DVB Multimedia Group

Lacking support, Burma’s mental health patients suffer in silence

Chit San, a former soldier and political prisoner who suffered from symptoms of depression, anxiety and post traumatic stress disorder (PTSD) after he was released. (Photo: Connor Macdonald / Myanmar Now)

In May 1989, as the military junta continued its brutal crackdown on those linked to the ’88 democratic uprising, Chit San, a former soldier, was arrested by Burma’s notorious Special Branch police. For the next five months he was held at a military barracks where he faced interrogations and torture.

His daily routine consisted of waiting in a tiny, dark cell for the inevitable beatings. “Usually it was midnight when the lights would turn on and they’d burst into my cell for an interrogation,” he said.

His daily meal consisted of a foul concoction of watery soup with rice and insects, and a cup of water. Later, he was moved to Rangoon’s Insein Prison where he spent six years of a life sentence in overcrowded and squalid conditions.

“I spent the whole time thinking I was never going to leave that place, but mainly I worried for my wife,” he recalled recently.

When Chit San was finally released through an amnesty in 1996 his struggle, however, was not over. Like many thousands of former political prisoners in Burma, he suffers from symptoms of depression, anxiety and post traumatic stress disorder (PTSD), which he developed as a result of the psychological and physical trauma he experienced at the hands of the former regime.

Another legacy of the regime, the country’s wrecked healthcare system, means that many of those suffering from psychological problems, whether from torture or other causes, cannot receive much-needed psychological treatment from government health care facilities.

Cultural stigmas and a lack of public understanding in Burma about common disorders, such as depression and anxiety, further worsens their plight. Many people choose to suffer in silence rather than face being labelled ayoo, or crazy.

A legacy of trauma

In the years after he was released, Chit San found it difficult to reintegrate into normal civilian life. “I had no job so it became a daily struggle just to find enough money to provide food for my family,” he said.

No longer wanting to associate with his political past, he cut all ties with his former friends. As the stress of life outside the prison walls built up he found himself becoming aggressive and losing his temper over the smallest things; sleepless nights became normal, he said.

These symptoms are common among people who have suffered intense psychological and physical trauma. Lifelong symptoms often also affect suffers’ relationships, employment and their behaviour. It is common to seek out high-risk situations as a coping mechanism, known as trauma repetition. Many turn to drugs and alcohol as a form self-medication.

“PTSD is the biological response to trauma” said Rory Magee, a psychotherapist who was involved in treating well-known political prisoner Gambira. The former monk-led protests in the so-called 2007 Saffron Revolution and spent over three years in five different prisons for his activism.

There, Gambira was subjected to repeated beatings as well as regular and “chemical torture,” which consisted of “the injection of unknown substances that induced both unbearable physical pain, as well as inducing terrifying psychotic states,” said Magee, who heads clinical services at The Cabin, a rehabilitation centre in Chiang Mai, Thailand, where Gambira received treatment for his mental health problems.

Like the many former political prisoners, Gambira suffers from Complex-PTSD, (C-PTSD),  a more severe form of PTSD that comes as a result of sustained physical, emotional and psychological trauma, such as time in prison or war, rather than a one-off traumatic experience.

“He was abused horrendously for a prolonged period of time,” said Magee,

“C-PTSD is far more difficult to treat.”

Sufferers often experience a range of symptoms that can be categorised under two extremes known as hyper and hypo-arousal. When suffering symptoms of these states, patients might have a faster heart beat, experience flashback nightmares and become easily startled.

Symptoms also include feelings of numbness and a patient disassociating themselves with the traumatic event.

“It’s recognisable when people get that ‘thousand-yard stare’ — they appear numb or blank. The nervous system goes into a freeze or numb state, it’s basically shutting down to avoid the pain of death,” said Magee.

Gambira was re-arrested for violating immigration rules in January after trying to return to Burma, where he is now in custody awaiting trial. Many think his arrest was politically motivated. He is now back in prison without support and medication; there are reports that his mental condition is worsening.

“Gambira was very adamant he’d go back, but he knew he’d be arrested. It’s almost like trauma repetition,” said Magee.

Lack of funding

Gambira received help in neighbouring Thailand where health expenditure as a percentage of GDP is more than double that of Burma’s — which stands at 1.8 percent — while Thailand has a vastly bigger GDP.

Little is known on how much is spent on mental health in Burma, according government health professionals, who could only refer to a ten-year old World Health Organisation report that says that 0.3 percent of the total health care budget is reserved for mental care.

With government care almost non-existent, non-profit organisations and overseas supporters have stepped in.

Programs like the Mental Health Assistance Program (MHAP), set up by the Thailand-based Assistance Association for Political Prisoners (AAPP), provide such support. Funded by John Hopkins university in the United States, MHAP uses a psychotherapy treatment method called Common Elements Treatment Approach, which is suited for low-resource settings like Burma.

Saw Thet Tun, chief clinical supervisor at AAPP and a former political prisoner, said since it began in 2013, MHAP has treated 967 clients, of whom 521 are former political prisoners, with the program extending to non-political prisoners in 2015. Currently, the program has 16 counselors in Rangoon, with each seeing five to six clients for at least three months of treatment.

This is not enough to meet demand, said Saw Thet Tun. “The people in this country suffered a lot under the military, five teams of counselors just isn’t enough. We can’t help all of those that need it so we train the community in basic understanding of our methods so they can provide support also.”

“Our country needs counseling but the government ignores it because they don’t understand how important it is,” he said, adding that the government has never offered support or interest to work with AAPP on its program, partly because some in the former government were responsible for past repression.

Overcrowded mental health hospitals

The few institutions that do provide mental health are severely overstretched, a situation that is painfully clear at Yangon Mental Health Hospital, one of Burma’s largest mental health care facilities.

Cracked paint comes off the walls of the hospital and its wards are seriously overcrowded and understaffed: just 25 doctors care for the hospital’s 1,500 patients, in a facility that was only intended to house 900.

With such a low doctor-to-patient ratio, doctors often can only treat patients with medication, rather than engage in more time-consuming psychotherapy, said Dr. Tin Oo, head professor at Yangon Mental Health Hospital.

“Around 500 patients would be ideal for our needs. We need more human capacity, we either need to expand the number of doctors or reduce the number of patients, our doctors don’t have enough time to care for the patients,” he said.

Battling stigma through public education

The neglect of the mental health sector by policy makers reflects a wider lack of public awareness on mental health issues in Burma. The stigma of being labeled ayoo stops many people from seeking the help they need, even for common disorders.

“People who suffer these illnesses are seen to be excluded from society so no one wants to be labeled as ayoo, they don’t even want to be seen to be going to a psychiatrist,” said Dr. Myint Oo, an outspoken advocate of medical ethics in Burma. “We need to lift the health literacy of the people in this country; people need to realise that everyone can suffer these issues in their life.”

In a recent pilot study conducted by Dr. Myint Oo and DIGNITY (the Danish Institute Against Torture), the general health, including mental health, of 330 former political prisoners was monitored over a year-long period.

When results showed only 1 percent of participants said they experienced signs of PTSD — well below the global average of 25 percent — Dr. San San Oo, a psychiatrist involved in the study suspected patients were hiding their pain.

She conducted a more in-depth study of a smaller number of former political prisoners and found about 50 percent suffered from PTSD symptoms.

“They didn’t want to be seen as disordered. They realised a high score meant they were disordered so they made sure they achieved a lower score,” she said. “These people were the country’s heroes, so they don’t want to show any weakness but in fact they were suffering.”

Chit San said that only when a friend who is a relative of an AAPP counselor suggested he try their programme, he considered getting help for his symptoms.

After explaining the programme to his wife and son, who were unaware of such counseling, they agreed to attend sessions included in his treatment. He has now completed a six-month course of counseling and says he has made significant progress in dealing with the effects of his trauma.

“This type of programme is very unusual for this country, but the counseling lets me cope in daily life and helps my family cope as well,” Chit San said, adding that he hoped Burma’s mental health services could be expanded to help former prisoners like him.

(Additional reporting by Phyo Thiha Cho; editing by Paul Vrieze)

This article originally appeared on Myanmar Now and is reprinted here with permission.