Navigating stigmatized motherhood: self-stigma of single mothers with mental illness in Thailand

ABSTRACT

Drawing on participant observations and in-depth interviews with twenty-two single mothers with mental illness and four medical workers from a psychiatric hospital in Thailand, this article analyses the self-stigma faced by single mothers with mental illness in Thai society. Using an intersectional approach and looking at motherhood as a social construct, the article shows the connections of intersectional stigma with single motherhood and mental illness, and demonstrates its relation to gender, class, ethnicity, religion and other identity markers within the Thai socio-cultural context. Findings from the research suggest that the current gender ideology, which shapes the stigmatized mothering experiences of single mothers with mental illness in Thailand, needs to be revisited and reformed by individuals, medical workers and the state at every level.

KEYWORDS:

• Single mothers
• mental illness
• stigma
• intersectionality
• motherhood
• Thailand

Introduction

It was a hot Friday morning in Bangkok when Lynn,¹ a social worker from the NGO where I conducted fieldwork for my research, invited me to visit some mothers and their families with her. Lynn’s NGO assists single mothers in the Bangkok metropolitan region; many of them had contacted her and told her that their lives had become onerous, both materially and spiritually, and asked whether they could get some help. As a mediator, Lynn contacted the Ministry of Social Development and Human Security; after waiting for two weeks, however, she received a negative response. She then used her personal connections to get in touch with some large enterprises that had a sense of social responsibility. They were willing to provide financial assistance, but asked Lynn for a report and a budget plan. As a gatekeeper of my fieldwork, Lynn knew that this would be a valuable opportunity for my research, so she invited me to visit some single mothers with her, and to write a report together. We believed that, in the face of the COVID-19 pandemic, this would allow us to see the harsh realities of life in these challenging times and to witness difficulties that single mothers may not have experienced before the pandemic.

After visiting some single mothers and their children with Lynn, it was clear that the financial burden had impacted their lives significantly. Many of them had lost their jobs, or only received minimum payment, because of the pandemic. In addition, some single mothers without family support needed to balance their working and family time; with the schools closed and teaching moved online, they had to make time to focus on their children’s learning, despite problems related to the lack of computers and internet connections. In this uncertain situation, many single mothers explained that they were very stressed, didn’t know what they could do and were feeling hopeless. Some even used terms like ‘break down’ and ‘give up life’ to describe their current feelings.

As painful as these stories were, Lynn warned me that the next single mother we were going to visit had even greater problems. We drove for about an hour and arrived at X hospital, a psychiatric facility located in Bangkok. In the cafe of the hospital, I saw Ghee, a woman in her mid-thirties, wearing simple but clean clothes and accompanied by Dr. Paw. Ghee is a single mother with mental health problems; because of the COVID-19 pandemic and stress, her condition had become severe and she required medication and regular follow-up visits with Dr. Paw. The meeting lasted about an hour; apart from Lynn and Dr. Paw discussing Ghee’s condition and treatment plan, the thing I remember most clearly is that Ghee was emotionally unstable. She cried and told us sadly,

I tried very hard to be a good mother and take care of my kids, because their father abandoned them, and they only have me now … I listen to the doctor very much and actively cooperate with the treatment and medication. I know that my condition does not look good to others, they all think ‘single’ and ‘mental illness’ are not associated with good mothering, but I really want to be a good mother to love my kids. I don’t want them to lose even me.

Ghee’s words revealed her marginal and stigmatized status and led me to think about the ‘double vulnerable identities’ of many women like her in Thailand, being a single mother and living with mental illness. Many studies have shown that single mothers experience severe discrimination and stigma. Single Parent Rights conducted a study examining the experiences of single-parent discrimination in the UK in 2020, which received a total of 1146 responses through an online questionnaire, of which 1083 were from single parents. The study found that 80% of single parents experienced discrimination, and single mothers were subject to more discrimination than single fathers (Single Parent Rights 2021). Lauster and Easterbrook (2011) suggest that, in Canada, single mothers face discrimination primarily based on their economic marginalization rather than other forms of prejudice. Zhang (2023) also demonstrates that single mothers in Thailand experience intersectional stigma in their everyday lives and face multiple forms of oppression and marginalization based on their gender, class and ethnicity status.

Thus, it is not only the high levels of stress associated with being a single parent, such as everyday problems, social isolation and financial stress, but also the stigmatization at the hands of family and society, that result in single mothers being at high risk of emotional distress and mental illness. Single mothers and their children are more likely to experience some form of physical or psychological problems, mainly due to exposure to poverty, maternal depression, poor parenting practices and social exclusion (Freeman and Dodson 2014; Taylor and Conger 2014). In his book Stigma: Notes on the Management of Spoiled Identity, Canadian sociologist Erving Goffman (1963) discussed the idea of stigma and what it is like to be a stigmatized individual. He defined stigma as the ‘situation of the individual who is disqualified from full social acceptance’, which reduces the sufferer ‘from a whole and usual person to a tainted, discounted one’ (3). In accordance with this definition, I observed that single mothers with mental illness are stigmatized in Thailand: they do not enjoy full social acceptance by others, and they constantly strive to adjust their multiple social identities, as single mothers and as individuals with mental illness. This article focuses on their daily lives, aiming to unravel the discrimination and prejudice they face, to better understand marginalization and stigmatization in Thailand from an intersectional perspective.

Mental illness in the Thai context

According to the World Health Organization (2021), mental disorders are associated with abnormal thoughts, perceptions, emotions, behaviour and relationships with other people; they include depression, bipolar disorder, schizophrenia, dementia and other developmental disorders. Mental health problems have become an important issue worldwide, and the number of people with mental disorders is increasing. In 2018, approximately 359 million people worldwide suffered from depression, bipolar disorder and dementia (World Health Organization 2020). The 2021 Annual Report from Thailand’s Department of Mental Health (2021) reported that mental health issues had become a severe problem in Thailand, which had the highest suicide rate in South East Asia. According to this report, some three million people were suffering from mental illness (out of a total population of around seventy million), but there were only twenty-one in-patient psychiatric facilities nationwide, with 4288 psychiatric beds.

These reports suggested that there had been improvements in mental health conditions and treatment in Thailand. However, there are still many ongoing mental health problems and challenges, as psychological treatment is usually not covered by the country’s Universal Health Coverage Scheme (UHC) and due to the minimal medical resources, there is a lack of medications for psychiatric treatment covered by the social security system and UHC. Appointments are often delayed, and only a few specific medications are provided, offering patients no choice. At the same time, the cost of talk therapy is still a financial burden for many people. Therefore, the number of people who actually make use of mental health services is relatively low; most patients are reluctant to disclose their condition and hesitant about receiving professional medical treatment. This reluctance can be attributed to the long-standing and deep-rooted stigma and discrimination against mental illness in Thai society (Kittirattanapaiboon et al. 2017; Pitakchinnapong and Rhein 2019).

Many studies conducted in Thailand (see Kaewprom, Curtis, and Deane 2011; Kongsuk et al. 2017) have acknowledged that the limited number of psychiatric hospitals and the increased number of people with mental illness have become a problem for the country’s socio-economic development. Rhein (2023) suggests that the shortage of clinical psychologists carries broader societal implications in Thailand, including adverse economic effects, an added burden on the healthcare system, and an unmet need for mental health care, particularly among vulnerable groups such as children, teenagers, refugees and the elderly. Academics and policy-makers have offered insightful suggestions to medical professionals and the Thai government to address such issues. However, the perceptions of mental illness and their role in the stigmatization of marginalized people in the Thai socio-cultural context are relatively understudied in the current literature, leaving a gap that this article seeks to address by exploring the phenomenon of stigma among single mothers with mental illness in Thailand from an intersectional perspective.

Stigma of mental illness

People with mental illness often suffer from stigmas that permeate the lives of these marginalized people in many different, negative ways, such as social discrimination, lack of financial support, denial or delay in treatment, and rejection by family members (Corrigan and Watson 2002). Within the South East Asian context, empirical investigations in Thailand (Pruksarungruang and Rhein 2022), Malaysia (Munawar et al. 2022) and Singapore (Subramaniam et al. 2017) have indicated that a substantial degree of stigmatization is associated with people with mental illness and this severely impacts their everyday lives. According to Goffman (1963), stigma is a powerful social phenomenon experienced by individuals who share a profoundly discrediting attribute; it is socio-culturally constructed and leads to the unfair treatment of those individuals who are deviant from the majority, such as people with mental illness (Ahmedani 2011). Studies on stigma have been developing since Goffman and shifting from the micro level to the macro level to explore its social mechanisms (Clair 2018). The stigma concept has then been productively applied to various circumstances, across a range of differences in physical, behavioural and mental characteristics. Link and Phelan (2001) describe stigma as ‘involving the co-occurrence of components of labeling, stereotyping, separating, status loss, social rejection, and discrimination in the context of power differentials that allow one group to devalue another’ (363).

Health-related stigma is defined as

a social process or related personal experience characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group identified with a particular health problem. (Weiss and Ramakrishna 2006, 36)

Considering the social aspect of illness, Stangl et al. (2019) highlight that certain diseases, including leprosy, tuberculosis and mental illness, are the targets of stigma. Patients with such stigmatized diseases are excluded from normal social life, which in turn impairs their treatment and recovery. Moreover, other features of patients, such as gender, age, socio-economic class and family background, might be the target of stigma, with adverse effects on the access of these patients to services. Health-related stigma is common for those suffering from chronic illnesses, such as people living with HIV and people with mental illnesses. Zhang (2023) argues that the different forms of stigma and discrimination associated with single mothers living with HIV in Thailand have demonstrated a negative influence on HIV prevention and treatment in the country. Likewise, Kaehler et al. (2015) suggest that leprosy-affected people are still stigmatized by health providers and by their neighbours in Thailand, which results in delays in diagnosis and poor compliance with treatment.

Many scholars have attempted to explain the causes of the stigma of mental illness and the negative impacts of such stigmatization on individuals, families and society (Mannarini and Boffo 2015; Parker, Gladstone, and Chee 2001). They argue that mental illness stigma is a well-known social problem and hard to tackle; it is a burden for those who suffer and can prevent them from seeking help (Hinshaw 2007). The impression of people with mental illness as dangerous and violent permeates society, even as knowledge of mental illness increases (Angermeyer and Matschinger 2005). For instance, in China, a communist country, stigma against mental illness is pervasive as it has been regarded as a source of social insecurity and instability (Guo 2016). In Thailand, where there is a strong belief in animism and the supernatural, many people hold the view that mental illness is caused by non-living things and spirits, thus contributing to the stigma directed towards the mentally ill and other marginalized people (Burnard, Naiyapatana, and Lloyd 2006). A study in eight Asian countries by Kudva et al. (2020) revealed that the majority of people in Thailand had a negative attitude towards mental illness and demonstrated the existence of stigma, especially vis-à-vis marginalized women, such as transgender women, sex workers and single mothers. Jantorn and Roomruangwong (2019) argue that female sex workers have been shown to have at least some degree of emotional distress; however, there is still a lack of direct mental health support for them in Thailand. According to Rhein (2023), the Thai government has indeed made efforts to enhance mental health awareness, but obstacles persist. These obstacles encompass the cultural taboos mentioned earlier, a historical inclination towards spiritual or supernatural solutions, misconceptions regarding mental health conditions, and restricted availability of mental healthcare services for the elderly and marginalized people, such as sex workers, LGBTQ people, stateless populations and single mothers.

Single mothers in Thailand

It is hard to estimate the exact number of single mothers in Thailand, as it is challenging to obtain comprehensive statistical data from the Thai authorities. However, recent studies suggest that the number of single parents, especially single mothers, has increased significantly. A report released by the United Nations Population Fund and the Office of the National Economic and Social Development Board (UNFPA and NESDB 2016) estimated that the number of single-parent households in Thailand had increased from 970,000 in 1987 to 1.37 million in 2013, and that 80% of these were single-mother families. Although the number of single-mother families in Thailand is increasing, social welfare targetting them is very limited; indeed, there are no welfare policies specifically designed to provide government assistance to single mothers. The majority of available support comes from general social security programmes, although other forms of commercial insurance may cover some single mothers. The Social Security Fund was established under the Social Security Act B.E. 2533 of 1990 to provide employment security and stability for Thai citizens. However, according to a report by the Ministry of Social Development and Human Security (2021), 16,413,666 people – just 23.52% of the total population of 69,799,978 (World Bank 2020) – received support through the Social Security Fund in the Thai fiscal year 2020.

Research in Western countries has shown that mothers with mental illness face many challenges and that their needs are not always well understood or fulfilled. The topic has received increasing attention from researchers and governments over the past two decades (Perera, Short, and Fernbacher 2014). However, in many developing countries like Thailand there is still a scant understanding of how different types of mothers, including single mothers, experience motherhood, and little research into mothering experiences associated with mental illness stigma from an intersectional perspective.

Incorporating intersectionality to understand stigmatized motherhood

Turan et al. write that intersectional stigma is ‘a concept that has emerged to characterise the convergence of multiple stigmatized identities within a person or group, and to address their joint effects on health and wellbeing’ (2019, 1). An intersectional perspective not only allows researchers and health professionals to think holistically about how multiple stigmatizations affect individuals’ behaviours and health outcomes, but also highlights the importance of considering and incorporating all identity categories when making policies to reduce health disparities and inequalities. In this research, my analytic approach builds on Weiss, Ramakrishna, and Somma’s (2006) definition of health-related stigma – the social process of the individual who is disqualified from a full social acceptance as a result of a particular health problem – but also incorporates Crenshaw’s (1989, 1991) intersectionality framework. By exploring how single mothers with mental illness suffer from multiple levels of oppression and stigmatization based on their gender, age and socio-economic class, this article furthers understanding of the affects of intersectional stigma for these women in negotiating their family roles as mothers, and the impact of such stigma on their mothering experiences.

Research methodology

Ethical perspectives

In the context of research, ethics can be seen as a set of moral principles that aim to prevent researchers from harming those they research. In investigating sensitive topics with vulnerable groups, there are several issues that researchers must consider before starting, as well as institutional approval. I adopted the four ethical principles of Beauchamp and Childress (1994) during my fieldwork, namely autonomy (informed consent), non-maleficence (do no harm), beneficence (benefits of the research outweigh the risks), and justice (research strategies are fair and just). Therefore, all research participants provided written or verbal consent before joining the study and their participation was voluntary; I adhered to the protocol of the study and the regulations of the organizations involved to ensure that no harm was done to participants; I developed strategies to achieve benefits, such as inviting psychologists to talk at the NGOs, organizing workshops with social workers to promote wellbeing, drafting policy recommendations and submitting these to the Thai government; finally, study participants were allowed to withdraw from the study without any repercussions, and they could submit complaints and suggestions anonymously. In appreciation of their time and contribution to knowledge production, participants received an honorarium of 1,000 Thai baht (USD 30). Given the sensitivity and complexity of mental illness and gender issues in Thailand, all the study participants were clearly informed that participant observation was a part of the research, that I would not take any photos or videos, and that their identities would be kept confidential.

Besides these four ethical principles, as a male researcher conducting sensitive research with a group of vulnerable and marginalized women, I also needed to be very cautious about gender and trauma-related topics at all times.

Field site and participants recruitment

The qualitative research, comprising participant observation and interviews, was conducted in 2020 and 2021 at X hospital in Bangkok, and participants were recruited through advertising on announcement boards at the hospital and referrals from doctors, social workers and NGOs.

X hospital is one of the largest national-level psychiatric hospitals in Thailand under the Department of Mental Health, with 750 beds and nearly fifty medical workers. It was opened as a mental asylum in the late nineteenth century, and later changed its name to reduce the stigma for patients visiting psychiatric hospitals for treatment. In 2021, a total of 127,845 out-patients and 5019 in-patients were treated there. Its medical space mainly comprises the psychiatry department buildings, which form a closed area for patients admitted to this department, divided into an outpatient division and an in-patient division. My participant observations and interviews were conducted in the in-patient division and hospital meeting rooms.

Sampling methods

I adoped a purposive sampling technique, and only recruited study participants who met the following criteria for this research. (1) Single mothers with mental illness who self-identify as a single mother aged seventeen or older; have the experience of being admitted and/or receiving treatment at the psychiatry hospital; are willing to communicate; and have been living with mental illness for at least one year. (2) Medical workers with at least one year’s working experience in X hospital, having professional knowledge of gender and mental health, and willing to share their insights. In total, twenty-two single mothers with mental illness and four medical workers from X hospital participated in this research. Table 1 presents the socio-demographic information of the study participants.

Table 1. Socio-demographic information of the twenty-two study participants (single mothers with mental illness).

Characteristics	Number
Category of single motherhood
Unmarried pregnant women	2
Never legally married mothers	3
Deserted mothers	6
Divorced mothers	6
Widows with dependent children	4
Other single mothers	1
Age
22–31	5
32–41	6
42–51	6
52–61	3
>62	2
Years of diagnosis of mental illness
1–5	7
6–10	9
>11	6
Number of children
1	9
2	7
3	4
4	2
Religion
Buddhist	17
Muslim	2
Christian	2
Other	1
Highest education level
Primary	3
Lower secondary	4
Upper secondary/Vocational education	7
Undergraduate degree	6
Postgraduate degree	2
Occupation
Home duties	4
Self-employed	5
Casual/Part-time job	5
Full time office job	2
Unemployed	6
Hometown neighbourhood
Urban	14
Rural	8
Family income (in Thai Baht)
<10,000	3
10,001–20,000	4
>20,000	15
Health insurance
30 Thai Baht Scheme	16
Social Security Scheme	4
None	2

The four medical workers in X hospital who participated in this research all focused on treating female patients. They all held postgraduate degrees in medicine, nursing, public health or counselling, and had at least five years’ work experience. One of the medical workers was involved at the executive level in the hospital, while the other three worked at the clinical level.

Data collection and analysis

A qualitative research methodology was adopted in order to reveal the complexity of the intersectional stigma of mental illness and single motherhood. It aimed to ascertain how social experience is constructed and what it means in practice by focusing on the nature of social reality.

In-depth interviews, medical records from the hospital and field notes were collected for this study in 2020 and 2021. In the interviews, the mothers and workers had the opportunity to share their experiences, opinions and stories with me. The interviews, lasting thirty minutes to an hour were conducted by me and my Thai assistant, and took place mainly within the hospital offices and in the public open space outside the hospital. They were conducted in Thai and recorded with consent. The single mothers were first asked why they came to the hospital; follow-up open-ended questions were then used to explore their life experiences outside the hospital and their mothering experiences with their children and family members. In the interviews with medical workers, the first question concerned their motivation to become mental health workers in a psychiatric hospital. They were then given chances to share their experiences of prejudices they felt in their daily lives and relationships and their views on single mothers with mental illness.

Field notes based on participant observation at the hospital also provided essential data for analysis. Participant observation is crucial for a researcher to delve into not only the explicit culture but also its tacit aspects, to ‘gain a greater understanding of phenomena from the point of view of participants’ (DeWalt and DeWalt 2002).

After cross-checking, the recorded interviews were transcribed in Thai and English, coded and analyzed in accordance with a thematic analysis approach. I used both Excel and NVivo 12 in the coding process, and an initial coding scheme was developed in line with intersectionality theory, topics outlined in the interview guide, and the narratives obtained from the interviews. When I re-read the narratives acquired through data collection, I focused on gender, class and other identity markers to develop a corresponding code to easily identify recurring words and ideas and to analyze the connections and relations among the different categories.

Findings and discussion

The twenty-two single mother study participants ranged in age from twenty-two to sixty-seven years, with a median age of forty-two. They were classified into six categories of single motherhood, most falling into the categories of deserted mothers, divorced mothers and widows with dependent children (Table 1). All of them had been diagnosed with mental illness at least one year prior to the research and all received treatment from X hospital. Of the sample, 64% were from urban areas, mainly from Bangkok and the neighbouring provinces, and 68% reported monthly household incomes of more than 20,000 Thai baht.

In this research, all single mother study participants reported that they had negative views of themselves and experienced negative attitudes and discrimination from other social groups regarding their single mother identity and mental illness status. In addition to gender and mental illness-related stigma, participants also discussed stigma related to their age, socio-economic class and family backgrounds. They saw this intersectional stigma as interlinked and interconnected with their motherhood, and discussed how they negotiate their roles as mothers and practise their motherhood in different ways in Thailand.

Self-stigma: resist, struggle and accept

All the single mother study participants perceived that they would be stigmatized by others because of their single mother identity and mental illness status, and they all believed that in Thailand the stigma of mental illness is worse than that of single motherhood. The public perception of mental illness, on the one hand, is rooted in traditional Thai cultural norms of ghosts and spirit worship (Burnard, Naiyapatana, and Lloyd 2006) and, on the other hand, is facilitated by modern Western psychiatry, in which mental illness is understood as a ‘chronic disease’ that needs long-term care and management (Thanaudom, Jampathong, and Udomratn 2018).

Thailand is a Buddhist country that is known for gender inequality and gender discrimination, where women occupy a lower status than men (Zhang 2021). The traditional discourse views the gendered subjectivity of Thai women as coherent and also as dichotomous: ‘good’ versus ‘bad’, or ‘modern’ versus ‘traditional’ (Thaweesit 2004). Born with ‘lower karma’, Thai women are taught to suffer bravely and sacrifice themselves. In traditional Thai families, the man is the head of the household, and Thai family norms encourage women to be selfless, nurturing, subordinated and devoted to their husbands, so that any woman who does not meet this expectation is considered a ‘bad’ woman (Fresnoza-Flot 2021).

Many people with mental illness face a double challenge: on the one hand, they struggle with the symptoms and disabilities caused by their illness; on the other hand, they are challenged by stereotypes and prejudices that stem from misunderstandings about mental illness. There are two types of stigma: self-stigma is the shame that people with mental illness turn against themselves, while public stigma is the reaction and response of others to people with mental illness (Corrigan and Watson 2002). This study found all the single mothers with mental illness interviewed experience self-stigma: the internalization of ideas and the reaction of those affected by a particular form of stigma. Their self-stigma is characterized by a subjective perception of devaluation, marginalization, secrecy, shame and withdrawal related to both their single mother identity and their mental illness status in Thailand.

Pip, a thirty-six-year-old single mother with schizophrenia, told me that she does not like talking to other patients, and she is very careful because ‘they are psychotic lunatics (khun ba), there is no cure for them and they can’t take care of their children and families’. In her eyes, mental illness is closely related to madness, people with mental illness are abnormal, and it is a stigma she desperately wants to avoid. Although Pip had schizophrenia, she did not consider herself a patient because she was aware of the discrimination and stigma directed at other patients, and therefore, she tried to dissociate herself from them. Pip’s self-stigma is implicit rather than explicit, she does not directly deprecate and look down on herself, but she has a deep prejudice against mental illness and discriminates against others with mental illness.

Some other study participants explained that self-stigmatization is a gradual and differentiated process; it is a social construct and is influenced by many factors and people. In this study, many participants had no prior knowledge of mental illness, and had to glean information from family members, friends, healthcare workers and the mass media. The urban–rural gap plays a significant role in Thailand’s socio-economic development; this is reflected in the fact that many single mothers from rural areas experience more severe self-stigma than those from cities. For these rural women, especially, their self-stigma begins when they first experience mental illness and treatment, and it has a profound impact on their family and social lives from then on. Pu, a fifty-year-old long-term patient with bipolar disorder, shared her life story and told me how being a single mother who is mentally ill made a huge difference to her life.

Because of my mental health condition, I’ve suffered for over thirty years. To others, I’m a phuying-khun-ba [an insane woman]. I never felt like I was mentally ill … In the beginning, after my first discharge from the hospital, I thought about suicide, to leave this world. I asked myself why this happened to me. Is it my karma? Is it because I did something bad in my last life? My ex-husband and I got divorced because of my mental illness, and my family members were scared of me … Indeed, I don’t have a place in my family and our village … they all hate me even more … until now, there are still some people who believe mental illness is equal to crazy … and we are not qualified to be mothers, because we will harm other kids … People like us have been marginalized in Thailand, I am used to this discrimination, I will not fight, I have learned to accept, I think it is my life, it is my karma.

Pu was admitted to the psychiatric hospital three times due to chronic mental illness. I met her in 2021 when she visited X hospital with her sons. She introduced herself to me: ‘I’m an abnormal person, I’m bipolar, one of the six serious mental illnesses’. I was shocked by her self-introduction because this was the first time I had heard a patient calmly say that she was not normal and identified herself as having ‘one of the six severe mental illnesses’. After a long struggle with herself, Pu had gradually accepted her identity as a patient and started taking medication. As Corrigan and Rao (2012) argue, people who live with conditions such as schizophrenia are also vulnerable to endorsing stereotypes about themselves. The illness has affected how Pu felt about her body and how she interacted with others. She expressed her distress in a letter to the social worker; she was often crying and constantly criticizing herself. It was easy for her to dwell on the past because of her low mood; as a single mother with mental illness, she blamed herself for not being a normal mother and giving her children a happy life. During interviews, doctors recommended that I should be a good listener and learn how to distract study participants like Pu from their pain and negative emotions, so I tried to avoid mentioning sensitive issues that may affect their feelings and trigger psychological trauma.

Like Pu, most of the study participants from rural Thailand that I met at X hospital initially denied their doctors’ diagnoses and would not admit to being mentally ill. Not only because many people in rural areas equate mental illness with madness, adding to the shame and stigma, but most importantly, due to the multiple forms of inequality constructed by the socio-economic gaps that exist in Thai society. In this study, because of deeply rooted self-stigma and the fear of being discriminated against, abandoned, or even hurt, many single mothers from rural Thailand refused to accept the doctor’s diagnosis. Still, they chose to keep it a secret, thereby delaying treatment and worsening their condition.

The study revealed that participants with different educational levels had different perceptions of their own identities and experiences. For some highly educated single mothers from urban areas, their views on single motherhood and mental illness are more complex, or even dramatic. Mint, a thirty-eight-year-old musician, shared her story with me:

You know, many painters and musicians are prone to emotional problems, we need inspiration, we need to vent … so when my ex-husband divorced me because he thought that I was crazy, I didn’t think it was a big deal, just because he didn’t understand me. Now, there are more and more single mothers, and we can accept it … I think it’s better for my daughter to be with me, so after the divorce, I took care of my daughter with my parents … Maybe because of the pressure of work, I can’t control my emotions very well, so I sometimes get angry with my daughter, and make her very scared of me … I don’t believe the doctor said I have schizophrenia … you know, I’ve seen mentally ill people, I’m different, they are dangerous, but I’m just emotional … I blame myself because my daughter is scared of me … I want to be a good mother, I don’t want her to think that I’m abnormal and she has an insane mother … 

Mint experienced hospitalization and mental illness in a quite different way from Pu. As a well-educated younger woman from Bangkok, Mint may have felt ‘desperate about the future’ as she could not control her life. However, her socio-economic class and education level emboldened her to confront the stigma and prejudices of others. She would share her story with friends of a similar in age and educational background to seek help, because she knew that similar experiences made it easier for them to accept her and understand her as a single mother with mental illness in urban Thailand. Comparing Mint to Pu suggests that living environment and education level affect patients’ self-stigma, and those with higher-level education in urban areas suffer less self-stigma. Similar to the patients themselves, many family members from rural areas internalize negative perceptions and attitudes due to public ignorance and discrimination against mental illness and thus withdraw from social networks, which exacerbates their family conflicts and precarious life situations.

Pai, a forty-two-year-old single mother who is a civil servant in the central government, also strongly contested the diagnosis given by the doctors and attempted to hide her experience of mental illness, even though her parents are medical doctors. Pai shared with me that she has some advantages over other participants in that she can use her family’s social connections to help her keep her mental illness a secret and thus avoid stigma and discrimination. In her eyes, although a single-parent family is not a perfect family and is not fully recognized by society, the increasing number of single-parent families in Thai society means that the public has gradually begun to understand and accept them. However, mental illness brings about severe discrimination and stigma; it will make people look down on you, it will make you lose your family and job and, ultimately, it will mean that you are locked up and lose your freedom. The Thai government can accept a single mother as a civil servant, but it will never hire a mentally ill staff member.

Although Pai’s parents are professional doctors and she herself has a high level of education, she still believes that mental illness represents a terrible stain on her life that must be concealed. If she admits that she has a mental illness, her future will be ruined. So, through her family connections with the hospital, and using her own powers of persuasion, she cajoled doctors to change her diagnosis from schizophrenia to a psychological problem of emotional instability. As she explained to me:

I know it is bad to fake my hospital history and record, but I can’t help it. As a single mother, I have a lot of pressure … . If my supervisor, my workplace, knows my mental health condition, I’ll be fired, I’ll have no income, my kids will be discriminated against, and I’ll lose everything … Especially when people around you believe and tell you that mental illness is a form of retribution and bad karma, you will gradually believe it and blame yourself … You know my parents and I both have the knowledge, and we know that this is just a common disease, but in Thailand, we care more about what others think of us and the serious social consequences of mental illness … Life is hard for us, single mothers with mental illness, but I am lucky to have my parents to back me up, and I still have a good job to make money … 

Pai’s narrative is a clear indication of the serious stigma around mental illness among the Thai public, which increases the self-stigma of people with mental illness and their family members. Mental illness can lead single mothers to face multiple forms of oppression and marginalization, one of the most severe consequences being the loss of jobs and income. As a well-educated civil servant, Pai’s considerable income has allowed her to raise her children alone, and the understanding and support of her parents have also brought some help to her as a single mother and have led to improvements in her mental health. In this study, many single mothers from urban middle-class families in Thailand were aware of the social stigma of mental illness and, therefore, resisted it in different ways. Some were even able to use medical discourse to benefit their situation because of their socio-economic class and their parents’ good connection with hospitals and government. However, many study participants from the rural areas, especially those older generation single mothers, were aware that public stigma would affect their job choices and chances, and their families also preferred them to stay at home rather than go out and cause ‘trouble’ because of the stigma.

For older adults, stigmatized attitudes toward mental illness have been shown to be a major barrier for them to seeking mental health treatment; suffering from mental health problems has also been described as a main cause of the increased risk of suicide in older people (Knaak, Mantler, and Szeto 2017). In this research, I also observed that in the case of older single mothers from rural areas, their families were reluctant to bring them home and take care of them, even when they had recovered from mental illness and were discharged from the hospital. Their relatives believed they would not be able to earn money when discharged, and would thus become a burden on the whole family. Some were also concerned about the potential danger to themselves and stigma from outsiders.

Lynn, the senior social worker from a single mother-related NGO introduced at the beginning of this article, gave her opinion:

To be honest, not many single mothers can get psychological counseling services from the government. Compared with other issues, the government does not pay much attention and just ignores this group. They think it is enough to have NGOs to help them, but we also need more resources to carry out our work.

Maintaining good mental health is essential for single mothers and their family relationships. However, the Thai government seems to have failed to provide adequate support. Recent studies (Stevenson 2021; Yoopetch 2020) have shown that for many marginalized women in Thailand, such as sex workers and single mothers, an increase in gender and medical knowledge, changing socio-cultural perspectives, and participation in economic and capacity-building activities are the key factors that contribute to their self-empowerment to fight against discrimination and stigmatization in their daily lives.

Reflections and conclusion

My empirical study on single mothers with mental illness uses Crenshaw’s (1989, 1991) intersectional approach, looking at motherhood as a social construct (Connell 2009), which allows me to explore the self-stigma faced by single mothers with mental illness in Thai society. It uses a gender perspective to make theoretical, methodological and policy contributions to research into the stigmatization of single mothers with mental health issues in Thailand.

First, by reviewing the history and the background of psychiatric development in Thailand, the article provides a picture of mental illness and its impact within the Thai socio-cultural context. Scholars who adopt feminist methodologies have enquired how the intersections of gender, race and class serve as the historical and theoretical basis for intersectional stigma, and have explored how such intersectional stigma negatively affects the health of marginalized populations, such as people living with HIV and people with mental illness. Zhang (2023) emphasizes how stigmatization is manifested at different levels and affected by social distance in Thailand, and how self, family, community and state perpetuate the oppression and vulnerability of single mothers there. This article has shown the links between mental illness and stigmatization at the level of the self, and demonstrates that intersectional stigma is related to gender, class, ethnicity, religion and other identity markers within the Thai socio-cultural context.

Second, the article shows that single mothers with mental illnesses do not fit into the normative gender ideals of motherhood in Thai society, whether as single mothers or as mothers with mental illness. However, despite experiencing varying degrees of stigma and discrimination from self, family and Thai society, they still try to find ways to negotiate, perform and practise their stigmatized motherhood in Thailand. Therefore, this article enhances our understanding of how mental illness influences the social construction of single motherhood, and challenges the view that the stigma of single mothers can be seen as a homogeneous experience in Thailand.

Third, by analyzing the rich narratives obtained from in-depth interviews and participant observations at X hospital, this article shows that gender inequality continues in Thai society, despite policy commitments to reduce it, and that marginalized women such as single mothers with mental illness are still suffering severe discrimination and stigmatization. The study also shows that gender inequality is experienced at the level of the self. Self-stigma and normalizing judgments shape single mothers’ experiences, so that they strive to meet the gender roles and expectations set by Thai society, and accept dimensions of gender inequality in their everyday lives. Moreover, cultural and religious structures specific to Thailand serve to reinforce this stigmatization of single mothers with mental illness.

Last but not least, self-awareness and self-adjustment need to be raised in the single mothers themselves to enable them to cope with stigmatization and to challenge gender inequality in Thailand, just as the social structures that continue to position and respond to women as unequal need to be addressed. For single mothers in Thailand, self-empowerment is essential for them to confront gender inequality, which is deeply rooted in the Thai socio-cultural contexts. Simultaneously, developing policies that contribute to enhancing gender equality, female empowerment and women’s rights protection remains an urgent agenda for the Thai government. In conclusion, if Thailand is to move towards gender equality and a gender-friendly position, the current gender ideology that shapes the stigmatized experiences of single mothers with mental illness needs to be revisited and reformed. This will require efforts at every level, from everyday practices to structural change, by individuals, medical workers and institutions, to consider how multiple markers of marginalization compound the risk of stigmatization of single mothers with mental illness – and then to improve its gender and social welfare policies accordingly.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was funded by the Research Grants Council of Hong Kong.

Notes

1 All names used in this article are pseudonyms.