Abstract
Background:
Since the 1990s, the mental healthcare field has begun shifting to conceptualisations of personal mental health recovery, emphasising the heterogeneous nature of how people develop and overcome the difficulties associated with mental ill health. Despite three decades of research on the topic, most recovery-oriented studies have been conducted in predominantly Western cultures, lacking the necessary nuances when applied in Asian settings.
Aims:
We sought to contribute to a growing body of research to fill this gap by exploring the experiences of people who experience mental ill-health in Singapore.
Method:
We adopted a constructivist grounded theory approach and interviewed 21 people who had been diagnosed as experiencing a mental health condition.
Results:
The core category emerging from interview participant perspectives was a ‘roller coaster ride of confusion’. This overarching category was made up of the following four sub-categories – ‘not understanding what was happening’, ‘losing control over self’, ‘unpacking the root of challenges’ and ‘trying to make sense of the situation’.
Conclusions:
Taken together, the journey of a person experiencing mental health recovery in Singapore is filled with obstacles and uncertainty due to various social and cultural influences such as family pressures, the competitiveness of society and the high-pressure nature of Singapore’s educational system. Future research needs to better understand if these are generalisable experiences, and interventions to mitigate their impact need to be explored. Given the strong societal influences, change will take time. Still, this study gives a voice to the lived experiences of people who face mental health challenges in Singapore in the hope that their insights may assist future generations in developing a more mentally healthy society.
Mental health conditions are common, with recent statistics suggesting that approximately 1.1 billion people experience them globally (Dattani et al., 2021). Given such commonality, it is imperative we continually refine existing mental health models so we can better support people who face mental health challenges as they traverse these journeys. Traditional twentieth-century conceptualisations of mental health recovery, such as those used in clinical or bio-medical approaches to care, aim to ameliorate symptoms interpreted as indicative of mental ill-health and restore people to a functional way of life. Such approaches often strongly emphasise the role of mental health professionals who assess, prescribe and administer treatments designed to restore people to an imagined prior mental ill health self (Deacon, 2013; Gyamfi et al., 2022; Jacob, 2015). More recent ideas, such as those in the personal recovery movement, suggest that recovery is better conceptualised as a meaningful journey experienced and led by people who face mental health challenges (Amering, 2012; Anthony, 1993; Davidson et al., 2006; Deegan, 1988).
Within the personal recovery model, people who experience mental health conditions are viewed as experts of their experiences and best placed to inform professionals regarding their needs and wants as they endeavour to move towards more satisfying lives. This paradigm shift also in the way mental health recovery is conceptualised has implications for roles within the therapeutic relationship as professionals are required to switch positions, from leading to partnering with people as they seek to achieve their recovery goals (Leamy et al., 2011; Slade et al., 2012; Warner, 2010). These changes have been accompanied by a more significant effort by researchers to illuminate the lived experiences of people who experience mental ill health so as to better understand how they perceive their circumstances and what they view as being helpful in mental health recovery (Bird et al., 2014; Byrne et al., 2015; Kidd et al., 2015; Leamy et al., 2014; McKenna et al., 2014; Slade et al., 2014, 2015; Slade & Longden, 2015; Williams et al., 2012).
Despite this increased interest, however, the majority of lived experiences studies have been conducted in predominantly Western cultures where there are distinct cultural differences from more Asian-centric ones, such as a greater focus on the individuals than collectivist influences on people’s experiences (Jacobson & Farah, 2012; Price-Robertson et al., 2016). For example, a highly cited narrative synthesis of personal recovery, the CHIME model of recovery, was primarily developed using lived experience studies from countries in western nations (Leamy et al., 2011). Consequently, many of its dimensions fail to reflect the necessary cultural nuances essential to consider when discussing recovery (Bird et al., 2014). A previous scoping review of various Asian lived experience studies echoed this view, highlighting the diversity of perspectives in the region (Kuek et al., 2020).
Therefore, more studies in different cultural settings are required so a more holistic understanding of recovery can be attained. Indeed, there has been a growing body of research in Asian cultural environments which demonstrates the importance of these efforts as they bring new contextual factors that need to be considered (Gearing et al., 2022; Lai et al., 2021; J. S. H. Lam et al., 2021; Meheli et al., 2021; Subandi et al., 2021; Suryani et al., 2022; Tasijawa et al., 2021; Tsoi et al., 2022; Yoder et al., 2021). Hence, this study sought to deepen these ideas by exploring and shedding light on the lived experiences of people who experience mental ill health in Singapore.
Methods
The Consolidated Criteria for Reporting Qualitative Research checklist (Tong et al., 2007) was referred to during the preparation of this paper. In addition, we approached the study using a constructivist grounded theory framework so we could better understand how participants perceived their experiences (Charmaz, 2017a, 2017b). The qualitative data collected from people experiencing mental ill-health came from a larger project that aimed to explore mental health recovery in Singapore from various stakeholder perspectives.
Ethical statement
This study was conducted after ethical approval was obtained from the University of Sydney (2019/934). We also ensured that verbal and written consent was received before any participants were interviewed after they were briefed about the study and given an opportunity to ask any questions about it.
Recruitment
Participants who joined this study were recruited from various social media and messaging platforms such as Facebook, Telegram, WhatsApp, Instagram and LinkedIn through intentional and convenient sampling procedures. Details of the study were shared in various informal Singapore mental health groups on the platforms above, and people interested in participating in the study needed to reach out by signing up for it. Congruent with constructivist grounded theory sampling processes, we ensured that adequate representation of various mental health challenges was obtained. To do so, the interviewer actively sought out people with different mental health conditions within the convenience sample and invited them to participate in the study. We also referred to existing studies which indicated that mood and anxiety disorders were the most prevalent in Singapore (Subramaniam et al., 2019).
Interview process
During the data collection phase (May 2021 and November 2021), people in Singapore were required to adhere to strict movement restriction guidelines due to the COVID-19 pandemic. These constraints necessitated the shifting of interviews from face-to-face sessions to an online video conferencing platform (i.e. zoom). Additionally, the benefits of an online interview have been documented in the past (Jowett et al., 2011) such as eliminating travel needs and the costs involved, improving anonymity and allowing participants to share more freely, and allowing participants greater flexibility in scheduling. These pros were amplified due to the pandemic and suggests the important role that online interviews could play in making data collection more efficient. A semi-structured interview approach was used, and questions were prepared to help guide the sessions. Examples of questions used include ‘what has experiencing a mental health condition been like for you?’, ‘how do you make sense of your experience with a mental health condition?’ and ‘what does it mean to you to be experiencing a mental health condition?’ All the interviews were done by the first author, who also took notes during the process for use while the data was analysed.
Reflexivity
Congruent with a constructivist grounded theory approach, it is acknowledged that untainted objectivity is not possible as researchers are inherently a part of the research process and bring their life experiences, values and beliefs along with them (Charmaz, 2017a, 2017b). However, steps were taken to ensure the impact of these influences was mitigated. Firstly, as the first author and interviewer was a Singaporean, his perspectives could have impacted the way the interviews were conducted. Hence, two Australian mental health scientists were included in this study to reduce such a possibility by reviewing the interview recordings to ensure they were as objective as possible. Secondly, the first author made sure to follow the prepared interview schedule and only touched on points brought up during the interview or from other participants. Finally, active reflection was undertaken by the first author after each session to ensure he did not deviate from the prepared questions; the two Australian researchers also checked on this during their review of the audio recordings.
Data analysis
The audio recordings were transcribed verbatim and the qualitative data was transferred to NVivo to manage it more effectively. Following this, initial codes were generated and constant comparison was applied to form various sub-categories and categories, eventually leading to the creation of a single core category representing the data. Disagreements during the process were resolved through discussion and group consensus to identify the best fit for our data within the context of our study. The final results were agreed upon by all authors.
Results
Twenty-one people experiencing mental health conditions were interviewed for this study (demographic information can be found in Table 1). The core category best encapsulating their lived experiences of mental health conditions is a ‘roller coaster ride of confusion’. It can be further delineated by four categories – ‘not understanding what was happening’, ‘losing control over self’, ‘unpacking root of challenges’ and ‘trying to make sense of situation’.
Demographic of participants.
Note. GAD = generalised anxiety disorder; MDD = major depressive disorder; BPD = borderline personality disorder; PD = panic disorder; PDD = persistent depressive disorder; OCD = obsessive compulsive disorder; BD = bipolar disorder.
Not Understanding What Was Happening
When study participants first experienced mental health conditions, many often assumed it was a regular part of their lives. These thoughts were further supported by the people around them who assumed they were overreacting to life situations rather than real challenges.
. . .who will notice a child having symptoms, especially in my era. Either the child is too quiet, or this child is just noisy. For me, I am too quiet, while my brother is the rebellious kind. So the parent will never think that the child has any mental health issues – PIR0021 (46, Female, Complex Trauma) I was constantly being invalidated and put down in demise. I thought it was kind of part of the experience, like it was a phase you would go through as you approach puberty, then it comes with a lot of changes. So I think okay, maybe this is one of the changes but I didn’t know that part of it was also that it wasn’t healthy or normal, not everyone experiences this. – PIR0016 (21, Female, Major Depressive Disorder/Social Anxiety)
A deep sense of helplessness was expressed at not being able to comprehend the issues occurring due to the onset of their mental health conditions. Yet, some also shared how they tolerated and tried to push on despite their conditions as they did not want to come across as weak or vulnerable to the people around them.
I think to me it felt like a weakness. To me, when I think about it, I feel weak, and then I try to balance that part out. Because I tell myself like I don’t want to go down and not be able to keep up with life and my work because those are what my parents really want me to do, so I don’t want to let them down, and I try really hard to not think of that. . . – PIR0004 (27, Female, Major Depressive Disorder/Generalized Anxiety Disorder) I felt very weak. Like why am I experiencing it while everyone else was happy mostly happy at school, they were able to go without too high of anxiety level, they don’t cry 2-3 hours a day, they weren’t tired. . .I felt very disgraced in a sense, like how come I couldn’t cope with these stresses. . .Like I was useless. . . – PIR0013 (23, Female, Major Depressive Disorder/Generalized Anxiety Disorder/Obsessive Compulsive Disorder)
Losing control over self
Beyond just not understanding what was happening, during these early stages of their conditions, participants shared about a loss of control over various aspects of their lives, such as not being able to control their emotions, energy levels, motivation, behaviours and other symptom-specific issues (e.g. auditory and visual hallucinations, paranoia, etc.).
I was not in control of my emotions so in one minute I could be you know, laughing happily with my friends, next minute I would be breaking down in the class. I couldn’t control my emotions. I couldn’t control the things that I was saying to the people around me. So I would unintentionally say things that would hurt them. – PIR0001 (24, Female, Generalized Anxiety Disorder/Major Depressive Disorder) . . .I did have suicidal thoughts and some of them actually manifested in such a way that it became a kind of like psychotic breakdown because I was experiencing hallucinations and I experienced this hallucination seeing this person hanging by a noose in my room and the lifeless body turned towards me and asked: do you want to join me. . . – PIR0007 (31, Female, Major Depressive Disorder)
Additionally, the inability to share about it with the people around them due to the culture in Singapore that does not view people experiencing mental health conditions kindly which exacerbated participants’ issues.
. . .we kind of never talked about the mental health issue to be honest cause my mom doesn’t like it. She was always concerned about me being on the equation, like what if you get addicted to medication, and be on it for the rest of your life, so she has a lot of anxieties about that, so I don’t really bring it up with her. But she does talk about it with reference to jobs, like she tells me when you get a job, don’t tell them you are seeing this therapist, in case they think you are crazy or something. – PIR0011 (22, Female, Major Depressive Disorder/Generalized Anxiety Disorder) . . .in an Asian health setting, mental health is not a very discussed topic, and we have terms for it that sound derogatory, that they are mad or something. And if you are mad you should go to the mental health hospital and things like that, and nobody talks about the recovery aspect of mental health and how to move forward and support a person through. . . – PIR0015 (45, Female, Schizophrenia)
Unpacking the root of challenges
In sharing their challenges, participants also discussed what they believed caused their issues to surface. Nearly all shared about familial influences in the way they were raised and which became embedded in their psyche that eventually pushed them to the edge of breaking, intentionally or unintentionally.
. . .in a family like ours, we don’t talk back because the elder is always correct. . .So this harsh criticism, from my mom also, when I was younger. . . Now I know how anxious I was as a kid, always crying in school. Nothing happened but I will just cry every single day for a whole month. At that time, I just thought I am weak, my friends don’t cry. When I go home my mother scold me while crying, and then throw my book against the window you know, because she got so frustrated that I was crying everyday. – PIR0010 (25, Female, Major Depressive Disorder/Generalized Anxiety Disorder) I think for me it was how I brought up because I remember I was in secondary school and I felt like I needed to seek help, and I approached my parents and told them that I wanted to see a psychologist, and they kind of like scolded me for it. It’s like they questioned: what’s wrong with you, that’s a waste of money or its unnecessary. . . – PIR0009 (22, Female, Major Depressive Disorder/Bulimia)
Furthermore, participants also talked about how the high-pressure education system and competitive society at large, especially in terms of the idea of being normal within the culture, had a negative impact on their mental health.
Participant: Because like my early onset experience with mental health condition was brought about by academic stress. . . Interviewer: could you share a bit more? What do you mean by academic stress? Participant: I didn’t do that well for my PSLE, and I took that as a form of personal failure because society always defines success as in terms of academics. So because of that I worked hard to get into the express stream, but then when I finally got into express stream, that didn’t stop there, because there was o levels and a levels, and so I found myself pushing myself to do well and to be like societal norms. – PIR0002 (21, Female, Major Depressive Disorder/Borderline Personality Disorder) . . .we are primarily driven by economy, we are driven by it and as one of my friends has said, when it comes to mental health or illness everything is secondary but we have to be economically viable before we can move on. So even culturally or social, economic forces are still the one driving the main entire thing. – PIR0020 (43, Male, Bipolar Disorder)
Trying to make sense of the situation
It was often a struggle for participants to make sense of their experiences and some of them took comfort when they finally got diagnosed. It was a sense of relief that there was finally some way to explain what they were going through.
Interviewer:. . .maybe you can bring me to university what were some feelings and thoughts you had when you first found out the GP stated that you had an issue and that you have a mental health condition now? Participant: I broke down crying, mainly from relief that you know, it’s not my character problem, it’s not that I’m a bad person, or I’m a bad student, it’s not my fault, cause that’s what I believed most of my life – PIR0014 (25, Female, Major Depressive Disorder) . . .we talked about what I have been feeling and what I’ve been going through and the therapist suggested it maybe anxiety and when I got the diagnosis per se, it made me relieved because it gave me an answer for something I didn’t have an answer to, so it kind of like made what I was feeling real, and I can put my finger on it. . . – PIR0019 (23, Male, Generalized Anxiety Disorder)
While some remained ambiguous about their experiences and shared how they were still trying to reconcile with what they have been through, some participants shared about how they were now trying to find some positivity within their challenges and reshape their world views.
I found that uh there’s more to life than just work which is very important and I learnt to live life a bit more fully cause of my diagnosis. Because I started to take care of my mental health and I started to take care of the people around me a lot more instead of working so hard. . .it was like a wakeup call for me because something told me if I continued on the path I was on previously, I wouldn’t have the rich relationships that I have – PIR0015 (45, Female, Schizophrenia) Participant: . . .on the better day, I would think of my depression as a gift, on a not so good day, it depends, so on the not so good day then it just be like: oh it’s just a condition I have to live with Interviewer: can you share more about a gift? Participant: a gift, maybe the way like I see situations is different than other people, like my family would call it that I’m very considerate, but actually is just the way that I tend to interpret situations I guess. – PIR0008 (27, Female, Major Depressive Disorder/Social Anxiety)
Discussion
Experiences of mental ill health in Singapore were akin to a roller coaster ride. During the early stages of their challenges, several participants shared how lost they felt. They felt helpless, weak and unsure of what was happening to them, some choosing to tolerate the symptoms and appear normal to the people around them. Similar findings have been echoed in other Asian studies, which showed that people were likely to hide their symptoms or not talk about them for fear of being viewed as different or weird (Gopal et al., 2020; M. M. Lam et al., 2011; Suryani et al., 2022; Wang, 2012). Hence, by not being able to live authentically, participants struggled to find a reason to carry on, with many expressing the desire to become numb or to give up entirely as they could not see the end to their challenges. Recognising the cultural nuances of why people may not be seeking help due to not wanting to appear different within a broader society that frowns upon mental health conditions is essential when supporting these individuals.
Exacerbating the situation was a lack of literacy by the people around them, coupled with a general stigma towards mental health conditions and not wanting to discuss them, resulting in participants feeling a sense of invalidation. These findings are understandable given the intense stigma and negative attitudes people in Singapore and Asia tend to hold towards individuals experiencing mental health conditions (Ran et al., 2021; Tan et al., 2020; Tasijawa et al., 2021; Yahyavi & Shahvari, 2022; Yuan et al., 2016). Given that we understand the importance of social support in assisting people through their recovery experiences, especially in Asian settings where interpersonal relationships are greatly valued, helping people better understand mental health conditions is a critical concern (J. S. H. Lam et al., 2021; Subandi et al., 2021; Yu et al., 2021; Yuen et al., 2019). Psychoeducation conducted by mental health professionals for families concurrent with supporting people experiencing mental health conditions could be an invaluable component of care.
Additionally, the negative attitudes surrounding mental ill-health in Asian countries cannot be understated as participants were unable to talk about their feelings due to their mental health symptoms. Not only did it make them feel alone, but it also brought about additional stressors and concerns, such as being unable to find employment or being admitted to Singapore’s main tertiary mental health hospital, which is highly stigmatised, both of which are commonly held beliefs. This is evidenced by the high treatment gap often observed in the nation, and relatively high usage of complementary and alternative treatments, with many who choose to use such modalities often ceasing to return to outpatient mental health services (Sagayadevan et al., 2015; Seet et al., 2020; Subramaniam et al., 2020). Similar findings in other Asian nations have also been reported where employment is a strong indicator of recovery and the preference for other forms of approaches towards mental health treatment is high (Gopal et al., 2020; Halliburton, 2022; Lai et al., 2021; Subandi et al., 2021). This could be a particularly Asian concern. Being a contributing member of society is often viewed as an important reason for recovery, an important consideration for mental health professionals to factor into their approaches.
Furthermore, familial issues were frequently raised while discussing participants’ beliefs about what caused their mental health conditions. Specifically, many cited how their families raised them to fit within societal norms was why they ended up with symptoms of mental ill-health. Given the significant role that the family unit plays in Singapore society, they are probably the ones with the most influence over the development of an individual and even later on in life, during adulthood (Teo, 2010). In fact, many Singaporeans live with their families, making clashes between family members even more salient and impactful (Department_of_Statistics_Singapore, 2021). Hence, it is vital that care providers also work closely with families to understand the potential influences that could be supporting or hindering the recovery process of people with mental health challenges.
Compounding familial influences are broader societal expectations whereby the pressure cooker-like education environment and highly financially driven economy create a situation in which there is little room for weakness or being less than perfect (Koh & Chong, 2014; Sidhu et al., 2010). When embedded into an individual’s psyche, such high stakes often result in unrealistic expectations being placed upon individuals. Consequently, participants were often relieved due to their diagnosis and found a reason to take in other aspects of life when trying to make sense of their conditions. In addition, having the diagnosis gave them a way to escape the cycle of stress they were in, and some embraced it. Similar findings were reported in Indonesia (Lemelson & Tucker, 2017; Subandi, 2015), where formal diagnosis gave explanations for behaviours that could not be explained otherwise. Hence, while diagnosis may not be a focal point within personal recovery approaches, they can still provide utility when used appropriately, especially in cultures that may not fully understand the concept of mental health conditions.
Limitations
Our study is limited by its size and the type of conditions covered. While we wanted to capture a broad spectrum of conditions, we could not find individuals with other mental health challenges who were willing to participate. Additionally, while representation was achieved, it could have also prevented condition-specific nuances to the lived experience from surfacing, given that the majority of our participants had depression and anxiety-type conditions, which are the most common in Singapore. This was in line with national level studies in Singapore which identified depression and anxiety-type conditions to be the two most prevalent mental health challenges. Nevertheless, future studies could adopt more homogenous samples or larger mixed samples to address these issues, and also consider examining more mental health conditions.
Conclusion
People experiencing mental health conditions in Singapore often face an extraordinarily confusing and challenging journey. It is also compounded by the highly competitive and stressful cultural elements that make up Singapore society. Coupled with low levels of literacy and families who may not be as supportive, they can often feel invalidated and unheard, forcing themselves to put on a strong front so as to appear ‘normal’ to third parties. Future research should attempt to replicate our findings with more extensive quantitative studies using culturally appropriate measures so that interventions can then be developed to better support people with mental health conditions. Although lived experience research is only just beginning to emerge in Asian cultures, we hope our paper adds value to such efforts but, more importantly, gives a voice to people who have various mental health challenges in Singapore.
Footnotes
Acknowledgements
The first author would like to acknowledge the assistance and support from the Tan Kah Kee Foundation throughout his postgraduate journey.
Author contribution
All authors contributed equally to the preparation of this manuscript
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
