A fear of playing with other children, speaking to the people around them, and worrying too much before exams or social events are all symptoms that Cambodians should pay attention to. These are symptomatic of what is called “social anxiety disorder.”
The Post spoke with two mental health counsellors, Lim Bouyheak and Hoeur Sethul – as well as the parents of one of Bouyheak’s clients – to learn more about the disorder, its impacts and its treatment.
Asked what exactly a social anxiety disorder is, Bouyheak explained that it led to disordered social interactions and relationships.
“Patients often feel nervous and uncomfortable and have difficulty communicating with others, or activities that involve a potentially challenging conversation – like meeting a stranger, speaking in public, or having to go for an interview,” she said.
“Before they begin a task or activity, they are afraid of being judged, or assume that they will fail. Their heart begins to beat faster, their hands get clammy, or they feel nauseous. Sometimes they feel like their thinking is clouded. Their voices break and they find it difficult to look people in the eyes,” she added.
Hoeur Sethul added that as defined by the The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition – The most common diagnostic system for psychiatric disorders – patients often display general signs of physical, emotional and behavioural changes.
“When confronted with new people or unfamiliar situations, they sometimes physically tremble with fear. They are visibly stressed. This is compounded by their negative view of themselves and the spiral of being embarrassed by their embarrassment. They convince themselves that they will not be able to handle a given situation, and consequently, avoid seeing people or attending school,” he explained.
Diagnoses of the condition
Most people fail to notice the symptoms because they think that this kind of behaviour is more or less common.
Asked at what stage people should be worried, Bouyheak said that first they should distinguish between what is a disease and what is not a disease. Usually, when the disorder is present, there will be a clear timeline of the symptoms appearing. Perhaps the most important thing to consider is whether the symptoms affect their daily life and relationships with the people around them.
“If they [the symptoms] are so disturbing that the person is unable to work or study, they should meet with a specialist who will help them treat the disorder,” she said.
Bouyheak, a senior psychologist at The Beekeeper who has worked as a psychologist for more than 15 years, said that an increase in people suffering from these issues is related to social media, new lifestyles and the Covid-19 pandemic.
She explained that when they rely heavily on technology for communication with others, it can affect their mental health. Some parents are unaware of the unhealthy online relationships their children have formed, with online bullying a particular concern. Family members also spend less time together. If children are less close to their parents, it can have a detrimental effect on their communication development.
During the pandemic, people were forcibly separated, she said, and WHO discovered a clear correlation with an increase in mental health complaints.
“Another side affect of technology it that we are slower to learn. Nowadays, children do not speak as early or as much as they used to. Modern parents are often too busy to spend a lot of time with their children, and rely on schools to raise their kids,” said Bouyheak.
“Often, most of the time they spend together is centred around mealtimes, and even then, each family member may be on their phone for the entire meal. So what opportunities do children have to learn to communicate with others? Parents should be more active in encouraging their children to interact with others,” she continued.
Sethul added the causes of the disorder could also be related to traumatic childhood experiences, such as violence. This could lead to a loss of self-worth and a readiness to see themselves in a negative light. Another factor of course, is the hormonal changes that take place when a child enters adolescence.
He said the changes can make them shy, and they are very vulnerable if they are not provided with enough care. The tragic events of Cambodia’s past meant that inter-generational trauma sometimes plays a part, too. A lack of warmth or indifference from parents is often a factor, along with a lack of affection and emotional support.
“When it comes to raising children, some people think that as long as they provide food and shelter and the occasional treat, they have played their part. People need more than these basic things. Love and affection are crucial in protecting the mental health of a child,” he said.
Sethul said that in his own experience, the disorder is more common in adolescents than in adults.
“They are afraid of school and do not want to go, preferring to sit silently in their room. When they do go to school, they are afraid to face their teachers and classmates,” he added.
A family shares their experience
A foreign couple whose child was receiving treatment from Bouyheak told The Post that they began to observe changes in their child’s behaviour in grade 4. Their child began to procrastinate, was anxious of being judged in social settings and had a fear of being reprimanded in public.
They said their child was not sleeping well, and would wake up and be unable to get back to sleep. Their child was especially anxious when he/she had school the following day.
“There are two main components in treating such a disorder: one is the parents’ interactions with their child, especially their reactions to the child’s anxiety. The second comes from the way the child sees him or herself. Addressing social anxiety disorder requires team work from the child, the psychologist and definitely the parents,” one parent advised.
“Treatment of mental health issues can often take a long time, but it is very important that both the child and the parents make a commitment to follow the advice and suggestions of the psychologist. This plays a large role in making the treatment successful,” the parent added.
Having met with the psychologist, their child has learnt several coping strategies to address anxiety on the spot but not yet acquired the skills to flip the perspectives that create the anxiety itself. They are still working through the process and have not yet completed the required number of sessions.
Understanding the therapy
Hoeur Sethul said that in psychotherapy, this is called behavioural therapy, which means strengthening the patient’s knowledge and attitude.
The counsellor helps the patient to understand their sense of identity better, giving them confidence and helping them adjust to their daily activities.
“For example, if they are afraid of school and don’t want to go, we devise a way of giving them the confidence to overcome this fear. It may be through input from the school, or increased parental support. We also encourage them to adapt healthy eating habits and teach them to avoid substances that may affect their health,” he said.
She added that research showed that behavioural therapy is effective because anxiety often comes from irrational thinking.
She said that she helped her patients to think reasonably and taught them techniques to relax their bodies and muscles. This included breathing exercises and other ways to address fear. Once they had acquired some of these skills, they could break down challenging situations and devise ways to deal with each stage of the scenario.
She used behavioural therapy, art therapy, and family therapy in her practice. She advised parents that they need to learn more about their child’s development and spend valuable time together, experiencing activities rather than using technology.
“We give them suggestions on how to spend time together, such as going for a walk outside, meeting relatives, playing sports, or going to an amusement park. Older children need to interact with their friends too, so we recommend they visit each others’ homes or play sports or other group activities, rather than playing individually on their phones,” she said.
Breaking the stigma
A mental health problem is not something to be ashamed of. If you have a cough, you take cough medicine to make it go away. If you have mental health problem, you should have it addressed, looked into and alleviated. Often, it will not go away completely but we can work together to teach the child how to cope with their mental health issue and still live a meaningful and happy life.
One important thing parents need to know is that, once a child has mental health issues, it won’t go away by itself. More than likely, it will get worse if left alone. It is very important that it is addressed early, so the child can enjoy a happy childhood and grow into an adult who has effective skills to cope with their mental health issues.
“I would like more parents to understand that any behavioural problems your child displays could be a manifestation of a mental health issue and not due to mischief making or a desire to manipulate you. If parents don’t support their child, who will? We need to give them the benefit of the doubt,” said a parent who asked not to be named.
“If you suspect that one of your children is suffering from mental health issues, it is best to have the child assessed by a psychologist. If there is no issue, great! If there is, early intervention is always the best choice for your child,” they added.
Sethul agreed that the advice given to intervene was the same thing recommended by him personally, along with the WHO. The faster help was sought, the better. If caught early enough, the disorder may not progress into serious symptoms.
“It’s like a physical illness. If you don’t treat it, it will continue to get worse until you use medicine. The cost of doing nothing is too high, and can put lives in danger,” he added.