Mental Health Services Overview & some useful links

[MorSage]

Part of a paper I prepared last year that should give a reasonable heads-up in regard to mental health services in Thailand or more approporiately lack of them.

Mental Health Service Considerations Bangkok, Thailand

Sociological and Cultural Background: The traditional family unit comprises surviving generations sleeping in close proximity, with parents and their children sharing the same bed until the late teens. These intimate and extended bonds offer support, develop self-responsibility and instil a communal code of behaviour largely based on respect for elders, both within the family and community further cultivated by assigning increasingly important tasks and showing greater respect with increasing age. The close knit nature of Thai families is well demonstrated by the normal practice of family members sleeping at a hospital and supplying food to their member if hospitalised.

Beyond the family, communal bonding and responsibility are developed in children by including them in social interactions and schooling that starts before age 3, in which love of the king, national pride, respect for monks, teachers and superiors respectively, are ritually reinforced. Buddhism is the dominant religion and Buddhist teaching based behaviours of anonymous sacrifice, compassion for strangers, forgiveness of ignorance and accidents, avoiding unnecessary conflict, respect for personal individuality and freedom, and viewing angry outbursts as immaturity are ingrained within Thai culture. Thai people are especially reluctant to interfere with anyone eating or sleeping as the importance of these activities is clearly acknowledged at a societal level.

Mental Health and Welfare Considerations in Bangkok: A child's wellbeing depends on their physical and mental health, and being socially well adjusted. Children thrive in close, dependable, loving and nurturing relationships that encourage exploration, development of respect for self and others, enjoyment of achievement and limit behaviours with responsive interactions. Conversely, threats from economic hardship, bad environments, family disintegration, social isolation and parental disabilities can adversely affect a child's development, potential and coping abilities (Roberton S., South M. 2007 pg 49-50). Thailand's traditional family and societal structures appear to provide many beneficial attributes related to a child’s wellbeing.

Sadly, within Bangkok, Thailand's traditional childcare strengths are now often compromised by fragmentation of the traditional family and village units, which previously provided much of the emotional support, education and assistance for children and adolescents to develop their coping skills, and sense of self within the broader community and world. Additionally, Bangkok’s rapid ‘westernisation’ including supermarkets and junk foods rather than fresh market food, lack of play space, pollution and smaller family units that are less able to regulate and care for their members or prevent abuse and compensate disabilities within the family now are common.

Thailand and Bangkok's social structures have altered greatly within recent decades by substantially reduced birth rates, 6 per woman in early 1960's to <2 in 2003, that compound the detrimental effects of dissociation and urbanisation of the rural population and further weakens Thailand's traditionally strong societal and family structures. The reduced family size also has very serious consequences for adults and especially the aged, as Thai families are responsible for the care of their elders and each other in times of need. Thailand does not have, and large families had little need of, a liveable aged pension and many other safety nets like Australia. Thus today’s children and many adults are now facing a much greater burden to support their elders while facing an uncertain future themselves. Combined these factors suggest a substantial and rapid degradation of Thailand's traditional support and welfare structures and an increased need for mental health and welfare services to help offset the loss of personal, cultural and societal identity, and support previously offered by Thailand’s traditional family and social structures. (Prachuabmoh V. & Mithranon P. 2003, pg. 37-48) Consistent with the loss of societal support and stress resulting from the described social upheavals, Thai society is now experiencing increasing levels of suicide, substance abuse, and mental illnesses as the health services and people of Thailand struggle to come to terms with their new reality and its’ attendant grief and anxiety promoting loss of conditioned expectations and uncertain future.

Buddhism, Superstition and Mental Health: Thailand is a predominantly Buddhist country, wherein Buddhists accept pain and suffering to be a normal part of life and that their ‘karma’ or life course is dictated by their past and present life deeds. Belief in reincarnation, ghosts and a supernatural dimension to life are accepted realities, as is the risk of incurring bad karma from even unknown ‘misdeeds’ or improving karma by ‘making merit’ from performing good deeds or resolving prior ‘wrongs’. Therefore most Thais believe that physical and mental afflictions can be caused or resolved by their deeds and are open to suggestions from spiritual guides that include; Buddhist monks, fortune tellers, Chi-Qong masters or others with a reputation for helping afflicted individuals. The legitimacy of these beliefs within Thai culture and society is demonstrated by meditation, guided imagery, Chi -Qong, universal energy, fortune teller, witchcraft, clairvoyance and Buddhist healing being included in the 25 types of alternative therapy acknowledged by the Thai Ministry of Public Health (translated from, National Centre for Complementary and Alternative Medicine, 2009).

Thai people also tend to have great faith in doctors, technology, science and pseudo-science, and will often follow instructions to the letter, without question. These behaviours while comforting to patients, helpful to treatment, and that may enhance the efficiency of healing ‘triggers’, suggestions and placebo effects also increase a practitioners’ responsibilities for their actions and can make patients vulnerable to exploitation (personal belief based on 16 years experience).
Bangkok Healthcare Services Overview: Within Thailand, healthcare is provided by an extensive public hospital system, wherein Thai citizens pay only 30 baht (about $1.25 Australian) or is effectively free if employed and making social security payments, and an extensive array of much more expensive private facilities. 25,280 or >18% of Thailand's hospital beds are in Bangkok despite only about 9% of the population residing here, and there is 1 doctor / 867 people compared to the national average of 1 / 3182 (Thailand Ministry of Public Health. 2007, pg. 27, 41, 241, 244).

Mental Health Service Overview: Thailand has 122 out-patient mental health facilities located in mental or general hospitals, 11% of these are for children or adolescents only. No day care facilities or residential facilities except for mentally retarded children and substance abuse patients exist. There are 25 community based psychiatric units with 0.4 beds / 100,000 and 17 mental hospitals with 13.8 beds / 100,000 people, a disproportionate concentration of these mental health services are in Bangkok, 5.6 times the national average. A human rights review body exists but does not oversee involuntary admissions, discharges or complaints, evidenced by no activities regarding these mental health patient issues occurring within the last year. Nationally, use of community in-patient facilities were 173 / 100,000 and 158 / 100,000 for mental hospitals, most in-patient admissions are involuntary, initiated by the police or family (WHO & Ministry of Public Health, 2006).

Thailand has only 7.29 personnel working in mental health / 100,000 people with few psychiatrists and psychosocial staff, even within its mental hospitals with just 0.01 psychiatrists, 0.15 nurses, 0.02 psychologists-social workers-occupational therapists and 0.05 other mental health workers per bed. Primary care doctors have limited training and interaction in mental health services, 6% of training hours, and only 1% of health research published in Thailand concerns mental health. Only 32 psychiatrists and 21 psychologists with at least 1 year of mental health training graduated in the last year. Less than 20% of primary healthcare physicians refer to a mental health professionals as “having contacts with mental health staff is still considered a stigma by primary health care doctors” despite this less than 20% of psychiatrists emigrated to other countries within 5 years of graduating! However, an estimated 21-50% of non-physician based primary healthcare clinics made 1 or more referrals / month to mental health professionals. (WHO & Ministry of Public Health, 2006)

Mental and behavioural disorders outpatient health services were performed on 4.2% of the population in the central region of Thailand that includes Bangkok in 2006. In-patient mental health services in the same region and time as a % of the population were:
1. Organic, including symptomatic mental disorders 0.09%
2. Mental and behavioural disorders due to substance abuse 0.42%
3. Schizophrenia and delusional disorders 0.40%
4. Mood (affective) disorders 0.14%
5. Neurotic, stress and somatoform disorders 0.62%
6. Mental retardation 0.03%
7. Epilepsy 0.50%
Therefore a maximum 2.2% of the Bangkok population received an inpatient and 4.2% an outpatient mental health service in 2006. In 2006 the Department of Mental Health received 3.1% of the Royal Thai Ministry of Public Health’s budget (Thailand Ministry of Public Health. 2007, pg224-232).

This data suggests mental health problems and disorders, and the care of these conditions are either much rarer in Thailand than in many other countries (Sarason I.G. & Sarason B.R., 2005) or, less acknowledged and catered for within the orthodox health system or, largely managed outside of orthodox healthcare settings, and that mental illnesses are associated with considerable stigma within both the medical and broader communities.

Local Mental Health Services: Central Bangkok mental healthcare needs are serviced by some of Thailand’s best equipped and staffed private and government hospitals all of which when purposely interviewed claimed to offer a complete range of mental health services including; medication, counselling, behavioural and cognitive therapy and availability of psychiatrists, psychologists, and mental health social and occupational therapists. However, interview of 20+patients with mental problems or disorders or their families failed to demonstrate any intervention other than diagnosis, brief counselling on a few occasions and psychotropic medications given by either a medical doctor or rarely a psychiatrist. This is consistent with the WHO-AIMS study that reports mental health therapy within the Thai system tends to rely on psychotropic medication, which can be prescribed without restriction by medical doctors (WHO & Ministry of Public Health, 2006). In reality, the lack of psychiatrists and other mental health professionals combined with the documented medical stigma regarding them virtually excludes the common availability of mental health interventions other than psychotropic drugs within the government and private healthcare systems.

Mental health problems are associated with 3 other levels of stigma; public, family and self within Thai society according a pre-eminent Thai psychiatrist Dr Prakarn, who also states “a psychiatrist is a medical doctor, able to prescribe drugs; a psychologist is more of a counsellor type figure” and the need of programs to de-stigmatise mental illnesses and encourage societal support of the mentally ill. ( http://www.bangkokpost.com/leisure/leis ... n-thailand )

Local Public Mental Health Services: Several local government hospitals and clinics provide specialised mental health services (Appendix 1). These services are either totally free or involve minimal costs for Thais and generally operate between 8.30am-4.30pm, but patients are treated ‘first come first served’ and need to cue up from the morning. Several of these hospitals also offer ‘special clinics’ between 4.30pm-8.30pm but charge 500 Baht ($20 Aust) for consultation and for drugs not on the free list. Only within the ‘special clinics’ can services be obtained by appointment and there be a reasonable chance of seeing a particular practitioner. Of note; Ramatipidee Hospital has a special interest in autistic children, Rajavithi Hospital suicide, Niti Jitavej narcotics and all of the other listed hospitals have special child and adolescent clinics. These services are only for Thais.

In addition, to the public mental health services most schools have a psychosocial care system with access to either full or part-time mental health professionals and programs to promote or identify mental health issues (WHO & Ministry of Public Health, 2006). This is complimented by an array of anonymous public help-lines or drop-in centres (Appendix 2). Due to the stigmas attached to mental illness these free services are an important component of local mental health resources despite normally only being staffed by ‘good Samaritans’ or social workers except for; To Be Number One Friend Corner and the Faculty of Nursing Mahidol University that have psychologists / students.

All services in Thailand, the land of smiles, tend to have a friendly and gracious ‘face’ with Thai society having a strong service minded mentality influenced by Buddhist teachings and beliefs.

Buddhist and other Societal Mental Health Services: Within Thailand and Bangkok, Buddhist monks and temples would be the most frequent source of mental health counselling, their services include counselling in individual, family and community settings, fortune telling, casting blessings performing ‘healings’ and guiding those seeking help to attain better karma often by behavioural and cognitive approaches such as guided meditation or ritual penances (personal investigations). Buddhist guidance is available to all regardless of faith, nationality or language barriers, albeit counselling is more attainable by those sharing a common language. Some monks and temples are especially revered for their ability to solve mental disorders but in general, the best monk to consult is an intensely personal issue for most Thais. Fortune tellers and Chi-Qong masters are other common sources of service utilised by Thais for both physical and mental problems and these practitioners often make similar ritual prescriptions to Buddhist monks (personal investigations).

Many religious denominations and special interest or ethnic groups also provide counselling and support for members of ‘their’ communities and sometimes others who seem to be in need. Within my experience the churches, especially Catholic, and the Bangkok Mothers and Babies Association seem to excel at assisting or befriending others, and have established networks of care providers. These services and other resources within the private healthcare sector are especially important to non-Thais within Bangkok, often far more than the consular sections of their embassies.

Private Mental Health Services: Private mental health services are especially important to non; Thais, Buddhists and members of well represented religious or ethnic groups. Samitijev Hospital http://www.samitivejhospital.com/Medica ... viceId=139 and Samitijev Srinakarin Childrens Hospital appear the best private hospitals for mental health services in Bangkok http://www.samitivejhospital.com/Medica ... rviceId=89 . In contrast to the nearly free public system these are very expensive with initial consultation alone approximately 2000 Baht ($80 Aust) with all other services ++. Other than these hospitals 2 other mental health services of note are the Psyclinic, telephone 02-2243-2142, consultation 1000 Baht ($40 Aust) and Manaron Hospital, a private mental hospital with both outpatient and inpatient services, consultation starts at 1200 Baht ($48 Aust) and room rates between 2500-6000 Baht ($100-240 Aust) / day. All of these facilities, ‘atypically’ offer both psychiatric and psychologist services.

The Thai yellow pages English edition (English is the official business language in Thailand) only lists 2 psychiatric clinics and no psychology clinics (Appendix 3). The Thai edition does not have a section for psychiatrists or psychologists but there are a few listings scattered in the general clinic section!

Utilising Local Mental Health Services: Nationality, religion, culture, language and economic factors are important considerations in regard to utilising the mental health services of Bangkok. Non-Thais have to rely on the private sector and expatriate or religious services, whereas Thais have an expanded array of options. However, functionally, both the private and public hospitals have great similarity in therapeutic approach; exclude or identify organic illnesses and psychotropic medication. Generally, the private services and government ‘special clinics’ facilities are more user friendly and have a real advantage by allowing a therapeutic patient-practitioner relationship to be developed, albeit at a much higher economic cost than normal government services.

In regard to mental problems and disorders that often have poorly defined expressions and variable interpretations it is critical to understand the nature and severity of the condition before considering referral and to whom. This is of even greater importance within Bangkok and Thailand due to high likelihood of psychotropic medication with their attendant risks resulting from medical consultation for a mental health condition and suggests that medical referral needs very careful application. Mental health conditions by nature are unique, but can usually be categorised as:

Mild: causing periodic not constant altered thinking, normal responses to a life event or loss that can probably be worked through with the help of the patient’s support group and time, and is not causing significant health, employment or activity limitations.
Moderate: dwelling on the disturbance/s, negative thoughts or loss, beginning or threatening to cause actual health, employment and activity problems, appears to need support and or relying on others to control or work through the condition.
Severe: inability to recognise the problem or distinguish reality from their altered perceptions, constantly being depressed for more than 1 month, thoughts of harming oneself or others, lack of ability to perform normal social, employment and self maintenance functions, establishing unusual or damaging coping behaviours, and or unprovoked aggression, fear/s and allowing the disorder to take over their life.

Based on the severity of the suspected or actual mental health issue; support group, conversation, counselling and diet /nutritional, tactile, botanic and or other modalities within a practitioners competence to enhance the physiological and mental integrity of a patient appear appropriate for mild disturbances. Moderate conditions in addition to the preceding interventions indicate a need for closer monitoring and involvement of specialised psychosocial professionals or workers, and a probable need of prolonged help and reinforcement to maintain improvements once attained. Severe mental conditions or suspicion of them indicates a probable need for psychiatric referral as psychotropic medication and or other interventions with known or other potentially detrimental effects and limitations may be required, prolonged treatment and supervision is normal.

Summary: In regard to the western medical perspective of mental health services, Bangkok services are more defined by ‘what does not exist more than what does’ and this is an especially acute problem for non-Thais in need of mental health services. Even for Thais the concept of non-drug therapy or having multiple prolonged sessions with a professional psychosocial worker to work through problems and or enhance coping strategies and skills functionally does not really exist, unless a practitioner has a special interest in a patient and or they are very affluent. Community services, undoubtedly similar to other regions of the world, strongly favour ‘locals’ and those literate in the local language. Buddhism is the dominant religion in Thailand and Buddhists are often more accepting of loss and adversity than other individuals, thus despite the recent erosion of Thailand’s traditional family and societal structures with their attendant mental health benefits many Thais are again better prepared for the losses and uncertainties that can promote mental problems and disorders. In contrast, non Thai individuals within Bangkok have a very limited array of mental health services while living in a culture that functions and views many life events very differently. However, for every individual within Bangkok that may benefit from a mental health service, understanding their economic, social and cultural beliefs or predicament, and the strengths and weaknesses of these circumstances is of primary importance to identifying and utilising the mental health services and support that are available to assist them and working with these resources.

List of References
Thailand Ministry of Public Health (2007). Public Health Statistics A.D. Nonthaburi, Bangkok, Thailand
National Center for Complementary and Alternative Medicine. National Institution of Health. viewed 13/07/09. www.med.cmu.ac.th/hospital/nis/download/2008/thai selective.doc Bangkok, Thailand.
Prachuabmoh V., Mithranon P. (2003). Below-replacement fertility in Thailand and its policy implications. Journal of Population Research. Volume 20, No. 1, 2003 http://www.jpr.org.au/upload/JPR20-1pp35-50.pdf ,
Roberton D., South M. (2007). Practical Paediatrics (6th edition). Edinburgh: Churchill Livingstone
Sarason I.G. & Sarason B.R. (2005). Abnormal Psychology: The problem of maladaptive behaviour. Pearson, Prentice Hall, New Jersey
World Health Organisation & Ministry of Public Health of Thailand (2006). WHO-AIMS Report on Mental Health System in Thailand. Nonthaburi, Bangkok, Thailand. http://www.who.int/mental_health/thaila ... report.pdf
 
Appendix 1
Local Government Hospitals / Clinics offering Mental Health Services in Bangkok
Somdej Joopraya. Telephone: Business hours 02-437-7061, After hours 02-437-0200-9 Service time: 8.30am–4.30pm
Rachanukul Hospital. Telephone: 02-245-4696 Service time : 8.30am–4.30pm
Child Mental Health Centre. Telephone: 02-245-7798, 02-245-7833, 02-246-1195, 02-246-0117 Service time: 8.30am–4.30pm
Ramatipadee Hospital Telephone : 02-2011235, 02-2011245, 02-2011726 Service time: 8.00am-12.00pm, Special Clinic: 4.30pm–7.30pm, Child Psychiatry Clinic: Wednesday 4.30pm–7.30pm Special : Autistic Child
Niti Jitavej. Telephone: 02-4419029 8.30am-12.00pm and 02-441-0084-93 ext.1305 after Service time: 8.30am-04.30pm, Special Clinic: 4.30pm–8.00pm Special: Narcotics clinic
Chulalongkorn Hospital. Telephone: 02-256-5180, 02-256-5182 Service time: 8.00am-4.00pm, Special Clinic: 4.30pm–8.00pm
Sririraj Hospital. Telephone: 02-411-0241 Service time: 9.00am 12.00pm, Child (Wed) 9.00am–12.00pm, Special Clinic: 5.00pm–8.00pm
Vachira Hospital. Telephone: 02-2430151-79 ext 2121 Service time: 8.00 am-2.00pm, Special Clinic Tuesday 4.00pm–8.00pm
Rajavithi Hospital. Telephone: 02-354-8108-9, 02-3548082, 02-3548159 Service time: 8.30am–12.00pm, Special Consult 13.30pm–16.00pm (1000-2000B/hr) Special: Suicide
 
Appendix 2
Community Based Public Mental Health Services within Bangkok
*** To be Number One Friend Corner: An outreach organisation of the Ministries of Health and Education for youths 10-24, with facilities in major 5 shopping centres tasked to provide counselling, 'happy' activities (music, sport, art, singing and dancing, conversation), solve problems and promote emotional growth. Staffed by psychologists and student psychologists. http://www.tobefriend.in.th/ , http://www.sbw.ac.th/Website/tobe/frien ... ntact.html
***Faculty of Nursing Mahidol University Helpline and Drop-in Centre Tel: 0 2982 7042 ext 1
Bangkok Mothers and Babies International (BAMBI) http://www.bambiweb.org/index.php , http://www.bambiweb.org/preSchool.php .
Love Care Station, HIV and STD helpline. Tel: 1330
Mental Health Hotline. Tel: 1677
Bug Hotline. A hotline that links to all available help and social services. Tel: 1113
Police Emergency Hotline. Tel: 191
Teenage Hotline. Tel: 0 2275 6993-4
Ramatipbodee Hospital, Child Psychiatry Clinic. Tel: 0 2201 1235
Suicide Helpline. Tel: 0 2713 6793
*** Preferred services
 

[Cing Jai]

MorSage, if you're subscribed to this topic could you please send me a PM? I've just registered and can't send PMs yet.
Thank you!

[nanyang]

Mor Sage, many thanks.

I've sent you a PM as I don't wish to air my views publicly.

[Cing Jai]

nanyang, I cant read your PM yet, just a few more posts to go. I think 10 is the magic number.

[nanyang]

nanyang, I cant read your PM yet, just a few more posts to go. I think 10 is the magic number.

Have you 'morphed' into MorSage?

[Cing Jai]

No, I don't know MorSage.

I'm just new to the forum today so it won't let me read or send PMs until I have a certain number of posts. I think it's 10 here. when I go to look at my PMs I'm told I have one but am not allowed to read it. :/

[buksida]

All explained in the "starter pack" which you were directed to when you registered: viewtopic.php?f=26&t=10054

[nanyang]

All explained in the "starter pack" which you were directed to when you registered: viewtopic.php?f=26&t=10054

Thanks buksida - another one in the category of, 'Doesn't get it', methinks.

[Cing Jai]

Yea, I must be too stupid to get it.

I did read the forum rules before posting but I missed the starter pack. Many apologies for that!
I've read it now and I still don't get it, whatever it is that I'm missing. That I need 10 posts before I can send a PM? I read that elsewhere on the forum and it's not unusual for forums to require a few posts before enabling these features.

Instead of being cryptic, because I'm obviously too stupid to figure it out on my own, can you just tell me or link me to the part I'm not understanding or overlooking? That would be helpful.

I got a PM about my thoughts on incest based on my comment in this thread? I've no idea what that is about.

If I'm too stupid to figure it out then I'll get my coat and log off because I don't want to break any rules or disrupt what seems to be a happy community.

Edit:
OK, here's my best guess. The original post is an abstract from a paper he wrote so it's self-promotion. By bumping the thread I have perpetuated the self-promoting?

Second Edit:
OK, that must be it. Now I get the "have you morphed into MorSage?" comment. Just delete all my posts then. I've already got my answer, there is no help for me.

[jingjoe]

thanks morsage very interesting post,certainly gives an insight into the hardships of a lot of thai families

[nanyang]

Yea, I must be too stupid to get it.

I did read the forum rules before posting but I missed the starter pack. Many apologies for that!
I've read it now and I still don't get it, whatever it is that I'm missing. That I need 10 posts before I can send a PM? I read that elsewhere on the forum and it's not unusual for forums to require a few posts before enabling these features.

Instead of being cryptic, because I'm obviously too stupid to figure it out on my own, can you just tell me or link me to the part I'm not understanding or overlooking? That would be helpful.

I got a PM about my thoughts on incest based on my comment in this thread? I've no idea what that is about.

If I'm too stupid to figure it out then I'll get my coat and log off because I don't want to break any rules or disrupt what seems to be a happy community.

Edit:
OK, here's my best guess. The original post is an abstract from a paper he wrote so it's self-promotion. By bumping the thread I have perpetuated the self-promoting?

Second Edit:
OK, that must be it. Now I get the "have you morphed into MorSage?" comment. Just delete all my posts then. I've already got my answer, there is no help for me.

I've sent you an apology and apologise publicly for my mistake.

My intended recipient was MorSage and, as I now know, I had some finger trouble!

Enjoy the forum.

[Cing Jai]

I've sent you an apology and apologise publicly for my mistake.

My intended recipient was MorSage and, as I now know, I had some finger trouble!

Enjoy the forum.

I got your PM and thanks for writing it here too!

[Big Boy]

I've already got my answer, there is no help for me.

On the contrary, in my response to your introduction, I have told you of the only doctor in the area to help you. This service is less than one month old, so not many will be aware of it.

[Cing Jai]

I did get your reply in the welcome forum BB and I appreciate you passing that info my way!

The, admittedly snarky, post you quoted from me was a frustrated reply to nanyang about a miscommunication. All sorted now though.