Thousands of mentally ill people residing legally in the United States have been deported after committing crimes as minor as shoplifting. Journalist Katya Cengel reports on Cambodians who fled the country’s killing fields as children and who, after being repatriated, are struggling to make a life for themselves in their unfamiliar homelands. She introduces us to Khe Khoeun, a former refugee now living with relatives in Cambodia, and describes how those with mental health problems are singularly ill-equipped to navigate America’s complicated immigration court system.

Battambang, Cambodia—One of Khe Khoeun’s few possessions is a small album of family photographs. In one picture, she is wearing a puffy, pastel wedding party dress; in another, she stands next to her four siblings. A third photograph shows her with her young son on Halloween.

She keeps the album of her life in America, the country where she was raised, in a one-room wooden lean-to in rural Cambodia. It offers some of the only clues to the decades Khoeun spent in Washington state. She is only 40, but her teeth are rotten, she tends to cry without warning, and she has trouble remembering details of her past. Repatriated in 2009 to Cambodia, which she’d fled with her family as a small child, Khoeun is one of perhaps thousands of mentally ill legal permanent residents the United States has deported in the last two decades.

After arriving on a U.S.-chartered flight to Phnom Penh, Khoeun moved in with extended family she barely knew. But when her emotional problems grew too burdensome, they brought her to the Returnee Integration Support Center (RISC), a nonprofit organization opened in 2002 to help Cambodians deported from the United States. RISC found her a therapist who prescribed anti-depressants and sleeping pills, medications she said she took in the U.S., though without Khoeun’s medical records it’s been impossible for RISC to confirm that information.

She lived at the group’s Phnom Penh office for two months, until RISC tracked down her uncle near Battambang, a provincial city in the country’s northwestern rice-belt region. He agreed to take her in. Two years ago she married an elderly man from the same village. Her uncle worries that the man drinks too much and mistreats her.

Since 2002, when Cambodia signed an agreement with the United States allowing the repatriation of Cambodian nationals who’d run afoul of American law, more than 560 people have been deported to the Southeast Asian country. Many escaped the killing fields of the Khmer Rouge in the 1970s or the preceding period of U.S. bombings and civil strife. The deportees rarely speak fluent Khmer or have strong ties to the country. Bill Herod, an American who helped establish RISC, says at least a dozen of the deportees he’s encountered suffer from severe mental illness—bipolar disorder, schizophrenia, or psychosis. He says: “These are people who required medication and constant care.”

But care is often a casualty of deportation. While immigrant detention centers have begun to offer improved mental-health services in recent years, refugees who are detained and deported often lose the support of their friends and families. Little is done to ensure they remain on antipsychotic medications or receive treatment once they arrive in their unfamiliar homelands. The consequences can be dire. One man deported to Cambodia in 2002 carried out a double murder. Two deportees committed suicide. Others have drunk themselves to death. Herod calls this “death by deportation.”

NO RIGHT TO A LAWYER

When Khoeun arrived in the United States as a child, she was among hundreds of thousands of people fleeing the wars of Indochina during the 1970s. The United States eventually granted asylum to more than 100,000 Cambodians between the 1970s and 1990s. Many were resettled in Washington state, and at the time, it seemed unthinkable that these refugees might one day be repatriated to their war-weary country.

But in 1996, amid rising fears of terrorism following the Oklahoma City bombing, Congress and President Clinton approved legislation expanding the list of “aggravated felonies” for which non-citizens, including legal refugees, could be deported, and limiting judges’ ability to consider the individual circumstances of each case. Under these rules, even those who commit minor offenses such as shoplifting are eligible for expulsion. In 2002, after the repatriation agreement was signed, the first Cambodian nationals were targeted for deportation. According to a spokesperson with U.S. Immigration and Customs Enforcement, Khoeun was deported after serving time for a felony drug conviction.

Given the links among crime, trauma, and mental illness, a disproportionate share of people facing deportation on criminal charges may suffer from mental-health problems. According to a 2010 report from Human Rights Watch and the American Civil Liberties Union, an estimated 57,000 detainees in deportation proceedings in 2008—roughly 15 percent of the total—had mental illnesses or intellectual disabilities. Yet those with psychological problems are singularly ill equipped to navigate America’s complicated, combative immigration court system.

The report, “Deportation by Default: Mental Disability, Unfair Hearings, and Indefinite Detention in the U.S. Immigration System,” documents dozens of cases of detainees, from countries including Cuba, Guatemala, and Liberia, who could not effectively represent themselves. Some were delusional; others failed to comprehend questions posed to them by a judge or struggled to understand the concept of deportation, believing they were being sent to another U.S. state.

Yet U.S. immigration courts do not guarantee free legal representation for the mentally ill, nor are judges required to accommodate a person’s limited comprehension, as in criminal court. Indigent defendants who suffer from mental illness are left with little recourse. The report also criticized the U.S. immigration system for inflexible detention policies, inadequate mental-health care at detention centers, and insufficient guidance for legal professionals handling cases involving the mentally disabled. “This is not a system that has a lot of safeguards to protect people who have mental-health issues,” says Grace Meng, a senior researcher with Human Rights Watch.

Legal pressure has prompted some improvements, however. In 2013, a class-action lawsuit in Arizona, California, and Washington compelled those states to begin providing free legal representation to mentally ill deportees. The same week as that judgment, the federal government announced a program to extend those services nationwide. But the rollout has been slow; only in the last few months has it expanded to roughly a dozen jurisdictions beyond those covered by the lawsuit, says lead counsel Ahilan Arulanantham, the legal director of the ACLU of Southern California.

The lawsuit also prompted new rules governing how detention centers screen detainees for mental disorders. Compliance has been uneven, however, and lawyers point to cases of people found incompetent to stand trial in criminal court who were nevertheless allowed to represent themselves in immigration proceedings. “There continue to be people who are slipping through the cracks,” says Arulanantham.

After they touch down in a new country, their circumstances often unravel. Mental-health services in most developing nations are sparse at best; in some countries, including Indonesia, the mentally ill are held in prison-like conditions. Some deportees, says Arulanantham, are “locked away forever because they are mentally ill.”

“REVERSE CULTURAL BEREAVEMENT”

Cambodia’s mental-health system may be less punitive, but it’s also rudimentary and overstretched, says Dr. Chhim Sotheara, executive director of Transcultural Psychosocial Organization, a nonprofit organization devoted to mental health. Headquartered in the Netherlands, the group runs four branches in Cambodia, including one in a large modern building in downtown Phnom Penh. For over a decade, it has been working with RISC to provide deportees with mental-health care.

Sotheara is among the first generation of Cambodians to study mental health after warfare subsided in the 1990s. Growing up in a prosperous family in Phnom Penh, he had dreamed of becoming an architect. But the Khmer Rouge swept into power when he was 9, and Sotheara spent the next three years hauling dirt as part of the communist regime’s brutal pursuit of an agrarian utopia. During that time, an estimated 1.7 million people died from starvation, disease, and execution.

After the Khmer Rouge was ousted in 1979, Sotheara’s dream of becoming an architect seemed extravagant. What the country needed were doctors, and he became one, obtaining his medical degree from the University of Health Science in Phnom Penh. Initially, as a junior surgeon, he was kept busy amputating the limbs of people injured in the fighting and by landmines. But physical wounds were not all he saw. He noticed emotionally troubled patients who were diagnosed as being possessed by spirits and sent to traditional healers. The treatment didn’t seem to help. Having never studied mental illness, Sotheara and his colleagues didn’t understand the problem. It was only in 1994, when the University of Oslo in Norway recruited Sotheara to study psychiatry as part of an International Organization for Migration-funded program to rebuild Cambodia’s mental-health services, that he began to comprehend the nature of psychological pain.

The rest of the country is still learning. The belief that spirit possession causes mental illness is common, particularly among rural Cambodians, Sotheara says. They take their mentally disturbed relatives to traditional healers instead of the hospital, and sometimes they physically restrain them.

I came across one such example while interviewing an indigenous Phnoung family in eastern Mondulkiri Province earlier this year. I noticed someone huddled in a dark corner of the wood plank home I was visiting. The person mumbled and spit but didn’t speak. She was covered only in a blanket. When I looked closer, I noticed one of her feet was chained to the wall, allowing her to move no more than 10 feet. Her parents explained that she’d been a smart, happy child before contracting malaria a decade ago. They never found proper treatment for her. Last year, after she beat a girl and set fire to a house, they decided to chain her.

After encountering dozens of cases of Cambodians shackling their ill relatives, Sotheara established a program two years ago to educate the public about mental illness. In that time his team has worked to unchain at least 40 people.

While Sotheara encourages the mentally ill to seek treatment, he acknowledges the short comings of Cambodia’s system. Just .02 percent of the national health budget is devoted to mental health, according to a Fordham International Law Journal article published this year. That compares with 5 percent in many developed nations. The country has only 14 psychiatric beds between the two hospitals offering short-term inpatient mental-health care—the lowest ratio in the region. In 2010, there were 35 trained psychiatrists and 45 trained psychiatric nurses for a population of nearly 15 million. Meanwhile, the incidence of mental illness in Cambodia is among the world’s highest, stemming in part from the suffering many endured under the Khmer Rouge. The rate of post-traumatic stress among survivors of the regime and other violence is between 14.2 percent and 33.4 percent, according to the article.

TWO DEPORTEES COMMITTED SUICIDE. OTHERS HAVE DRUNK THEMSELVES TO DEATH.

But post-traumatic stress and other mental-health issues are rarely discussed in Cambodia, says Sotheara. This silence complicates the adjustment of deportees, who are accustomed to a culture in which mental illness is less stigmatized. The deportees suffer from a dual sense of loss, says Sotheara, mourning both their original exodus from Cambodia and their more recent exile from the U.S. He calls it “reverse cultural bereavement.”

“LIVES WERE IN DANGER”

Herod, a white-bearded man with an eye patch, established RISC as a first line of defense for these reverse refugees. In its early years the group ran a residential facility providing around-the-clock care for the mentally ill, but funding dried up, and a decade ago it closed. Today most of the group’s support comes from the U.S. Agency for International Development and the nonprofit Mennonite Central Committee Cambodia. Now RISC occupies three lightly furnished floors of a gated building in downtown Phnom Penh. Herod, who is retired and lives in the east of the country, usually meets visitors in a coffee shop when he is in town.

The most challenging cases are the deportees who are prone to violence. One of the earliest arrivals was a man who snapped and attacked a security guard one night while watching television at the RISC center. Im Song, a manager with RISC, tried to intervene, but he was also attacked. Staff called the police on the man several times before learning to restrain him themselves. (His name has been omitted at Herod’s request.) When the man reached Cambodia in 2002, there was no documentation alerting officials to the threat he posed, according to Herod. “Lives were in danger because we didn’t have his medical records,” he says.

With the assistance of the U.S. Embassy, Herod eventually obtained the man’s files from the United States. Included was a September 2002 note from an American psychologist who had evaluated the man in an immigrant detention center after he served time in prison. It advised against his release into the community because of his mental illness, his refusal to take medication, and the violent nature of his crime—attempted murder. The evaluator concluded: “He is likely to require long-term psychiatric care in a forensic facility and efforts should be made to facilitate such a transfer.”

The man was in RISC’s care for five years before his extended family in Cambodia asked to take him in. Herod warned the family of his mental-health problems and dependence on antipsychotic medications, but had no choice but to let him go. Not long after, the man killed two people. In 2014, he died of a heart attack in a detention facility at the age of 45.

Under the 2002 repatriation agreement, the United States is required to furnish the Cambodian government with detailed information on the medical histories of deportees. But Herod and other aid workers say this rarely happens. After much lobbying, the U.S. government now provides RISC with a single sheet of paper for each deportee that typically just affirms their permission to travel to Cambodia, the group says. In response to my questions regarding medical records, the U.S. Embassy referred me to the Department of Homeland Security, which sent me to ICE spokesperson Brendan Raedy. In an email, Raedy outlined the medical care detainees receive in custody but declined to comment on whether medical records are provided to Cambodian officials.

The repatriation agreement has long been a source of resentment for many Cambodian-Americans. For more than a decade, they lobbied U.S. government officials and held public events to draw attention to the treatment of deportees. Last year, activists from 1Love Movement, an immigration advocacy group based in Philadelphia, traveled to Phnom Penh to pressure the Cambodian government to join their call for change. The group coordinated meetings between deportees and Cambodian government officials in an attempt to educate the latter about the precarious existence of many former refugees. This February when I met with Chou Bun Eng, secretary of state for the Ministry of the Interior, she expressed many of the concerns raised by 1Love, namely that deportations shatter families and those who are repatriated have few ties to Cambodia. She acknowledged that her government was unprepared to accommodate deportees in 2002 but said it has been trying to improve. “The integration takes time, resources, and full support,” she said. “We haven’t done enough in the past and we don’t want to repeat this mistake again.”

Last October, Cambodia asked the United States to review the agreement and in the meantime suspend deportations. When I sought a response from the State Department, Anna Richey-Allen, information officer for the Bureau of East Asian and Pacific Affairs, acknowledged the U.S. had received the request but declined further comment. Deportations to Cambodia have not ceased, and, in August, the U.S. announced that it would sanction Cambodia and three other countries deemed “recalcitrant” for delaying repatriation of their own citizens.

This asymmetry isn’t unique to the U.S-Cambodia relationship. Small countries have little leverage in their negotiations over immigration policies, despite the fact that the practice of deporting mentally ill individuals has been condemned by the United Nations. Two years ago, the U.N. Human Rights Committee said Canada’s decision to expel a Jamaican man suffering from schizophrenia amounted to “cruel and inhuman treatment.” But deportations have continued, and this past March, the country again faced criticism after repatriating to the Netherlands a severely bipolar man who had lived in Canada since he was 8 months old.

LIFE IN EXILE

Keo Sarith, RISC’s co-director, examines a thick manila folder. Soft-spoken but direct, he is seated at a large table in the group’s upstairs conference room on a quiet afternoon in late January. Inside the folder is all the information he has on Khe Khoeun. There is a photo of her from 2007, two years before she was deported. She is wearing jeans and her black hair falls below her shoulders. Wrapped around the photo is a sheet of binder paper on which Khoeun has written Sarith a note, something about being a teacher. It makes little sense. Khoeun’s accounting of things has been jumbled since she arrived in Cambodia. Sarith thinks earlier drug use may have affected her memory. Her court records show numerous run-ins with the law for drug use and prostitution. ICE spokesperson Rose Riley declined to comment on whether the agency was aware of Khoeun’s mental illness or sent her medical records with her to Cambodia.

SHE IS SKINNY AND WEATHERED, EASILY MISTAKEN FOR AN ELDERLY VILLAGER—UNTIL SHE SPEAKS.

Sarith knows little of Khoeun’s past beyond what she’s shared with him. Her son, who is now a teenager, lives in the United States along with her elderly mother and siblings. But Sarith does not know how to contact them; Khoeun says their phone numbers are always changing.

Sarith checks on her when he visits deportees in Battambang. He brings her money, but she has never learned to budget so it quickly disappears. A few years ago he found her work teaching English, but she often cried on the job and was soon let go. He has not tried to find her employment since. RISC pays for her medication and monthly sessions with a psychiatrist in Battambang.

He calls her each month to remind her of her appointment. She telephones him as well, usually in tears. In the past she would call RISC when she was feeling depressed and wanted to end her life. Now she calls to say she can’t get her husband to stop drinking.

The day I visit Khoeun in the rural region surrounding Battambang, she is wearing a scarf and leggings even though it is brutally hot. She is skinny and weathered, easily mistaken for an elderly villager—until she speaks. Her accent is West Coast American. She meets me in the village center, accompanied by her husband and a little boy, an orphan. Back at their home we sit under a covered area in front of the wooden shack. A puppy scratches in the dirt. Khoeun was born near here, but considers the U.S. home and wants to return. She talks about how much she misses American food, pizza and hamburgers, which she cannot afford in Cambodia.

Khoeun doesn’t remember always being this sad or confused. She thinks her mental problems worsened after she began using cocaine more than a decade ago. In her 20s, she’d worked as a card dealer in a casino, but switched to dealing drugs because it paid better. She says she got caught, did time, and got deported; she can recall little else about her case.

She says she feels guilty for abandoning her son. She believes her neighbors judge her for it, that they wish her harm. But Sarith says the people in her village watch out for her and call RISC when they think Khoeun needs help. Her friends and family from the U.S. never call, she says. Khoeun worries they’ve forgotten her. “I really miss my home,” she says. “I want to go back.”