Deep-seated, unresolved trauma suffered by millions during the Khmer Rouge regime
is causing massive problems, and depression of parents is being transferred to their
children, say mental health experts.
Child laborers during the Pol Pot era.
In Phalla wipes away her tears with a red krama as she calculates how long she put
up with physical abuse. She says her husband began beating her soon after her third
child, a boy, was born. He is now 13. The ordeal seemed never ending, and culminated
in her husband dousing her with kerosene in an attempt to set her alight.
"I ran away from home because I couldn't take it any more. He beat me for 13
years. When I was in despair at my destiny I tried to kill myself," says Phalla,
who is still too scared to use her real name. "I was ready to hang myself in
the forest with my krama but my six children asked me not to. I changed my mind because
I felt so sorry for them."
There is a virtual absence of reliable statistics on suicide rates in Cambodia, but
mental health and women's issues experts say the two groups who are most likely to
attempt suicide are adolescents, and women like Phalla who have suffered trauma and
Ministry of Interior (MoI) figures show that 198 people either committed suicide
or attempted suicide in 1999. That number increased to 253 the following year, before
dropping back to 193 in 2001.
However Chea Bunthol, administrative chief of the MoI's crime department, admits
the statistics are not accurate because police fail to fill out MoI suicide forms
and often don't investigate suspected suicides.
Mental health issues are depicted in this poster produced by the TPO organization.
"When the police conclude it is a suicide case, they just hand over the body
to the family and don't study what pushes people to commit suicide," he says.
"The [country's] leadership hasn't paid attention to this issue."
Dr J. Bhoomi Kumar, director of the Center for Child Mental Health at Chey Chumneas
Hospital in Kandal, believes that suicide is "grossly unreported" here
as in most Asian countries.
"This is because of cultural issues such as Cambodia's form of Buddhism which
looks down on suicide," he says. "Suicide is much more acceptable in Japan
The Ministry of Cult and Religion says that Buddhism, the country's major religion,
forbids suicide. Secretary of state Chhorn Eam believes suicide is wrong.
"As human beings we must be useful to society," he says. "We shouldn't
kill ourselves - we should find a way to live and contribute. To kill oneself is
cowardly. Life means struggle."
Suicides are reported almost daily in Khmer language newspapers, and several mental
health experts say they think this indicates that the number of attempts is increasing.
Across the world the figures are dramatic: the World Health Organization (WHO) estimates
that around one million people committed suicide in 2000. That equates to one death
every 40 seconds.
WHO's figures show that suicide rates have increased globally by 60 percent in the
last half century. Suicide attempts are even more common, running at 20 times the
number of suicides.
The increased reporting of suicide in Cambodia may be an indication of society's
increasing openness, with families now allowing the media to write about the deaths
of their relatives when previously the subject was taboo.
Dr Kek Galabru, the president of human rights NGO Licadho and a medical doctor, says
that until 1992 there was little discussion of the issue in the media.
"There were only five newspapers that were always controlled by [political]
parties, but now the press has more freedom," she says. "We cannot say
there are more suicides - it is just much more open now and people are willing to
let others know outside the family."
Despite uncertainty over whether the rate of suicide is increasing, Dr Kek, Dr Kumar
and other experts do agree that deep-seated, unresolved, trauma suffered by millions
during the Khmer Rouge regime is causing massive problems.
Dr Kumar says the trauma and depression of parents is transferred to their children.
"The current parents were in Pol Pot's children's groups, so they lack direct
parenting experience and lack knowledge in how to help, counsel and provide guidance,"
he says. Alcoholism has increased as some struggle to cope with their mental burden,
he adds, which has led to a rise in domestic violence.
Kann Kall is a mental health expert and former managing director of a local mental
health NGO called the Transcultural PsychoSocial Organization (TPO). He says psychological
and emotional distress is the major cause of suicide attempts.
Kall believes that most Cambodians aged below 25 have been living with stress projected
from their families their entire lives. The collective nature of Khmer society, he
says, means children are bound to their families and, unlike in Western societies,
are unable to escape transferred stress by leaving when they are young.
"Parents suffered directly from the civil war and the Khmer Rouge regime, and
the tension keeps on and on because these people never have a chance to feel relief,"
he says. "They project it onto the younger generation, so most of today's society
is a second trauma generation without knowing why."
Kall says that a culture of 'saving face' and hiding problems from outsiders to protect
a family's reputation compounds the problem of widespread stress as people feel unable
to express themselves and seek counseling.
"According to the women's code of conduct, women should behave well and not
speak out, but this kind of philosophy suppresses women," warns Kall. The result,
he says, is that women younger than 25 are the most likely to attempt suicide.
On the surface, many suicides reported in newspapers seem to be related to lost or
unrequited love. However Dr Kek says other issues such as the absence of parental
support, limited career opportunities, and poverty are often the real culprits. An
unhappy love affair simply acts as a trigger for suicides.
"It is a disease of our society," says Dr Kek. "The young should be
happy and not commit suicide. They should stay and fight, but the issues are so deep
and then [problems with] love tip them over the edge."
Poverty and lack of education are recognized by mental health experts as major factors
in suicide, and Cambodia is afflicted with both: it is one of the poorest countries
in Asia, with 36 percent of the population living under the poverty line of 50 cents
per day. The government estimates that little more than one-third of the population
TPO's Kall says most people committing suicide in Cambodia have little education.
Along with psychological and emotional distress, he cites poverty and a lack of accessible
social support as the main reasons behind suicide.
"A lot of the social mechanisms don't work and police don't give hope when people
are abused," Kall says. "For the poor it is a cycle: many are forced to
leave home to work in a brothel or as slaves, and when they complain about abuses
to the police they are asked to pay fees and the police make trouble."
Women and children are hit particularly hard by this cycle. Experts in the fields
of women's issues and mental health identify domestic violence, human trafficking,
rape and forced prostitution as important factors.
Naly Pilorge, deputy director of Licadho, says her organization has received a number
of victims of domestic violence who want to commit suicide.
"We also have a few cases of women who are victims of other abuses, compounded
by other problems such as economic [worries]," she says.
Chanthol Oung, executive director of the Cambodian Women's Crisis Center, says five
women at her shelter have attempted suicide this year alone. They are most vulnerable
when they first arrive.
"We do have many cases of women who try to commit suicide because of domestic
violence," she says. "Also some women come because of depression, trafficking,
rape and forced prostitution."
Besides acknowledging that women and adolescents are most vulnerable to suicide,
experts say those in urban areas are more like to take their own lives. Dr Kumar
attributes this to the 'anonymity factor': people are more alienated and less likely
to know their neighbors.
The methods used in suicide differ both between the sexes and between rural and urban
areas. Kall and Dr Kumar both say people in rural areas are more likely to use pesticides
to end their lives.
Dr Kumar says use of drugs is increasing among urban adolescents as a form of "chronic
suicide", and that in the city, "drowning is more common among women, and
hanging among men".
Officers from Police Protection Unit 3 in Phnom Penh say suicide by drowning is common.
More than 30 people, mostly women, have attempted suicide from the Japanese Friendship
Bridge this year. The unit managed to save 20 of them.
Raising awareness of issues surrounding suicide is key to prevention. TPO runs three
one-hour radio broadcasts each week on FM 96 and 99.5, and invites callers to share
their problems with an on-air counselor.
The NGO says its innovative approach has been successful, but the limited number
of NGOs and government institutions providing mental health support means there is
an urgent need both for more counselors and support services.
That is something the government recognizes, and the Ministry of Health (MoH) has
been working with the International Organization for Migration on a mental health
project to train psychiatrists and psychiatric nurses.
Twenty psychiatrists have graduated to date from the nine-year-old project and are
working in hospitals across the country. But Mam Bunheng, secretary of state at the
ministry, worries that this is insufficient.
"We need at least one psychiatrist for each of the 62 provincial and district
hospitals," he says. "We will train more nurses and specialists. We are
worried about mental health - it is a priority."
Experts state that blaming Cambodian culture for a lack of support services is counterproductive
and unfair to an impoverished society that has suffered unique stresses. Dr Kumar
says that "pointing the finger at society" is not a constructive way to
look at the problem.
"Society has recovered marvelously well," he says.
TPO's Kall says a healthier economy, better education, and a satisfactory system
of social justice should help reduce the number of suicide attempts. However he admits
there will always be those for whom it seems the only option.
"Committing suicide is not part of the culture, but [if] people have nowhere
to go, it is their last choice," he explains.
Kall says Cambodians are well aware of the lack of support available to those who
encounter difficulties: there is even a saying for it, he explains.
"You go down to the water and there is a crocodile; you come up to the dry land,
and there is a tiger; if you escape into the forest, the thorns will cut you; and
if you go to the market, the police are there."