially perceived psychopathology in Ms. SR because of depression, inability to satisfy her husband (sexually and otherwise), and departure from traditional roles as a virtuous wife serving her husband. Drawing upon Buddhist principles, a male Cambodian faculty member (SK) emphasized the importance of the patient’s accepting her difficult life situation. He recommended meditation and prayer; he also discussed a healing method from Buddhist scripture resembling Cognitive-Behavioral Therapy. After he left, in the middle of the videoconference, female Cambodian residents became more vocal, emphasizing the husband’s drinking, philandering, and violence as precipitants of her depression and overdose. They maintained that ST’s external problems would require real-world solutions, rather than the spiritually-oriented solutions suggested by their Cambodian supervisor. American residents agreed with the Cambodian women that external solutions were required and questioned why ST did not consider leaving her husband. The ensuing discussion clarified that economic necessity and cultural norms dictated the patient’s need to stay in the home. Cambodian residents thought that family members might help ST gain control of the household finances (a traditional role for Cambodian women), thus perhaps limiting her husband’s access to alcohol. Concurrently, engaging in Buddhist practices might help ST improve her mood.
Male and female Cambodian psychiatrists’ reactions to the husband’s wife-beating differed. The women objected strongly; the men remained silent on this point. Regarding corporal punishment, male residents supported a father’s right to strike his child, noting the importance of teaching children “respect.” A female psychiatry resident opined that non-controlled corporal punishment was not justified.
Five major teaching points emerged from these consultations (see Table 1):
TABLE 1.Major Teaching Points in Establishing an International Telepsychiatry Consultation Service
| Add to My POL
|A long-term relationship among individuals is necessary to initiate and sustain a successful collaboration between institutions.||• Strong commitment required from both consultants and consultees.|
|Culture shapes interactions between consultants, consultees, and patients.||• Consider hierarchical nature of societal and educational relationships, gender relations, and urban/rural differences.|
|• Actively elicit culturally-pertinent information from consultees.|
|Culture shapes solutions.||• Understand that beliefs about illness causation and treatment are culturally-based.|
|• Participants must blend Western psychiatry with local approaches to healing.|
|Limitations of technology and language differences may represent significant challenges to communication.||• Even as communications technology and bandwidth improve with time, in-person visits fostering strong rapport between individuals are essential.|
|Learning is a two-way street.||• Collaboration is best when both sides benefit.|
Long-term relationships among specific individuals are necessary to initiate and sustain successful collaborations between institutions.
DS’s sustained interest in Cambodia was critical to developing the relationships that eventually led to this collaboration. Through multiple visits to Cambodia, American faculty and residents learned about Cambodia’s rich culture, complex history, and developing healthcare system. In 2011, TC, the Cambodian residency-training director, visited the University of Colorado’s psychiatry residency training program and subsequently adapted new teaching methods, including review of video-recorded patient sessions. In 2013, the University of Colorado’s Center for Global Health offered a Pediatric Disaster Public Health/Mental Health Program in Phnom Penh. A child psychiatry clinical observership in Colorado for Cambodian psychiatrists is also under consideration. As there are currently no Cambodian child psychiatrists, this opportunity could help develop much-needed services.
Culture shapes interactions.
Important cultural variables shaped interactions between American and Cambodian psychiatrists, between the Cambodian psychiatrists, and between Cambodian psychiatrists and their patients. The traditional hierarchical Cambodian teaching style still prevails. Teachers instruct and guide compliant students. Open discussion is not encouraged, and we initially encountered resistance to such an approach. To overcome this barrier, the Americans expressed interest in the Cambodian residents as individuals and inquired about their backgrounds and interests in psychiatry, thereby generating a supportive learning atmosphere conducive to open discussion. DS also modeled open dialogue with American residents. Consequently, Cambodian residents gained comfort voicing their opinions about sensitive and taboo issues, including sexuality, sometimes disagreeing with both American supervisors and Cambodian colleagues.
The contrasting attitudes to the West exhibited by urban and rural Cambodian communities critically shaped the interactions. Most Cambodian psychiatry residents are raised in urban settings, where exposure to Western ideas is common. They emphasize what they perceive as Western diagnosis and treatment, which includes rigid application of DSM-IV–TR and emphasizing medication. In contrast, 80% of the Cambodian population, including the patients described in our cases, come from rural areas, where traditional beliefs prevail. These differences in backgrounds and beliefs between doctors and their patients shape clinical encounters. In Case #1, for example, initially classifying fear of ghosts as psychopathology, rather than normal cultural variation, resulted in misdiagnosis.
Appreciating diverse cultural factors and social dynamics shaping interactions among consultants, treatment providers, and patients is critical to devising meaningful assessments and treatment recommendations. All participants are obliged to learn about each other’s cultures.
Culture shapes solutions.
The telepsychiatry collaboration has been particularly helpful in facilitating conversations around cultural issues that are sometimes overlooked as not “scientific.” The Americans have found that discussing their own cultural values and beliefs encourages open discussion. For example, when American psychiatrists talked about their own religious/spiritual practices, Cambodian residents’ embarrassment around their belief in ghosts diminished.
This embarrassment was further reduced after the Cambodian residency director (CT) discussed her own positive working experiences with Buddhist monks and traditional healers.
Technology and language represent significant challenges.
Although the decreasing cost of bandwidth in Cambodia from 2010 onward allowed for sustained video contact, imperfect technology continued to hamper communication. Participation was especially difficult for Cambodian residents who lacked confidence and English-language skills.
With limited bandwidth, four simple procedures markedly improved communication. First, to decrease echoing, all participants used earphones, rather than speakers. Second, to increase sound output for multiple participants, amplifiers were helpful. Third, for better sound quality, unidirectional microphones worked better then omnidirectional microphones. Finally, communication was much better if participants took turns, so that only one person spoke at a time.
Unfortunately, our enforcement of the “one speaker at a time” rule supported the traditional Cambodian preference for lecture by “experts.” American facilitators often encouraged Cambodian residents to generate and discuss ideas among themselves, even if and when the Americans could not understand all that was being said. Extra time, patience, and good humor improved the quality of our communications.
Learning is a two-way street.
Cambodian residents report that our discussions help them learn about history-taking (especially in the psychosocial realm), differential diagnosis, and both pharmacologic and psychosocial treatment. They appreciated learning how psychiatry is practiced in the U.S. and enjoyed learning about American culture in the process. Writing up, presenting, and discussing cases in English also helps them improve their language skills.
American residents report learning to appreciate how case-formulation can be profoundly affected by cultural context. They learn to think creatively, even “out of the box,” to provide meaningful treatment interventions when resources are limited; these skills are highly relevant to working with many of their American patients. American residents who traveled to Cambodia reported, particularly, benefitting from observing how mental health care is delivered in another country. All participants, Americans and Cambodians, faculty and residents, valued the long-term personal and professional relationships promoted through this project.
Our project has been faithful to the initial goals put forth by the Cambodian faculty: increasing trainees’ knowledge; connecting the Cambodians with American psychiatrists; fostering critical thinking and open discussion among Cambodian residents; helping to improve trainees’ English competencies; and developing long-term sustained collaborative relationships with an American university. Cambodian faculty believe that our project integrates well with the biopsychosociocultural and spiritual context in which mental illness is understood and treated in Cambodia. The collaboration illustrates how videoconferencing offers effective and inexpensive approaches to address disparities in global mental health by enhancing psychiatric training across cultures and international boundaries. We hope that the model described in this initial report will motivate other psychiatry departments to pursue similar efforts and provide opportunities to advance beyond the interactive-focused program evaluation utilized here (29).