South Thailand’s battle against the trauma of conflict

Narathiwat, Thailand – Cholathee Charoenchol, a 51-year-old teacher at Tanjung primary school in Thailand’s southern Narathiwat province, waited patiently in his cafeteria on January 23, 2013. It was lunchtime, and the young pupils were slowly trickling in from class.

Between 30 to 40 children, including his six-year-old daughter, had already made their way to their tables when masked gunmen burst through the cafeteria doors. One of them walked up to Cholathee and shot him in the head at point-blank range.

Amid the ensuing screams, the gunmen fled, and the schoolchildren sprinted from the school grounds. Nearly every one of the school’s 290 children heard the gunshots; many were left severely traumatised.

In 2004, the simmering sectarian tensions in Thailand’s “deep south” – an area making up the three southernmost provinces of Yala, Pattani, Narathiwat and four districts of neighbouring Songkhla –  erupted into violence.

The majority of the Muslim, ethnic Malay population of Thailand’s deep south have long-held strained relations with the rest of their overwhelmingly Buddhist countrymen. More than 6,000 people have been killed over the past decade.

With the conflict now entering its 12th year, this latest round of ethnic and religious violence is forcing more than a million people to live out their lives under the spectre of car bombs, assassinations, heavy military presence and death.

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With over a decade of low-intensity but unceasing violence, psychologists say it is no longer the dead but the living who really concern them, with their invisible scars of trauma growing with every passing year, threatening the mental wellbeing of an entire generation.

“In Pattani now, they are no longer shocked. If there’s a bomb, people will just say, ‘OK, there was a bomb. How many dead? How many injured?’ That’s it,” says Dr Pechdau Tohmeena, director of the Regional Mental Health Centre in the Southern Provinces branch of Thailand.

For Dr Tohmeena, the desensitised facade to violence in the deep south is a typical, and completely acceptable, reaction to a setting of prolonged violence.

“Twelve years is a long time, and the general population have modified themselves just in order to stay [sane] in this situation,” she explains.

Trauma and depression

The focus for the mental health workers in the deep south has been on finding, documenting and helping the ever-expanding group of people most acutely affected by traumatic events, such as witnesses to violence, as well as those made orphans, widows as well as the physically disabled.

In the first decade of the conflict, an estimated 3,000 women were widowed, while 5,686 children were made orphans, according to the Ministry of Social Development and Human Security.

Addressing the stresses, anxieties and general mental conditions brought on by these tragedies is “of the utmost priority”, says Dr Tohmeena.

Off a major road just a few miles outside Pattani, 47-year-old Wan Chai pulls himself slowly from his bed and on to his wheelchair. In 2005, while out driving his car, he suddenly found himself under a hail of gunfire. He survived, but one of the bullets entered the right side of his chest and smashed into his spinal cord, forcing him to face a paraplegic future.

Soon after, his marriage fell apart and his wife moved away, taking their daughter with her. Wan was devastated.

“I always dream of seeing my daughter again,” he says.

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Nasruddin, a coordinator at the Pattani Medical Health Centre, explains Wan’s situation at the time: “He was very depressed afterwards … He was actually suicidal for a time.” 

With no work and no family, a high prevalence of depression among the newly physically disabled is very common, expalins Nasruddin. “For many, they don’t know what they are going through, so they suffer without any help,” he adds.

The stigma and general lack of understanding of mental health is, for Dr Tohmeena and others, a major obstacle facing psychiatric health workers in the deep south.

“There is still a stigma [attached] to mental health,” says Dr Hartinee, a psychologist at Bacho hospital in Narathiwat district.

“People think it is OK to cry only for a funeral; but we have to show them that after seeing a deadly attack or having a friend killed, it is totally normal to have trouble sleeping, to cry a lot, not be hungry or have nightmares,” Dr Hartinee explains. “Then they can come see us.”

The stigma of mental health 

Thailand is a country without a history of seeking out psychological treatment, says Dr Tohmeena. “Typically, a mental health problem is translated as ‘craziness’,” she says. But the doctor is keen to point out, however, that a lot of ground has been made over the past 12 years.

“Originally, we were very under-prepared,” she says. “In 2004, there was only one psychiatrist posted to cover Yala, Narathiwat and Pattani.”

In response to the dearth in personnel, Dr Tohmeena was relocated from Bangkok to her native Pattani by the director general of the Department of Mental Health in late 2004.

“I was tasked with building the first mental health office in the deep south,” she says. “Within four years, we had 74 trained psychologists posted around the region.”

After the murder of Chonlathee Charoencho at this school, Dr Hartinee, right, deployed swift and thorough mental-health support to the children, families and teachers [Amanda Mustard/Al Jazeera]

Even with the extra help, most psychiatric centres are still understaffed, forcing those involved into more resourceful methods of work.

Dr Hartinee considers her department one of the best examples of success despite limited manpower. She highlights efforts in training a network of people throughout their different community groups.

“We have security people, religious leaders, village elders, health volunteers and teachers. We tell them how to behave and what to look for in someone who may be suffering,” she says.

In turn, she explains, this network can then further spread a general awareness and understanding of mental health, while providing Dr Hartinee’s team some insight into where to go and whom to help.

Today, mental-health workers highlight their outreach programmes, mobile clinics, and network building as major reasons why they have some 70 percent coverage, according to Dr Tohmeena’s estimates.

For Dr Tohmeena, Dr Hartinee and their colleagues, to succeed in better helping these “at risk” groups, while changing the general understanding of mental health, would be to make significant inroads into mitigating a potential mental health disaster.

According to the Violence Related Mental Health Surveillance (VMS) database, which records mental health issues resulting from the ongoing violence, some 11,772 adults have exhibited mental-health issues since 2008, while nearly 1,200 children have been affected since 2010.

These numbers are actually thought to be conservative by Dr Tohmeena, who makes the point that the data excludes those who never make their plight known, as well as those unrecorded for any reason.

“You can imagine [the numbers] are much higher,” she adds.

Additionally, Dr Tohmeena notes that only 10 percent of the children orphaned are included in the VMS database, and thus, are not screened by mental health officers. She worries that PTSD – post traumatic stress disorder – which she already thinks is severely underreported in general, “is even worse for children”.

Grade 6 pupils at Tanjung School raise their hands when asked who was in the canteen and saw the murder of their teacher, Chonlathee Charoenchol, in 2013 [Amanda Mustard/Al Jazeera]

Long-term effects 

A little over three years after Cholathee’s death, Dr Hartinee returned to Tanjung school. She was part of the response team who came immediately after the murder to help screen every pupil from the school. In the first month, some 90 pupils were identified as suffering from some mental-health issues, but today, all is well, she says.

Dr Hartinee greets students from the doorway of the Grade 6 classroom. After a nod from the teacher, she steps in and asks the class with a smile: “Who remembers what happened in the cafeteria three years ago?”

What follows is a peculiarly open dialogue between Dr Hartinee and the class of 11-year-olds about the murder of Cholathee.

“Who was in the cafeteria?” she asks as a few hands are raised. “Who ran to the field?” A few hands drop. “Who jumped into the pond?” Laughter while a few children raise their hands. Eventually, one boy is pointed out as having actually been splattered with blood during the attack.

“And how do you feel about it today?” asks Dr Hartinee. 

“I’m fine,” responds the boy. “But I’m afraid of blood.”