A Stick in the Heart

Tin Tun rides his motorbike through the Thai border town of Mae Sot.

He cruises past rice fields on the outskirts until he reaches the warehouse of a corn-processing plant. A wiry man with a broad forehead and receding black hair, he ducks into a passageway that leads to an encampment for Burmese migrant workers.

Tin Tun must travel here each week to counsel Yi Yi (not her real name) because she is afraid to leave the workers’ compound. Like other undocumented Burmese, Yi Yi fears the Thai police, who often demand bribes to ignore migrants who lack the proper papers.

Tin Tun’s counseling session is part of a study by the Bloomberg School’s Applied Mental Health Research (AMHR) group. Its aim: to test whether lay counselors with brief training and close supervision can provide effective therapy to people within their communities who have suffered from trauma or violence.

For Yi Yi and the roughly 2 million other Burmese who have crossed into Thailand, harrowing stories are commonplace. Since 2011, a quasi-civilian government in Burma (also known as Myanmar) has eased repression. However, these reforms follow on nearly 50 years of military rule that gutted the economy, outlawed dissent and waged war on ethnic groups seeking self-determination. The junta packed the prisons with dissidents.

The army burned thousands of villages, destroyed crops and forced people to do dangerous work without pay; Tin Tun’s colleague Mya Mya Win, for example, counseled a woman whose brother died doing forced labor.

Tin Tun himself has faced prolonged hardship. He was arrested for political activities the day after his daughter’s birth. Torturers deafened his right ear and scarred his body.

When the regime released him in 2009, his baby daughter was 19 years old.

“Can we make therapeutic interventions that work? Can we train people who don’t have a mental health background to provide them?” —Paul Bolton

Today, it is Yi Yi’s suffering that he will address. Tin Tun walks down the trash-strewn lane between two rows of houses pieced together from bamboo, corrugated zinc, plastic sheeting and empty rice sacks. Yi Yi emerges into the glare to greet Tin Tun. She is 45, has short black hair and dresses in stylish capris. Tin Tun kicks off his flip-flops and stoops to follow her into the wobbly 8-by-10-foot shack with a roof made of leaves. He sits cross-legged on a woven mat facing Yi Yi, and they begin to talk.

The purpose of therapy with Yi Yi and others is to help them recognize the connections between thoughts, feelings and behavior and to use this understanding to feel better. In eight to 12 sessions, Tin Tun and 16 other counselors teach their clients to notice negative or self-defeating thoughts and behaviors and then to reconsider them. The counselors guide clients in moderating their intense emotional and physical reactions to memories of trauma.

More is at stake than the clients’ psychological distress: depression and anxiety can lead to physical illness, risky behavior, fractured relationships, injuries, lost wages, even suicide.

Today Yi Yi talks to Tin Tun about her divorce. She thought it was all her fault, but Tin Tun has helped her see that her husband’s drug addiction played a role. When Yi Yi began therapy, she recalls, “I felt so hopeless. I had no future.” These days, she says, “I have many goals.” Each day, she and her new husband manage to spend only $1.50 of the $5 to $7 he earns loading trucks. “When we go back to Burma, we can open our own rice shop in Yangon,” she says.

Another of Tin Tun’s clients was a young man who was furious with his father for the political activism in Burma that landed him in jail. The son felt abandoned. Tin Tun says he helped his client to recognize that the father had been attentive before his imprisonment, and that after his release, the father had helped his son to find work in Thailand. At the start of therapy, the young man “felt as if a stick was stuck in his heart,” says Tin Tun. “Now he feels he can take out the stick.”

Tin Tun’s own children refuse to see him because they resent his absence while in prison. To avoid obsessing over his grief, Tin Tun applies to himself the coping skills he teaches to his clients. He redirects his thoughts and seeks positive interpretations for events.

Tin Tun’s supervisor, Kyaw Soe Win, and his colleagues learned a structured method of counseling from assistant scientist Laura Murray, PhD. She and two colleagues spent two weeks in Mae Sot in early 2011 training the counselors, mostly high school or college graduates.

Research is scarce regarding the mental health of Burmese in Thailand, but two studies, one of ethnic refugees and one of exiled dissidents, both found that four in 10 were depressed. Among the dissidents, one in four had PTSD. The Thai health care system provides little in the way of counseling, and Burmese without papers generally don’t feel safe going to a government clinic.

The project in Thailand is one of eight linked studies in Asia and Africa under AMHR’s aegis. The research, supported by the USAID Victims of Torture Fund, tests strategies for using local counselors to help people with problems such as anxiety or depression stemming from extreme poverty, trauma or systematic violence. Other study sites are in Zambia, the Democratic Republic of Congo and Iraq.

In all eight studies, “the principle is always the same,” says International Health associate scientist Paul Bolton, MBBS, MPH ’93, MSc, the group’s leader. “Can we make therapeutic interventions that work? Can we train people who don’t have a mental health background to provide them?” The unmet need is stark: a 2011 Lancet commentary reported that more than 75 percent of people with neuropsychiatric problems in poor countries get no treatment. To help fill that gap effectively, says Bolton, researchers must first test interventions through randomized studies like these.

So far, he says, results in all sites show that most people in the communities accept counseling and that “task-shifting” works: that is, paraprofessionals like Tin Tun can learn to conduct it correctly. But do the therapies help the clients themselves? Bolton says it’s too early to judge.

The Thailand study, led by International Health assistant professor Courtland Robinson, PhD ’04, and doctoral student Catherine Lee, took unexpectedly long to enroll 154 clients and 131 controls (who can get free counseling after waiting 10 weeks). Counseling for people without severe psychiatric illness is virtually unknown in Burma. As Kyaw Soe Win explains, “Most people think counseling is for people who are crazy. I finally got the idea of telling the community, ‘If you were crazy, we couldn’t give any counseling to you.’ ”

Ultimately, he and several other counselors want to return home and provide therapy in Burma if the recent reforms prove to be genuine and lasting. “Many prisoners have been released, and they have been tortured,” says Mya Mya Win. “I want to counsel them.” Among the ex-prisoners are two of her own sisters.

Meanwhile, Kyaw Soe Win says he will look for money to keep counselors working in Mae Sot after the Hopkins study closes at year’s end. “I’d like to do this for the migrant community,” he says. “They have faced so much suffering.”