New Internationalist

When Western therapies fail

Issue 452

Is a Western approach the best way to engage with the mental health issues of other cultures? Nick Harvey visits Burmese refugees in Thailand to find out.

This special report was published in the May edition of the New Internationalist 'Mental health: Looking beyond the pills'. Buy this issue or subscribe from just £7.

Thiha Yarzar spent more than 20 years in Burmese jails as a political prisoner. He was tortured, shackled and forced to eat and sleep with dogs. In 2008, shortly after his release, he fled to Thailand to claim asylum. Although in Thailand he may have a semblance of freedom, in his mind he is not free.

‘I feel a lot of anger, paranoia,’ he says. ‘I feel like I’m still in prison, always being hassled by the police for money, never feeling safe. My heart is still burning, I miss my daughter, I want to work.’

Nick Harvey
‘My heart is burning,’ says Thiha Yarzar in the Thai town of Mae Sot. Nick Harvey

Many refugees in Thailand never receive refugee status and even those that do cannot work legally. They live in dire conditions and face harassment and extortion. This takes a heavy mental toll on these migrants, many of whom also bear the burden of past traumas.

To deal with such ongoing challenges, several NGOs operate mental health services both in the refugee camps and the border towns. But while many workers from these organizations, and the methods they use, come from the West, some maintain that Western models of mental healthcare are not always relevant to the experiences of people in Asia.

‘People often make the mistake of coming here and trying to impose Western-style mental healthcare,’ says Nada Abshir, mental health liaison manager for Burma Border Projects, a charitable foundation working with migrants in the Thai town of Mae Sot. ‘But people here have been traumatized from childhood when their village was burned down, and then they come to Thailand and are traumatized constantly from the experience of living here. They simply will not have the same mental health issues as a Western person.’

In his book, Crazy Like Us: The Globalization of the American Psyche, Ethan Watters explores this idea that Western psychiatric models may not apply to those from other cultures. ‘Mental illnesses are not discrete entities, like the polio virus, with their own natural histories,’ he wrote in the New York Times. ‘They have never been the same the world over (either in prevalence or in form) but are inevitably sparked and shaped by the ethos of particular times and places.’

And there are many instances of culturally specific mental health issues in Asia that remain largely unknown in the West. For instance, within the Burmese community there is a reaction known as galaba whereby a traumatized person will, when startled or surprised, begin dancing around in circles and singing as if possessed.

‘Although people may find galaba amusing, they also realize it is a result of the trauma this person has faced,’ says Julia Carroll, a mental health support co-ordinator in Mae Sot. ‘People with unusual behaviour often get a lot of compassion from the community, especially if they know a bit about what the person has been through.’

A different language

Then there is the thorny issue of language. Even the most basic Western terms such as ‘depression,’ ‘anxiety’ or ‘trauma’ don’t translate directly to Burmese.

‘When I use Western mental health terms people think I’m trying to educate them in something foreign that doesn’t relate to them,’ says Whitney Haruf, a psychotherapist and mental health trainer at Mae Tao clinic in Mae Sot. ‘But if, instead of depression, I used “severe sadness” and instead of anxiety I spoke of “worry” and “fear”, people would relate to it much better.’

Similarly, many argue that the term ‘post-traumatic stress disorder’ (PTSD) is a misnomer as the trauma felt by the Burmese refugee community is ongoing.

‘The whole concept of PTSD is irrelevant to the refugees here – they are still deep in the crisis,’ says Julia Carroll. ‘The model was based on Vietnam veterans going back to the US and living in a safe community, but refugees here are not in a safe community. It is all still present; it is all current.’

It seems counterintuitive, but mental health professionals argue that, for some refugees, it is precisely the ongoing nature of their wretched circumstances that acts as a protective factor against complete mental breakdown. For when people are in the depths of this ‘survival mode’, focused purely on staying alive, they have little time to dwell on past traumas.

‘They have no job, no money, no ID and no documents, and their future is uncertain. These are the things occupying their minds, not the traumatic experiences of the past,’ says Kway So Win, an ex-political prisoner who co-ordinates a mental health assistance project in Mae Sot.

Conversations not counselling

This could be part of the reason why counselling, which Western psychiatry puts forward as a sovereign remedy for a wide range of mental health burdens, is viewed with suspicion within the Burmese refugee community: people don’t want to bring up and focus on past traumas when they have enough problems in the present.

‘Many people, including myself, don’t fully understand counselling,’ says Thiha Yarzar. ‘I don’t want to talk to strangers about what’s wrong with me. I know what it is, it’s something I got in prison.’

This attitude towards counselling is related to a deep stigma that many Burmese attach to anything directly related to mental health.

‘People here think counselling is just for serious mental problems and that they don’t need it for smaller stresses or depressions,’ says Kway So Win. ‘When Burmese people think of mental health, they think of full psychosis. They often don’t understand that mental health comes in many different levels of severity, so as soon as you mention counselling, they think you’re calling them crazy.’ Mental health workers in Mae Sot adapt not just their vocabulary but the way they frame their methods.

‘People here have been traumatized from childhood when their village was burned down. They simply will not have the same mental health issues as a Western person’

‘We no longer refer to it as counselling, because of the stigma issue,’ says Whitney Haruf. ‘And we don’t base it on set times and appointments like we would in the West. We try to talk to people when they come to the clinic, so they just see it as a conversation with a medical professional rather than a counselling session.’

While going to the doctor with a mental health concern would be unthinkable to many here, it is far easier to talk to doctors about something concerning the body.

‘There are “culturally recognized” or “culturally accepted” symptoms,’ says Julia Carroll. ‘It is more acceptable to describe chest pains or heart problems, often a “heavy heart” or a “burning heart”, which are recognized symptoms of deep sadness, whereas [in the West] a doctor would start hooking you up to a heart monitor as they would not necessarily link it straight away to depression or anxiety.’

All of these challenges faced by aid workers, already frustrated by the heartless and uncooperative attitudes of the Thai and Burmese authorities, mean many find it hard to be optimistic.

‘I question how much we can affect things here,’ says Nada Abshir. ‘We can reach a few hundred people but there are millions of Burmese who need help. If you can’t access food and security and basic protection for yourself, then talking is like bailing out a leaking boat with a spoon: you can talk and talk, but more trauma keeps pouring in.’

Nick Harvey is a New Internationalist staff writer.

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