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Protecting Mental Health During COVID-19

Amidst the COVID-19 pandemic, there is evidently a growing sense of distress amongst the public – from panic-buying at supermarkets to wearing several layers of masks for fear of being infected. While ensuring our physical well-being is of great importance, we cannot deny that our mental health is also equally important – especially during the stress of a pandemic. The ever-changing situation can cast a shadow of uncertainty over us, creating feelings of vulnerability and helplessness.

However, allowing coronavirus related fear to overcome us certainly isn’t the way to go. Let’s take a look at how we can help ourselves by avoiding the pitfalls of anxiety and depression.

CNN recently published an article on how to keep coronavirus fears from placing an undue burden on our mental well-being. In the same vein, we would like to emphasise the utmost importance of self-care during these trying times.

In the context of this pandemic, what does self-care entail? By keeping our minds from straying into muddled uncertainty, we can avoid the toxicity of excessive worry – with the world already so volatile, it’s in our best interest to try to stay cool-headed to better make decisions. There’s no point expending precious processing power on unwarranted concerns. With the influx of information and ease of access to social media, it can be mentally exhausting if we choose to hang on every update. If you feel the urge to check your phones for up-to-date news constantly, learn to walk away. Know when to put away your phones if necessary.

Depending on the individual, the idea of self-care may vary, but ultimately, it is still a means of managing our stress and anxiety levels.

During this period, some of you may well experience higher levels of mental stress. Worry over your own health and your loved ones’ may consume your mind, in turn leading to knock on effects such as – changes in sleep and eating habits; worsening of chronic illnesses; and increased substance usage. Needless to say, we would do well to guard against the deterioration of our mental health, to better cope with our negative emotions appropriately.

Connecting with our own feelings is a great place to start. It’s important to stay in touch with our feelings, taking care to identify our worries and concerns. Try naming your emotions. It sounds simple enough, but you’ll soon learn that there are nuances that set apart sensations, emotions and feelings.

Is there anything specific about the situation that is heightening your stress level? Emotional awareness is often neglected, with some studies showing that only 1-in-3 people have the ability to correctly identify them. If you have reached a state of panic or hysteria regarding the virus, you might want to start considering how realistic your concerns are. There is a high chance that we often over-magnify our fears and underestimate our capacity to handle the situation.

As mentioned, there is a need for us to remain cool-headed and not plagued by excessive worry in these trying times. Here are some tips that may help you to get through this difficult time, if you ever find yourself feeling overwhelmed with anxiety or fear.

Firstly, it is of great importance to consider if your worry is solvable. Is the problem within your control? In the case of the COVID-19, you may be constantly worrying about contracting the virus. However, if you are certain that you have done your part, such as washing your hands occasionally and not touching your face unnecessarily, does worrying excessively help in any way?

In some cases, excessive anxiety may cause one to hyperventilate – and this is where proper breathing techniques will come to your rescue. The 7/11 breathing technique is an exercise where one breathes in for a count of 7 seconds and exhales for a subsequent count of 11 seconds. This exercise is very simple, yet proven to be extremely effective in helping one regain his or her composure. Try this for approximately 5 minutes (or whatever duration that is best for you), and you’ll eventually feel calmer and be able to think more clearly.

Remember, while you may not have power over what happens to you, you are able to control how you react to it hence your state of mind. 

Avoidance and escapism from acknowledging the root of our uneasiness is not a healthy method of coping. Coming to terms with and recognising our concerns can in fact help us to better seek social support. Stay connected and start talking to the people you trust. Talk to them about your feelings and worries. Get them to share theirs too, and by the end of it, you’ll realise that you are not alone. Understanding others’ perspectives on the situation and recognising that they are most probably experiencing the same concerns will surely help to calm your nerves and help you feel less lonely and vulnerable.

It is also important that we spend more time with our families and friends. Taking a break from our busy lifestyles and hectic work schedules will benefit your mental health. Make sure to take time off to unwind, and to do activities that you enjoy. This could mean exercising, socialising, or some form of recreation in your spare time.

Although socialising may be slightly more of a challenge due to the increased need for social distancing, it is still largely possible, especially with technological advancements. Now and then, you can opt to organise your own get-together through ‘Zoom’ or ‘Skype’, and perhaps have lunch with your friends over video-calls. Do you have something you’ve always wanted to learn, but could never find time for? Well, this might just be the right time for it too. In addition, some places of interest have started providing virtual tours. With this, one can explore and discover new areas whilst staying in the comforts of his/her home. With countless things to do on the internet, one can easily find various means to unwind and to de-stress.

Doing things you love will help to ease the burden on your shoulders and distract you from your fears and concerns. Life goes on even with the COVID-19 situation, and constant worrying is in nobody’s interests.

One crucial thing to note is that you should never feel guilty or ashamed of your fears, and neither should you blame yourself for worrying. It is completely normal to worry, especially with uncertainty at every turn. After all, evolutionary biology dictates that it’s perfectly natural to feel threatened and afraid during a pandemic.

Do not hesitate to seek help and support when the going gets tough. If you ever find yourself barely treading water, there’s absolutely no shame in reaching for a helping hand. Stay safe!

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Bibliography

https://edition.cnn.com/2020/03/14/health/coronavirus-fears-mental-health-wellness-trnd/index.html  (Retrieved 18/3/20)

https://www.cdc.gov/coronavirus/2019-ncov/prepare/managing-stress-anxiety.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fabout%2Fcoping.html (Retrieved 18/3/20)

https://www.apa.org/practice/programs/dmhi/research-information/pandemics?utm_source=linkedin&utm_medium=social&utm_campaign=apa-pandemics&utm_content=pandemics-resources (Retrieved 18/3/20)

Reducing Stigma and Overcoming Shame

As we celebrate World Mental Health Day (10/10), I pause to remember the patients/clients whom I have worked with in the past 17 years. I want to recognize and honour their courage, resilience and grit in continue living even though it is so hard.

I am heartened that there are more open conversations on mental health compared to a decade ago. Earlier this year there was even the inaugural Singapore Mental Health Film Festival. More sufferers are willing to step forward courageously to share their stories to encourage and inspire fellow sufferers. All of these efforts are pointing in the right direction and we should persist.

What makes mental illness so painful is the shame that individuals feel; the fact that they are less than, inadequate, weak and worthless. Society has not arrived at a place where we can talk about it as openly as our physical health. At least, no one is hesitant to get a medical certificate from a general practitioner but one from Institute of Mental Health, no way!

How can we reduce the stigma of mental illness?

I have one suggestion that I like to propose and it is as follows:

we need to start sharing our “failure” or “screwed up” stories.

Every person undergoes challenges in life and experiences deep pain for various reasons. For someone who suffers from mental illness, the natural thought is that “I am alone in this. Everyone but I can deal with life.” He/she looks around and sees “successful” people who seem to have it all and feel demoralised.

We, the supposed “successful” people have in some way perpetuate the stigma of mental illness by keeping silent and not share our pain openly.

Recently, I shared with a client of my struggle with anxiety and she was surprised because outwardly I appear mostly calm and confident. I believe my story gave her hope that if my therapist can overcome and learn to manage her anxiety, so can I.

The challenge that I want to extend to everyone is this: share your struggles, not just your victory.

When something painful is a common experience, there isn’t a need to hide the secret any longer and we can better support one another. Truthfully, all of us has some form of dysfunction; it is only a matter of degree and how well we manage it.

I shall walk the talk and share the times when I felt like a failure.

·     After getting a scholarship to come to study at a top Junior College, I did so poorly for my promo exam that I was put on probation. That was my first taste of failure as I had been an excellent student up until that point. My self-esteem took a hit and I seriously considered quitting school and return to my hometown. I persisted.

·    Being diagnosed with Moya Moya Disease and suffering stroke where I lost the ability to read and write and my right visual field.

·     The first year of my marriage was really tough. It caught me by surprise as we had a wonderful courtship and seemed to get along really well. We went through several challenges, including my brain surgeries and stroke. I was left confused and disillusioned. The upside of it is that I started to learn more about what makes relationship work and I ended up discovering my call and passion.

·     Infertility. As we looked forward to expanding our family, we received bad news after bad news with each visit to different specialists. I seriously felt that perhaps something was wrong with me that I was not good enough to be a mother. After 4 years, we had wanted to give up when our miracle baby came along.

·     The years that I was a trailing wife, I lost my sense of identity and I watched my peers moving ahead in their career and life while I was trying to figure out what I wanted to do with my life at age 32. I couldn’t let go of the narrow definition of success. I was a nobody. It took me 3 years to re-calibrate and find my voice and I started my blog- Winifred & You, Flourishing Together.

The above wasn’t easy to write; it’s not what we usually do and it feels risky and uncomfortable.

That’s the challenge; are we ready to share and reveal the pain that we too keep in our hearts?

To de-stigmatize mental illness, we need to acknowledge and embrace authenticity and vulnerability. As long as we breathe, we hurt. We fall and we rise.

Let’s share our resilient stories so that everyone else will be inspired to do the same. In so doing, we kill shame because it no longer has a hold on us.

Will you join me? #killshame #resilientstory

COVID-19 Easing and Mental Health in Singapore

The COVID-19 pandemic is unprecedented. The ubiquitous influence of the pandemic has been—and continues to be— felt by individuals globally. Many experiences the fear of being infected or infecting others, disruptions in their daily routines, social isolation, the likelihood of unemployment, financial hardship and the looming economic uncertainty (Ministry of Health Singapore, 2020). As such, there is a detrimental impact on the mental health and wellbeing of individuals, including an increased risk of suicidal behaviour.

Globally, the prevalence rates for depression and anxiety in the COVID-19 pandemic were 28.0% and 26.9% respectively (Nochaiwong et al., 2021). Factors contributing to depression and anxiety include suffering, fear or potential death, grief and financial stressors (World Health Organization, WHO 2022).

Young people have been identified as at increased risk for suicidal and self-harming behaviours (WHO, 2022). Women’s mental health, compared to men’s, has been more adversely impacted by the pandemic (WHO, 2022). In addition, people with existing medical conditions such as asthma, cancer and heart diseases, have been found to be at higher risk for developing mental health disorders (WHO, 2022).

In Singapore, a study conducted by the Institute of Mental Health (IMH) (Ministry of Health Singapore, 2020) found that 8.7% of Singapore residents reported having clinical depression, 9.4% reported having clinical anxiety and 9.3% reported mild to severe stress levels.  Older adults were identified as a vulnerable group, particularly, those who lived alone. Similar to the findings from WHO (2022), youths in Singapore were also identified as vulnerable to experiencing poor mental health in response to the pandemic. There is an urgency for countries to boost their mental health and psychosocial support services as part of the pandemic response plan.

According to the COVID-19 mental wellness task force, initiatives in Singapore include providing psychological support via helplines such as the National CARE hotline and a mental health help bot (‘Belle’), incorporating mental health materials in the school curriculum, fostering family resilience and supporting parents with parenting skills.

Here are some recommendations for mental health support during this pandemic:

  • Parents are encouraged to have conversations with their children about their children’s worries and responses to the pandemic. Parents have been found to underestimate such responses (Pfefferbaum & North, 2020). Such “talk time” can also help in trust and bond-building
  • Seniors can be equipped with digital skills and also expand their options for help and support i.e. the provision of telehealth counselling and support services (Brydon et al., 2022).
  • Health care workers can monitor their stress responses and seek assistance in relation to both their work and personal lives from a mental health professional (Pfefferbaum & North, 2020).
  • People can be encouraged to limit their consumption of news related to COVID-19 to once a day and to focus solely on credible news sources.
  • Having social interactions with family and friends and offering to help support one another during this difficult period can also be particularly beneficial.
  • Being outdoors and exercising are good habits for maintaining healthy wellbeing.

As restrictions are slowly easing around the world, it can also be challenging for most people to adjust back to when restrictions were first introduced (during lockdowns). With new changes and uncertainty, being mindful of one’s mental health and well-being is crucial. For example, larger social gatherings (e.g. group of 10) may seem overwhelming at first, therefore it is important for people to recognise their anxiety levels related to social gatherings.

Here are some suggestions that might help regulate your emotions as you enter this new season of Singapore opening up amidst the COVID-19 Pandemic (Black Dog Institute, 2022):

  • Gradually, increase your time spent in a larger social gathering at your own pace.
  • You can also start to focus on things that are within your ability and control. For instance, you can engage in different relaxation techniques such as deep breathing and focusing on being in the present in order to better cope with your stress levels (American Psychological Association, 2021).
  • it can be useful to discuss reasonable adjustments back to work with your managers such as flexible working arrangements and other training opportunities in order to increase work efficacy
  • Seek professional help if there are concerns regarding stress levels related to the easing of restrictions.

It is particularly evident that the COVID-19 pandemic has taken a toll on the well-being of Singaporeans and the rest of the world. The pandemic has highlighted the importance of mental health and wellbeing and there is an urgent call for countries worldwide to provide people with mental health and psychosocial support to help them maintain psychological wellness.

Some Local Helplines and support:

Raising Emotionally Healthy Children

What Is Circular Causality?: Understanding Your Child’s Reactions

The American Psychological Association defines ‘Circular Causality’ as a sequence of causes and effects that leads back to the original cause and either alters or confirms it, thus producing a new sequence, as in a feedback loop.

This is an important concept that helps to explain certain interactions within relationships better. Relational patterns and rules between family members within the family system dominate how individuals interact and engage with one another. These rules are often silent, unconscious or multi-generational in nature. Within this system, the family operates according to some ‘thermostat’ which sets the ‘desired setting’ for how each member is expected or required to function. The functioning applies to how situations or people are viewed, how much self-disclosure is welcomed or permitted, how personal or interpersonal difficulties are addressed or not, how disagreements or secrets are to be dealt with, or what relational values are being promoted. Families in different cultures may operate with certain predictable rules or patterns, eg. within families sensitive to shame, avoidance or non-verbal disclosure, communication is often practised. Tapping into the honest emotions of members over time tends to reveal the ‘temperature’ within the family system.

Families nurture the psychological ‘birth’ of the sense of self within children during their childhood. In the process, parents shape within their children how young children will engage themselves (intra-personal relationship) to function in later childhood and adulthood (inter-personal relationships). Healthy relational patterns and appropriate rules are important to foster healthy emotional development towards an important psychological milestone for children: healthy identity formation. Because these patterns and rules are so fundamental in the shaping process, it is important for parents to understand how they can shape their children towards this healthy identity. If not, the child could begin a life-long struggle from having accepted an identity that is diffused, confused or distorted in nature. This is usually accompanied by secondary effects of this outcome, eg. a pattern of difficult or troubled relationships with others. This usually adds additional distress to the sufferer and to those who relate to them.

Instead of understanding interactions within relationships along a linear continuum where there is a definitive start and end, circular causality opens up to appreciating the relational context where interactions can be examined between two events in more useful detail. With an understanding of circular causality, understanding the interactions between two or more individuals can better reveal where an interaction can get stuck. This pattern occurs in all relationships but it is especially within ongoing relationships where being stuck in a negative cycle can lead to particular disappointments, hurt and pain. For children, unhealthy patterns and rules within families can undermine the child’s emotional development over time.

Circular causality is particularly useful to explain conflicts between family members which can become persistent and damaging. Persistent hurts can undermine relationships and lead to how negative expectations of each person are viewed and engaged with over time. They are a concern because of the prospect of children’s sense-of-self being hurt or damaged within certain family systems. Therefore, careful attention is usually necessary in understanding the attribution of cause-and-effect of what is problematic between family members.

Individuals attribute cause and effect or causation in situations and within relationships. Linear cause and effect of A 🡪 B 🡪 C are defined by a specific start and end point. Individuals who operate from understanding relationships based on linear causality tend to assume that problems are caused and maintained by the other individual’s beliefs, biology, emotions or other abnormal factors within the individual, i.e., they are self-generated. Therefore, solutions are found when the individual in question changes their beliefs or emotions within them to respond differently to the situation.

In contrast, circular causality refers to the reciprocal relationship between two events. Family members influence each other in a continuous process within a feedback loop. A vicious cycle is often present when two or more family members have relied on unchecked assumptions to carry out their attributions of cause-and-effect in the situation. The perspective of reciprocal relationships stems from the foundations of cybernetics, which refers to the regulatory action where one part of the system impacts another. Events usually do not happen in isolation. There is a feedback loop which tend to result in a new equilibrium. It is more that A 🡪 B 🡪 A.

 

Case Studies

Case 1:

Susan refuses to go to school and goes into her room. Mom and Dad raise their voices and lecture her. When they raise their voices, Susan isolates. Mom and Dad’s frustrations or anger heighten Susan’s need for isolation, and Susan’s isolation heighten Mom and Dad’s anxiety, and therefore their escalation.

For parents who operate on assumptions of linear causality, their perception can easily overlook other reasons to explain the child’s original presenting problem, eg. Susan may be bullied at school, she has an unhappy relationship with her teacher, or she may be afraid of facing exams but is afraid to tell anyone. Parents who operate based on linear causality tend to see their child as the source of the problem, and to overlook their contribution or other reasons leading to the child’s presenting problem.

Instead of being quick to judge the situation as the child choosing to misbehave, parents should focus first on establishing a safe, trusting relationship with their daughter before their intervention.  They can raise concerns about what their child may be fearful of with empathy. The following statement could be as follows, “Hey Susan. You usually would enjoy attending school. But something unpleasant or uncomfortable may have happened to make you afraid of returning to school. I remember that when I went to school, I have at times been uncomfortable going to school because I was afraid of meeting someone I did not like, or having to face an exam I was not prepared for, or having to face a teacher who was mean. Can you tell me what is going on for you at school that you are uncomfortable facing? I will like to help you.”

Case 2: 

John struggles in completing his homework and his poor grades. The father Mr. Lim responds to him with harsh criticism. Hurt and demoralized by his father’s criticism, John does not put in his best effort at school. His father’s criticism then intensifies and John puts in even less effort to learn. 

Family difficulties are often not rooted by a simple mistake made by the child (mistakes are common for children and instrumental for how they learn).  In this scenario, the father’s response to John may be reflective of how Mr. Lim was regarded as a child himself by his own parents when he was growing up. Criticism then is an extension of how he was treated as problematic as a child (to regard himself as stupid, inadequate, irresponsible) so as to repeat the cycle here. Without knowing all this history, John becomes hurt and angry against his father’s accusation. He can try to defend himself and retaliate with, “I am not useless. You are.” Mr. Lim who is outraged by John’s apparently disrespectful reply can bear down on John for what he considers to be John’s defiance to intensify his attack: “You are not only useless but disrespectful.”  This pattern can then set up a loop that becomes self-perpetuating or self-reinforcing based on their view of each other. John is seen by his father not only as stupid or irresponsible, he is also viewed as disrespectful and defiant. In turn, John sees his father as unloving and hurtful whom he needs to distance himself from. If they had a positive relationship earlier in John’s life, this relationship can deteriorate over time if the underlying issues are not addressed.

In reciprocal relationships, circular causality is often revealed in the course of the interplay between emotional experiences, false or valid expectations and eventually how we experience each other. It often reveals how one or both parties perceive and interpret their individual world, and there is usually a historical reason  behind their perception. Our current experiences, perspectives and approach to relationships are often already influenced or shaped by our previous significant relationships with our family-or-origin and culture.

[ In this situation, Mr. Lim should be advised to consult a child clinical psychologist when he sees no improvement with his son’s behavior. He needs to be alerted to the importance and quality of the parent-child relationship in impacting the child’s self-esteem, emotional conditions for what children need to thrive and the nature of the unconscious. If Mr. Lim was armed with the appropriate knowledge and possibly obtain personal help to address his relationship with himself as defective or inadequate, he could approach his son with, “Hey son. Studying in Singapore can be challenging or difficult. The workload can be heavy and the material can be difficult. I struggled with it too when I was a student. What struggles are you facing at the moment?” ]

 

Case 3

In the midst of ongoing conflicts between parents, their child Ben develops anxiety because the two people he loves appear to be hurting each other. Ben acts out with anxiety and/or depression, eg. temper tantrums, excessive withdrawal from school or play, trouble at school. This draws the attention of his parents who attend to him. In the process, their own conflict decreases. From this, Ben learns that he can influence his parents’ conflict through his anxiety. 

Circular causality helps to explain why family members may be stuck arguing about the same subject every time through communication traps or failures. Understanding cause & effect on a linear perspective in relationships can result in an artificial understanding: one cause & one effect or multiple causes & the same effect. In this scenario, Ben’s parents may wish to see Ben as having difficulties coping with school. Their solution may be to improve Ben’s responses to become more resilient. But if Ben attempted to communicate his difficulties with his parents’ conflict, they may not wish to believe that they contribute to his struggles. In so doing, they fail to capture the root of the problem for what it is. A child’s struggles may be defined by their parents because the child’s limitations reflects the parents’ limited emotional insights on themselves or their children. This lack of emotional insight and understanding is often expressed through circular causality to reveal that children can be misunderstood often and that the parent-child relationships can often be negatively impacted.  The parents’ own limitations are often overlooked in the situation.

Repeated over time, the negative rituals expressed in circular causality can be locked in place by ignorance, emotional hypersensitivity, defensiveness, contempt for one or more family members, hopelessness, hurt, anger, blame, fear and avoidance or stonewalling. Emotional cut-offs may be used frequently. If this happens, the effects of circular causality in an unhealthy family system can be experienced as intolerable. If there was previously a positive bond that bound the relationship, it can now be worn down by pain and the relationship may become damaged.

In this situation, the parents should consult a clinical psychologist familiar with children and family issues when they notice their child struggling with school or presents with anxiety in the midst of their conflict.

How To Break The Cycle

Raising healthy children require establishing healthy relationships and healthy boundaries. Because the goal of raising healthy children is so worthwhile and essential to their future growth and success, parents need to be concerned that their relationship with their children are not defined by misunderstandings and conflict which are painful. To foster family unity and raise healthy children, three important values and practices are essential to promote certain patterns and rules in the family system:

  1. Parents need to learn about child development. They should also remember that children function at a disadvantage because they tend to lack the emotional insight to explain their fears, their confusion, and what they need. Subsequently, children often have difficulty articulating what they feel or need. They need parental help to develop their emotional insight and offer them a broad emotional vocabulary to learn to express and communicate themselves clearly and honestly. When this is offered by parents who are emotionally mature and aware, intentional to raise children in their best interests, and when these parents are trusted by their children, the groundwork is being laid for the healthy formation and development of the child’s emerging identity.
  2. Parents need to develop the courage to have honest conversations with each other and their children. This courage needs to be accompanied by the believe that each member has important value so that each person is treated with respect. With courage and respect, each person can be approached with caution about making inaccurate or false assumptions of each other, and engaging in a self-serving bias. Being honest and courageous is important to clarify if inaccurate attributions are being made. Being ready to listen without judgment prior to making honest inquiries would further help to avoid misunderstandings or address misunderstandings when they occur.
  3. The willingness to develop healthy emotional intimacy promotes the value of sharing for each family member to know one another and to being known by the others in the family. This offers the basis for bonding and closeness. When communication is constructive, affirming and respectful, it can establish the sense of security within children and trust between family members. For children, this is particularly important since secure attachments contribute significantly to the child’s emotional development and mental health. This in turn offers a basis for them to acquire a healthy approach to future relationships and healthy functioning.

    To promote relationships which are safe and nurturing, words are powerful to convey that each family member is highly valued. They should be deliberately selected to promote each other’s well-being. Having a pattern of honest and constructive communication with healthy rules where individuals are affirmed and supported help to promote a family system where each member can safely practice saying what they mean and mean what they say. Misunderstandings are not left to stay but are promptly corrected. This offers the most fertile ground for healthy personal and interpersonal growth to happen. When parents notice they have difficulty delivering these practices, they should consult a clinical psychologist.

 

References:

American Psychological Association. (n.d.). Apa Dictionary of Psychology. American Psychological
Association. Retrieved October 22, 2022, from https://dictionary.apa.org/circular-causality

Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. W W Norton & Co.

Understanding Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD), in simple terms, is a condition involving an obsessive focus on one or more perceived flaws or defects in appearance. While the perceived flaw may be minor and inconspicuous, individuals struggling with this disorder are inclined to spend a large proportion of their waking hours worrying and finding means to fix these flaws. This includes seeking dermatological or cosmetic procedures and exercising excessively to fix their appearance. Depending on its severity, BDD can be disabling – the emotional distress it causes can affect one’s functioning at social events, work and in the public eye.

BDD is estimated to affect approximately 2 percent of the adolescent and adult population worldwide, and preliminary studies in Singapore have also noted a similar proportion. This figure is, however, likely to be underreported due to the nature of the disorder, where affected individuals are unable to recognise the symptoms of the disorder. Coupled with the lack of awareness of BDD, people associate these BDD symptoms with the “physical flaw” itself.

While there is no definitive cause, there are risk factors that can contribute to the onset of BDD. These can include bullying or abuse, perfectionism, constant competition with others, genetics, and other mental health conditions such as depression, anxiety or obsessive-compulsive disorder (OCD). With the prevalence of social media, this condition is further exacerbated as it perpetuates body image comparison and the image of an “idealised body”. This can trigger such compulsive behaviour in vulnerable individuals, especially if they struggle with low self-esteem. Chemical imbalances can also trigger the onset of BDD in the brain or the use of certain drugs such as ecstasy in susceptible people.

What is the diagnostic criteria for BDD?

For a BDD diagnosis, there is a set of criteria that the individual must meet. According to the Diagnostic Statistical Manual of Mental Disorders (DSM V), they are:

  1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
  2. At some point during the course of the disorder, the individual has performed repetitive behaviours (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
  3. The preoccupation causes clinically significant distress or impairment in social, occupational or other areas of functioning.
  4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

In addition, the individual would need to be assessed on their degree of insight regarding body dysmorphic disorder beliefs. In other words, how convinced are they that their bodies look “deformed” or “ugly”? A person with good or fair insight recognises that these beliefs are definitely or probably false. A person with poor insight would think that these beliefs are probably true. In the worst-case scenario, a person with absent insight or delusional beliefs would be completely convinced that their body dysmorphic beliefs are true.

What forms of treatment are available for BDD?

A combination of psychotherapy and pharmacotherapy is often implemented in the treatment plan for BDD. Cognitive Behavioural Therapy (CBT) is a psychotherapeutic method which aims to help one recognise maladaptive thought and behaviour patterns, and teach self-help coping strategies that can improve one’s quality of life. CBT has been proven to be an essential form of treatment for other mental health conditions as well, including depression and anxiety disorders. CBT for body dysmorphia would focus on helping the patient build self-esteem, and learn to tolerate the distress of “exposing” their perceived defects to others. It helps them manage their concerns with healthier coping mechanisms instead of taking extreme measures to fix their appearance. This includes training them to cope with symptoms of anxiety.

Medication is sometimes used in combination with CBT for maximum efficacy. One common medication used to relieve BDD symptoms include antidepressant medications. Selective Serotonin Inhibitors (SSRIs) in particular, can ease and reduce compulsivity, as well as overwhelming symptoms of anxiety or depression.

You may wonder why we don’t proceed with cosmetic or surgical procedures to correct their perceived flaws, especially if they seek such measures. As mentioned, BDD often involves flawed beliefs surrounding an inconspicuous or minor flaw in appearance. We must acknowledge that any medical or surgical procedure carries health risks, regardless of the extent of the surgery. Any unnecessary alterations or body modifications may not only lead to undesirable health effects but may also lead to dissatisfaction with the results. Should the surgical procedure not turn out as expected, this could worsen the patient’s BDD.

If you believe a loved one may be showing signs of BDD, do encourage them to consult one of our mental health professionals at Promises Healthcare. 

References:

  1. https://www.channelnewsasia.com/commentary/body-dysmorphia-vanity-obsession-mental-health-treatment-1883421 (Accessed 25/07/2022)
  2. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t19/ (Accessed 25/07/2022)
  3. https://www.mind.org.uk/information-support/types-of-mental-health-problems/body-dysmorphic-disorder-bdd/causes/ (Accessed 25/07/2022)

Gaming Addiction Among Kids in Singapore

The Straits Times interviewed Juliana Pang, Addictions Therapist at Visions by Promises* to weigh in on her thoughts on the rise in Gaming Addiction among children in Singapore.

She shared that gaming addictions often develop in the context of underlying issues, such as struggles with schoolwork, bullying, or tensions at home. Children hence turn to gaming as a coping mechanism, she added.

*Visions by Promises is the addiction treatment arm of Promises Healthcare. This interview was done before its formation.

Follow the link to read the full article: https://www.straitstimes.com/singapore/community/gaming-addiction-on-the-rise-among-children-amid-pandemic-counsellors

Maximizing the Benefits of Therapy

Deciding to see a therapist is a big step – and staying in therapy requires a commitment to effect real change.

It is not surprising that many hesitate before starting therapy.

Some may be wondering how talking to a stranger can change their lives for the better.

They may not know which therapist they ought to approach – and what they should be looking for in a therapist.

Others may hesitate because they are anxiously thinking ahead: “what happens if I don’t like the therapist?”; “what if the therapist doesn’t understand my struggle?”; “what if I don’t think that enough progress is being made?”.

They may also be wondering if they can change their therapist and if they can have more than one therapist.

If you are struggling with these questions, thankfully, there may be some answers that put your mind at rest and give you the confidence to seek a therapist and engage in the healing process.

Choosing the Therapist – The Qualifications 

Most clients can articulate why they wish to seek therapy – and have clear ideas about what is causing them distress or difficulty.

Clients with clinically diagnosable mental illnesses may have already sought help from a family member, friend, doctor, psychiatrist or religious leader. They may have even “Googled” their symptoms.

If specialist help is needed, choosing a therapist with the relevant qualifications and experience will be the first step.

In addition, you may wish to choose a therapist you are more likely to be comfortable with based on the therapist’s language ability, gender, culture and so on.

What should I look for in a Therapist?

Research has shown that the positive connection a client makes with their therapist accounts for 36%-50% of the changes clients experience as a result of treatment. (1)(2)

Sometimes called the “therapeutic alliance”, this is experienced by clients as liking and trusting their therapist.

Some will bond strongly with therapists if they demonstrate empathy, warmth, unconditional regard and respect. They would like their therapist to be open, non-judgmental and curious about the clients’ struggles – to have a strong desire to “walk in the clients’ shoes”.

Such clients make good progress in therapy when they feel understood and heard – as well as valued.

Others may seek therapists who are good communicators and are well informed about the issues the clients are facing. They tend to bond with therapists who are able to impart and discuss information; offer practical suggestions; articulate action plans, goals and timelines; and support the clients in their motivation to take action to effect positive change.

Many also seek insights into themselves, their emotions, the ways they react to people or situations; and their perspectives and intrusive thought patterns.

By being more present with what arises in themselves, they seek to take more control over their own lives – to respond to people and situations instead of habitually reacting to them – and to accept and let go what they cannot control.

These clients appreciate therapists who can assist in self-discovery. Therapists who are able to help articulate their “inner worlds,” and to reframe them. Therapists who empower them to navigate this “world” with more ease and confidence by playing to their strengths, rather than dwelling on what they perceive as their weaknesses.

Interestingly, studies have repeatedly shown that the type of therapy used for individual therapy (such as cognitive behavioral therapy, psychoanalytic or psychodynamic therapy, dialectical behavioral therapy, person centered therapy and so on) has only a marginal effect on the outcomes of therapy (3)(4)(5).

So, the key to choosing a therapist involves articulating what you expect from therapy and your therapist, and what kind of person you think will best meet your emotional and other needs.

It would be helpful to articulate what you want the therapist to do (and not do); and what your end goal or “vision” for therapy is. You can do this by first asking yourself the question: “what changes am I seeking that will make a real positive difference in my life?”.

Many benefit from putting all this in writing and bringing it to the first therapy session to discuss it with the therapist.

Beginning Therapy – And then Changing the Therapist 

On the first meeting with a therapist, some clients – though this may be rare – simply do not like or trust the therapist, or that they do not have the experience or knowledge to assist them.

It also sometimes happens that a client feels that the therapist is not present or really hearing the client’s narrative.

Worst still, they may see the therapist jumping to conclusions – or solutions. They may feel disrespected and “unheard” – and that they are being left behind, while the therapist is “racing” ahead of them.

Other clients may feel that the therapist is judging them or telling them what to do, think or feel – and not to do, think or feel. The clients may feel anxious, disempowered, dismissed, angry or offended.

If this happens to you, let your therapist know. If you don’t see any change in their approach, rest assured that changing therapists is likely to be helpful.

Changing Therapists Along the Way 

One situation that you may wish to avoid though, is changing therapists regularly. This is because continuity in therapy is one of the keys to progress.

Therapy is very much a journey.

Whether the goal is self-discovery, empowerment, executing action plans to change behaviour, building confidence, or managing anxiety or depression. The journey has stages, and keeping the same guide on this journey is likely to facilitate progress.

If you are in the middle of your therapeutic journey, and you wish to change therapists, it would be helpful to articulate clearly why you want to do this.

Is the therapeutic bond broken – and cannot be fixed? Is there little or no progress in your clearly articulated goals? Have you changed the goals and discussed them with your therapist – and it is clear that the therapist will not be able to assist?

Some clients simply feel that therapy has become “stale”; or they feel as though they are attending therapy to “tick the box” and to show others that they are willing and able to change.

Whatever the reasons, write them down. Discussing them openly and honestly with your therapist is likely to help.

If you wish to make a change, ask the therapist for a referral to another therapist, and give permission to the current therapist to brief the new therapist. You may wish to join in this discussion.

This is more likely to ensure that your therapeutic journey continues without disruption.

One situation you may wish to be conscious of, is changing therapists solely because the therapeutic work has become difficult. “Jumping ship” may not be the answer.

There is no doubt that therapy can be very challenging – perhaps the most challenging thing you have ever done.

The challenge could arise because the insights are uncomfortable (or even painful); the changes in behaviour require a lot of motivation to sustain; a change in perspective seems counterintuitive; or because the anxiety, intrusive rumination or low mood seem relentless.

Changing therapists may not be the answer – and may simply delay or disrupt the difficult therapeutic work ahead of you.

It is likely to be more helpful to articulate these challenges, write them down and discuss them with your therapist.

Having more than one therapist

Some clients may need more than one therapist.

A client may have an individual therapist who assists the client on their own personal journey.

They may also have a couples’ therapist to address their relationship with their partner. In that event, the therapist treats the couplehood as “the client” – and provides equal support to both parties and works towards their joint goals.

Other clients may also have a family therapist to address the relationships within the family. Again, the therapist will see the family as “the client” and assist with the family goals.

Couples and family therapists tend to provide specific modes of therapy, which have proved effective for couples and families.

In the case of individual, couple and family therapy, in most cases, it is generally considered unethical and a conflict of interest for one therapist to play all three roles.

The therapist cannot best serve the client’s, couples’, and family’s interests while wearing all three “hats”.

Once a therapist tries to do this, they may (for example) feel obliged to keep secrets from one person in the couplehood or others in the family. This may reinforce the unhealthy dynamics of secrets and deceit that brought the clients to therapy in the first place.

Conflicts of interest create confusion, anxiety, anger and disappointment for clients.

Keeping to ethical boundaries is more likely to ensure that the therapeutic journey is not sabotaged.

Unethical conflicts of interest also arise if a client is seeing two different individual therapists.

Broadly, therapists are obliged to decline to see a client if they already have an individual therapist they are actively working with.

Having two therapists engaged in the same work exposes clients to confusion, anxiety and conflict, and is likely to disrupt a client’s progress in their therapeutic journey.

If you are considering seeing two therapists for individual therapy, it would be helpful to clearly articulate why you think this will assist – and to discuss this openly with the therapists.

Some clients may change therapists to “find the right answer”; the “best answer”; or the answer that fits their “view of the world”. That “view” may be the same “view” that has been causing them the trouble – and motivated them to seek therapy in the first place.

All this is worthy of open and honest discussion and exploration.

Another situation in which other therapists may be involved occurs when a client has an individual therapist and also attends group therapy. Group therapy can be a very effective way to continue the therapeutic journey, once progress has been made in individual therapy.

Again, therapists commonly use specific modes of therapy for groups.

Working with Multiple Therapists 

If you are working with multiple therapists, it is helpful to let them know who else you are working with, and what goals you (e.g. as an individual, couple or a family member) have agreed to pursue with the other therapists.

From time to time, it will assist to share with your therapists what you took away from the other therapy sessions, how the sessions are progressing and what plans you have agreed with the therapists.

It is always open to you to ask the therapists to communicate with each other and to coordinate treatment.

It is also your right to maintain confidentiality and not to coordinate treatment – but “dovetailing” these different therapy sessions is more likely to help optimize your outcomes.

The Promises Healthcare website provides assistance to clients to identify their issues and provides photographs, names, languages, qualifications and experience of the specialists who can assist: https://promises.com.sg/our-team/

We hope that you will be able to find the right help from us.

  1. Horvath, A.O., Del Re, A.C., Fluckiger, C., and Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16. Doi:10.1037/a0022186
  2. Duncan, B. (2014). On becoming a better therapist – evidence-based practice one client at a time. (2nd Ed.) Chapter 1, pp.23-24. The American Psychological Association, Washington DC.
  3. Stiles, W.B., Barkham, M., Mellor-Clark, J., & Connel, J. (2008). Effectiveness of cognative-behavuoural, person-centred and psychodynamic therapies in the UK primary-care routine practice. Psychological Medicine, 38, pp 677-688. Doi:10.1017/S0033291707001511
  4. Benish, S.G., Imel, Z.E., & Wampold, B.E. (2008). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychological Review, 28, 746-758. Doi:10.1016/j.cpr.2007.10.005.
  5. Duncan, B. (2014). On becoming a better therapist – evidence-based practice one client at a time. (2nd Ed.) Chapter 1, pp.9-12. The American Psychological Association, Washington DC.

Challenges of a Nomadic Expat Life on Kids

Expat life and moving around the world places a great deal of stress on children. DR REBECCA GIESS and DR MARK TOH from Promises Healthcare share how parents can help them adapt to new environments and people.

What issues do children deal with when adjusting to expat life?

Rebecca: They suffer mostly from homesickness, and grief from losing friends, extended family and familiar places. In a new country, they find it difficult to fit in and feel a sense of belonging. They have a fear of missing out (FOMO) on life back home.

Mark: They perceive a threat in relocating. Extended family and friends represent the emotional resources the child depended on, and the disruption in daily routine affects their emotional security and stability. This is an important and largely overlooked stressor. How children experience this, and how prepared they are for the change, is based on their relationship with their parents.

DR REBECCA GIESS

What are the red flags?

Rebecca: It can be difficult for children to know how they are feeling or how to express it. They may exhibit anti-social behaviours by breaking the rules or defying expectations. Tune into your child to uncover the underlying emotional triggers, and what they might need emotionally from you.

Mark: For children under the age of eight, there may be more crying, moodiness and irritability, complaining about school, expressing worry, or becoming withdrawn and clingy. There may also be regressions such as thumb-sucking, temper tantrums or toilet accidents, despite being potty-trained.

Children aged seven to 10 may worry about their health or family and express anger and irritability. They may also pin negative labels on themselves. Some of these behaviours may manifest at school more than at home.

Preteens may be more reactive to the demands and stress of the new school, complaining about the different system or classmates. They could become withdrawn, have more incompleted homework, or have declining grades.

DR MARK TOH

How can we help teenagers adjust?

Mark: Teenagers will miss their friends, prom, graduation and sports pursuits – the rites of passage – and they may feel their sense of identity being stripped away. They may display depression, anxiety, irritability, apathy and withdrawal, which increases their sense of isolation.

Those who feel ready to be independent may feel trapped with their family. They blame their feelings on the relocation and start to resent the family for it.

If the teenager is close to completing Grade 12, consider allowing them to graduate before they relocate.

How can parents navigate their child’s emotions?

Rebecca: Create space and guidance for their emotional experiences. Parents can validate and normalise their emotions by saying things like: “It makes sense.” Or: “It’s normal to feel sad or stressed.”

Don’t place any expectations on how your child “should be feeling”. They feel what they feel. Parents can help them label their emotions and work out how best to manage them.

Talk to your child about becoming a “third culture kid” – someone who spends a portion of their developmental years in another country. There are several benefits and challenges worth understanding and planning for.

I recommend parents read Third Culture Kids: The Experience Of Growing Up Among Worlds (Pollock, Van Reken & Pollock 2017).

What is most important to the child?

Mark: Children are looking for safety and security. With younger children especially, this depends on how close they are to their parents. Pay more attention to any work or social activity that might threaten this bond. Parents must remain accessible to the child, meeting regularly, exploring and discovering the country together and having fun in the process.

They should also assess how they themselves are coping, and if they might be unintentionally neglecting their child’s needs.

What can parents do at home?

Mark: Help children to set up their room. They are more likely to embrace their new home when they know that their needs are being met predictably. Parents should be ready to share their personal feelings and discoveries to encourage their children to communicate as well.

Create routines that bring everyone together. Playing games encourages bonding. Team games, where discoveries can be made individually and shared collectively, are particularly useful. In the process, the family learns about each member together.

How can a therapist help?

Rebecca: Therapists are trained to work with children experiencing anxiety and depressive symptoms due to adjustment difficulties. Children are rarely completely open with their parents and may do better in a non-judgmental safe space.

Mark: A therapist looks at both the child and family’s wellbeing. How is each person in the family coping? If there are individual or collective difficulties uncovered, the therapist could help them get unstuck.

About Dr Giess & Dr Toh

Dr Giess has extensive experience in working with teenagers and parents. She also helps adults address severe and chronic mental and physical health issues, and is trained in couples relationship counselling.

Dr Toh treats troubled children and their families and helps them to address their challenges. Helping parents to parent well is also a concern for him. He also works with couples and individual adults, as well as individuals with personality disorders.

Promises Healthcare is at #09-22/23 Novena Medical Center, 10 Sinaran Drive. Contact the team at 6397 7309.

*This article first appeared online on Expat Living Magazine’s website. Anna Murphy, an editor at Expat Living Magazine, wrote this article.

Explore mental wellness strategies for navigating CBLITE and improving stress management.

When the ‘circuit-breaker’ measures were put in place, there is no doubt that our lives have been drastically impacted. Even travelling to work or school – what was once considered a part of our daily routine – is no longer the same. Rules and regulations are put in place too, such as the wearing of a mask is now deemed mandatory and not being able to speak onboard public transports. With such increasing obstacles, it is unfair if we do not acknowledge the effort Singaporeans have put in to manage and cope with these disruptions to our daily routines. While we have moved into the phased circuit breaker emergence period, it may be still some time before we can resume our normal lives.

To cope with being house-bound, some of us have chosen to take on a new hobby or to learn a new skill to pass time and keep ourselves engaged. Others have embarked on some self-reflection and have come to realise that they had taken their past freedom for granted. Whichever the case, we are all trying to keep ourselves mentally healthy in different ways, and this in itself is commendable.

However, with the recent announcements of the circuit breaker emergence phases, this may have once again taken a toll on people’s mental health, with their sense of relief that it’s ending being diminished abruptly. In light of this, we need to help each other ride through these challenging times as circuit breaker measures continue on. Here are some simple tips to help you keep yourself sane, and to adjust to the new “norm”.

First of all, start being grateful for your privileges in life. Gratitude will give you a sense of hope amidst these trying times, and that there is light at the end of the tunnel. There are many things to be grateful for, such as the increased connection and bonding with your friends and family. As they say, distance makes the heart grow fonder. Have you found yourself wanting to reach out to others more than ever, be it through the phone or video conferencing platforms? Do you appreciate that you are not just stuck at home, but that you have a home that provides comfort, safety and security? During these times, also be grateful and appreciate that you are in good health. For those of you who are feeling artsy, perhaps you can create a gratitude vision board. Whenever you are feeling down in the dumps, write notes of affirmation or gratitude and decorate your walls. Take a look at them and remind yourself of the little things in life that keep you whole.

Another tip that is often overlooked is to set goals and a fixed routine. For some of us, staying at home is an excuse to idle, especially if you are not working from home or waiting for HBL to start. Contrary to what people think, that there is nothing much to do at home, there are in fact many activities that we can keep ourselves busy with. Make time for indoor exercise routines, do online crossword puzzles, read books, hang out with your friends on online platforms – you name it. Try setting weekly goals and track your progression too, and don’t forget to reward yourself for every milestone achieved. Believe it or not, stimulating your mind can definitely help reduce feelings of helplessness and to deal with cabin fever.

Nonetheless, it is also important that you seek help whenever necessary. Consultations for psychological services are available at Promises during this period of time, with Teleconsultations as an option. You should never hesitate to seek help if things get hard.

Stay home, stay safe, stay happy!