Development of a Monk-Led Elderly Mental Health Counseling Program in Thai Buddhist Communities

Abstract

The increasing mental health challenges among elders demand specialized interventions, especially within Thai communities where resources are limited and stigma persists. While monks offer spiritual support, there is a gap in addressing complex mental health needs. This research aims to develop a monk-led elderly mental health counseling program in Thai Buddhist communities. From January 2023 to March 2024, this study underwent four phases. Initially, qualitative interviews with thirty-six monk and elder participants elucidated requirements. The program development integrated findings from the requirement study, the Solution-Focused Brief Therapy process, and Buddhist mindfulness principles to create a prototype. The quality assessment involved expert content validation, feasibility examination by stakeholders, and a small-scale pilot testing with five monks. Finally, the feasibility of the program was assessed with thirty-two monks. The study reveals three key components of the monk-led elderly counseling program focused on mental health: the counseling process known as MPS-MAV-PI (an Introduction to Mindfulness, Identifying Problems, Assessing the Severity, Mindfully Observing Thoughts and Emotions, Acceptance, Visualizing Success, Planning Strategies for Problem-solving, and Implementation and Subsequent Monitoring), the C-TIME strategy (Collaboration, Training Manual, Implementation, the Monitoring, and Evaluation), and the program manual. Moreover, feasibility assessments among monks show the high feasibility of the program for implementation. The monk-led counseling program holds promise in addressing these challenges, with high feasibility indicating potential effectiveness and scalability. Future research will prioritize evaluating its cost-effectiveness and overall effectiveness.

1. Introduction

The global rise in elderly populations, particularly in aging societies like Thailand, has led to increased mental health challenges, including depression and anxiety disorders.

From 1994 to 2021, the number of older adults in Thailand surged from 4.01 million to 13.36 million, with their share of the total population rising from 6.8% to 19.6% (National Statistical Office 2022). The aging index, which compares the number of older adults to the younger population, more than doubled from 22.6% to 120.5% (National Statistical Office 2022). In 2021, 15.5% of Thai older adults reported feelings of anxiety or depression, often linked to living alone or not being with family (National Statistical Office 2023). The percentage of older adults living alone increased from 7.9% in 2016 to 12% in 2021, potentially due to factors such as the death of a spouse, divorce, or abandonment by children and grandchildren. Moreover, the suicide rate among older adults continued to rise in 2021, with those aged 60–64 showing higher mortality rates than those aged 65 and older since 2017 (National Statistical Office 2022, 2023). This highlights the urgent need for specialized support for the elderly, as changing family structures, financial difficulties, and evolving societal values increase feelings of loneliness and lower self-esteem among older adults. These issues contribute to a range of mental health problems, making it crucial to implement targeted interventions to effectively address these challenges (Bódi 2005; Yoelao et al. 2017; World Health Organization 2017; Amiri 2018; Khan 2019; Asian Development Bank Institute 2019; Oon-arom et al. 2021).

Mental health covers a wide range of cognitive and social skills, emotional awareness and regulation, empathy, resilience, and the harmony between body and mind issues, affecting everyone’s well-being (Gautam et al. 2024). Dementia is a condition that is more commonly seen in elders. Dementia, specifically referring to cognitive impairments that disrupt daily functioning and worsen over time, is particularly relevant to older adults (Aggarwal et al. 2022). Those with dementia often experience significant emotional distress, including anxiety and depression (Lal and Kumar 2023). By focusing on enhancing overall mental health, we can improve well-being across the elderly population and potentially prevent or delay the onset of dementia in those who are at risk (Friedman et al. 2017; Tsai and Shen 2022). In this context, both caregiver and societal support are crucial.

By 2021, only 10.4% of Thai elders had caregivers. Of these, over half (59.9%) were their children, followed by spouses (23.0%), other relatives (14.3%), and a small percentage (2.8%) came from other sources like domestic workers, service center staff, or friends (National Statistical Office 2022). Therefore, societal involvement is key in addressing this issue. As the demand for caregiving resources increases, the country’s economic and social stability will significantly affect the national budget as more tax revenue will be needed to fund these services (Watana 2022). Addressing mental health among the elderly is crucial given Buddhism’s influence in Thai culture, especially in communities where mental well-being, particularly for seniors, is highly valued (Chuengsatiansup 2019). However, mental healthcare resources are limited in Thailand, with primary healthcare providers playing a vital role (Hill and Brettle 2005; Leggett and Zarit 2014; Kabir 2017; Amanullah and Firdos 2018; Dev and Narayan 2021). Moreover, mental health support systems face challenges such as limited access to professional services and stigma.

Issues such as shame, power dynamics, and cultural perceptions can hinder access to therapy, particularly in Asian communities (Gopalkrishnan 2018). To address these challenges, integrating Buddhist principles with evidence-based interventions is crucial (Chentanez et al. 2019). Building cultural partnerships will be essential for engaging individuals in their mental healthcare through holistic solutions that utilize community resources and foster cultural collaboration (Gopalkrishnan 2018).

In Thailand, where Buddhism is widely practiced, elderly individuals are familiar with Buddhist values. Buddhist teachings emphasize elder care through principles like Kāyabhāvanā (physical health), Silabhāvanā (moral support), Cittabhāvanā (emotional well-being), and Paññābhāvanā (spiritual growth). While both monks and nuns provide spiritual and emotional support, monks are usually more prominent in public roles and community leadership due to their higher status as spiritual guides. Nuns often face more restrictions in their roles, leading to their historically smaller numbers compared to monks. Since monasticism traditionally began with monks, they play a more active role in Thai society and are more familiar to Thai elders than nuns (Watana 2022). Research indicates that Thai individuals often turn to monk healers for mental health support, resulting in significant improvements (Pengpid and Peltzer 2020, 2021). Notably, Buddhism holds deep cultural significance in Thailand, particularly among older generations, influencing daily routines and providing comfort during difficult times. Central to Buddhist teachings is the cultivation of inner peace and mindfulness, often practiced through meditation. Karma and compassion promote ethical conduct and empathy, fostering mental well-being. In Thai Buddhist communities, these principles serve as a guiding light, offering solace and support for individuals facing mental health challenges (Phongsuphap and Pinyopornpanish 2017). Consequently, monks, who serve as spiritual guides (Pigultong 2020), are highly esteemed for providing psychological strength and relief during challenging circumstances, highlighting the importance of religious and spiritual practices and emphasizing the pivotal involvement of monks in improving the mental health of the elderly (Pengpid and Peltzer 2020; Klangrit et al. 2021).

The Buddhist framework positively impacts the mental well-being of Thai elders, fostering positive aging through engagement in religious and spiritual activities (Klangrit et al. 2021; Coelho-Júnior et al. 2022). Mindfulness (sati) originates from Buddhist meditation, which highlights ethical conduct and mental states aimed at alleviating suffering and cultivating a deep awareness of existence (Ditrich 2017). The mindfulness process centers on developing a nonjudgmental awareness of both internal thoughts and external experiences in each moment. Practitioners focus on “bare attention”, which involves observing thoughts and sensations without reacting or making judgments, thereby minimizing automatic responses. This practice progresses in stages, promoting better self-regulation, emotional stability, and overall functioning and ultimately contributing to enhanced well-being (Kristeller 2007). In contrast, modern secular mindfulness often emphasizes stress reduction and psychological well-being, sometimes neglecting its foundational ethical and philosophical roots. Integrating traditional Buddhist mindfulness with contemporary psychological practices can enhance both understanding and effectiveness. Incorporating Buddhist principles like ethical behavior, self-awareness, and the concept of non-self into therapeutic practices not only aids in symptom relief but also fosters profound personal growth and resilience by offering deeper insights into mental health and promoting holistic well-being (Ditrich 2017). Counseling initiatives integrating Buddhist principles with Western psychology present collaborative opportunities to address older adults’ mental health needs, leveraging teachings such as the Middle Way, the Noble Eightfold Path, mindfulness, meditation, and compassion (Marma 2022; Wongsurin et al. 2022). However, Buddhist communities often lack specialized resources to address older adults’ unique mental health needs, exacerbated by limited access to trained professionals and stigma (Andary et al. 2023). Addressing these challenges requires a holistic approach that integrates traditional spiritual practices with modern mental health interventions, facilitated by collaboration between monk healers, mental health professionals, and elders (Shonin et al. 2015).

In Thai Buddhist communities, specialized mental wellness services are insufficient or lacking for the elderly, leaving many concerns unaddressed (Chentanez et al. 2019). Innovative approaches blending Buddhist principles with modern practices are needed (Chentanez et al. 2019). Culturally sensitive interventions are crucial to engage and support elderly individuals effectively. Implementing holistic strategies that merge religious and mental healthcare is recommended. In Thailand, the roles of family, monks, and the community are pivotal in supporting seniors’ mental well-being, fostering a deep sense of belonging and collective responsibility. Mental health interventions should honor and integrate these cultural and communal practices, emphasizing the need to adapt care approaches to fit local traditions (Langgapin et al. 2024). Thus, this study underscores the need to assess the requirements of both monks and elders prior to developing a mental health counseling program for the elderly. The findings indicate that monks need training in elderly mental wellness, counseling techniques, Buddhist teachings, and preferred counseling methods. Simultaneously, the elderly require monks who are trustworthy, experienced, and accessible through various channels. These insights highlight the importance of integrating mental health practices with Buddhist principles to address the needs of both groups effectively. Further details are provided in the results Section 3 Results of this article. Integrating Buddhist principles with counseling approaches is crucial for aligning with the values and needs of Buddhist communities. Mindfulness, a core tenet of Buddhism, involves cultivating nonjudgmental awareness to alleviate suffering and gain insight, which supports mental health challenges through the Four Noble Truths and the Eightfold Path (Kabat-Zinn 2003; Goleman and Davidson 2017). Combining mindfulness with counseling approaches enhances therapeutic outcomes by leveraging the strengths of both methods. Solution-Focused Brief Therapy (SFBT) complements these principles by focusing on strengths and achieving positive outcomes (de Shazer 1985).

Solution-Focused Brief Therapy (SFBT) aims to achieve effective and efficient results by concentrating on solutions rather than problems. It guides clients to focus on their future goals and utilize their existing strengths and resources. The approach is collaborative, viewing clients as experts in their own lives and encouraging small, practical changes that build momentum. The process begins with setting clear, client-driven goals and identifying times when the problem was less severe to uncover existing solutions. Practical, small-scale strategies are developed and implemented, with progress regularly assessed and adjusted as needed. Therapy concludes when goals are reached, with follow-up plans to maintain progress and address any future challenges, creating a supportive and solution-oriented environment (de Shazer 1985). SFBT’s goal-oriented and solution-focused approach provides practical steps for improvement while respecting cultural values, making it a culturally sensitive method that integrates Buddhist insights with SFBT’s structured, client-centered techniques. Incorporating mindfulness into SFBT enriches the therapy by grounding clients in the present moment and helping them observe their thoughts and emotions without judgment. This combination enhances SFBT’s practical solutions by fostering a deeper awareness of older adults’ current states, thereby supporting their ability to address immediate concerns with a mindful perspective and achieve their mental health goals.

This research aims to develop a monk-led counseling program tailored to the needs of both monks and elderly individuals and to evaluate its quality and feasibility in enhancing mental health support within Buddhist communities. The study focuses on identifying the specific needs of monks and elders, assessing the components and quality of the monk-led counseling program, and evaluating the feasibility of its implementation.

2. Materials and Methods

The study employed a research and development process that included four main activities: studying requirements, developing the program, and conducting quality and feasibility examinations. The outcome is the verified program, although it has not yet entered the implementation phase to assess its effectiveness.

• Stage 1 Investigating prerequisites

1.1 Design: Using qualitative methodology, researchers conducted interviews to grasp the requirements for mental health counseling for the elderly, facilitated by actively involved monks.

1.2 Participants: Thirty-six participants, divided into two groups of twenty monks and sixteen elders, fulfilled the data saturation process. Purposive and snowball sampling methods were used to identify the participants. (1.2.1) A group of twenty monks, including a leader for Thai health volunteer monks, seven provincial leaders, a secretariat, and eleven temple health volunteer monks, were selected using purposive and snowball sampling methods. Participants were chosen from various locations across ten northern provinces of Thailand. The criteria for participation included being a Thai Buddhist monk with experience in elderly care, being capable of conducting online interviews, and consenting to participate. The exclusion criteria included a withdrawal from the study and refusal to have interviews recorded. (1.2.2) A group of sixteen elderly individuals, including nine club leaders and seven members, were chosen with the assistance of the Provincial Chiang Mai’s Elderly Club leader. Participants were selected from eleven districts in Chiang Mai Province. Eligible participants were elderly Buddhists with general mental health issues who could participate in online or telephone interviews and agreed to take part. The exclusion criteria included high scores on the Thai version of the Brief Psychiatric Rating Scale, choosing to discontinue involvement, declining recordings converted from voice to text, or being absent throughout the interview process.

1.3 Instrument: Semi-structured interview questions were developed for monks and elders based on the literature review and prior experience. The monk interview form included four general questions and nine key inquiries, covering topics such as the role of monks in counseling, the qualities needed, and the program requirements. Similarly, the elder interview form comprised five general questions and nine key inquiries, focusing on the feasibility and requirements of monk-led counseling. Five experts confirmed the content validity of the questions, and two monks or elders tested them before finalization.

1.4 Data collection: (1) The interviewer would first establish a confidential, courteous setting conducive to relaxation or ease to enhance the interview’s functionality. (2) Semi-structured questions were used to interview participants in January of 2023. (3) Individual online or telephone interviews were conducted on mobile devices with the thirty-minute content of each interview being preserved as voice-to-text records using an office dictation tool. All participants granted permission before each interview. (4) The gathering and analysis of the data were performed simultaneously. The selection of participants was completed after the codes were repeated and the data analysis revealed no additional themes. Conclusively, data saturation was achieved among the twenty monk participants who were interviewed and the sixteen elder participants. (5) Transcripts were manually revised after each session to assure overall accuracy.

1.5 Data analysis: To identify the significant themes, thematic analysis based on an inductive approach was carried out using Braun and Clarke’s technique (Maguire and Delahunt 2017). The analysis process involved the careful review of the dataset to identify relevant points, followed by the generation of initial codes and the creation of a codebook. Subsequently, an initial thematic map was developed to identify patterns, which were then refined and combined to form themes and sub-themes. Final themes were established, and a mind map of the dataset was created. The authors drew analytical conclusions and reviewed themes for accuracy and representativeness, resolving any disagreements through discussion. The first author, experienced in mental health counseling, led the coding process, while the other authors ensured the reliability and validity of the analysis. Theme saturation was reached when no new themes emerged.

• Stage 2 Developing the program

The initial prototype was formulated by integrating the study of requirements, the process of Solution-Focused Brief Therapy (SFBT), with mindfulness, derived from Buddhist principles.

• Stage 3 Conducting Quality Examinations and Improvement

3.1 The content of the prototype was validated; five experts, comprising a psychologist, two monks, and two psychiatrists, collaborated on refining the prototype iteratively, leading to the creation of the second version.

3.2 Seven stakeholders evaluated the feasibility of the second version, comprising a counseling psychologist, two monks, a psychiatrist, two older adults, and a nurse. This was then refined based on stakeholders’ input to create the third version.

3.3 Pilot testing on a small scale was performed involving five monks to further improve the program for the finalized version.

• Stage 4 Assessing the Feasibility

4.1 Design: Utilizing a quasi-experimental study.

4.2 Sample: The feasibility of the program was examined through the purposive sampling of 32 monks, selected based on specific criteria, with voluntary participation. Sample size calculations were performed using G*Power for a test with a specified direction (one-tailed), with a significance level (α) set at 0.05 and a power of 0.80. The magnitude of the effect, estimated to be approximately 0.45, was derived from a prior study titled ‘Development of Health Education Model for Monks’ conducted by Leeyutthanont et al. (2019). The inclusion criteria encompassed monks who acted as health volunteers in communities and possessed experience in elderly services, all of whom were required to provide informed consent. The exclusion criteria involved withdrawal from the study or refusal to participate.

4.3 Instrument: The feasibility questionnaire, utilizing a 5-point rating scale, was refined and validated by five experts, comprising two psychiatrists, a counseling psychologist, and two monks. Acceptable Item–Objective Congruence, IOC, values ranging between 0.60 and 1.00, were achieved. Reliability testing involved administering the questionnaire to 30 participants, resulting in a Cronbach’s alpha of approximately 0.85, signifying high internal consistency.

4.4 Data collection: The researcher distributed the questionnaire to the sample at the Mahachulalongkornrajavidyalaya University Chiang Mai Campus for completion in March 2024. Permission was obtained from all participants before administering each survey.

4.5 Data analysis: Descriptive statistics, including means, medians, modes, standard deviations, and ranges, were calculated. Average values assessed using a 5-point scale were classified to evaluate feasibility levels based on DeVellis (2016).

3. Results

This report details the creation of a mental health counseling program tailored for elderly individuals in Buddhist communities, led by monks. It describes the program’s evolution, incorporating Buddhist principles and counseling techniques, and concludes with an assessment of its feasibility, which indicates high feasibility in all aspects.

1. 

Study on Requirements

1.1

Monks’ Requirements

(1) General data: The monk participants, averaging 41.3 years old (ranging from 30 to 64), including monks (50%), abbots (45%), and a monk lecturer (5%). Geographically, 35% resided in Chiang Mai Province, 15% in Phayao Province, and 10% each in Chiang Rai and Lamphun Provinces, with other provinces contributing 5% each. All participants had counseling experience, with 100% providing counseling for health conditions, 35% for general concerns, and 20% for mental health issues.

(2) Themes: The thematic analysis identified two primary themes regarding the prerequisites for monks to provide counseling to the elderly.

(2.1) Theme: Training Requirements

(2.1.1) Comprehensive Training Domains: Monk participants required training in multiple domains to provide effective counseling for the elderly, encompassing areas such as elderly mental wellness, mental well-being within families, the comprehension of counseling principles and Buddhist teachings (Dhamma), interpersonal interaction, problem evaluation and resolution, active listening, questioning techniques, motivation, observation, relaxation techniques, and referral procedures.

(2.1.2) Training Protocol Compliance: Monk participants were required to comply with the program’s training protocol, involving one or two days of face-to-face sessions, excluding Buddhist holy days or official holidays. Training techniques included motivational, practical, participatory, recreational, and certified approaches.

(2.2) Theme: Preferred Approaches to Geriatric Counseling

(2.2.1) Qualities of Effective Geriatric Counselors: According to the monk participants, effective geriatric mental health counselors should embody traits such as trustworthiness, maturity, volunteerism, collaboration, and a willingness to seek new experiences.

(2.2.2) Preferred Methods for Geriatric Counseling: Monk participants require a range of methods (online, phone, in-person, home-based, and mobile) and techniques (simplified listening materials, visual aids) for geriatric mental health counseling. These approaches should be easily implemented in various settings (temples, elderly homes, schools, activity centers, multipurpose halls, and public areas) and consider social attitudes.

 1.2

Elders’ requirements

(1) General data: Elderly participants, equally split by gender, averaged 69.1 years in age (range: 62 to 85, standard deviation: 6.2). The majority (62.5%) had education below an undergraduate degree and 37.5% possessed an undergraduate degree or advanced qualifications. Most were leaders within clubs (56.2%), spread across various districts. All had received health counseling but none had received mental health counseling.

(2) Themes: Thematic analysis identified one overarching theme, “Expectations of Monks’ Role in Geriatric Counseling”, and three sub-themes representing the elders’ needs for geriatric counseling led by monks.

(2.1) Counselor Monks: Elderly individuals seek mental health assistance from monks who exhibit trustworthiness, maturity, positive qualities, and prior experience in counseling.

(2.2) Monks’ Expertise Preferred: Elderly participants prefer monks who possess expertise in various areas, including counseling, mental health, positive communication, and problem assessment. They seek guidance from monks with skills in understanding the stigma, listening, questioning, and accessing additional support resources.

(2.3) Monks’ Counseling Accessibility: Elderly participants expect monks to offer accessible and ethical counseling services through various channels, including in-person, online, and mobile platforms. They suggest appropriate venues such as temples, elderly clubs, and natural settings. Monks should also be sensitive to the societal stigma surrounding mental illness and services for female elders.

2. 

Development of the Program

The initial prototype integrates monks’ and elders’ requirements, along with Buddhist and counseling approaches for developing an initial prototype. It delineates specific concepts, sources, and components of the initial prototype related to each aspect, encompassing monks’ and older adults’ requirements, the Buddhist approach (mindfulness), and the counseling approach, Solution-Focused Brief Therapy (SFBT) processes.

The initial prototype generates three primary outputs, comprising (1) the 2(MPI)-SV counseling process, which encompasses an Introduction to Mindfulness, Identifying Problems, Assessing the Severity and Strength Evaluation, Identifying Values and Positive Goals, Visualizing Success, Planning Strategies for Problem-solving, Mindfully Observing Thoughts and Emotions, and Implementation and Subsequent Monitoring; (2) the PG-TE strategy (Program, Guidelines, Training Manual, and Evaluation); and (3) the Program Manual (Part 1: Instruction, Part 2: General Information about Counseling for Older Adults, and Part 3: Older Adult Mental Health Counseling Program).

3. 

Program Quality Evaluation and Improvement

3.1 The second prototype refines the program further according to feedback from five experts, comprising a psychologist, two psychiatrists, and two monks, making necessary adjustments based on their recommendations. The IOC values, falling between 0.60 and 1.00, demonstrate the suitability of each item concerning both its specific criteria and the broader goals of the program. Key adjustments include the incorporation of Buddhist principles such as integrating concepts such as impermanence, suffering, soullessness, and acceptance into the counseling procedure. Additionally, the sequence of activities was revised, with mindfulness of thoughts and emotions now preceding problem-solving. Terminology in the guidelines was also adjusted to better cater to the needs of the elderly, as per expert recommendations.

The second prototype yields two main outputs, consisting of (1) the MPS-MAV-PI counseling process, which includes an Introduction to Mindfulness, Identifying Problems, Assessing the Severity, Mindfully Observing Thoughts and Emotions, Acceptance, Visualizing Success, Planning Strategies for Problem-solving, and Implementation and Subsequent Monitoring; (2) the PG-TE strategy (Program, Guidelines, Training Manual, and Evaluation); and (3) the Program Manual (Part 1: Instruction, Part 2: General Information about Counseling for Older Adults, and Part 3: Older Adult Mental Health Counseling Program).

3.2 The third prototype underwent refinement following feedback from seven stakeholders, focusing on addressing questions related to feasibility assessment. Being inclusive, the program demonstrated high feasibility in all assessed areas, with mean scores surpassing 4.00 indicating robust feasibility for each aspect. Key adjustments include emphasizing to monks the importance of minimizing advice-giving during counseling sessions and raising awareness about enhancing mental well-being through educational resources. Additionally, the engagement of crucial stakeholders, including the leader of the volunteer monks associated with the health initiatives in Chiang Mai Province and the council governing monastic affairs in Chiang Mai Province, is highlighted as crucial for supporting the implementation process and fostering interaction with monks.

The third prototype produces three primary outputs, comprising (1) the MPS-MAV-PI counseling process, encompassing an Introduction to Mindfulness, Identifying Problems, Assessing the Severity, Mindfully Observing Thoughts and Emotions, Acceptance, Visualizing Success, Planning Strategies for Problem-solving, and Implementation and Subsequent Monitoring; (2) the CT-PE strategy (Collaboration, Training Manual, Program and Guidelines, and Evaluation); and the program manual (Part 1: Instruction, Part 2: General Information about Counseling for Older Adults, and Part 3: Older Adult Mental Health Counseling Program).

3.3 The final version of the prototype was improved following input from participants who engaged in a small-scale pilot test, which included five monks utilizing the program. Changes involve compressing the training period into one day, offering a brief summary of the counseling process, administering practical skills tests in a group setting, and making sure that trainers are present throughout practice sessions. Furthermore, monitoring and evaluation aspects have been included to augment the program’s effectiveness.

The final prototype generates three principal outputs, which consist of (1) the counseling process known as MPS-MAV-PI, which includes an Introduction to Mindfulness, Identifying Problems, Assessing the Severity, Mindfully Observing Thoughts and Emotions, Acceptance, Visualizing Success, Planning Strategies for Problem-solving, and Implementation and Subsequent Monitoring; (2) the C-TIME strategy (Collaboration, Training Manual, Implementation of the Program, Monitoring, and Evaluation); and (3) the program manual (Part 1: Instruction, Part 2: General Information about Counseling for Older Adults, and Part 3: Older Adult Mental Health Counseling Program).

Conclusively, the program’s structure evolved, being influenced by strategic modifications implemented throughout the program’s iterations and spanning from the initial prototype to the final version. The four outlined prototypes share the commonality of incorporating counseling processes like MPS-MAV-PI within their program strategies, yet they diverge in their overarching approaches and outputs. The initial and second prototypes both utilize the PG-TE strategy, with distinct counseling processes, while the third prototype introduces the CT-PE strategy, emphasizing collaboration alongside program development. In contrast, the final prototype adopts the C-TIME strategy, focusing on collaboration, implementation, and monitoring. Moreover, while the program manual retains its three parts (Part 1: Instructions, Part 2: General Information about Counseling for Older Adults, and Part 3: Older Adult Mental Health Counseling Program), all processes have been thoroughly revised based on feedback.

Table 1. Monk-Led Elderly Counseling Process (MPS-MAV-PI) Overview.

Usage	MPS-MAV-PI	Methods
1. Monks may counsel once, ideally twice for follow-up and evaluation, with sessions lasting 35–45 min each. 2. Monks can integrate Buddhist concepts into each stage.	1. “M”—an Introduction to Mindfulness—3 min	Initiate counseling by promoting mindfulness in the elders, guiding them to be present through closing their eyes, deep breathing through the nose, counting 1–4 while inhaling, and counting 1–4 while exhaling.
	2. “P”—Identifying Problems—5 min	Encourage the elders to explore their emotional discomfort, fostering an environment where they feel encouraged to openly express their thoughts and feelings about the situation.
	3. “S”—Assessing the Severity—5 min	Support the elders in determining the severity level of the problem on a scale of 0–10 based on its impact, to understand the problem and track progress. Also, inquire about strengths or support systems.
	4. “M”—Mindfully Observing Thoughts and Emotions—5 min	Support elders in coping with thoughts and emotions by the following: 4.1 Exploring thoughts and emotions related to the situation. 4.2 Accepting thoughts and emotions without judgment, such as feeling unworthy or sad. 4.3 Encouraging verbal expression of thoughts and emotions. 4.4 Evaluating the usefulness of thoughts or emotions and their effects on the body. 4.5 Imagining thoughts or emotions as passing clouds, letting them come and go. 4.6 Identifying the source of thoughts or emotions and then releasing them. 4.7 Inhaling while counting to four and exhaling while counting to six.
	5. “A”—Acceptance—5 min	Support the elders in considering the impermanence of events based on Buddhist principles, fostering a mindset that acknowledges constant change.
	6. “V”—Visualizing Success—5 min	Encourage the elders to visualize positive outcomes if they manage to solve today’s problems, inspiring them to envision a brighter future, inspiring them to envision a brighter future.
	7. “P”—Planning Strategies for Problem-solving—5 min	Support the elders in generating practical solutions to attain their objectives, emphasizing tangible and achievable steps.
	8. “I”—Implementation and Subsequent Monitoring—5 min	Plan and execute the solutions, possibly with follow-up appointments or referrals. Summarize progress and reassess. Encourage progress or set new goals if unresolved.

summarizes a counseling process led by monks for elderly individuals, highlighting its frequency, duration, and incorporation of Buddhist principles. It delineates eight stages, encompassing mindfulness exercises, problem identification, coping strategies, acceptance, visualization, problem-solving, and follow-up. Sessions, ideally conducted at least twice, last 35–45 min, enabling both follow-up and progress evaluation.

Table 2. Overview of the Contents of C-TIME Strategy.

C-Time Strategy	Methods
1. C—Collaboration	1.1 Coordinate with focal point persons to introduce the elderly mental health counseling program led by monks. 1.2 Collaborate with the focal point persons to promote the program and invite participation through online channels. 1.3 Plan joint activities with the focal point persons to brief monks.
2. T—Training & Manual	2.1 Preparation:   2.1.1 Develop training programs and manuals.   2.1.2 Coordinate with the focal point persons to introduce the program.   2.1.3 Plan training sessions for monks, in collaboration with the focal point persons.   2.1.4 Collaborate with the focal point persons to promote the program online.   2.1.5 Send invitation letters to the district Sangha for monk participation.   2.1.6 Coordinate with the trainers for program introduction and materials.   2.1.7 Prepare training documents. 2.2 Training:   2.2.1 Assess monks’ knowledge before training.   2.2.2 Conduct 7 h training sessions with a break from 11:00 a.m. to 12:00 p.m.   2.2.3 Evaluate knowledge and practical skills post-training. 2.3 Post-Training: Distribute certificates to attendees who completed the training.
3. I—Implementation of the Program	3.1 Conduct one counseling session, ideally two for follow-up, each lasting 35–45 min. 3.2 Integrate Buddhist concepts throughout the counseling process. 3.3 Follow the MPS-MAV-PI counseling process.
4. M—Monitoring	4.1 Trained monks demonstrate adaptability in applying the program to various contexts. 4.2 They schedule personalized follow-up sessions with each monk. 4.3 Post-training, they conduct assessments, lasting about 20–30 min, to evaluate knowledge retention, discuss implementation challenges, and provide additional guidance and encouragement as needed.
5. E—Evaluation	5.1 Evaluate monks’ knowledge and practical skills. 5.2 Passing criteria: Attain at least 70% of the total score in both knowledge and practical skills sections (out of a maximum of 20 points). 5.3 Participants who score 15 points or higher pass the training. 5.4 Evaluation materials include a knowledge test, a practical skills test, and an observational form.

outlines the content components and methods for implementing a comprehensive program for elderly mental health counseling led by monks. It covers various aspects, including collaboration with focal point persons, training and manual preparation, program implementation, monitoring, and evaluation. Each component is detailed with specific methods and steps to ensure the effective implementation of the program. Additionally, it highlights the importance of integrating Buddhist concepts, conducting training sessions, monitoring monk adaptability, and evaluating their knowledge and practical skills through assessment criteria.

As shown in

Table 3. Overview of the Contents of Program Manual.

The Program Manual	Key Messages
Part 1—Instructions	The program aims to guide monks in providing mental health counseling to elderly Buddhists in Thai communities, considering time constraints and specific requirements.
Part 2—General Information about Elderly Counseling	Monks, central figures in Thai communities, offer spiritual guidance to the elderly, who rely on Buddhist teachings for emotional support. By blending mental health counseling with Buddhist principles, monks provide culturally attuned assistance, emphasizing personal growth over mere advice-giving
Part 3—The Elderly Mental Health Counseling Program	The program offers mental health counseling for elderly individuals facilitated by monks and combines Solution-Focused Brief Therapy with Buddhist mindfulness techniques. Sessions begin with mindfulness, progress to problem identification and severity assessment, and conclude with collaborative solution planning. Emphasis is on accepting impermanence, envisioning success, and integrating Buddhist teachings. Follow-up sessions ensure progress monitoring and strategy adjustments, while guidelines and examples support ongoing mindfulness practice.

, the program merges Solution-Focused Brief Therapy with Buddhist mindfulness, tailored for elderly Buddhists in Thai communities. Sessions involve mindfulness, problem-solving, and severity assessment, emphasizing acceptance and integrating Buddhist teachings. Follow-ups monitor progress, with ongoing mindfulness guidance provided. Led by respected monks, this approach fosters personal growth within Buddhist principles.

4. 

Program Feasibility Assessment

4.1 The distribution of sample ages and educational levels spanned across a range between 21 and 67 years old; the average age was 41.41 years old. Most participants have bachelor’s degrees, followed by individuals without bachelor’s degrees, and individuals with a level of education above a bachelor’s degree, at 46.9%, 34.9%, and 18.8%, respectively.

4.2 The Program’s Feasibility.

As shown in

Table 4. Feasibility of the Monk-Led Elderly Mental Health Counseling Program.

Feasibility Assessment Questionnaire	Average Score	Feasibility Interpretation
1. Monks have the capability to implement the program for mental health counseling with elderly individuals in communities adhering to Buddhism.	4.37	High
2. Monks can follow and practice the manual in communities adhering to Buddhism.	4.31	High
3. Monks can develop their understanding further post-training.	4.06	High
4. Monks can acquire practical skills following the training.	4.09	High
5. The program’s steps are clear, easy to understand, follow, and apply.	4.06	High
6. Participating in mental health counseling programs for the elderly can enrich monks’ capabilities, proficiency, and effectiveness in providing mental health assistance to older individuals.	4.28	High
7. Collaborative efforts from relevant stakeholders are anticipated in implementing the mental health counseling program for the elderly, led by monks.	4.16	High
8. The effectiveness of elderly mental health counseling programs led by monks in yielding positive results substantially contributes to averting mental health issues among the elderly.	4.25	High
9. Government entities have the capacity to provide support and allocate resources to facilitate the implementation of the mental health counseling program for the elderly, thereby assisting monks and ensuring the availability of essential facilities.	4.03	High
10. The suggested schedule for introducing the mental health counseling program for the elderly is in line with the capacities and limitations observed in monastic settings.	4.06	High

, each aspect assessed with scores above 4.00 demonstrates strong feasibility, indicating the program’s overall high feasibility.

4. Discussion

The Monk-Led Elderly Mental Health Counseling Program generates three principal outputs, which consist of the following: (1) The first is the C-TIME strategy (Collaboration, Training Manual, Implementation of the Program, Monitoring, and Evaluation). Within the program strategy output, a key component is (2) the MPS-MAV-PI counseling process, which includes an Introduction to Mindfulness, Identifying Problems, Assessing the Severity, Mindfully Observing Thoughts and Emotions, Acceptance, Visualizing Success, Planning Strategies for Problem-solving, and Implementation and Subsequent Monitoring. Moreover, (3) the program manual consists of three parts: Part 1: Instructions, Part 2: General Information about Elderly Counseling, and Part 3: The Elderly Mental Health Counseling Program.

The C-TIME strategy (Collaboration, Training Manual, Implementation of the Program, Monitoring, and Evaluation) offers an all-encompassing strategy for fulfilling the mental health requirements of elderly individuals through collaborative efforts. The C-TIME strategy—encompassing Collaboration, Training Manual, Implementation, Monitoring, and Evaluation—provides a comprehensive framework for effectively addressing elderly mental health needs through collaborative efforts. This approach is particularly well suited for monks, who can leverage their roles as spiritual leaders to bridge the gap between spiritual and psychological support. The strategy’s collaborative component fosters engagement with mental health professionals, community members, and the elderly, enhancing trust and cooperation. The Training Manual equips monks with essential knowledge and techniques, integrating psychological concepts with their existing spiritual practices. During Implementation, the monks’ disciplined approach ensures systematic and consistent execution of the program. Monitoring allows for ongoing assessment and adjustments based on feedback, aligning with the monks’ reflective and adaptive practices. Finally, Evaluation provides insights into the program’s effectiveness and informs future improvements, benefiting from monks’ unique perspective on well-being. Overall, the C-TIME strategy aligns with monks’ strengths and roles, blending structured mental health support with spiritual guidance to create a compassionate and effective model for elderly mental health counseling. Based on the foundational principles outlined by Kroon et al. (2023), which emphasize partnership and collaboration, the program prioritizes fostering shared goals and vision among stakeholders. Additionally, Suebkrapan et al. (2024) highlight the importance of involving diverse stakeholders, including volunteers and networks, in providing holistic support for elders within the community. Effective collaboration is vital for the success of the monk-led counseling program, promoting synergy and expanding the reach and impact of interventions. However, challenges such as the hierarchical structure of monks may not be fully understood by laypeople. The early engagement of laypeople could be beneficial in addressing the challenge posed by the hierarchical structure of monks not being fully understood. Despite time constraints limiting direct engagement opportunities, utilizing online meetings and ensuring clear communication channels are crucial. Recognizing the intrinsic value of monks as spiritual leaders and key figures in elder support is essential, motivating stakeholders to actively involve them in the counseling program. This acknowledgment can foster greater cooperation and collaboration between laypeople and monks, facilitating a more comprehensive and potent method for fulfilling the mental health requirements of the elderly in communities adhering to Buddhist principles.

Furthermore, the effectiveness of the training program within the monk-led counseling initiative is essential for equipping monks with the necessary practical skills and knowledge. The program manual for elderly mental health counseling is carefully organized into three key sections: Instructions, General Information about Elderly Counseling, and The Elderly Mental Health Counseling Program. Each section plays an essential role in aiding monks with their counseling responsibilities. The Instructions section offers detailed, step-by-step guidance, aligning with the monks’ methodical approach to their work and ensuring consistent application. The General Information section provides crucial insights into the specific psychological and emotional needs of the elderly, helping monks integrate their spiritual insights with a deeper understanding of elderly issues like isolation and grief. The final section, detailing the counseling program, presents practical strategies and techniques that monks can seamlessly incorporate into their spiritual practices. This comprehensive manual equips monks with the necessary tools to offer effective and compassionate mental health support, making it ideally suited for their role in serving the elderly. Drawing on insights from studies by Decorby-Watson et al. (2018) and Pitchalard et al. (2022), the program emphasizes comprehensive training curricula and ongoing evaluation to ensure continuous improvement. Pre- and post-training assessments, as recommended by Pardoel et al. (2024), offer valuable insights into knowledge acquisition and skill development, enabling targeted interventions to address areas needing improvement. Feasibility assessment, as underscored by Körner et al. (2023), is crucial for program implementation. Evaluating the program’s feasibility from the perspective of direct users enables the identification of access barriers and the implementation of targeted strategies to enhance acceptability and accessibility, as noted by Hill and Brettle (2005). Additionally, ongoing monitoring mechanisms provide valuable insights into program effectiveness, guiding adjustments to optimize outcomes.

Robust partnership and collaboration strategies lay the groundwork for successful program implementation, fostering stakeholder engagement and buy-in. The comprehensive training program ensures that monks are equipped with the necessary skills and knowledge to effectively support older adults, thereby enhancing the program’s impact. Feasibility assessments play a crucial role in ensuring program accessibility and acceptability, further enhancing effectiveness and sustainability. Suggestions for enhancing the program include enhancing laypeople’s understanding of the hierarchical structure of monks through early engagement and clear communication, as well as ongoing training and evaluation efforts to identify areas for enhancement in the training curriculum and delivery methods. Strengthening partnerships with diverse stakeholders and integrating their feedback into program design and implementation can enhance program relevance and impact. Despite certain limitations, such as limited engagement with laypeople, future studies could develop advanced programs and assess their impact by thoroughly evaluating the mental health status of elders, thereby addressing this limitation and offering a more comprehensive support system. As monks become more proficient in their skills over time, they may be able to employ more nuanced techniques and tailored approaches, thereby enhancing their professionalism and the effectiveness of the program.

The MPS-MAV-PI counseling program’s success is rooted in its meticulously designed process, which encompasses key components such as an Introduction to Mindfulness, Identifying Problems, Assessing Severity, Mindfully Observing Thoughts and Emotions, Acceptance, Visualizing Success, and Planning Strategies for Problem-Solving, followed by Implementation and Ongoing Monitoring. By merging Solution-Focused Brief Therapy (SFBT) with traditional Buddhist practices, the program effectively addresses the mental health needs of the elderly. SFBT’s emphasis on solutions and future goals is ideal for older adults seeking immediate relief and a clear path forward, helping them leverage their strengths and build resilience against challenges such as isolation and grief. The incorporation of Buddhist mindfulness practices complements this approach by providing tools for promoting mental clarity and balance for elders. The program’s structured format ensures a comprehensive and practical framework that facilitates engagement and meaningful outcomes. Ongoing quality improvement, driven by expert feedback and collaboration between monks and mental health professionals, maintains the program’s cultural and spiritual sensitivity, enhancing its overall effectiveness. Monks, with their deep understanding of mindfulness and ethical practices, are particularly well suited to deliver this program, making it both impactful and accessible for elderly participants. Ultimately, the MPS-MAV-PI program’s innovative integration of SFBT and Buddhist practices offers a highly effective model for elderly mental health counseling, addressing their needs while aligning with the monks’ spiritual roles.

Marma (2022) highlights that monks are seen as spiritual leaders and counselors who must be well equipped to address the various secular challenges faced by the laity. Their effectiveness in this role is greatly enhanced by a strong understanding of both Buddhist teachings and modern psychological practices. This integration is considered essential for monks to make meaningful contributions to their communities. Furthermore, monks provide spiritual guidance and counseling in exchange for material support from the laity, underscoring the importance of this reciprocal relationship for the overall well-being of the community. The study results support Marma’s assertion that monks frequently incorporate principles of genuine acceptance and support, regardless of actions or traits, along with accurately empathizing with others’ feelings and experiences, into their counseling sessions. This underscores the program’s psychosocial support benefits. Furthermore, mindfulness-based therapy, based on the teachings of Buddhism, successfully deals with distress and mental disorders, and it encourages personal development, suggesting the likelihood of positive results from counseling interventions. Moreover, the program consistently garnered high feasibility ratings across a range of evaluated factors, pointing to its feasibility, expansiveness, and durability. This discovery resonates with prior studies conducted by Anderson et al. (2018), Godzik et al. (2021), and Amarti et al. (2022), affirming the viability of comparable counseling initiatives and ensuring their effectiveness when implemented in Buddhist communities.

5. Conclusions

In conclusion, this study highlights the creation and evaluation of a unique mental health counseling program tailored for elderly individuals in Buddhist communities, led by monks. The program, developed with careful attention to the needs of both monks and elders, integrates Buddhist principles with effective counseling techniques. The thorough feasibility assessment demonstrates the program’s strengths and its potential to effectively address the mental health needs of the elderly. By focusing on collaboration, cultural sensitivity, and innovation, the program represents a promising approach to enhancing the well-being of elderly community members. Its success reflects the dedication and adaptability of those involved and marks a significant step toward reducing the stigma surrounding mental health support in traditional contexts. Overall, the program offers a practical model that combines spiritual and practical elements, improving mental healthcare for the elderly and providing valuable benefits to monks, healthcare professionals, community leaders, and policymakers.