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Myanmar is steeped in trauma from past and present conflict and dictatorial rule – but with the breakdown of already meagre public health infrastructure since the 2021 coup, communities themselves are acquiring the tools to tackle the mental toll.
By RAMONA DROSNER | FRONTIER
Many of the people who wait outside on the row of plastic chairs next to Dr Hnin’s office didn’t come with the intention of seeing her. They come to Kawthoolei Care Hospital because of physical pain, only to find themselves talking to a psychiatrist.
One man arrived with abdominal pain, but received treatment for alcohol abuse, depression and suicidal ideations. For people like him, being referred to a psychiatrist is a leap in the dark. But Dr Hnin hopes they will come to understand that their pain is not just physical – and there is treatment available for their mental anguish too.
The 33-year-old is the only psychiatrist among the nine doctors covering 40,000 people in Klo Yaw Lay, an area of Kayin State across the border from Thailand’s Mae Salit, and the work feels never-ending. Like many others, the man suffering from alcohol addiction did not return for his follow-up session.
The stigma against mental health treatment remains pervasive. And because it’s impossible for Dr Hnin to reach everybody in need on her own, she’s begun training community health workers to spread mental health awareness.
The COVID-19 pandemic and 2021 military coup have been disastrous for mental health, but they have helped to spread awareness of this crucial aspect of wellbeing. Mental health workers say there have been notable shifts in terms of stigma and community engagement in Myanmar, but others have warned that putting too much responsibility on the community without proper training can do more harm than good.
During the pandemic, there was a surge in social media posts raising awareness about mental health, as new online and telephone counselling services were launched. Some of these services were then taken up at record levels when the military seized power.
“In the aftermath of the coup the caller number doubled to seek emotional support,” said Ma June, 27, using a pseudonym due to security concerns. She worked for a helpline for several years and is now studying psychology at a master’s programme abroad.
It’s impossible to get reliable figures on mental health in Myanmar, but the limited data is clear: this is yet another enduring crisis in the country. Last year 81pc of respondents in a nationwide online survey reported feeling mentally exhausted. A separate survey of 7,720 Myanmar people, conducted by a University of Cambridge psychologist via Facebook and published in 2022, found at least 60pc suffering from depression or anxiety in the aftermath of the coup, a rate that corresponds to previous studies on armed conflict.
This comes as little surprise, given the continued brutal violence around Myanmar, mass displacement of civilians and economic collapse. However, the legal framework for mental health was poor even before the coup, and is still based on the 1912 Lunacy Act, which defines people with mental health problems as “lunatics” and “idiots”. A draft revision remains in limbo.
Other than two mental health hospitals in the major cities of Yangon and Mandalay, and psychiatrists that rely mostly on drug treatments, there is no infrastructure, regulation or institutional oversight of mental health programmes in the country. Undergraduate medical students receive only two weeks of mental health lectures, and there is no existing university degree in psychology or counselling.
WHO data from 2019 shows that with less than one mental health worker per 100,000 persons, there has always been a huge treatment gap and lack of trained professionals. The situation has deteriorated further under the current regime: as well as increasing military spending, the junta has slashed the budget for public health, with no specific numbers for mental health services.
In the absence of public healthcare infrastructure, civil society organisations have had to fill the gap, often training ordinary people on mental health support as a form of first response in line with WHO recommendations.
This takes the form of online classes or in-person group meetings. Some organisations are sending trained individuals back to their rural communities, where they try to help locals with simple mental health tasks like expressing their feelings through clay sculpting.
But without a nationwide strategy and regulations, well-intentioned efforts could have negative effects.
Ma June said she was glad to see programmes scaling up, “because four years ago we didn’t have anything. But I wish this movement would be more constructive.”
She said for more severe forms of mental trauma, like depression or post-traumatic stress disorder, this approach could do more harm than good.
“A lot of people do just a three-day training. In the end, this does more harm, because the service provider is for example not experienced in PTSD,” she said.
From studying in the field, Ma June knows that training requires years rather than days, especially when working with severe trauma.
“In this very sensitive situation, we should be more careful.”
For example, she said some social workers aren’t trained in confidentiality and may share the private stories of people they are trying to treat. This exposes these people to potential humiliation and makes them lose trust in mental health treatment.
Other difficulties are rooted in traditional Myanmar culture. Myanmar’s majority religion of Buddhism is a source of mental comfort and resilience to many people, with its teachings of mindfulness and encouragement of meditation, but some aspects of the religion can conflict with modern, secular mental health treatments.
“More people follow Buddhist sayings than listen to psychiatrists,” said 34-year-old Ashin Citta, a monk born in the ruby mining hub of Mogok in northern Mandalay Region.
Buddhist doctrine says that suffering is caused by desires that can never be satisfied, so many believe it is better to simply accept life’s hardships – even including mental illness. It’s also commonly believed that people suffering from mental or physical disabilities are being punished for something they did wrong in a past life, thereby compounding the social stigma they face.
However, some Buddhist leaders believe it’s possible to find a middle ground.
“Spiritual leaders must support society not only spiritually, but also mentally,” said Ashin Citta, who is doing a PhD programme abroad researching the differences between Western therapy and traditional Myanmar Buddhist practices.
While he’s critical of the mainstream Buddhist approach to mental health, he said Western terminology like “depression” or “anxiety” can also be harmful.
“People avoid those labels because admitting to such conditions may be perceived as a sign of weakness,” he said.
In his experience many prefer to use Buddhist terms for mental anguish such as dukkha or vedanā – terms for suffering and feeling – which the religion says are unavoidable aspects of life.
“It allows individuals to feel validated and less judged by their community,” he said.
Ashin Citta says the attitude of the Myanmar monkhood towards mental health is in transition, at least partly because younger monks like himself are more open to new techniques.
“I believe modern Myanmar people want to listen to a more scientific presentation,” he said, adding that he offers science-based online mindfulness classes on emotion management in times of crisis.
Ma June is also hopeful that attitudes will change more broadly in society, thanks to a new generation that knows more about mental health and tends to share feelings more freely.
“During our teenage years, we had democracy,” she said, referring to the era of political and economic reform that started in 2011 and ended with the coup. “We are the first generation with the internet and mobile phones, that is why I am optimistic that the stigma around mental health will decay.”
Intergenerational trauma
But there is still much for the younger generation to overcome – including trauma passed down from their parents, who spent decades living under a brutal military dictatorship like the one that rules Myanmar today. Persistent poverty has also created tensions within families and communities, and domestic violence has traditionally been tolerated by society as a private matter.
Ko Ron, 24, said growing up, he was routinely beaten by his parents, which was seen as normal in his community. He remembers lying awake at night because of the bruises covering his body, but when he tried to bring it up with other people, they’d tell him: “Your parents beat you because they love you.”
Four years ago he started online counselling with a Myanmar psychologist who lives abroad. “The counselling helped me in breaking every stigma I believed before,” said Ko Ron, who asked to use a pseudonym to speak freely about his mental health struggles.
“‘Men don’t cry’ – I was big on that,” he said.
Therapy has also helped Ko Ron to understand the actions of his parents, who also experienced violence as punishment while growing up. His therapist diagnosed him with complex post-traumatic stress disorder, or CPTSD, due to his abusive childhood.
CPTSD often leads to anxiety and aggression or difficulty in sustaining relationships. But thanks to his counselling, Ko Ron says he’s better equipped to handle these challenges.
“I became more emotionally mature and resilient,” he said. “It’s okay not to be okay sometimes.”
While intergenerational trauma is already rife in Myanmar, it is likely to only worsen due to the greater spread and intensity of armed conflict today. The next generation risks experiencing increased anxiety, depression, suicidal ideation and extreme reactivity to stress, to name only a few trauma reactions.
“The younger generation now faces similar things as we did,” said U Kyaw Soe Win, who runs the mental health assistance programme of the Assistance Association for Political Prisoners. A former political prisoner himself, helping younger people is part of what has kept the 56-year-old motivated for the last 14 years.
AAPP closed its office in Yangon after the coup, but the organisation continues to support people in exile. Together with the Mae Tao Clinic in the Thai town of Mae Sot on the Myanmar border, it has built a network of mental health services, with psychiatrists, trauma therapists, meditation experts and psychosocial providers.
Many people in the border area, being there illegally, are afraid to seek mental health support or simply don’t know it’s available. So Kyaw Soe Win and his colleagues also conduct home visits.
“They need to learn about skills for resilience,” he said of the people they treat, adding that just discussing their suffering can help. “People can’t change the situation, but they can cope better.”
AAPP psychosocial service provider Suri, who fled across the border from Myanmar after the coup, calls herself a “wounded healer” because her own trauma allows her to connect with and help others. Suri works as a first responder, treating people on site while referring more severe cases to fully trained professionals at the Mae Tao Clinic. She said her clients trust her because they feel understood, knowing that she too struggled with anxiety about her lack of proper documentation and other matters after arriving in Thailand.
Kyaw Soe Win himself learnt the hard way about resilience, and the importance of sharing and solidarity, when he was imprisoned by the former Myanmar junta for six years in the 1990s. “I didn’t know anything about mental health back then,” he said, but he remembers how talking to another inmate helped him endure his torture.
One thing that sustained them both was their shared desire to get out of prison so they could share evidence of the human rights abuses occurring there. By changing his perspective to see himself as a survivor rather than a victim, Kyaw Soe Win was unconsciously using resilience techniques.
He hopes younger generations can be more aware of their mental health from early on. However, he says there are severe challenges for them, too, with the coup suddenly crushing their dreams.
“Many adolescents feel hopeless for their future; some of them suffer trauma even without direct contact [with traumatic events],” said a psychiatrist at the Mae Tao clinic, who spoke on the condition of anonymity.
One recurring problem is young people arriving in Mae Sot from Myanmar expecting safety and comfort, only to be re-traumatised by conditions of chronic insecurity and financial distress. It’s difficult for many migrants to find work in Mae Sot and Myanmar nationals are routinely extorted or threatened by local Thai police and immigration officers. Meanwhile, long periods of being jobless and isolated can lead them to dwell on what they suffered beforehand.
“After three years they can’t handle it anymore,” said the psychiatrist. “They get re-triggered from what they have been through in Myanmar.”