It is widely understood that victims of trafficking and abuse would be in need of mental health care services to aid in restitution and rehabilitation. It probably comes with no stretch of the imagination that social workers in the anti-trafficking industry would also need support to handle the emotional toll of the work they do. What may not be obvious, however, is that mental health services are also critical to the prevention of child slavery and exploitation. In this piece, we’d like to share the story of one of our students, Nong Gaht, to emphasize the role proper mental health care can play in expanding freedom and opportunity—and how oppressive the lack of it can be.
Nong Gaht comes from the same village as one of our Freedom Story staff members. At the age of 11 years old, he had been living in the village with his mom, who is illiterate and has mental health issues, and with his drug-addicted stepfather. He began getting into trouble for getting more aggressive and doing inappropriate things, like hitting and inappropriate touching of himself and girls. The behavior was, naturally, unacceptable to the local community, but the causes were not understood. Village elders had a meeting and decided he needed to leave. With the help of Freedom Story staff, his mother took him to a government home and lived with him there. However, the people there were also ill equipped to understand or help manage his behavior. They took him to see a psychologist who had diagnosed him as bipolar and gave him heavy medications (ones typically used to treat seizures, epilepsy, Parkinson’s, bipolar disorder, mania and schizophrenia) essentially to sedate him so he could be better controlled.
Very quickly, Nong Gaht became close to catatonic.
Staff members at The Freedom Story were shocked and horrified to see him reduced to a zombie-like state. Our staff took him back to the doctor to verify the diagnosis and prescribed treatment, and the doctor admitted Nong Gaht’s case was beyond the scope of her expertise. She had recommended taking him to Chiang Mai for better treatment. The doctor in Chiang Mai switched his medication and he now seems to be in somewhat better shape, but Freedom Story staff remain unconvinced that this is the best treatment for his case. He is still not going to school because of his behavioral issues, while our staff members try to find an alternative school situation. His case is further complicated because he is stateless, and thus has severe restrictions on his ability to travel to Chiang Mai for regular treatment and care. Meanwhile, our staff had set him up with an non-governmental orphanage whose staff are trained to deal with complicated cases like his, but he subsequently left their facility and went back to a government home. Next steps remain both critical and uncertain.
The State of Mental Health Care Services in Thailand
To better understand mental health care in Thailand, I spoke with Chalermkwan (Amm) Chutima, Founder/Executive Director at Upstream Family & Community Learning Center (website in progress), which provides holistic care and legal assistance to vulnerable children and their families. She agreed that it was not uncommon to sedate people as a method of controlling behavioral issues. It is symptomatic of a larger problem where mental health care professionals in Thailand are insufficiently trained in best practices and the wider culture lacks understanding of mental health problems. What follows is information that she has graciously provided to help summarize the major areas of concern.
Ms. Chutima outlined four major challenges to adequate care: negative attitudes around patients and the need for treatment, the inadequate number of health care providers, the high costs of treatment, and inexperienced or unskilled staff dealing with complicated cases.
Negative Attitudes Towards People Who Need Help—And to Getting Help
“Most Thai people are embarrassed and afraid to seek assistance or be admitted to mental hospitals. This is mainly because Thai people do not fully comprehend the benefits of receiving fundamental counseling in order to prevent further development of the symptoms.”
One of the primary concerns is that Thai society harbors serious prejudice against and intolerance for those who have mental health problems. As Chutima explains, “Most Thai people lack valid knowledge and understanding about mental problems. They perceive people seeking counseling or treatment as insane. Thus, [people who need help] are ashamed to seek counseling or treatment. This includes relatives and family members because they fear society’s disgust and aversion or that people will be paranoid that the patient, who is their relative, will harm others.” This situation highlights a complex problem: people who need help try to avoid getting help because they fear the stigma attached to it. In their view, getting help doesn’t prevent you from being insane—it means you are insane. Therefore, problems go undiagnosed and untreated until they get so bad someone gets hurt.
In 2012, the Department of Mental Health and Health’s Policies And Technology Evaluation Project conducted a survey to evaluate mental health situations in several provinces. The subjects of the survey included people with depression, chronic depression, hypomania, mania, emotional disorders, drug and alcohol consumption disorders, psychosis, dementia and suicidal risk. The survey results showed that only 13% of the participants received treatment. It was shocking to note that fewer than 10% of the participants in the following categories sought treatment: patients with drug disorder, suicidal risk, alcohol disorder, and dementia in the elderly. The results revealed other problems. For example, some patients did not take medication prescribed by the doctors, or the patients did not go to the hospitals regularly. It was found that there was no improvement or there was only slight progress in the condition of 1 out of 5 patients. Even though they sought counseling or treatment, they usually waited until the condition worsened or became unpredictable, or until there were harmful incidents that threatened the lives and safety of the patient. (Source: Policy Brief, Year 1, Volume 1, April 2012)
The Inadequate Number of Health Care Personnel and Service Providers
In Thailand, there is a severe lack of trained mental health personnel, including counselors, psychotherapists, psychologists, occupational therapists, and social workers. While subjects related to mental health are offered as part of the curriculum at universities, there are not popular among university students and only a small number of graduates pursue careers in mental health. A report conducted as recently as August 2016 put the number of personnel working in the mental health department at 2,801.
Regarding mental health counseling centers, there are only 19 service providers managed by the Department of Mental Health whereas there are 77 provinces in Thailand and the population is higher than 70 million. Some regional big cities, such as Bangkok or Chiang Mai, have mental health counseling centers managed by private sectors. There are only two such places in Chiang Mai that Ms. Chutima is aware of: Cornerstone Counseling Foundation and The Well Member Care Center (The Well International).
The High Costs of Health Care
Thailand is a developing country and the majority of Thai people who are mentally affected are those from low and middle classes. The factor that impacts them the most is stress resulting from a bad economy. These people do not have enough money to seek continual mental health counseling. Furthermore, those who do not live in the areas in which the government offers counseling centers as a part of Universal Health Care Coverage have to receive services from private hospitals. If they want to receive counseling or treatment from public hospitals located in other towns or provinces, they will have to pay for transportation and accommodation.
Normally, the people from middle to upper classes are those who earn better salaries and receive better education. However, they still perceive that the cost of treatment per session as high. They rationalize that mental disorders are not dangerous diseases so they believe it is unnecessary for them to seek counseling or treatment. Usually, patients or relatives will only consider seeking counseling and treatment when the symptoms have worsened or affected the patients physically and socially, for example: symptoms as chronic stress or poor work performance, violence against family members, drug usage, attacking other people, or attempting suicide.
“It is rare to see general Thai people seeking mental health counseling, except those who are well educated and have knowledge of English [notably those who can afford a good education].”
These problems highlight several important biases in who can access help, where those who live in big cities, who are well-educated and can speak English, and who have enough money to be able to afford treatment are much more likely to get help than rural, uneducated, poor, and otherwise excluded counterparts.
Eventually, both direct and indirect financial damages resulting from the fact that the patients do not seek counseling or treatment in the early stages are estimated to be as high as tens of thousands of million baht—or they can be immeasurable, as in the case of loss of life.
Inexperienced and Unskilled Staff in Key Positions
The final challenge our friend, Ms. Chutima, discusses is the problem of social services provided outside the official system: at community and religiously affiliated centers, nonprofits and other related organizations. People who have been victims of abuse, violations, or have been trafficked suffer from a myriad of complicated symptoms and conditions. Their cases require staff with sufficient understanding, knowledge, skills and experiences, and each victim requires specialized care. Ultimately, the most challenging aspect for the staff is determining how to support these victims to return to the society and continue their lives. In many cases, this has not been successful. Most private shelters do not have psychologists or social workers registered with the government. The people who many victims are most likely to come in contact with for help may be untrained or improperly trained to handle their cases. Thus, even those people who do reach out for help may not get the kind of care they need.
All these issues have played out in our student’s story
We at The Freedom Story have seen all these issues play out in the case of our student, Nong Gaht. From the systematic exclusion in being ostracized from his local community, to the difficulty finding help, and the lack of skill and understanding from even trained professionals, Nong Gaht has been treated in a way that could only be seen as tragic and abusive. Without proper care and help from a supportive community, how might his story play out? Would he have remained in a catatonic state, shunned from all society? What kind of effect does even the exposure of those heavy medications—given to a young child—have on his long-term well-being? If the people around him can no longer afford the medications, where would they put him?
In our experience, people who are impoverished, who are systematically excluded and alienated from society, who lack education and awareness or are in some way controllable are the most vulnerable to trafficking and exploitation. However, even if Nong Gaht’s end point does not result in sex trafficking, finding help for him remains essential to those of us working in trafficking prevention when society actively chooses to sedate people they don’t want to deal with—when “help,” improperly conceived and executed, becomes just another form of incarceration.
Many thanks to Chalermkwan Chutima for her expertise and generous time spent helping to write this article, and to Paweena Nakha for her help with translation. Nong Gaht’s name has been changed to protect his and his family’s privacy.
Dr. Jade Keller is the Thailand Program Advisor and Editor for The Freedom Story (previously The SOLD Project). After receiving a PhD in Political Science from UC Santa Barbara, she moved with her family to northern Thailand to work in child trafficking prevention, education, and helping to raise awareness. She is half American, and half Thai.