Pinky Project Research Aug 2014

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ATTITUDES OF FAMILY CARERS TOWARD MEDICAL TREATMENT,COUNSELING,
AND WORK FOR PEOPLE WITH MENTAL ILLNESSES IN RURAL THAILANDChoose a
building block.
PinkaewSaowichit
An Independent StudySubmitted in Partial Fulfillment
of the Requirements for the Degree of
MASTER OF ARTS IN INDIVIDUAL AND FAMILY STUDIES
Graduate School of Psychology
ASSUMPTION UNIVERSITY
Thailand
2014

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Copyright by
ASSUMPTIONUNIVERSITY OF THAILAND
2014

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ABSTRACT
There is a large treatment gap for the seriously mental ill in Thailand and this gap is
particularly acute in rural Thailand. Because of this gap, the burden of caring for the
chronically mentally ill in Thailand falls primarily on their families. The current independent
study project examined the experiences and attitudes of the family carers of people with
serious mental illnesses in rural Thailand. Specifically, the study examined carers‟ attitudes
toward medical treatment systems, toward counseling and toward employment. This study
utilized a phenomenological qualitative research design. Data were collected in one-on-one,
in-depth interviews with five family carers of people with mental illnesses. The participants
were all family carers of people diagnosed with a chronic mental illness who were interviewed
in their homes in Thungsaliam district of Sukhothai province in Thailand. The most
prominent common theme was participants‟ deeply felt responsibility to take care of their ill
family member, which has imposed great hardship on the family. The participants are both
concerned and frustrated by their care recipients. The carers reported receiving financial and
social support from family members and close relatives, but hardly any from the government.
All shared the experience that there are no specialized care units for people with mental
illnesses in their areas; none of them have ever received any form of mental health education,
counseling, or rehabilitation due to total absence of such facilities. All of our participants
support their care recipients in receiving treatment and would support participation in
specialized treatment if it were available. All of the carers admitted that their care recipient
does not currently work and confided theirhope/expectation that the care recipient could be
able to work again someday.

ACKNOWLEDGEMENTS
First, I want to thank four women who were great examples for me supported me fully in
my life and my education. My grandmother who raised me was a great woman who was faithful to
her beliefs. She inspired me and continues to inspire me every day. She has been and will always
be a great role model for me. My mother who gave me life and always supported and stood beside
me. Sister Marisa Silueng, my good friend who supported my education until I graduated with
my bachelor‟s degree. Sister Glenda Hill, a senior return missionary who always supported all my
projects. She is a sponsor for my academic graduate program.
Second, I would like to acknowledge and thank the many people who have encouraged
and supported me along the way. Art Saowichit, my loving son who is always there for me. Judy
Caldwell, who helped edit my English. The Bangkok Thailand Mission President of The Church
of Jesus Christ of Latter Day Saints and his senior missionaries who support the work of Liamsiri
Mar Hill.Robert Bus the first editor and Dr. Maria Bella C Bamforth the final editor of this thesis.
Dr. SomrakChuvanichwong, founder of the volunteer team at Thai family link association who
supported me during my volunteer work with them. Thank you to the Dean, Dr.
SuwattanaEamoraphan, Dr. Jon Blauw, Dr. Natalie Chantagul and especially my project advisor
Dr. Ben Weinstein. They make me feel pleased and happy while I am studying here.
Finally, I want to acknowledge and express gratitude to Col. Charat Lima-roon President of
Sansamphan Association, SuanprungHosptialand President of Kaew –Arun foundation; Mr.
MualSupasay and Mr. PongthornAuethaweesamphant; the committee of Liamsiri Mar Hill
Association. All of those involved have helped me to live a worthwhile life and achieve my goal:
advocating for education and rehabilitation services for the mentally ill. Your support has filled
me with happiness as I work and I am grateful for my experiences with all of you.
P.S.
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TABLE OF CONTENTS
Contents Page
Title Page i
Copy Right ii
Approval Page iii
Abstract iv
Acknowledgements v
Table of Contents vi
List of Tables vii
Chapter I. Introduction 1
Background of the Study 1
Statement of the Problem 4
Purpose of the Study 23
Significance of the Study 24
Definition of Terms 27
Conceptual Framework 30
Chapter II. Literature Review 31

Caregiver Experiences 31
Stigma and Discrimination 35
Attitudes of Carers 37
Research Objectives 52
Chapter III. Research Methodology 53
Research Design 53
Participants of the Study 53
Research Instrumentation 55
Data Collection Procedure 56
Data Analysis 57
Chapter IV.Discussion 58
Summary of Results 58
Discussion of the Results 73
Limitations of the Study 79
Avenues for Future Research 80
References 82
Appendices 94

Appendix A. Participant Information Sheet (Thai) 94
Appendix B. Informed Consent Form (English) 98
Appendix C. Sample Recruitment Participant Information (Thai) 100
Appendix D. Interview Questions (English and Thai) 103
Appendix E. Transcript of Cases (English) 108

List of Tables
TABLE Page No
Table1. Responses to Item 1.1 58
Table 5. Responses to Item 1.5 60
Table 7 Responses to Item 1.7 61

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CHAPTER I
Introduction
Background of the Study
People with mental health problems including depression, bipolar disorder, and
schizophrenia need access to quality healthcare that is timely, affordable, appropriate, and fits
with the behavioral health treatments and services they may already receive. Research shows
that the proportion of the population with psychiatricillness will increase, especially in
developing countries, unless proper treatment is widely available (WHO, 2007).
Unfortunately, proper treatment will not be widely available very soon as there is still
the „mental health gap‟ or treatment gap – the percentage of people with mental disorders who
go without treatment because treatment resources are not available. This lack of mental health
treatment in developing countries may even increase up to 80-90% (WHO, 2007, p.5). The
mental health gap problems will not clear up quickly; it will take a lot of time and effort to
close this gap, unless the government invests more in treatment of mental health problems.
According to Rosenberg (2010), “currently, many people served by mental health and
substance abuse treatment systems are not able to access primary care in the usual setting due
to coverage issues, stigma, and the difficulty of fitting into the fast-pacedvisit model of
primary care” (p. 4). These problems stem from many reasons such as people with mental
illness and, possibly, family members who are also their care takersmay nottruly understand
the nature and treatment of mental illnesses, and are afraid of the social stigma attached to the
illness. This makes the affected individuals unwilling to seek treatment and, instead, ignore
the illness. Not surprisingly, this can prolong the mental illnessuntil it stays with them for

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life.This causes problems for many concerned parties, considering the healthcareexpenses and
lost productivityresulting from lack of treatment.This situation is not strictly Western-based; it
is reflected across many countries, including Thailand.
Due to the stresses of modern society, including the challenges of poverty, illicit drugs,
and other social problems, a significant number of Thai people experience mental health
problems. A 2008 nationwide survey estimated that roughly one in five in the general Thai
population was at risk for mental health problems. Mental health problems will probably
increase among Thai people and cause economic, employment, and financial hardships for
families and communities alikebecause Thai society has very limited mental health
resources(as cited in Chamratrithirong et al., 2010).
The Singapore Psychiatric Association reported thatThailand has only 502 registered
psychiatrists for a national population of more than 60 million (0.8 per 100,000 inhabitants),
compared to the 5,000 registered psychiatrists in Singapore, with a population of 4,939,000
(or 101 per 100,000 inhabitants) (SPA, 2006). The treatment gap in Thailand is relatively
large, compared to neighboring countries. More specifically, Thailand has 0.8 psychiatrists
and 2.7 psychiatric nurses per 100,000 people. By way of comparison, there are 2.06
psychiatrists and 6 psychiatric nurses per 100,000 people in the Philippines. In the same vein,
there are 1.2 psychiatrists and 7.5 psychiatric nurses per 100,000 peoplein South Africa (Jacob
et al., 2007). It is easy to see that Thailand has comparatively few mental health professionals,
compared to the Philippines and South Africa – countries that are deemed to be low-income
countries but can provide better treatment and better services to their mentally illpopulation
than Thailand.Thus, Thai people with mental illnesses who want treatment have nowhere to
go.

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A Thai-based study which utilized interviews with practitioners and clients in
Bangkoknoted that a typical mentalhealth outpatient visit in a public hospital might only last a
few minutes and result in a quick diagnosis and prescription (Ojanen, 2010). The primary role
of both psychiatrists and psychologists in the public sector includes provision of knowledge,
attitude modeling, family education,and interventions toward effective mental health
treatment;thus, if fewer psychologists and psychiatrists are giving effective primary care
services, it follows that fewer people will return to good mental health. With an increasing
proportion of people with mental health disorders, the treatment gap may get larger for
Thailand.
The current researcherhas observed, however, that the enormous treatment gap of
resources in Thailand is filled largely by family caregivers who are, usually,family members
who play the role of primary caregiver for people with mental illnesses (hereafter referred to
as „carers‟). Solomon (1966,as cited in Radcliffe, Adeshokan, Thompson, &Bakowski, 2012)
pointed out that family members around the world play a central role in caring for individuals
with major psychiatric disorders and should be natural allies to professionals.While
carers/caregivers may not reach mental healthcare standards because of current social and
mental health services problems in Thailand, their opinions can help mental health
professionals and governments improve their services.
Meebunmak (2009) asserted that the attitudes of carers toward people with mental
illnesses can influence how policy makers allocate public resources to mental health service.
He suggested that if family carers are dissatisfied with the services provided by mental
healthcare professionals, their complaints will create an atmosphere of non-cooperation

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between themselves and the service providers, leading to a decrease in the quality of services
provided.
In a study that examined community mental health care in Thailand, Meebunmak
(2009) warned that, should service providers show reluctance in rendering quality services,
people with mental illnesses as well as their carers would most likely discontinue services at
that place. It can be inferred from this scenario that complaints about government mental
health care services can either help the government improve their services or damage their
reputation because of inadequate services which might lead to discontinuation of essential
care.
Statement of the Problem
Mental illness not only affectsthe afflicted person but also the carer, the family, and
the surrounding community. Within the context of caring for the mentally ill, caregiving
suggestsa relationship between two adult individuals who are typically related through
kinship. One of them, the carer, assumes a generally unpaid and unanticipated responsibility
for another, the care recipient, whose mental health problems are disabling and long-term in
nature, with no curative treatment available (Gubman&Tessler, 1987; Gallop, McKeever,
Mohide, & Wells, 1991).
Thailand has many complex problems relative to mental health and psychiatry,
according to Udomratana (2004) who reported on the country‟s mental health situation during
the period 2002-2003. The author identified current and emerging concerns within Thai
society, namely:growing elderly population, high number of poor and/or disabled individuals,

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unfavorable changes in family makeup or lifestyle, higher divorce rate, and increase in the
number of those who consume alcohol. All of these problems help create or aggravate mental
illness and are added stressors to caregivers. It was recommended that the Thai government
should treat this urgent issue and take immediate action before the problem overwhelms
Thailand and becomes even more complex to solve.The author also listed other factors that
help to explain the increase in mental health concerns in Thailand in the recent past. For
example, there are not enough mental health professionals such as psychiatrists, psychologists,
psychiatric nurses, and social workers. If these professionals do not increase in numbers, there
will be an increasingly negative impact on the quality of mental healthcare services provided
in Thailand. Paradoxically, this may lead to greater challenges in meeting the needs of persons
with mental illness by the very healthcare services instituted to treat them. (Udomratana,
2004).
People with chronic mental illnesses require ongoing treatment, usually called
rehabilitation. There is no proper rehabilitation system for people with chronic mental illness
in Thailand; in her work as a community advocate, the researcher has seen that not only does
the Thai government not provide enough support for mental healthcare services and
practitioners, but it also neglects caregivers. Therefore, caregivers, people with mental
illnesses, and mental health professionals have no recourse but to face these problems by
themselves, with no clear indication of assistance from the authorities. According to the World
Health Organization (WHO, 2007), Thailand has only 122 mental health outpatient facilities
which are under the auspices of the Public Health Ministry, located in mental hospitals and
general hospitals. Eleven percent of these facilities are for children and adolescents only. The
researcher believes that this shows that the Thai government does not provide enough long-

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term care programs and facilities for people with mental illnesses. In her opinions, this lack of
proper resources could be considered a form of discrimination against those who require more
care than short outpatient visits. This neglect of proper care contributes to other social
problems such as patient isolation, public ignorance,lack of understanding of the problem, and
greater stress on the community and its services.
As in the case of other developing countries, Thailand has a shortage of mental health
professionals, particularly psychiatrists. Thailand is a lower-middle-income country based on
World Bank criteria, with a population of 68,229,000 people in 2013, 65% of whom reside in
rural areas. It has a geographical area of about 514,000 sq. km. There are 76 provinces, 795
districts, 7,255 „tambons‟ (local government units), and 68,881 villages. In 2000, there were
180,252 practicing medical doctors in Thailand.
In 2004, there were only seven psychiatrists per million inhabitants and 55% of them
were concentrated in Bangkok. There are no psychiatrists available in a number of provincial
general hospitals (WHO, 2006). Moreover, there were 10 university hospitals and 17 (both
public and private) hospitals for the mentally ill. Outpatient clinic visits were 1,432.5 per
100,000 of the general population in 2006 (WHO, 2007).
The point of the current project is to suggest and provide data supporting the argument
that these numbers suggest insufficient mental health services across Thailand and particularly
in rural Thailand. The current researcher posits that the Thai government should create and
implement interventionsaimed at encouraging students to study in the mental healthcare
services field, train and employ themwhere they fit best, and offer them an attractive
compensation package to keep labor turnover at bay and help them stay in their careers.

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Mental illnesses are like physical illnesses; that is, affected individuals require long-
term care and ongoing treatment.“Across Europe, much effort has been made over recent
decades to overcome these barriers and to ensurehigh-quality longer-term care for people with
severe mental disorders” (European Union, 2011).In Thailand, reportedly, there are no day
care/treatment facilities for mentally ill people, except for facilities specifically for children
with mental retardation or for people being treated for substance abuse, as reported by the
WHO (2007). The Thai government needs to broaden and extend its mental healthcare
services to include people with psychiatric problems. It is important and necessary to have day
treatment facilities for them in each district to allow them opportunities to meet others with
similar problems. Social/group therapy, work therapy, or self-help groups can help people
with mental health problems gain self-confidence and sympathy while adjusting socially
among people with the sameor similarissues. They can share their problems, feelings, and
experiences with those who can empathize and best understand their situation and affliction.
Such opportunities also initiate positive attitudes toward treatment of mental illness as well as
dispel the social stigma attached to the condition. The government would be well-advised to
provide sufficient funds to build rehabilitation centers for people who have not fully recovered
from their mental illness and ensure that the services are available, accessible, and affordable.
In addition to the lack of rehabilitation services, there is a lack of continuing care (e.g.,
facilities to support patients being discharged from the hospital). Currently, there is still a
scarcity of facilities to receive patients who have beendischarged from psychiatric
hospitals/centers. The government‟s emergency measure has been to establish halfway houses
sponsored by the Ministry of Social Welfare and Human Security (MSWHS) which provide
temporary shelterfor those who are homeless after being released from a mental hospital. The

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World Health Organization (WHO, 2007) recommends thatthe MSWHS should join forces
with the Ministry of Public Health in providingsuitable services that could help oversee
mental health service facility systems effectively.The current researcher visited a halfway
house for people with mental illnesses severalyears ago in Pratumthani province, Thailand. It
was this researcher‟s observation, then, that the halfway house did not meet health and safety
standards.For example,the residents did not have beds; they slept on unkempt and malodorous
mattresses on the floor and, worse, there werenopsychiatrists and other healthcare
practitioners.
There are some non-governmental resources in communities, such as local NGOs, but
these are very few. For example, a few Buddhist temples support people with mental health
problems but this is not a system. There is no regular funding support from the Thai
government and not enough professional mental healthcare workers to regularly visit and
monitor them. In these cases, there is no verification about the quality of care (WHO, 2007).
Even if there were a lot more, they are not a substitute for proper treatment.
The following true story is typical ofthe treatment gap in Thailand: A father took his
22-year-old daughter to the local hospital in Thungsaliam district, Sukhothai early in 2013
andwas told that there was no psychiatrist at that hospital. The nurse received him and his
daughter but could not make any decision about giving his daughter medication or admitting
her into the hospital. The nurse sent the father to the hospital director who simply told the
father that he doesn‟t know how to help the daughter as he is not a specialist. The father had to
take his daughter to another hospital in another district without any referral documentation.
Without these referral documents, the father has to pay for his daughter‟s medication himself,
because of the hospital staff‟s negligence. He already travelled 24 kilometers away from

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homeand still could not get treatment for his daughter. He then had to take her to another
hospital 80 kilometers farther away.For this poor family, this was a very significant distance
that involved time, expenses, and disruption.
Burden of family caregiving.
Carers often find it difficult to adjust to the needs of the mentally ill person under their
care. They often sacrifice their own physical and emotional needs; the emotional and physical
experiences involved with providing care can strain even the most capable person. The
resulting feelings of anger, anxiety, sadness, isolation, exhaustionand, consequently, guilt for
having these feelingscan exact a heavy toll (Family Caregiver Alliance, 2002). Because of the
lack of resources in Thailand, caring can become a full-time occupation. Some carers have to
give up their work and stay home to care for a family member. Many feel stressed by the very
person they are caring for and some may evenabuse him or her verbally and/or physically. In
one of this researcher‟s workshops, a participant admitted feeling stressed out and upset by her
husband‟s behavior on account of his mental illness and alcohol addiction. The wife and their
son soon became alcoholics themselves andtheir condition persisted even after the father quit
drinking alcohol.
Carers are themselves vulnerable to depression. Early preventative care for depression
through exercise, healthy diet, positive support of family and friends, or consultation with a
trained mental health professional may help to prevent the development of more serious
depression over time. Gaining knowledge about depression, medication, and self-care helps
people with depression recovery (Family Caregiver Alliance, 2002). Carers tend to feel
isolated, which intensifies their stress. A participant in one of this researcher‟s group therapy

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sessions revealed that she suffered from depression and had attempted suicide. She had
depression for five years but recovered after having joined the Thai Family Link program [a
community-based training program intended to help the mentally ill, their family
members/carers gain knowledge about mental illness and its treatment as well as their rights
and entitlements], although still under medical supervision. Through the program sessions
attended by other mentally ill persons and their carers, she realized that there were others like
her and that she did not have to face her problems alone. She knew then that there were
friends who understood her and had sympathy for her. The new knowledge and support
increased her self-esteem. She resumed her work and has not attempted to commit suicide
since. She is confident that she can take on additional work and responsibilities, and can live
happily in society. Getting over her depression helped relieve her carers‟ (parents) suffering as
well. After all, carers require long-term responsibility and cannot predict when it will end. It
takes time and requiresasubstantial amount of work.
Surveys of family experiences show the effects of stress on the psychological and,
sometimes, physical health of carers, as well as their inability to make or fulfill personal plans,
and their worries about what will happen to the patient “when I am gone,” particularly among
elderly parents of chronic patients (Lefley, 1989, p.557). Some families that live far away
from the city and in poverty cannot receive regular treatment, resulting in chronic life-long
disability which parents strive to find a way to cure. There are those who are forced to sell
their small property in order to pay for the treatment of a mentally illfamily member and are
left with almost nothing. By way of an anecdotal account, a participant who underwent
training in the Thai Family Link program was a 75-year-old widowed mother with an adopted
daughter. Her 40-year-old daughter has had mental illness since she was a teenager and,

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therefore, cannot work to support her mother who has a physical ailment. She can, at least, do
simple housework such as cleaning and cooking simple food. This requires an inversion of the
usual Thai family paradigm where children care for aging parents. The mother has lived with
fear since her husband died many years ago; she worries that her daughter will have no one to
look after her when she passes away. This is a chronic stress that wears on the aged mother in
addition to her daily challenge of caring for herself and her daughter. This type of problem
impacts many people with a history of mental illness in the family.
As seen in this anecdote, the care recipient is often unable to fulfill the reciprocal
obligations associated with normative adult/family relationships and, quite often, the mental
health problem is serious enough to require substantial amounts of care. What makes it
burdensome is the addition of the caregiving role to existing family roles and responsibilities
(Gubman&Tessler,1987; Gallop et al., 1991). Many carers have the responsibility to care not
only for the mentally ill in the family, but also for another family member who is unable to
take care of him/herself; this dual role may cause the carer to spend less time with the
mentally ill sibling or parent. A case in point is that of afamily member in Thungsaliam
district, Sukhothaiwhom this researcher invited to participate in the Thai Family Link course
(2012). The person was unable to attend the course because she has a 50-year-old brother with
mental illness and a 90-year-old mother who lay on a mattress on the floor all day. She is
unable to go anywhere and does not have sufficient income to support her family. The
mentally illbrother refuses to take medication, walks around all the time, and does not sit still
or stay in one place. She had a cage built to restrain him so that when he turns manic and
becomes a danger to others and himself, she would lock him in that compartment. She would
take food to him and when he calms down, she would open the door and let him out. Once

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free, he hurries out of the house and walks restlesslyaround the area. He is often seen picking
through trash on the side of the road.
Long-term carers‟ behaviors and attitudes may turn negative toward people they are
caring for due to chronic stress. A study demonstrated that family caregivers can experience
high levels of stress, self-blame, substance abuse, and depressive symptoms. Being the
principal caregiver to a mentally ill family member is a long-term stressor that often creates
high levels of burden and contributes to depressive symptoms (Nauert, 2011). Many
caregivers fall prey to drug abuse or increased use of alcohol or cigarettes; some have been
known to physically abuse a person with mental illness because of unmanageable stress. They
claim that no one listens to their problems and they feel that they are confined with no way
out.
To illustrate this point, there was aelderly widowed caregiver (more than 60 years old)
who attended the Thai Family Link program with this researcher. He confessed that he often
scolds and beats his handicapped son who has brain damage and depressive disorder (that
resulted from an accident). The father does not understand brain damage and depression; he
wonders why his son does not cooperate and get up to do anything, instead of laying in bed,
day and night. The father is stressed over the fact that his son constantly resists being bathed
or fed. He has to literally spoon-feed his son who defecates and urinates in his bed. In
addition, the man also cares for his granddaughter (his son's daughter). After beating his son,
he feels terrible and blames himself for being a bad person. This type of situation often
involves a mentally handicapped person who cannot complain or fight back, but is passively
injured. Both the sufferer and the caregiver fall into a dilemma – in this case, the father cannot
abandon his son, and the soncannot leave and must continue to endure being abused. When he

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first participated in the Thai Family Link program, the father was restless, distracted, and
talked about his son negatively, trying to conceal his frustration and disgust by mentioning
that he loves his son. After completing the program, the father exhibited a more positive and
accepting frame of mind.
There are many people in Thailand with a psychiatric problem, or have a mentally ill
sibling or parentbut choose not to seek medical care or treatment because of social stigma.
SuksawangandSawangsin (2005)examined the stigma attached to mental illness and posited
that many families and caregivers experience panic upon realizing that a family member has
schizophrenia or any other mental disorder. Their initial emotion is one of shame and fear of
being ostracized by society. The response is very common and widespread. A mini-case is that
of a female over 40 years who was diagnosed mentally ill. In one of the group sessions of the
Thai Family Link program in Thungsaliamdistrict, Sukhothai province, she tearfully shared
her story of how people maltreated and humiliated her by calling her names, including „mad
woman‟.She has, subsequently, gained self-confidence since she joined the program, and has
been able to visit family, friends, and neighbors. However, she soon expressed reservations
over attending further sessions because her teenage son is afraid that his friends will find out
that his mother is mentally ill. Moreover, she is reluctant to pursue further sessions because
her husband feels embarrassedby her public appearances and revelations. She confided,
though, that she will attend future group sessions occasionally, when her husband is away.
So, stigma within a family can prevent people from even seeking assistance.

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Resources for families.
In their exposition on schizophrenia and the family, Anderson, Reiss, and Hogarty
(1986) explicitly expressed that families need to be informed about (1) mental illness and its
treatment, (2) caregiving and management issues, (3) the mental health system and
community resources, and (4) family coping and adaptation. Unfortunately, because of the
absence of mental healthcare system, rural Thailand has extremely limited information about
mental illness; people only begin to understand what the condition means when the illness has
worsened, or only after treatment has begun. Affected persons and potential carers, generally,
have little or no idea what to do or how to begin dealing with the problem.
SuksawangandSawangsin (2005) observed that when mentally ill people experience an
acute attack orrelapse, this is the first time they are taken to hospital. Furthermore,
familycarerslook at them with pity while thinking that they are going to be a burden while also
fearing stigma. With very little knowledge about what to do when a relapse or an attack
occurs, family members and/or the caregiver takes the sufferer to hospital repeatedly. In the
end, they have to give up when they can no longer afford the travel expenses. A case in point
is that of a 70-year-old widowwho resides in Thungsaliam, Sukhothai. While looking after her
90-year-old mother, she is also caring for her two mentally ill brothers,aged over 40 and 60
years, a task she has been doing for over 20 years. In the early years, she had, reportedly,
taken her brothers to Suanprung Psychiatric Hospital in Chiang Mai quite often, butwhen they
reach home, they would go into a relapse again. Travel expenses to and from the hospital were
quite expensive and financially draining; she has since stoppedtaking them due to lack of
personal funds. With little knowledge about treatment, she allowedher brothers to get by
without medication. Their living conditions are bound to make matters worse. One brother

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hasnot taken a bath for years; the other does bathe, but occasionally. Their sleeping area is
unhygienic and generally impoverished; there are nomattresses, only old, bare pillows and
thin blankets.During cold weather, they would light a small fire together to keep out the cold.
With a mere 5,000 Baht a month from elderly and handicap pensions, the carercannot do
much for her mentally ill brothers except feed them when she can afford to.
Psychoeducation.In a case such as the latter, the widowed carer could benefit from
Psychoeducation. However, it would not be enough for the widow to be educated alone, but
that the whole family should be involved. Lam (1991) asserted that family Psychoeducation
differs from family education in that the former proposes that both the family and the patient
are involved,and that coping and stress management skills training are provided to the entire
family over a relatively long period of time. The effectiveness of family Psychoeducation
seems warranted with the following outcomes: (a) the program has been successful in
reducing the rate of relapse beyond the effects of medication; (b) relapse ratesare reduced by
including coping skills training for families; (c) the addition of social skills training for
patients further reduces the risk of relapse; (d) programs that decrease the expression of
criticism and hostility between family members are more effective than those that do not. The
strength of the research model and its replication in diverse settings argue strongly for the
availability of family Psychoeducation for families who are trying to cope with mental illness.
Psychotherapy and family interventions are largely educational and supportive. These should
be the initial interventions of choice for family members whose central needs are for
information, skills, and support. If these interventions are not sufficient, other services may
also be appropriate, including individual, marital, or family therapy(Lam, 1991).

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Thai Family Link.Advocates of Psychoeducationhave applied the process successfully
to local people with mental illnesses and their carers since 2004 in the form of the Thai Family
Link program, initially offered at the Srithanya hospitalin Nonthaburi province. The program
developed a reputation asan effective course for self-help groups but was not well known in
the provinces. The course expanded to Sukhothai province in 2011. The instructor has since
educated 120 mentally ill people and their carers (Lim-arun, 2011).By 2013, the training
covered all areas in Thungsaliam district, Sukhothai (Lim-arun, 2013a, 2013b).
Psychoeducation – better known locally to the people of Nonthaburi province and
people around Bangkokas Thai Family Link – is deemed a very effective course for family
caregivers and mentally ill family members who are trying to cope with mental illness and its
consequences. This program was founded by Dr. SomrakChoovanichvong, a psychiatrist who
started the course in Thailand 10 years ago. The primary aim of this training program is to
help participants (mentally ill persons, family members, and carers) understand the symptoms
of mental illness, their basic human rights and entitlements, and how to recover from mental
illness (Choovanichvong, 2011).
The Thai Family Link training course proved to be very useful for those who were
personally trained by the current researcher in Thungsaliam district, Sukhothai. Many people
with mental illness have improved and many carers were freed from their crisis.By way of
example, one trainee‟s story is as follows: The carer concerned attended one of this
researcher‟s Thai Family Link Psychoeducation courses with her mentally ill sister. The carer
shared some highlights of her sister‟s condition in the early years of her illness. She reportedly
took her sister to see a psychiatrist at the Suanprung Psychiatric Hospital many times in the

17
past.Her sister used to hurt herself by biting her arms, scratching her face, using wire to cut
her wrists, shaving her hair, climbing a tree, and attempting to jump down. The carer revealed
her sister‟s other self-inflicted acts to harm her, including standing in the middle of the road to
let cars crash into her. She once removed her clothing and walked in the middle of a busy
street. She often refused medication and had to be given oral injections twice a month which
she resisted by locking her jaws every time.In the course of the training, the carer observed
that her sister takes medication more regularly and does not secretly throw the medicine away.
As a caregiver, she feels she understands her sister better. Before the program, she admitted
never having listened to her sister. Before, when her sister was manic, she would push her
away, causing her to become more aggressive. During meal times, her sister was not allowed
to eat together with other family members, and had to eat separately. After participating in the
program, the family‟s attitudes and behaviors changed. Nowadays, the whole familyeats
together.They treat the sister better. The carer reports that her sister‟s condition is much better
now to the point that she has taken the responsibility to care for her 80-year-old mother. She
doessome of the housework and has often gone out to buy milk, food, and treats for her
mother. She now washes her own clothes and keeps herself clean and presentable,
considering that she used to refuse to bathe herself. She has even givensome money to her
caregiver sister to spend for necessities – something that never happened before. The happiest
person these days is their mother who constantly praises her daughters for their
perseveranceand determination to succeed.

18
Family therapy as a resource.
Several versions of family therapy have been created, some of which were designed
for use with families of people diagnosed with schizophrenia. This type of therapy is
conducted by trained professionals. There were several uncontrolled studies of effectiveness
and the usual anecdotal accounts, but there were few controlled studies and these were so
flawed that Terkelsen (1983), after reviewing the literature, stated there was no evidence for
effectiveness. Perhaps even more important is that families of people with schizophrenia
tended not to like family therapy. A key element of family therapy is that the family must
have been a pathological system because it caused a serious mental illness in a child.
Therefore, the family as a system was the patient. Relatives did not like this because they
knew it was not them but the ill relative who was the patient and who needed treatment. The
other principal objection is that family therapy does not provide educational information. As
adaptations to include more education are being made to family therapy, results for patients
with schizophrenia appear to have improved (De Giacomo et al., 1997).
Dealing with mental illness: the Thai perspective.
Buddhist caregiving.Thailand is a predominantly Buddhist country, which plays a
direct role in the reaction to and treatment of mental illness in the general population, but the
Buddhist system does not incorporate a belief in spirits. However, animism is similar to
Buddhism, but the belief in spirits and ghosts arise out of older traditions. Animism believes
that these spirits and ghosts can „cause‟ mental illness. Buddhist caregiving research and care
in the mental health field is sparse (Burnard, Naiyapatana, & Lloyd, 2006). However,
Buddhist concepts are viewed by many as part of daily life, and this also applies to Thai
caregivers. A qualitative study about Buddhist family caregiving and caring for the seriously

19
mentally ill in Thailand supports the Buddhist view highlighting caregivers‟ suffering,
acceptance, and compassion (Sethabouppha& Kane, 2005). Many mentally ill people,
especially in the countryside, are locked up or chained by their relatives or other people in
their villages. They are called “baa” (crazy) and are often considered possessed by ghosts or
demons. Sometimes, the village head or „healers‟ will involve some amateurish form of
electro shock therapy which causes memory loss or more serious neurological damage. If
mental patients are lucky and a medical doctor or even psychiatrist is within reach, treatment
usually only consists of prescribing pills, but there is no psychotherapy, counseling, or social
work involved in the treatment plan for the patient(Sethabouppha& Kane, 2005).
Gender difference in Thai carercharacteristics.A previous research showed
thatmaleThai carers are more likely to report higher mental capacity (can control emotions and
are confident in facing crises), whereas female carers have higher mental quality (sympathetic
toward others, help others when they have a chance, happy in helping out others).Male
carersare more likely to report higher social support than non-carers (feeling secure when
staying with family, and family members love and care for each other),but no such trend was
observed among females (Yiengprugsawan,Seubsman, &Sleigh., 2012).
Community residential facilities.Community residential facilities for patients being
discharged from psychiatric hospitals simply do not exist in Thailand. Before being
discharged from the hospital, patients are transferred to the hospital‟s rehabilitation center for
occupational training. Some Thai studies found that social support is important for both
caregivers and care recipients and can reduce depression among impaired Thai older
adults(Suttajit et al., 2010; Thanakwang, 2009). In Thailand, ideally, each district should have
adequate community residential facilities for purposes of therapy and rehabilitation of people

20
with mental illness whohave been discharged from a psychiatric hospital in order to adjust
themselves and learn necessary skills to live with their families and communities. The
government should help people with mental illness regain their self-confidence and avoid the
problem of relapsethrough effective interventions as mentally ill persons are vulnerable and
may return to their old ways, including substance abuse. These people as well as their
carersshould have a fair chance to learn interpersonal communication skills to enable them to
form and maintain good relations with others in the community and also to help them find
suitable employment and be useful members of society.
The Hong Kong model for rehabilitation.
The current researcher has had several occasions to visit two of Hong Kong‟s reputable
treatment and rehabilitation centers: the Mental Health Associationof Hong Kong and the
New Life Psychiatric Rehabilitation Association. These two rehabilitation centersare widely
known for training their rehabilitation officers to very high standards. People with mental
illnesses who benefit from their services and facilities have good hygienists, live in clean and
well-maintained premises, and have good jobs that suit their physical and mental
health.Compared to the general populace, they have good income. Disabled residentsreceive
monthly income and welfare provisions from the government that are deemed sufficient
enough for them to live comfortably; in addition, they all have suitable jobs provided by the
rehabilitation center. This researcher observed that rehabilitation experts work with the
mentally ill through programs that act as a „voice‟ for the mentally ill. Through outreach
programs, rehabilitation specialists go out into the community to educate people on how to
perform self-checks for risk of mental health disorders, along with giving advice to those at
risk for mental illness. These programs extend to all of Hong Kong.

21
During her last visit to Hong Kong‟s New Life Psychiatric Rehabilitation Association,
this researcher learnedthat the Thai Ministry of Social Development and Human Security and
the Baan SomdetChaopraya Psychiatric Hospital have sentsome of their staff to visit the two
rehabilitation centers in Hong Kong and that a Mental Health International Conference
involving both countries was held in 2013. This researcher proposes that the Thai government
should use the Hong Kong rehabilitation centers as exemplars on how to improve the
standards of services for people with mental illness.
In their investigation of the impact of caregiver burden on the psychological well-
being of caregivers with relatives suffering from mental illness in Hong Kong, Keung Wong,
Kit Lam, Chan, and Chan (2012)reported that “caregivers suffer from poor psychological
health and that some of them may even develop mental illness”(pp. 2,6). Social support is a
part of the treatment process, along with medication, counseling, and therapy. Together, these
are the most effective means of treatment of people with mental illnesses. Empirical findings
attest to the important role of social support not only for mentally ill individuals but also for
their carers. It was found that social support could help provide respite care and leisure time to
carers, enabling the caring role to be sustained (Stevens et al., 2004; van Exel, de Graaf,
&Brouwer, 2008).In a similar vein, a Thai study found that social support is important for
both caregivers and care recipients and can reduce depression among impaired Thai older
adults (Suttajit et al., 2010). These points reveal the important but complex role that social
networks can play in assisting both mentally ill persons as well as their carers. Thus,
enhancing access to social support within the Thai setting should be further examined.

22
Employment of people with mental illnesses.
Mentally ill persons are, generally, unable to find work or maintain employment;
thisimpacts on carers‟ financial status. Unemployment is common among people with severe
mental illness such as schizophrenia and bipolar disorder, with rates of competitive work
typically ranging between 10% and 20% (Anthony & Blanch, 1987; Mueser, Salyers,
&Mueser, 2001). Despite the high rate of unemployment, most people with severe mental
illness want to work (Mueser et al., 2001; Rogers, Walsh, Masotta, &Danley, 1991). A study
that examined unemployment and depression revealed that depressed individuals who became
unemployed had over twice the risk of increased depressive symptoms and diagnosis of
clinical depression than those who remained employed (Dooley, Catalano, & Wilson, 1994).
Not surprisingly, mentally ill people feel a loss of security and low self-esteem when they lose
their jobs, just like anybody else. The increase in mental illness symptoms can be caused by
social isolation and economic hardship. Many become homeless because family members do
not want their mentally ill sibling or parent to live with them, causing the family to become
dysfunctional. There is a significant amount of research that demonstrates the effectiveness of
helping individuals with serious mental illness achieve competitive employment (Bond, 1992;
Crowther,Marshall, Bond, & Huxley, 2001; Killackey, Jackson, Gleeson, Hickie, &McGorry,
2006; Lehman, 1995).
The current researcher believes that in Thailand, there is a pervasive lack of support
and interest among employers in offering employment to people with mental illnesses. The
very few who might give them a chance would quite likely offer much lower pay than the
standard rate or even require them to work for very long hoursin exchange for food or low
wages. This discrimination may be due to Thai people‟s limited knowledge about the nature

23
and symptomology of mental illness. It is not easy for these people to find a job; their success
depends on finding a sympathetic employer who knows how to respond to or deal with mental
health issues. The situation, however, is not totally hopeless; there are a few organizations that
exist to help mentally ill persons find employment such as the “Kaew-arun Foundation” (Lim-
arun, 2013b). However, the rate of progress of this type of organization is perceived as slow
due to high demand and low number of employers willing to provide jobs to persons with
mental health issues.
Purpose of the Study
Inasmuch as the burden of care falls on the family of people with mental illnesses,
there was a need to study the experiences of the family, particularly the family caregiver,
considering that attitudes toward mental illness vary among individuals, families, ethnicities,
cultures, and countries. We see the aim of this study as giving voice to a group of people
whose voices are not frequently heard: the poor, rural family caregivers of the seriously
mentally ill.
The objectives of the current study are the following:
1. To examine the general experiences of carers of people with mental illnesses.
Although it is not the main focus of this project, the researcher expected to obtain
carers‟opinions about their general experiences and feelings as caregiver to a family member
diagnosed with mental illness, particularlyin rural Thailand.

24
2. To examine carers‟ attitudes toward medical treatment systems. Because of the
absence of specialized mental healthcare that has already been described, carers and their
wards must interact with a medical treatment system that is ill equipped to handle their needs.
It is important to documents their experiences in their own voices.
3. To examine carers‟ attitudes toward counseling. Even though it is not widely
available in Thailand, it is very valuable to document the experience of the rural families with
specialized mental healthcare where it may have been available. Sharing the experiences and
attitudes of family caregivers toward various treatment procedures and techniques including
counseling can lead to their deeper understanding of the various ways of managing mental
illness in the family.
4. To examine carers‟ attitudes toward employment.A report on carers‟ attitudes
toward caregiving work for family members with a mental illness can influence government
policymakers in their task of allocating public resources for the promotion of mental health
services. In addition, the conclusions generated from this study and their implications would
serve as bases for interventions aimed at staff retention in mental health settings, increase the
standards and quality of medical care for people with mental illnesses, and create fund-raising
challenges for organizations that are committed to helping mentally ill people and their
families.
Significance of the Study
It is very significant to give a voice to the rural poor. The voices in this project
represent those whose voices are not heard in places like Bangkok. These voices come from

25
the heart and soul of Thailand, from Thailand‟s farms and rice paddies. To give expression to
their concerns is significant in and of itself.
Furthermore, community members can influence the promotion of mental health and
can make a big difference to people with mental illness. They can also help mentally ill
individuals and their caregivers have better quality of lifeeven after a diagnosis has been
made. The sharing of experiences by carers was deemed beneficial in the overall care and
management of people with mental illnesses.
The researcher expected that the government and community-based organizations
dealing with mental health education or promotion would benefit from this research by
applying its findings and recommendations in their work. The voices of the carers reflected
the problems of families facing mental illness challenges. The results would act as catalysts
for the government to respond to the issues identified in this study. This way, the government
can provide the right care interventions for families who are adversely affected by mental
health issues. The opinions and revelations of those who live with the problem can guide the
government and offer insights to relevant organizations on ways to improve and expand their
services.Mental illness in the family can impact heavily on the afflicted individual, his/her
family members, carers, and friends. The whole family, along with the person concerned, need
to have adequate information to deal with mental illness in order to avoid the condition‟s
potentially huge, negative impact on their lives. They need to have good guidelines and
knowledge resources to support the mentally ill person as well as his/her carerin their quest to
alleviateor even eliminate the difficulties they find themselves in. In light of the
aforementioned, this investigation would provide the relevant perspectives, models, and
empiricalfindings from related studies that can be used as theoretical and practical bases for

26
proactive action and decision making by family carers, helping professionals, and policy
makers aimed at improving the quality of life of all concerned in families with mental health
issues.
The current study focused on the caregivers of people with mental illnessesat the
LiamsiriMar Hill Center. It was anticipated that this study would benefit carers in terms of the
knowledge that they are not alone in their plight, that there are many carers who havesimilar
or related problems and who would do everything to alleviate the suffering of their mentally
ill loved one, family member, relative, or friend. This study offers carersnew strategies,
treatment alternatives, new ways of thinking, and even bright and innovative ideas on how
best to optimize their work and improve their competencies.
Finally, a study of this nature and importance is bound to be profoundly useful not
only to the researcher in terms of new knowledge and skills that can be applied in her work as
a counselor but also to other researchers who are interested in the same variables, objectives,
and target population. The design, methodology, instrumentation, data collection procedure
and analysis employed in this unique study can be used as reference material in their search
for the truth about the practices, fears, and aspirations of carers of people with mental
illnesses. Additionally, it is anticipated that this study would add to the body of knowledge or
literature about caregiving for the mentally ill within the Thai context.

27
Definition of Terms
Attitude.
Attitude is an expression of favor or disfavor towards a person, place, thing, or event
(the attitude object). Prominent psychologist Gordon Allport once referred to attitudes as the
most distinctive and indispensable concept in contemporary social psychology.An attitude can
be formed from a person's past and present. It is measurable and changeable and can also
influence the person's emotions, moods, and behaviors.
Carer/caregiver/caregiving.
Caregiving refers to the relationship between two adult individuals who are typically
related through kinship. One, the carer or caregiver (used interchangeably in this study),
assumes an unpaid and unanticipated responsibility for another, the care recipient, whose
mental health problems are disabling and long-term in nature, with no curative treatment
available (usually referred to as serious mental illness or SMI) (Gubman&Tessler, 1987;
Gallop et al., 1991).
Counseling therapy.
Counseling therapy refers to the advice or guidance given by a specially trained person
(counselor) to relieve the distress of a person having emotional problems/difficulties/crisis. It
can also refer to the treatment given by a trained person by means of interpersonal
communication to relieve the symptoms of a disease or mental disorder.

28
DALY.
DALY stands for Disability Adjusted Life Year and is a overall measure of the burden
of a disease or condition that is very widely used. The DALYs for a disease or health
condition are calculated as the sum of the Years of Life Lost (YLL) due to premature
mortality in the population and the Years Lost due to Disability (YLD) for people living with
the health condition or its consequences.
Employment.
Employment is a relationship between two parties, usually based on a contract, one
being the employer and the other being the employee.
Liamsiri Mar Hill.
Liamsiri Mar Hill is a community-based center supported by donations and work by
volunteers to serve people with mental illnesses and families in the Thungsaliam district,
Sukhothai province. Because of the serious mental health treatment gap in Thailand, which
means there are no government services for people with mental illnesses in rural Thailand,
Liamsiri Mar Hill provides vital support for the community.
Mental illness.
Mental illness is another name for „mental disorder‟ with medical connotations that
some consider misleading or tendentious (Oxford Dictionary of Psychology). It refers to any
of various conditions characterized by impairment of an individual's normal cognitive,
emotional, or behavioral functioning, and caused by social, psychological, biochemical,
genetic, or other factors such as infection or head trauma. Mental illness can also be called

29
emotional illness, mental disease, and mental disorder. Additionally, it denotes any of various
psychiatric disorders or diseases, usually characterized by impairment of thought, mood, or
behavior.
Psychiatrists.
Psychiatrists are medical doctors who evaluate patients to determine whether or not
their symptoms are the result of a physical illness, a combination of physical and mental
disorder, or a strictly psychiatric one.
Psychoeducation.
Psychoeducation is one component of many types of psychotherapy and other mental
health conditions. During Psychoeducation, the outpatient is provided with knowledge about
his/her psychological condition, the causes of that condition, and the reasons why a particular
treatment might be effective for reducing their symptoms.Psychoeducation is a crucial
component in helping patients and families understand their problems and improve their lives.

30
Conceptual Framework
This project studied the family carers of people with mental illnesses in rural Thailand
to learn about their attitudes toward medical treatment, attitudes toward counseling, and
attitudes toward work.
Thai family carers of
people with mental
illnesses
1. Attitudes toward medical treatment
2. Attitudes toward counseling
3. Attitudes toward work

31
CHAPTER II
Literature Review
“And they shall look to the poor and the needy, and administer to their relief that they shall not
suffer” (Doctrine and Covenants, 38:35.The Church of Jesus Christ of Latter Day Saints).
Chapter II presents the theoretical perspectives, models, and empirical findings relative
to the key variables of the current study. Based on the review of literature, the research
questions were generated and presented as the concluding section of this chapter.The current
study attempted to examine the attitudes of family carers toward medical treatment, counseling,
and work for people with mental illnesses in rural Thailand.More specifically, this study aimed
to investigate the feelings, beliefs, and intention of carers toward their work as caregivers and
toward the treatment systems and procedures used to help their mentally ill family member
reintegrate with the community and society at large. It was proposed that if a carerhas a
favorable attitude towards people with mental illnesses, along with a feeling of pride over
their work and satisfaction with the treatment processes, then the carerwould be more
understanding, compassionate, and committed to the recovery of the person they are
supporting. If, on the other hand, the carerhas an unfavorable attitude towardscaring for
someone with mental illness, then the carer would feel burdened in the course of their work,
thus, adversely affecting the treatment process.
Caregiver Experiences
Mental disorders impose a heavy burden on individuals, families, and societies.
According to the most recent available data from the WHO‟s Global Burden of Disease study,
neuropsychiatric disorders are the second cause of DALYs lost in the WHO European Region,

32
amounting to one fifth of DALYs lost due to all health conditions (WHO, 2005, p. 44) [The
“disability-adjusted life year” or DALY is a measure of overall disease burden, expressed as
the number of years lost due to ill-health, disability, or early death] (DALY, 2010).The family
constitutes a major support system in the continuing care of the mentally ill in the community.
Although many families show a strong resilience in caring for an ill relative, their share of
physical and emotional distress cannot be ignored. Carers‟ sense of accomplishment or failure
depends partly on the timing of the caregiving responsibility in their lives and on their roles
and responsibilities within the family structure since, as it happens, caregiving is usually
provided by a family member such as a parent, spouse, sibling, or relative, more so in Asian
nations such as Thailand. Surveys of family experiences show the effects of stress on the
psychological and physical health of caregivers as well as the inability of caregivers to make
or fulfill personal plans, along with their worries about what will happen to the mentally ill
patient if the carer is incapacitated or dies. This situation applies particularly to elderly parents
of chronically ill patients (Lefley, 1987). This problem of uncertainty impacts the whole of
Thailand, especially in relation to the uncertain future of family members with mental
illnesses, considering the lack of resources and facilities for the mentally ill. One helpful
strategy would be for the Thai government toincrease its budget allocation formental health
welfare to ensure a better quality of life for mentally ill people. The Thai government should
also follow the lead of many developed countries that implement a system of paying a
reasonable monthly allowance to people suffering from mental illness for life. Presently, the
Thai government gives a monthly allowance of 500 Baht to the disabled which, obviously, is
not enough for them to live on for a whole month. The welfare arm of the government should
develop and implement policies that ensure that people with physical as well as mental

33
difficulties are given sufficient disability living allowance to live in reasonable comfort. The
latest figures showed that wages in Thailand increased to 12,772.47 Baht in the first quarter of
2014 from 12,163.15 Baht (Trading economics).
Thais value their extended family as a source of support between family members
inasmuch as mental illness distresses both family members and carers. A study revealed that
in Botswana, the extended familystructure allowsfor distribution of caregiver responsibilities,
although most families reported that lack of financial and medical resources at the family and
community levels made it difficult and stressful to provide adequate care (Seloilwe, 2006).
Many carers of mentally ill persons are poor people themselves with little understanding about
mental illness and often live far from psychiatric hospitals. They may find it a heavy burden to
look after someone with mental health problems. For example, family members of
schizophrenic patients reportedly experience burden on a practical, financial, and emotional
level and the extent of the burden is closely linked to the amount of symptomatic behavior of
the patient (Lowyck et al., 2004). In some cases, caregivers themselves become mentally ill
and the condition is believed to be either hereditary or the result of a combination of
personality factors, poverty, chronic stress, andother adverse circumstances.A case in point
was that of a woman in Thungsaliam district who went through a succession of life
difficulties: she cared for her mentally ill motheruntil she died;she had to deal with her
brother‟s death from drowning; and she was in such dire straits that people would give her
food out of pity. Eventually, she became mentally ill. The current researcher learned that
neighbors believed the condition was hereditary. They did not consider the possibility that
mental illness, in this case, may have been due to a combination of many difficult
circumstances, including the individual‟sinability to care for herself.

34
The lack of understanding about the antecedents, consequences, and treatment of
mental illness poses a great problem for carers. Adding to this problem is the lack of sympathy
and compassion from other people, made even worse by calling people with mental illness
„crazy‟. According to Lefley(1989), primary caregiving responsibilities are most often
assumed by the mother, wife, or daughter of the ill person, thus carrying the heaviest part of
the family burden. They have to constantly deal with the uncertainty and stigma associated
with chronic psychiatric illness in the family. They not only care for their ill family member,
but also need to make a living for themselves, in addition to having to face ridicule from
others, including their own relatives.This researcher learned in a Thai Family Link course in
Thungsaliam, Sukhothai that a caregiver‟s close relative used to call her on the phone and ask,
“How‟s your crazy husband?” which made her veryupset. She learned advocacy from the
workshop and started to respond with the statement, “Please do not call him crazy; he is a
human being like you.”
Caregivers are often at the receiving end of unkind remarks which make them
confused or put them in a dilemmatic situation as to whether they should continue taking care
of their kin or not. This situation can make the whole family feel insecure, particularly the
carer.It is commonly acknowledged that the caregiving burden can lead to carers of mentally
ill family members experiencing poor quality of life (Keung Wong et al., 2012). Many carers
have no means of financial support to enable them to purchase expensive medication for their
ill family member (Black, Cohn, Smull, & Crites, 1985; Lefley, 1987). In the same vein,
McCubbinet al.(1982, as cited in Lefley, 1989) argued that caregivers experience a variety of
hardships such as financial problems due to medical bills and the patients' economic
dependency, disruption of household functioning, curtailment of social activities, and altered

35
relationships with friends and relatives. Caring for a family member with mental illness can be
burdensome; carersreportedly experience financial problems, difficulty handling disruptive
behavior, and fluctuating emotions that cannot be controlled (Keung Wong et al., 2012).This
researcher believes that many families, especially in the rural areas of Thailand, are often
confronted with similar difficulties. A case in point was that of a widowed woman (now
deceased) from Thungsaliam districtwho cared for her son (in his 40s) since he developed
psychotic disorderat age 17 years. Initially, the mothertook her son, not knowing what was
wrong, to several local hospitals but he remained unwell until she decided to take him to a
psychiatric hospital in Chiang Mai, two provinces away. Without a disability card or even
with the 30 Baht Health Care Scheme and Health Security in Thailand and her smallincome
from farming work, the mother could not cope with her son‟s high medical bills. She had to
sell her personal things (old jewelry, parts of her house, etc.) to pay for his treatment. Her son
had been admitted in psychiatric hospitals several times which cost the mother a lot of money
but she never gave up on him. To this day, the son remembers his late mother‟s hardships. He
still takes medication for psychosis and now lives with a sister. He continues to grapple with
the public stigma attached to his condition, including having to bear with neighbors‟ offensive
name calling (e.g., “mad dog”, etc.).
Stigma and Discrimination
There have been studies about the public stigma that impacts on people with mental
illness and their carers. For example, Lefley(1989) posited that sufferers of mental illness tend
to conceal their disorder and worry a great deal about others finding out about their psychiatric

36
status and treating them unfavorably. The respondents (people with mental illness) reported
experiencing discouragement, hurt, anger, and lowered self-esteem as results of their
experiences, and they urged public education as a means for reducing stigma. Some reported
that involvement in advocacy and speaking out when stigma and discrimination were
encountered helped them to cope with stigma.
The results of related studies in Thailand came out quite similar to those of Western
studies. For example, SuksawangandSawangsin (2004) found that many Thai people believe
that mentally ill individuals are harmful and frightening. Many people often try to keep at a
distance, avoid, reject, or consider the mentally ill as objects of ridicule. The authors also
reported that when people with mental illness go for treatment ina hospital, they are often
treated in a strict and inflexible manner.It appears that hospitalstaff fail to consider the rights
of people with mental illness; that their perception of their patients reduces the human value of
mentally ill people, causing them to see themselves as valueless (Suksawang&Sawangsin,
2004).One of the participants of the cited study lived with chronic mental illness. She had
been admitted to mental health hospitals many times before, without her consent. She revealed
that, occasionally, hospital staff would put her in an isolated roomwhich she abhorred. She
hesitates to travel or stay overnight with family caregivers for fear that they might take her to
a psychiatric institution for long-term confinement. According to
SuksawangandSawangsin(2004), most of the people who live in the same community as the
mentally ill have negative attitudes toward them. Community members fear them and hardly
ever associate with them. They think that the illness could be the result of sinfulness or bad
fortune; that it is supernaturalin nature; or that it derives from their own or their parents‟ bad
actions, thus, resulting in the belief that the ill person is undeserving of pity. It is easy to

37
observe that many people in the community do not want mentally ill persons to participate in
community affairs and activities (Suksawang&Sawangsin, 2004).
Most of the participants in the current researcher‟s Thai Family Link workshop
reportedly experienced stigma and discrimination as well as unfair treatmentby certain
professional services. Family members and caregivers alike feel a sense of panic having a
person with schizophrenia in the family. They fear not getting enough professional help or
treatment opportunities for their ill family member. In case of a relapse, the ill person is
rushed by family members tothe nearest hospitalin order to avoid the burden of caregiving. As
Suksawang andSawangsin (2004) opined, when the ill individual has a relapse, caregivers,
generally, do not know what to do or how to deal with the situation effectively. This
researcher is of the opinion that what makes the situation worse is that carers and their patients
are generally reluctant to ask for information about mental illness and its treatment or
medication (e.g., typology of mental illness, medication and side effects, traditionalversus
modern medication, etc.). As it happens, some powerful medicines have side effects which
manycarers are afraid to ask about. They may not even be aware that they have theright to ask
and the right to be told. It is important that carersand person with mental illnessesunderstand
the nature of medication and their role in making the treatment process successful.
Attitudes of Carers
In the following section, the general topic of „attitudes of carers‟ is discussed in
different specific contexts, namely, attitudes of carers toward (1) medical care services, (2)
hospitals, (3) mental health professionals, (4)counseling, (5)andwork.

38
Attitudes toward medical care services.
It is difficult for people with mental illness not only to admit having the illness but also
to take care of oneself. It is not unusual for these people to refuse to see a doctor as well
astake medication. It is essential that family members and carers have some basic
understanding about mental illness, its symptomology, and treatment/medication procedures
in order to effectively care for their mentally ill family member. It is important for significant
others to gain the confidence and patience to live with mental illness in the family by taking
the initiative to find out as much information as possible about the illness and to seek help
from appropriate agencies and individuals on how best to manage the situation. A study that
examined help-seeking behavior in families of schizophrenics found that the most important
external services that can be offered to affected families include: information about
symptomsand medications, behavior management techniques, and involvement with a support
group (Hatfield, 1979). This researcher remembers a case in which Psychoeducation attended
by a patient made a big difference in the process of recovery. Through Psychoeducation
sessions facilitated by the current researcher, the patient gained a better understanding of his
condition. The new knowledge helped him recover gradually to the point that he can now
work and live with his family, and not beabusive anymore towards some family members.
Attitudestoward hospitals.
Many people across the globe lack basic mental health knowledge such that, if they
ever experience having a case of mental illness in the family, they would not know how to
deal with the situation. Turner (2011) posited that programs facilitated by qualified mental
health professionals can be a source of referral for parents and provide opportunities for

39
parents to have their questions answered without the pressure of initiating treatment. In
situations where a mentally ill family member is taken to see a mental health professional,
miscommunication may ensue among the professional, the caregiver, and the person with
mental illness. Harrison, McKay, and Bannon (2004) examined pathways to urban child
mental health care and also explored the reasons why care was not received; it was found that
miscommunication between adult caregiver and service provider was the most often cited
reason for non-attendance. Shankar and Muthuswamy (2007) conducted in-depth interviews in
their study and gave evidence that mental health staff often labor under conditions of severe
resource limitations. Their perceived indifference to the needs of caregivers may partly be due
to the conditions under which they are forced to operate. This researcher is aware that
psychiatric hospital staff often neglect to pay attention to or communicate directly with carers,
despite the fact that most carers are familiar with the symptoms of their ill family member.
Many caregivers are even discouraged from seeing or consulting with the psychiatrist unless
they insist on their right to ask. Additionally, carers are not given due recognition because of
time constraints on the part of hospital staff. It is this researcher‟s belief that the treatment
process would be more effective if carers were given the time and opportunity to participate in
the treatment planning and implementation because of their personal ties with the mentally ill
individual.This researcher is reminded of a caregiver in her late 50s who had participated in
one of her training sessions. She took her 21-year-old son to a mental hospital for his monthly
visit. The mother felt disrespected when staff ignored her presence and persisted in
questioning her son in a rough and inconsiderate manner, not knowing that such behaviors
distressed her son. She was very unhappy with the hospital staff but did not say anything. She
still vividly remembers the events of that day.

40
Shankar andMuthuswamy (2007) suggested that mental health staff should undergo
continuous training and be given periodic technical support in order to be more effective in
assessing the diversity of needs of mentally ill patients and to be able to provide appropriate
holistic interventions. Through her training sessions, this researcher has become aware of a
number of valid verbal complaints about hospital services but there seems to be no formal
documentation involved. Hence, to pursue past complaints by family caregivers is ineffectual.
There are still many obstaclesto a more efficient and effective system of referral, diagnosis,
treatment, and follow up with regard to mental illness.
An editorial by Choovanichvong (2011) posits that there are many people in Thailand
with mental illnesses, and that not even 20% of them have access to proper mental health
services and care. The existing services are inadequate in terms of their capacity to provide
thorough and effective diagnosis and treatment. Most families have limited support system,
understanding, and skills to help the mentally ill. This researcher had observed that
rehabilitation services that can help patients return to regular society are inaccessible and
unavailable because of distance and scarcity.Moreover, majority of caregivers struggle to
access full care services for their mentally ill family member because of limited funds and
government restrictions. It can be concluded that immediate and effective services and
treatment facilities and expertise for people with mental illness are hard to come by in
Thailand, more so in the rural areas. This situation is clearly depicted in this documented case
of a 60-year-old father whose daughter, aged 24, suffersfrom bipolar disorder. His daughter‟s
behavior was predominantly manic and restless. She traveled to different provinces and
refused to return home. When they met in a neighboring province, the father took his daughter
to the nearest mental hospital and asked that his daughter be admitted for treatment. After a

41
few words with the daughter, the psychiatric staff simply prescribed some medicines and told
them to go home. In spite of the father‟s appeals, he was told that his daughter seems all right,
that it is a familymatter, and that the two should discuss the situation between them. Upon
returning home, the family found the girl‟s behavior quite disturbing.Consequently, the father
requested the community doctor to write to the Thungsaliamdistrict hospital on his behalf. The
district hospital then referred the case to a mental hospital in the north of the country, which
soonadmitted his daughter. She underwent treatment there for about a month, during which
time her father was finally told that she has bipolar disorder.
Attitudes toward mental health professionals.
In her study on deinstitutionalization and women, Thurer (1983) described the mental
health risks of the overburdened caregiver, typically the mother of a deinstitutionalized adult
patient. The mothergenerally suffers from the pain of her child‟s illness, the stigmatization of
having “caused” it, and the burden of overseeing a treatment plan that maybe unrealistic in
terms of time, energy, money, and demands from the rest of the family. While the
motherworks to make a living and deal with her child‟s illness, she still has to balance
conflicting advice from professionals. And when things do not go smoothly, she is blamed.
Should she discourage her child from unnecessary risks, she may be deemed as being an
overprotective caregiver(Thurer, 1983).In support of Thurer‟s position, this researcher posits
that self-supporting mothers (single parent) with a mentally ill child faces unimaginable
hardships and dilemmatic situations, almost on a daily basis. A case in point was that of a
widowed woman, aged over 60 years,who has a 30-year-old son with mental illness. The
mother constantly tried to balance her life (financially, physically, emotionally, socially, etc.).
She had to literally do multi-tasking on a day-to-day basis: look after her mentally ill adult

42
son, generate income to buy his medicines, do house chores, keep healthy for her son, make
decisions for her family, and cope with the chronic stress. She was about to take her son to a
halfway house near Sukhothai province where he can be taken care of, according to friends.
Through a community volunteer, the case reached this researcher who promptly sent word to
the mother that the situation was volatile as there is no guarantee that her son would be cared
for adequately as the halfway house is always full of homeless people. This researcher is
aware of the risks involved in sending a family member to such temporary shelters.
Consequently, the mother decided against putting her son in the halfway house.
Saxena,Thornicroft,Knapp, andWhiteford(2007) stated that, “In developing and
developed countries, limited knowledge about mental illness can prevent individuals from
recognizing mental illness and seeking treatment. Furthermore, poor understanding of mental
illness also impairs families‟ ability to provide adequate care for mentally ill relatives” (p.
878). Hong Kong has very good mental health rehabilitation facilities and services for people
with mental illness; however, there is still some degree of dissatisfaction with caregivers, as
indicated in a study by Keung Wong et al. (2012). The authors stated that their study
attempted to clarify the roles of a set of factors associated with the quality of care by Chinese
caregivers in Hong Kong. It was found that caregivers were young, have chronic illness, low
level of education, experienced high caregiving burden, are dissatisfied with mental health
services, and exhibit poor quality of care. An article in The Star (2011) mentioned about the
right to receive treatment. It stated that, “Mental illnesses are similar to physical [illnesses];
they have causes and there are effective ways to treat and rehabilitate. Furthermore, people
with mental illnesses have the right to receive treatment, as with other illnesses” (p. 38). Mass
media can make people believe anything about mental illness in negative and positive ways;

43
limited knowledge about mental illness makes society fear rather than help the mentally
ill.When media presentsexaggerated news that are against but linked with these people
(violence, crime, drugs, etc.), mental health professionals face greater challenges in assuring
the public that mental illness is not a menace to society.Media has been known to use phrases
such as “crazyfamilies” and may have misinterpreted comments by mental health practitioners
and social scientists. For example, a certain article stated that mental illness is the patient‟s
fault and that they should go away shrouded in guilt and leave the professionals to undo the
damage (Goldstein, 1981). Therefore, it comes as no surprise that results of surveys of
families indicate general dissatisfaction with the service delivery system in the treatment of
persons with major mental illnesses (Hatfield, 1982; Holden &Lewine, 1982).
Even today, many people with mental illnesses are abandoned and abused because
their carers do not know how to help them. Mental health professionals cannot take immediate
action because of various obstacles such as lack of funds, facilities, and government support.
There was thiswidely-known case of a mentally ill woman, aged 39, from the south of
Thailand who was imprisoned by her 86-year-old father in a small island for over 20
years.The father reportedly dug a canal around her shelter to prevent her from running away
until she was able to get help from a mental health professional(The Gendarmerie News
Team, 2013).
It would benefit both caregivers and the mentally ill individuals they care for to know
about and participate in Psychoeducation.And it would be more effective for both if the self-
help group can meet regularly (e.g., monthly) for therapy and rehabilitation through social
therapy. Social therapy can facilitate patients‟ return to society, much earlier than expected.
Mental health professionals are part of the treatment team that visitpeople with mental

44
illnesses and their families in order to help them gain confidencein the knowledge that they
can take care of themselves and can live with their illness with a brighter outlook in life. A
study that explored mental health literacy among family caregivers of schizophrenia patients
cited a case in which the mother of a patient admitted that after talking to the psychiatrist, she
began to understand her son‟s mental condition and his need for medication. However, she
also revealed that she learned more about her son‟s situation and how to handle him through
the Psychoeducation programs conducted by staff nurses who visited her home. She realized
that she could easily forget what she had been informed about by the psychiatrist but felt more
at ease with the home visits where she had the opportunity to take notes, ask questions, and
review what had been said (Mohamad, Zabidah, Fauziah, &Sarnon, 2012).
Past research had emphasized that collaboration between parents and psychiatric
professionals is important; however,there have been reports that parents of mentally ill
children do not find mental health professionals helpful or supportive(Ewertzon, Lutzen,
Svensson, &Andershed, 2010; Goodwin &Happell, 2007). Similar findings were reported in
studies by Clarke and Winsor (2010) and Reid, Lloyd, and de Groot (2005). Parents‟
experience of a negativeapproach on the part of mental health professionals and powerlessness
in the care provided are in line with Ewertzon et al.‟s (2010) findings. In a study on fathers‟
everyday experiences of having an adult child who suffers from long-term mental illness, it
was demonstrated that fathers felt being alienated from professional care (Johansson,
Anderzen-Carlsson, Ahlin, &Andershed, 2012). The researchersopined that it is the duty of
mental health professionals to cooperate with the government to ensure that mentally ill
people live in good and healthy conditions. In situations where a mentally ill member of the
family is neglected or abandoned because he or she is seen as a burden by the family, the

45
government should step in to fill the gap. According to Johansson et al. (2012), provision of
adequate information about disease, diagnosis, and treatment options is important and can
probably help relieve some of the burdensome experiences described by the fathers in the
study. Generally, people do not understand much about mental illness; consequently, they may
develop fearbecause of lack of knowledge or understanding. Hence, the government should
set aside a large budget to support mental health projects aimed at educating the public about
mental illness and help dispel the myths that surround the condition.
There is a need for greater awareness among mental health professionals, particularly
nurses, of the ways in which the carer can be seen as a subject who also needs care (Useros,
Espín, Parra,&Martínez, 2012).Doctors and nurses should be involved in the education of both
the mentally ill and their carers as well. The current researcher believes that there is still much
room for improvement in the system used by doctors and nurses in educating the mentally ill
and the caregiver, and this should start with giving enough time for patients and carersto ask
questions, express their uncertainties and fears, and even take down notes which they can
review later. It can be argued that both the patient and carer are able to advocate for
themselves. Ideally, they should have free and easy access to proper medical services. At the
moment, the existing services are not only inadequate but also inaccessible because of
physical distance (Choovanichvong, 2011). Thus, it is imperative on the part of mental health
practitioners to inform the public that psychiatric disorders can be better managed.
One of the more effective treatments for mental illness is physical activity and exercise
(Jakkrapan, 2011). This researcher believes that helping professionals should monitor their
clients and find ways to encourage them to continue their exercise program so that their
medications can be reduced and their quality of life improved. As it happens, the Thai

46
government had already encouraged the nation to exerciseby various means (e.g., aerobic
dance, yoga, etc.); however, the mentally ill have been largely ignored in this national
incentive. This researcher believes that the government should incorporate exercises or
physical activities into the mental health plan. This could prove to be a worthyendeavor,
especially if the exercise program is promoted as a form of ‟social therapy‟ where patients and
carers alike can interact with others.A potential consequence could be that mentally ill patients
might find their way out of social isolation.
In Thailand, nurses are a big influence to people with mental illnesses as well as their
caregivers, considering the lack of mental health professionals. They give medication, conduct
Psychoeducation, visit homes, and so on. According to Jothimani, Nagarajaiah, Joseph, and
Ramachandra (2013), nurses are very much involved in the treatment process and provision of
services for people with mental illnesses. The authors examined the sociodemographic
characteristics of nursing professionals and compared their attitudes toward the rights of
mentally ill with those of caregivers. They concluded that,due to the chronic nature and
significant impairment in the decision making capacity among mentally ill patients, both
nursing professionals and caregivers tend to control their patients and limit their freedom
rather than their rights (Jothimaniet al., 2013). Sometimes, nursesand carersact independently
of the thoughts of their patients; thus, it can be said that despite their desire to be of help to the
mentally ill, their actions can be harmful. For example, they may control their patients‟
financial expenses because they think that it will help the patients save money. However, it
could end up hurting the patients who prefer to take charge of their own expenditures, thus,
leading to conflict. There is also the possibility that patients might think their caregiversare
interested in their money.

47
Caregivers, themselves, may expect some help from clinical staff who might be so
busy that they actually have little time for them.According to Radcliffe, Adeshokan,
Thompson, and Bakowski (2012), “the needs of families and carers are often not met by the
busy staff on duty at in-patient units” (p. 751). By the same token, Pinfold et al. (2004) posited
that for many years, surveys have shown that the needs of in-patients and their carers are not
so well served; there is little evidence of systematic progress. Carers say that they want
practical and emotional support and better information from professionals. Bailey, Burbach,
and Lea (2003) demonstrated that carers‟ satisfaction with level of contact with staff trained in
family interventions was low, with 30-50% satisfaction rates relative to having time and space
to talk about their experiences, having opportunities to ask questions, helping them understand
their relative‟s mental health problem, and receiving advice. Respondent carers described
problems such as meetings being continually interrupted, not being kept updated, not knowing
when staff were free to talk, and feeling that their input was not valued. In addition, Bailey et
al. (2003) found that 45% of respondents had not met with a nurse on the unit, and that 68%
said they would have wanted more contact with nursing staff. It was also found that in-patient
nurses had greater difficulties in seeing families than community staff. Fadden (1997)
provided training in a type of family therapy to a range of mental health professionals and
found that in-patient staff were the least likely to put the training into practice. “There is a
need for nurses and other mental health professionals to better understand the parent
caregiving experience resulting from the emergence of a first episode of acute psychotic
illness” (Wilson, 2012, p. 24).

48
Attitudes toward counseling.
Carers and family members may not understand much about the nature of mental
illness and how to care for persons with the condition. They may not know where or how to
access as well as utilize community resources. Self-help groupsarethe key for caregivers and
family members to reach effective mental health care in the community. It is now recognized
globally thatcarers will continue to play an important and ever-expanding role inasmuch as
health and social services systems are resource-challenged (WFMH, 2010). The family
constitutes a major support system in the continuing care of the mentally ill in the community.
Although many families show a strong resilience in caring for an ill relative, their share of
physical and emotional distress cannot be ignored (Wongpiromsarn, 2011). The author stated
that Thai psychiatristshave acknowledged the importance of self-help groupsin explaining to
caregivers and their patients how mental illnesses relatetotheir problems which, in turn, helps
the therapy and rehabilitation process.Within the last five years, there has been a movement
towards establishing non-governmental organizations (NGOs) for patients and relatives that
aim to represent them by expressing their needs as well as helping them to help themselves
through guidance and counseling services. It is believed that, inasmuch as NGO staff
haveeither personal or acquired experiences with mental illness, they can empathize and
personally connect to patients better than doctors or nurses(Wongpiromsarn, 2011). In a
related vein, the current researcher had worked with self-help groups in establishingseveral
clubs for each subdistrict in Thungsaliam, Sukhothai province through Psychoeducation
training. Today, there are around 140 members (carers and persons with mental illnesses) who
are actively engaged in various activities, including sharing their knowledge and their skills in

49
taking care of each other‟s needs. This social interchange leads to changes in attitudes–
negative to positive – toward counseling and other related services.
Attitudes toward work.
Unemployment is common among persons with severe mental illness such as
schizophrenia and bipolar disorder, with rates of competitive work typically ranging between
10% and 20% (Anthony & Blanch, 1987; Mueser et al., 2001). Despite the high rate of
unemployment, most clients with severe mental illnesses want to work (Mueser et al., 2001;
Rogers et al., 1991). A number of researches demonstrated the effectiveness of helping
individuals with serious mental illnesses achieve competitive employment (e.g., Bond, 1992;
Crowther et al., 2001; Killackey et al., 2006; Lehman, 1995).
According to the latestavailable statistics on national supported employment data from
the USA suggested that 13.7% of the 25,383 participants are individuals with long-term
mental illnesses, according to a study by Wehman, Kregel, and Shafer (1989). In terms of job
retention in supported employment for this population, available studies are limited. A report
on supported employment outcomes in Virginia (Wehman et al., 1990) listed a 6-month
employment retention rate of 66% and a 12-month retention rate of 59% for 233 persons with
chronic mental illness, although sample characteristics in terms of previous hospitalizations,
diagnosis, or other disability information were not provided. Trotter, Minkhoff, Harrison, and
Hoops (1988) described a smaller supported employment program in Massachusetts, noting
that 35% of their sample remained employed at a 4- to 6-month follow-up. Fabian and
Widefeldt (1989) reported a 6-month retention rate of 59% for individuals with severe mental
illness in a supported employment program in Maryland. For purposes of comparison,
retention rates in supported employment for individuals with mental retardation have been

50
reported as 66% after six months and 33% after one year (Kregel, Wehman, Revell, & Hill,
1990). For individuals with severe mental illnesses, employment retention has been of
considerable concern within vocational rehabilitation programs. Earlier data emerging from
the public vocational rehabilitation program indicated that individuals with psychiatric
disabilities have the lowest employment outcomes of any other disability groups served in the
state/federal program (NIHR, 1979). In a 1984 review of studies predicting vocational success
for individuals with severe mental illness, Anthony and Jansen (1984) noted that the intent of
including individuals with severe mental illness in the 1986 Rehabilitation Act Amendments
was to improve competitive employment opportunities for those individuals for whom past
employment had been interrupted or intermittent as a result of severe disability.
The best-known and best-researched supported employment model is “individual
placement and support” (Becker & Drake, 2003). This is considered an elite category of „best
treatment‟, more effective than any alternative in use for helping individuals with severe
mental illness achieve success in competitive employment (Kazdin, 2004). The underlying
assumption is that „work is therapy‟ (Black, 1988). In other words, work is assumed to benefit
clients in non-vocational domains by increasing self-esteem, having better control of
psychiatric symptoms, improving quality of life, and so on. Unfortunately, the goal of
increasing employment rates, particularly competitive employment, has proven elusive with
traditional vocational approaches (Bond, 1992; Bond et al., 1999). Finally, it is often noted
that work can be stressful and, in fact, clinicians are often wary of encouraging clients to seek
employment for fear that they will be adversely affected (Blankertz& Robinson, 1996;
Braitman et al., 1995; Marrone&Golowka, 1999). On the other hand, other studies have not
found increased hospitalization rates for clients participating in employment programs (Bond,

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