Mental health as public health in Thailand
When I arrived in Thailand in the 1990s and told people I worked in psychology, I was often asked the same questions a fortune teller would be asked. Today, both knowledge and acceptance of psychology have evolved significantly. As a teacher, I greatly appreciate these advances and the increasing acceptance of psychology, yet there is still a lot of work to be done to improve mental health in the Kingdom.
The history of mental health in Thailand is rooted in traditional beliefs and the association of mental illness with supernatural forces, such as karmic repercussions for sins committed in past lives; thus, most treatments were reliant on Buddhism, and this reliance on supernatural explanations for those struggling with their mental health continues today. King Rama V established the first mental institution in 1889, and psychology was officially recognised in 1930. The first generation of Thai psychologists primarily worked with children. The first bachelor’s degree program in psychology with a clinical track was introduced at Chiang Mai University in 1964. In Bangkok, Mahidol University offered the first master’s degree program in clinical psychology in 1979.
Since then, psychology has experienced a boom. But, as with most growing industries, there are issues with growth management and conflicting groups vying for market share or access to government coffers. In this article, I would like to discuss some of the factors impeding the development of clinical psychology in Thailand today and offer some potential solutions for consideration.
Thailand’s mental health challenges
Let’s start with the idea of mental health. While some readers may recognise the prevalence of mental health issues, many societies still struggle with accepting the existence of mental illness and its impact on the afflicted. Mental health literacy, defined as knowledge and beliefs about mental disorders that aid in their recognition, management, and prevention, can help combat social and personal stigmas associated with psychology and increase treatment-seeking behaviour among the afflicted. Studies show that higher levels of mental health literacy correlate with lower rates of mental health stigmas, which are more prevalent in Asia. In Thailand, where a historically supernatural or spiritual approach has dominated mental health care, there is an increasing number of holistic healing centres accessible to the general public that do not carry the stigma associated with traditional psychotherapies. The acceptance of the supernatural also explains why Thais—older people in particular—prefer to see monks, fortune tellers, palm readers, face readers, tarot cards or birthday number analysis experts.
Efforts to increase mental health literacy have been made, yet challenges remain. These challenges include the aforementioned cultural stigmas, a historical preference for spiritual or supernatural remedies, misconceptions about mental illness, and limited access to mental healthcare resources for the elderly. Therefore, there is a need for more significant investment in education as well as clear and accessible clinical licensing procedures. Reforming the licensing process should also involve the inclusion of mental health treatment in the state universal healthcare system. By doing so, Thailand will be better positioned to ensure access to therapeutic intervention for those in need.
A look at the numbers
The COVID-19 pandemic has clearly exacerbated mental health concerns. The number of people in Thailand suffering from mental health-related problems rose from 1.3 million in 2015 to 2.3 million in 2021. Unsurprisingly, the number of suicides is also increasing. A multi-country survey conducted during the height of the pandemic indicated that 21% of Thai respondents reported mild to extreme depression, 22% reported significant anxiety, and 15% reported stress-related issues. Other disorders, such as alcoholism and psychoactive substance abuse, are also rising. It is important to note that stress, anxiety, and depression are common psychological reactions to the COVID-19 outbreak, and the prevalence of such distress should decrease as Thailand slowly normalises. However, the pandemic notwithstanding, the trend over the last 20 years is evident and the growing prevalence of psychological disorders is alarming.
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As Thailand experiences a rapidly ageing demographic profile, a particular challenge is the steadily rising incidence of stress and anxiety among the elderly population. This data is supported by hospital-based reports, which indicate an increasing burden of stress and anxiety among older adults. Recent studies have also shown that the likelihood of experiencing stress increases with age, particularly in ageing populations. Furthermore, secondary data from rural Thailand suggests that a significant proportion of the elderly suffers from mental health disorders, including mood disorders associated with loneliness and social isolation. Research has identified several factors contributing to stress among the ageing population, including family relationships, financial status, social and community environments, physical health, and chronic illnesses.
Where do those that are suffering get help? Herein lies an additional problem. In 2001, it was estimated that approximately 400 clinical psychologists were practising in Thailand, whereas today, there are 1,037 psychologists, which amounts to about 1.57 psychologists per 100,000 people. The uneven geographical distribution of psychologists is also a problem. With most psychologists in Bangkok, elderly patients often have to travel long distances, which isn’t always practical. This Bangkok bias also means that psychologists in rural areas often suffer from the heaviest workload. Even more disturbing is that six provinces have no psychologists at all, while some provinces have a ratio of one psychologist for every 52,717 people. The shortage of psychiatrists is even more severe, with only 845 across Thailand, or 1.28 per 100,000 people. The increasing prevalence of disorders and the dangerous ratios of professionals to patients highlights the need for mental health care reform.
The institutional problems
So far, we’ve addressed the history of psychology in Thailand, the current state of mental health and the lack of clinical psychologists. Now, let’s look at the causes that have contributed to the situation we find ourselves in. There are several reasons for the shortage of clinical psychologists in Thailand. Firstly, while mental health literacy has significantly improved in recent years, psychology, as a profession, has yet to be widely recognised or understood among the general public.
This lack of recognition is partially due to the bureaucratic administration of psychologists. For example, three prominent organisations are involved in the field in Thailand. The Thai Psychological Association (TPA) was founded in 1961 to promote psychology education and research, coordinate knowledge exchanges, and control the quality of psychology-related works. The Thai Clinical Psychologist Association (TCPA) was established in 1969 to enhance clinical experiences among members, standardise practice, create research and psychometrics, and disseminate results to the public. The TCPA is also responsible for overseeing the progression of the clinical psychology profession and disciplinary actions. The third organisation is the Thai Counseling Psychology Association, also known as TCPA, which was officially registered in 2018, and aims to improve mental well-being and Thai wellness. However, the Thai Clinical Psychologist Association (the first TCPA, not the second TCPA) is Thailand’s only licensed professional psychology association.
Secondly, the postgraduate education and training opportunities for psychologists in Thailand are limited. The need for practising clinical psychologists also means a need for more role models and mentors to guide and support aspiring psychologists. Additionally, there is a quality (TCPA licensure) vs quantity (all other practitioners) discussion among the licensed and unlicensed that is causing division among mental health care workers. The dearth of licensed clinical psychologists in Thailand is also attributed to the limited number of licensure internship placements and the high competition for these placements. Psychology students must graduate before applying for the required licensure internship program, which lasts six months and includes one month of core courses and five months of practical training.
The competition for internship placements is fierce, and some potential interns postpone their training for another year unless they receive their desired institution. There is also significant financial concerns as psychology students must pay for their internship program, and related living expenses and cannot work elsewhere during the program, leading to additional financial burdens particularly when these students are assigned placements which are geographically inconvenient.
Another unexpected obstacle to licensure is the Thai language requirements, as many prospective interns need help with the language sections of the exam. The need for language assistance is the by-product of undergraduate and graduate-level educational materials that are often in English. Most textbooks are in English, students learn from academic journals that are often in English, the most updated scientific literature is first published in English—and the natural consequence is that many candidates are de facto educated in English.
The aforementioned constraints have all contributed to the fact that relatively few psychology students in Thailand become licensed clinical psychologists. Yet, the licensure track is the only option for professionals who wish to work in government hospitals, military, judiciary, and state agencies. As a result, the abundance of unlicensed practitioners must refer to themselves as psychologists, counsellors, therapists, coaches, wellness facilitators or mentors but not as clinical psychologists, which is the legally protected title. This situation also creates an undercurrent of division among licensed and unlicensed practitioners. More importantly, it creates problems for the increasing number of Thais seeking mental health treatment and trying to discern who is a clinical psychologist and whether these psychologists are any better than counsellors, therapists, fortune tellers or monks. It is unfortunate that the unintended impact of the requirements for TCPA clinical licensure means that mental health services are often provided by the unlicensed, untrained, and potentially unqualified.
This shortage of clinical psychologists also has broader societal consequences, such as negative economic impacts, an increased healthcare system burden, and a mental health treatment gap, mainly affecting marginalised populations such as children and adolescents, refugees, and the elderly. The shortage of mental health professionals is not just a problem in Thailand: the shortage of professionals is a significant problem in most low and middle-income countries, and the UN has taken notice.
A shortage of psychologists affects a nation’s ability to progress towards the United Nations Sustainable Development Goals of improving health and wellbeing by reducing premature mortality from non-communicable diseases, including mental health-related diseases and disorders. The World Health Organization’s Comprehensive Mental Health Action Plan for 2013–2030 emphasises a multi-sectoral approach to address social determinants of mental health and ensure a comprehensive and holistic approach. This mainstreaming of mental health also involves moving away from institutional care to community care and adopting a comprehensive approach to treatment that includes medication, psychotherapy, and other mental health treatments.
Ideally, every nation will achieve the SDGs yet pragmatically, we need to address the problems each nation faces with country specific solutions. So, in the case of Thailand, we know there is a problem, and we know some of the reasons for the confusion surrounding the responsible provisioning of resources to address this problem. What can be done to improve mental health systems in Thailand?
To address the shortage of mental health workers in Thailand, an integration-based community care approach could be adopted, and the Ministry of Health should recognise the mental health related problems publicly. In addition, the Ministry of Public Health should allocate a significant portion of its budget to mental health treatment and services, allowing people access to talk therapy and medication via the national universal healthcare system. Increasing the mental health budget would also demonstrate the Ministry’s understanding of, and agreement with, the notion that mental health is a public health concern. Investing in mental health systems and services is crucial to reducing unmet needs, particularly the needs of the elderly. Globally, only a small portion of the government expenditure on most national health budgets is dedicated to mental health, creating a significant disparity between the high burden of mental disorders and the financial resources allocated to mental health.
The 2020 WHO Mental Health Atlas indicates that globally, only 2.1% of total government expenditure on health is dedicated to mental health. In Thailand, it is less than this. The WHO also emphasises that more than simply increasing mental health knowledge, societal understanding and mental health literacy is needed for effective reform. Adequate financing is necessary to implement mental health policies. This financing should include allocating funds for administration and governance, building infrastructure, and training the workforce. To achieve adequate financing, policymakers must allocate more funds for mental health by obtaining resources from the state and external sources or redistributing resources from other government budgets. Thailand can enhance the effectiveness and fairness of existing resources by reducing institutionalisation and addressing resource misuse. This mobilisation and the additional funding is crucial for meeting the public’s mental health needs.
Another potential solution to address the shortage of mental health professionals in Thailand requires more significant investment in educating new psychologists in various subfields, such as geriatric psychology. The Ministry of Public Health currently funds public hospitals nationwide to train new psychiatrists to work at hospitals. These general practitioners are offered positions, with speciality duration varying between 1 to 3 years, depending on their field. Notably, GPs preparing for careers in psychiatry get paid during internships, which continues into the residency program.
It is now necessary for the Department of Mental Health via the Ministry of Public Health to invest in training and specialisation for psychologists offering similar financial support for education and internship access as is provided for psychiatrists. Without equality of investment in training, these departments indirectly reinforce the perceived professional hierarchy of mental health care workers and potentially prioritise psychopharmacology over psychosocial support. Just as medical doctors receive scholarships and are required to complete a set number of years of service at government hospitals, potential psychologists should have the same opportunity. This investment could also lessen the urban vs rural discrepancies—aka the “Bangkok bias”—in available mental health care.
The demographic shift towards an ageing population will continue to significantly impact many governments’ financial resources, particularly regarding growing welfare budgets. Currently, the government services targeting elderly mental health are insufficient to meet the needs of an ageing society. More must be done to address this issue. Thailand will need help with a decreasing workforce and fewer taxpayers. To address the economic challenges an ageing population poses, the government must explore ways to improve transparency of expenditures and increase revenue through legal mechanisms such as restructuring the tax system to include property taxes and improving the tax collection system. Furthermore, Thailand would benefit from focusing on economic revitalisation, investing in innovative technologies and promoting value-added products and services which support mental health.
While Thailand has made some progress in improving mental health, there is still a significant gap in providing adequate access to psychological resources for those in need. These include establishing specialised mental health care services within existing community health systems, collaborating with various organisations, and allocating a significant portion of the public health budget towards expanding psychology-based services and education. These solutions are not a magic bullet, and mental health problems will continue to exist in Thailand, but it’s time we recognise the state’s role in providing mental healthcare.