Mental Health Care Thailand: Views of Mental Health, the Karen Refugees and Young Thai Mental Health Situation, and Cultural Sensitivity for Counselors.

By: Devyn Kerr

Mental healthcare in Thailand just like in other country, including ours is complex. Both countries share some similarities in having to deal with refugees, young people within the country, and various therapies, and finally, having to be aware and sensitive to the cultural and place to some extents focus on global citizenship. The United States does use global citizenship perhaps a little more but also many Americans lack the education, knowledge and motivation to engage in such activity. This isn’t always due to ignorance but can be a part of it as well as other complex factors. In this paper I will discuss the views of mental illness and mental healthcare in Thailand. Additionally I will discuss how Thailand has to take special care to mental health care emphasis and practitioners in Thailand have to adhere to cultural sensitivity to be effective, additionally care of the Karenni refugees and young Thai populations is needed, and knowledge how to be effective as a practitioner; finally I will discuss global citizenship throughout.

An ethnographic study carried out in Thailand over a 2-year period was conducted containing interviews of three clinical nurses, three student nurses, 14 nurse educators, one psychiatrist, one Buddhist monk and two lay people for a total of 24 people about their views of mental health and mental health care in Thailand. Ethnography in broad definition is the process of capturing ‘normal’ or naturalistic situations in everyday life in a different culture to that of the researcher (Burnard, Naiyapatana & Lloyd, 2006). Data from this study was collected through observation and conversation though this paper only reports the findings from the interviews (Burnard, Naiyapatana & Lloyd, 2006).

Thailand, is a predominantly a Buddhist country that is located in Southeast Asia and bordered by Laos, Myanmar (Burma), Cambodia and Malaysia. Its culture is distinctively Buddhist in nature and pervades in almost all aspects of everyday life and cultural activities. Buddhism plays a direct role in the reaction and treatment of mental illness my professionals and the general population; other cultural beliefs and practices, additionally have a similar effect. In addition, for the effect and perspective of this study, in regard to global citizenship, it is important to know who conducted the study as it does effect perception. It was conducted by two researchers: one is a native Thai and the other is from the United Kingdom. They felt that this collaborative approach addresses to an extent the problem of ‘where to stand’ in relation to subject matter, in an ethnographic study and also address the ‘insider/outsider’ issue (Burnard, Naiyapatana & Lloyd, 2006).

To understand the culture aspect of mental health and mental illness,  that it is necessary to understand something of the broader culture; to deepen that understanding, it is necessary to talk to the people who live within that culture. It helps to define normality and abnormality in any given society and it can be part of the causation of mental illnesses. Similarly, it can influence the ways in which doctors and other healthcare professionals view their patient, make diagnoses and otherwise label or explain mental illness. Finally, it can influence the way others see those labeled ‘mentally ill’ in any given community. In other words,  mental illness is not something just diagnosed by a psychiatrist, but it is also something that lay people will have views in regard to the points of both causation and treatment. Likewise, in cultural issues and Thai context in which it is a belief in the spirit world may have implications for the ways in which mental illnesses present themselves (Burnard, Naiyapatana & Lloyd, 2006).

An interesting Thai ‘cultural’ view about mental illness is, that as we know that Thailand is a predominantly Buddhist country, but the Buddhist system does not incorporate a belief in spirits. However, animism is similar to Buddhism but the belief in spirits and ghosts arise out of older traditions. Animism though believes that these spirits and ghosts can ‘cause’ mental illness. Buddhism care giving research and care in the mental health filed is sparse (Burnard, Naiyapatana & Lloyd, 2006).

The overall findings of this study were categorized into five areas. The identified causes included: a) effects of drug abuse; b) problems with brain pathology; c) genetic factors; d) environmental, social, and economic factors; and e) family breakdown induced by alcohol, stress or physical illness. A final conclusion that some limited number of respondents discussed that they believed that it could be caused by ‘ghosts or spirits’ because they have done something bad. One responded posed an interesting view in that she indicated a possible difference between the beliefs of those in urban and rural areas, “Most city people believe mental illness can be caused by spirits less that rural people. I am from rural part and I was taught this and I still believe it despite having scientific knowledge—you cannot prove about spirits” (Burnard, Naiyapatana & Lloyd, 2006). Education about mental illness and in general could have an impact on the views of those who have mental health. There are also three Buddhist teachings and notions that impact the way people view mental illness, those who have it, and how they treat it. (Burnard, Naiyapatana & Lloyd, 2006).

An important feature of Buddhism is the notion of karma. Karma is most easily described as intention, good or bad, actions; such action can in turn affect future aspects of a person’s life or future lives. Avoidance of bad karma is a very important part of a Buddhist life. Karma, then, can be linked to unpleasant, disturbing, or dangerous events in a person’s lives; these could include mental illness by definition. Merit making is a Buddhist concept with the foundation largely consisting of doing good and is often expressed by a person visiting the temple, offering alms to monks or the poor, and just generally helping others. This has two functions. The first is to demonstrate a person’s commitment to the Buddhist principles of living a ‘good’ life: it is a good thing to ‘do good’ for one’s own sake. The second is that it is sometimes felt to be a method of leavening the effects of bad karma. Kwan is the final concept that lies alongside Buddhist teachings. It is an animist concept that is not necessarily a Buddhist concept but most Thai monks involve themselves with it. Kwan is perhaps described as a ‘life spirit’ or ‘life force’. In extreme illness or debility it is sometimes thought that kwan’ leaves the body’ or ‘goes away’ (Burnard, Naiyapatana & Lloyd, 2006). In Burma there are political troubles that are causing harm to a population known as the Karen. These people often flee and become refugees in Thailand but not until they have seen horrors of trauma and experienced other traumatic experiences. For more information about the Karen and the situation in Burma please look at these websites Challenger, D. (2008, June 23). http://edition.cnn.com/2008/WORLD/asiapcf/05/27/thai.karen/

The Karenni refugees often flee to Thailand after a long trek through rough terrain and live in camps along the Thai-Burmese border. With the situation in Burma many of them, including young children deal with many traumatic experiences in Burma or while traveling that impact their mental health. A study done in 2001 assessed the mental health problems among Karenni refugees residing in camps in Mae Hong Song.  The study assessed the prevalence of mental illness, identified risk factors and developed a culturally appropriate intervention program. They used a systematic random sample with stratification for three camps compiling of a total of 495 people aged 15 years or older from 317 households. They additionally constructed a questionnaire that included demographic characteristics, culture-specific symptoms of mental illness, and some formal health and psychological questionnaires (Cardozo, Talley, Burton & Crawford, 2004).Image Photo: (Challenger, 2008)

Mental health outcomes scores indicated elevated levels of depression and anxiety; post-traumatic stress disorder (PTSD) scores were comparable to scores in other communities affected by war and persecution. Psychosocial risk factors for poorer mental health and social functioning were insufficient food, high number of traumatic events, previous mental illness, and landmine injuries. Of the 317 households constituting 495 participants for three camps they sampled more women (58%) than men. Most participants were married (82%), but had no education (61%). Twenty-seven percent reported the quality of life as miserable or very miserable, and 60% responded to it as neither pleasant nor unpleasant to help give a sense of how they felt their life was going.  Culture-specific symptoms such as ‘numbness’ (51%), ‘thinking too much’ (42%), or feeling ‘hot under the skin’ (26%) were common. On a good note, 59% of respondents reported talking to family or friends to make them feel better if they were feeling unhappy. Other coping mechanisms reported were sleeping, thinking about their homeland, visiting the clinic, singing or playing music, and drinking rice wine (Cardozo, Talley, Burton & Crawford, 2004).

The most common traumatic events experienced during the past 10 years before this study included hiding in the jungles, forced relocation, lost property, and destruction of houses and crops. Three percent of women and men reported of having been raped which is low compared to other communities affected by war and persecution (Cardozo, Talley, Burton & Crawford, 2004).

Since the Karenni refugees have experienced many traumatic events and repressive measures inside Burma and still continue to face some problems adjusting in Thailand, the high level of depression and anxiety in this culture seems as expected. It is also to note some of the physical ailments could be psychosomatic symptoms, or physical expression of psychological complaints. The lower level of PTSD could be to the lower level of rape experienced by men and women and also the type of traumatic events causing more anxiety and depression symptoms. On the other side the young Thai population is also susceptible to abuse and mental health issues. Image

A study was conducted in a suburban community of Thai people to examine the prevalence of child abuse exposure and to describe the association of abuse experiences with common mental disorders (CMD), alcohol use disorders and substance use. A population-based cross-sectional survey was conducted in Northern Bangkok of a representative sample of 202 young residents aged 16-25 years old. The study was done by a simple interviewer-administered questionnaire by a trained interviewer in their own homes and a self-administered questionnaire on abuse exposure and history of drug use (Jirapramukpitak, Prince & Harpham, 2005). The experience of abuse and mental health was present among the young Thai population.

Thirty-eight respondents reported experiencing some form of childhood abuse: 5.8% subjected to some form of sexual penetration, 11.7% having been physically abused and 31.8% emotionally abused. There was a graded relationship also present between the extent of exposure to abuse during childhood and mental problems. Even after controlling for potential confounding variables, CMD remained significantly associated with emotional abuse, and alcohol use disorders remained associated with sexual abuse. Risk factors for abuse were associated with low levels of education for the head of household (with physical abuse and sexual abuse). Violent treatment to mother was also a risk as it was regarded as a persistent feature of the relationship between parents. Finally, having witnessed maternal battering was strongly associated with all forms of abuse. Additionally, a logistic regression was performed in an attempt to unravel the influence of abuse on the adult mental health outcomes from the effects of the potential confounders, which they associated with both increased levels of abuse and many of the same negative outcomes in adult life (Jirapramukpitak, Prince & Harpham, 2005). For those in the mental health field there is emphasis on training counselors to be competent multicultural practitioners.

This includes having a shared world view rather than generalizing characteristics based on cultural or religious stereotypes. Also it is important for the counselor to have knowledge of the norms, values, and attitudes of minority clients and be aware that there are individual differences among members of these groups. Finally, counselors should be cautious about trying to tailor counseling interventions to presumed group differences (Scorzelli & Reinke-Scorzelli, 2001).

In conclusion, the mental health field in Thailand is still misunderstood but there have been improvements in the level of care, treatment, and overall understanding of those that suffer from mental illness from lay people and also professionals and government workers. While in the treatment of care there is respect of the teachings and ways of the Buddhist life and teachings. Additionally, the Karenni refugees and also young Thais themselves are both susceptible to abuse, trauma, and other problems that can lead into mental health problems such as anxiety, depression, PTSD, and alcohol and substance use. It shows that no one is immune to mental illness or mental problems in Thailand, as with the US or any other country but with continued research, treatment, and cultural learning of Thai views mental illness will become more understood, level of care and  understanding perception will continue to increase.

References

Burnard, P., Naiyapatana, W., & Lloyd, G. (2006). Views of mental illness and mental health care in      Thailand: A report of an ethnographic study. Journal of Psychiatric and Mental Health Nursing, 13(6), 742-49.   doi: 10.1111/j.1365-2850.2006.01028.x

Cardozo, B. L., Talley, L., Burton, A., & Crawford, C. (2004). Karenni refugees living in Thai-Burmese border camps: Traumatic experiences, mental health outcomes, and social functioning. Social Science & Medicine, 58(12), 2637-644. doi:10.1016/ j.socscImed.2003.09.024

Challenger, D. (2008, June 23). Karen refugees a ‘forgotten story’. CNN,com/Asia. Retrieved from http://edition.cnn.com/2008/WORLD/asiapcf/05/27/thai.karen/

Jirapramukpitak, T., Prince, M., & Harpham, T. (2005). The experience of abuse and mental health inthe young Thai population. Social Psychiatry & Psychiatric Epidemiology, 40(12), 955-63. doi:10.1007/s00127-005-0983-1

MSNBC. (Photographer). (n.d.). Karen kids refugees. [Print Photo]. Retrieved from http://www.google.com/imgres?hl=en&client=firefox-a&hs=2cH&rls=org.mozilla:en-US:official&biw=1600&bih=810&tbm=isch&tbnid=YMLeXt_xFsx2oM:&imgrefurl=http://worldnews.msnbc.msn.com/_nv/more/section/archive?year=2012&month=4&ct=a&pc=25&sp=200&docid=6jrD0LwZ_z9rzM&imgurl=http://msnbcmedia.msn.com/j/MSNBC/Components/Photo/_new/120406_karen_kids_refugees.photoblog600.jpg&w=600&h=450&ei=eaqdT_qgAojbiALN762BAQ&zoom=1&iact=hc&vpx=569&vpy=471&dur=878&hovh=194&hovw=259&tx=156&ty=144&sig=112000461999087795323&page=1&tbnh=139&tbnw=168&start=0&ndsp=28&ved=1t:429,r:16,s:0,i:102

Scorzelli, J. F., & Reinke-Scorzelli, M. R. (2001). Cultural sensitivity and cognitive therapy in Thailand . Journal of Mental Health Counseling, 23(1), 85-92.

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