By Angela Simcox, clinical psychologist and Judith Strasser, clinical psychologist Transcultural Psychosocial Organisation, Phnom Penh, Cambodia

Cambodians experienced appalling atrocities committed by the Khmer Rouge (KR) regime from 1975 to 1979. Nearly two million Cambodians, one quarter of the population, were killed or died, by execution, starvation, exhaustion from forced labour and torture. Radical social restrictions were imposed upon traditional society challenging the way people made sense of their own existence, relationships to others and spiritual world.

After a decade of negotiations the Extraordinary Chambers in the Courts of Cambodia (ECCC), commonly known as the Khmer Rouge Tribunal, is the first serious effort to prosecute the senior KR leaders for their crimes. Experiences in other countries show active participation in a court can be empowering for victims of mass atrocity. Evidence also shows that facing the past and seeking truth and justice are crucial processes in trauma recovery.

However, the participation of KR survivors is not without dangers: painful memories may resurface and trial participants are at risk of secondary traumatisation, re-traumatisation and re-victimisation, which may exacerbate existing posttraumatic stress disorder (PTSD) symptoms.

The Transcultural Psychosocial Organisation (TPO) in Cambodia therefore implemented a program to provide psychosocial, advocacy and rehabilitation services to KR survivors and their families. This work highlighted a remarkable lack of services and research on the mental health of the Cambodian population considering the long-term psychological damage inflicted on almost every family by the KR regime.

This realisation led to a number of studies being undertaken, culminating in a conference on December 3, 2009 in Phnom Penh entitled ‘Mental Health: Khmer Rouge Survivors and their Descendants'. Through this conference and dissemination of the information presented there, the TPO aims to initiate debate on mental health issues and highlight the need for psychological services in Cambodia to a broader audience.

Summary of conference presentations

  • Dr Sotheara Chhim, Executive Director of TPO, introduced the intergenerational progression of unhealed trauma with a presentation on the cycle of violence and victimhood.
  • Nadine Stammel, from the Berlin Treatment Center for Victims of Torture, presented a 2008-09 study on mental health and readiness to reconcile in the context of the trials. Most respondents were not ready to reconcile with former KR members but had high expectations of the trials in contributing to reconciliation. The prevalence of current probable PTSD was 11.4 per cent. Nearly 30 per cent presented symptoms of depression and 36.8 per cent had symptoms of anxiety.  
  • A 2008 nationwide survey with a randomised sample of 1,000 Cambodian adults by Phuong Pham from Berkeley's Human Rights Center, yielded similar results. Of those respondents who lived under the KR regime, 14.9 per cent showed symptoms of PTSD and 11.6 per cent demonstrated symptoms of depression. Respondents born after the regime showed a prevalence of PTSD of 12.6 per cent and depression of 6.7 per cent.
  • Loss and grief following the regime were discussed by Nigel Field, Professor of Clinical Psychology at Palo Alto University. He reported higher levels of PTSD and grief for interviewees who believed the deceased was still physically present or had dreams in which the deceased communicated with them. As the Cambodian belief in a mutual influence between the living and the dead is widespread it is difficult to fully explain these experiences as unresolved loss. The nature, rather than the presence, of the continuing bond should be of interest to mental health workers.
  • As 70 per cent of present-day Cambodians were born after the regime to parents who were likely to have experienced extreme trauma, Sochanvimean Vannavuth of the Royal University of Phnom Penh examined second generation effects of trauma. Role-reversing and overprotectiveness was common. Parental PTSD was associated with higher anxiety and depression in children. However, Cambodian society expects children to take care of their parents, complicating interpretation of role-reversal findings.
  • After 20 years of research in the Cambodian community, Maurice Eisenbruch, Professor of Psychology at Monash University, asked listeners to question the Western concepts of trauma, justice, guilt and responsibility. He discussed how these concepts are made sense of in Asian communities through religious and healing systems which may be unfamiliar to Western researchers.
  • The day closed with the conclusion that, alongside increased support services, it is essential to empower Cambodians to conduct the necessary research to expand these findings. Contradictions and confusion around unfamiliar cultural and religious beliefs, as well as language and translation barriers, face the Western researcher. This could lead to the creation of a narrative shaped by Western beliefs which barely reflects the true experience of the Cambodian people.

Mental health services, research and awareness in Cambodia are at an early stage and face many teething problems including funding deficits, poor retention of qualified staff and a lack of quality education to enable Cambodians to take this work forward. International awareness and support is crucial to the future of these services.

For further information on the work of psychologists in Cambodia, please contact the principal author at angela.simcox@hotmail.co.uk.

InPsych February 2010