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Dr Rajesh Jacobs Speaks with Expat Living on the misconceptions of psychiatric medication

Dr Rajesh Jacobs Speaks with Expat Living on the misconceptions of psychiatric medication

There are many stereotypes about mental health medication. One acute misconception is medication dependence and addiction – that it’ll be difficult to stop these medications once people with mental illnesses get well and recover.
Dr Jacob Rajesh from Promises Healthcare speaks to the editorial team from Expat Living to help debunk some of the myths and tells us more about new techniques like Transcranial Magnetic Stimulation.
What Are Panic Attacks and How To Manage?

What Are Panic Attacks and How To Manage?

Written by: Dr Elaine Yeo, Senior Clinical Psychologist

All of us have felt anxiety at some point in our lives, whether before a big test, public speaking, or a job interview. Anxiety is a perfectly normal emotion that serves the purpose of motivating us to prepare for a big event or protect ourselves from potentially dangerous situations. However, too much anxiety may put us at the risk of experiencing panic attacks. In this article, we will discuss the symptoms, causes, and strategies for managing panic attacks. 

 What are panic attacks?

A panic attack is a sudden episode of intense anxiety and fear that triggers strong physiological reactions. These reactions can feel so intense that the individual feels as though they are having a heart attack. Common symptoms of a panic attack include but are not limited to:

  • Heart palpitations
  • Sweating
  • Trembling or shaking
  • Shortness of breath
  • Chest pain or discomfort
  • Feeling dizzy
  • Fear of losing control or going crazy

It is important to note that panic disorder can develop if an individual starts to fear the panic attack itself (i.e., worrying about when the next panic attack may happen or avoiding situations and places when the panic attack occurred). 

What causes panic attacks?

Similar to anxiety, anyone can experience a panic attack. However, some of us may be more prone than others. Several factors play a role in increasing our risk for panic attacks:

  • Family history: Anxiety often runs in families. If you have a family member who has a diagnosed anxiety disorder or, tends to experience anxiety more intensely and frequently than others, you would be at a higher risk for panic attacks. 
  • Mental health issues: Individuals experiencing burnout, intense anxiety, depression, or any form of mental illness are more prone to panic attacks. 
  • Traumatic experiences: A past or recent experience of trauma can result in our bodies remaining in constant “fight-or-flight” mode—the physiological reaction of anxiety and fear—which may then increase the likelihood of panic attacks.
  • Substance abuse: Addiction to substances such as alcohol, drugs, and caffeine can put us at a higher risk for panic attacks. 

How to manage panic attacks? 

If you are experiencing panic attacks at an intensity and frequency that is distressing and debilitating, please seek professional help. Panic attacks can be treated with talk therapy, psychotropic medication, or a combination of both. If not, here are a few ways to manage panic attacks: 

  • Stay calm: It is important to remember that while panic attacks can be scary and extremely uncomfortable, they will not cause you to die. When a panic attack comes, notice and name it as a panic attack, and remind yourself, “It’s just a panic attack, it will pass.” For those of you who are unsure if it may be a medical issue, please see a doctor to rule out such concerns first. 
  • Practice grounding exercises: Grounding is a useful technique that helps us to detach from our anxiety, often with an added calming effect. It works best with regular practice, even when you are not experiencing a panic attack, so that muscle memory can kick in when you most need it. Examples of grounding include:
    • Notice the environment around you with all your five senses, such as what you can see, hear, touch, smell, and taste. Describe this to yourself, either mentally or quietly out loud. 
    • Carry a grounding object (e.g., a rock, gem, ring, small toy) in your pocket. Hold the object and notice its size, shape, texture, and temperature of it. 
    • Engage in slow, deep 4-2-4 breathing – inhale for four counts, hold your breath for two counts, exhale for four counts. You may also focus on your breath and notice the feel of the air entering your nostrils, the movement of your shoulders, chest, and stomach as you breathe, the feel of the air coming out of your mouth. 
  • Avoid caffeine: Caffeine is a stimulant that can activate your body’s “fight-or-flight” response. Adding caffeine to your anxiety-ridden body would be akin to throwing a lit stick of dynamite into a house on fire. 

Overall, please remember that the presence of panic attacks indicates high levels of anxiety. They are our body’s way of telling us that it is at its limit. Should you experience one, it would be helpful for you to reflect on your stress and anxiety levels, identify any triggers and manage them, as well as ensure that you engage in your self-care routine and practice adaptive coping strategies.

Family Therapy 101 in the context of the pandemic.

Family Therapy 101 in the context of the pandemic.

The year 2020 saw a rise in uncertainties. Many have experienced anxiety, job loss, a strain on finances and family relationships due to the impact of the pandemic. By default, couples need to adjust to working from homes, with blurred boundaries between work and family, lesser personal space and challenges in new routines. They may not have readily communicated effectively about their roles, given the constant changes in adjusting to tightening and lifting measures.  Coupled with the labour crunch, families may find it increasingly formidable or costly to hire a helper to care for children, who are required to stay home for home-based learning or the care of elderly parents who may be weak and frail.  This may inevitably lead to unresolved conflicts between the couple due to the stress and demands of constant transition and change. In 2020, a survey for mums showed that 60% of the participants rated their stress level at a 7 out of 10. In addition, 3 out of 10 of the participants felt sad most of the time.   

Children and young people are not spared from the raging wave of anxiety. According to a survey conducted by Focus on the Family, kids are more anxious about exams than Covid 19 (The Straits Times, 18 Sep 2020). However, in an international study of 72 countries (including Singapore), only 6% of teens share their problems with their families (Impact of the Pandemic on Family Life Across Cultures 2020, Namad Bin Kalifa University). No wonder the CEO of the Institute of Mental Health says that “Gen Z faces different forms of stress, maybe more anxious, depressed than others before them (Today, updated on 1 Mar 2021).” President Halimah also urged Singapore to step up efforts to protect children’s mental health early (The Straits Times, 2 Dec 2020).    

Given the tremendous stress that kids and adults are facing, families are stretched very thinly. Therefore, they ought to rise above their concern of seeking a mental health facility to deal with their issues early, so that family members can get the professional help they need.   

It is timely for the family to consider attending family therapy to address and deal with the mental well-being issues, be it stress or anxiety collectively.   

You may have some questions about family therapy, and here are some FAQs that seek to answer your questions. 

 

Why Family Therapy? 

Having to deal with unhealthy family dynamics constantly puts a toll on one’s mental wellness. Family therapy focuses on improving family communication; it deals with family conflicts, seeks and creates better functioning and environment. It provides family members with an opportunity to talk about how they think and feel, being affected by the issue they face. It enhances skills to facilitate healing. Therefore marriage and family therapy are essential. 

Family therapy shifts the focus from blame, diagnostical lens, linear causality, and looks at circular causality in an issue. For example, a teen who exhibits school refusal may be staying home because of his worry and caregiving role to his mum, who is in chronic health and has a strained marital relationship with her spouse. It helps the family understand the issue confronting them in the family context and the larger contexts, i.e. the pandemic. 

Family Therapy is often used to help treat an individual’s problem that has dire effects on the entire family, i.e. depression, anxiety and behavioural issues. This type of psychotherapy is also helpful in addressing family-centric problems, i.e. conflicts between spouses, siblings, parents and children. 

 

What is Family Therapy? 

Family therapy is psychotherapy designed to identify family patterns that may have contributed to behavioural or mental well-being concerns. The idea is to help family members break those habits as the family therapist involves the family in discussion and problem-solving. 

 

What can I expect when my family and I attend a Family Therapy session? 

During family systems therapy, the family therapist works individually and collaboratively to resolve their issue, which directly affects one or more family members. Each family member has the space to say what they think and how they feel as the issue affects them. For example, when a teen has anxiety issues, a family member gets to talk about how this issue impacts them.  

 

How long is each session and how long is the therapy period? 

1.5 hours per session over a period of 4-8 sessions, subject to review with your family therapist. Family therapy is a specialised counselling process. No one is a miracle worker. It takes time and commitment for the family to work through their issues. 

 

Are family therapists trained? 

Yes, systemic family therapists are trained with a Masters in Family and Systemic Psychotherapy, a specialised skills competency in systemic couple and family work. It draws on systems thinking and views the family as a unit. It evaluates the parts of the system (individual) in relation to the whole (family) and examines how an issue of one or more members of the family affects the whole family. It suggests that a family member’s behaviour or issue may be embedded in the family dynamics and influenced by the family of origin issues. 

Family Therapists would have undergone at least 560 hours of academic instruction and supervised clinical practice, accompanied by years of experience. 

 

When should my family and I attend Family Therapy?

It is always helpful to seek family therapy early before the issue snowballs and becomes more difficult or complicated to manage at the later stage. 

 

Who should attend Family Therapy? 

Immediate Family members in a family nucleus should attend Family Therapy, i.e. couples, parents, children (includes teens and adult children) siblings.

 

Does my whole family need to attend? What happens if I am unable to get all my family members to attend Family Therapy? 

It will be helpful if your family can attend therapy together. However, it is okay if not all family members can turn up for therapy. The family therapist will collaborate with the members who come for therapy sessions. 

 

How do I prepare for Family Therapy? 

Discuss with your family members about attending therapy together. Think and write down what you want to discuss before each session. Then, ask your family therapist how you want to improve the communication in the family. 

 

Is there confidentiality? 

Yes, the session is confidential under the Singapore Data Protection Act 2012 (“Act”). 

 

Where can I attend Family Therapy? 

Promises Healthcare provides family therapy service, so feel free to visit our website or contact us at Tel: 6397 7309 to make an appointment. 

The Power of Physical Presence in Therapy

The Power of Physical Presence in Therapy

Therapy is an indispensable tool to recovery, or in helping one gain deeper insights and achieve self-actualisation. In light of the ongoing COVID-19 pandemic, traditional face-to-face therapy has been forced to take on various forms, including sessions conducted via telephone or through video-calling platforms. Of course, therapy serves the same purpose, regardless of whether it is conducted in person or otherwise. However, there is definitely something restorative about being able to connect with a therapist physically. Humans are innately social creatures after-all, and sometimes when things get tough, a little more human interaction and comfort can go a long way. 

 

Physical presence in therapy certainly provides a deeper sense of connection, in contrast with virtual therapy where one might feel more distant and detached. It may seem bearable at the very beginning, but as you progress through the sessions, having to interact with your therapist through a screen all the time can get frustrating. Similar to how students may have trouble coping with online school and home-based learning, virtual therapy has some form of hindrance when it comes to relationship-building with your therapist. For most psychotherapy methods, it is indeed possible to shift them online. However, for others such as psychodrama, it may not be entirely ideal. How expressive and comfortable can you get, when you’re struggling to follow your therapist’s directives through the small screen and having to deal with technological lags? 

 

Seeing your therapist in person also allows for him/her to detect any subtle body language and somatic movements. These are all non-verbal cues that may be lost through telecommunication. Non-verbal cues are just as important as verbal ones, and can provide your therapist with greater insights. Non-verbal signals can serve to convey your feelings along with what is being said, and can either reinforce or contradict verbal messages. Ignoring them would be very much a failure to be fully engaged in a conversation. Moreover, seeing you in person provides therapists with the ease to identify any form of dissociation. During the session, clients may not necessarily attune well, and may not be fully present in the moment. The client may be engaging with the therapist, but seemingly thinking about something else that is going on in their life at the same time. This does not mean that the session is unhelpful or “boring”. While this could simply be attributed to the lack of presence, it could also point towards other concerns regarding the client’s state of mind. Fragmentation can occur especially when one is recovering from a past trauma and can be brought to the forefront, causing incomprehensive emotional reactions when triggered. Fragments of self are usually suppressed, often attributed to the lack of a sense of safety when it comes to expressing their inner needs or desires. When these feelings start to show during therapy, therapists can identify them through common tell-tale signs such as a switch into dissociation, noticeable body movements (twitching, scrunching of fingers or toes etc.). Body language is not definitive, but can offer clues about one’s thoughts and feelings. With telecommunication, it is more often than not impossible to see the client below shoulder-level, thus making it difficult for therapists to assess any somatic movements that may be occurring. 

 

Another issue with telecommunication is the lack of control over the therapeutic environment.  In a traditional face-to-face session, the clinician has considerable control over the environment, and is able to ensure a private, safe and quiet space for the entire duration of the session. This limits the number of distractions and allows for both the therapist and the client to concentrate on psychotherapy. Moreover, in a clinical setting, furniture is often set up in particular ways to facilitate clinician-patient interactions. For instance, seats may be arranged such that the clinician would be facing the client at an angle of 45 to 90 degrees, and approximately 2 to 3 feet away. Facing the client directly can feel somewhat threatening for some, and this angle allows for the client to feel more at ease. Additionally, it allows for both parties to break eye contact naturally (intermittently) without seeming antisocial or distracted by having to do so actively. In contrast, having a session online or through telephone allows for less control over interactions and the client may be more exposed to external distractions or undesirable interruptions. This also leads us to our next point, where teleconsultations also increase the risks of privacy breaches. 

 

Due to the lack of environmental control, having a consultation via telecommunication methods can be a challenge especially for those who do not have access to their own private space. For individuals living with others, there could be situations that compromise client confidentiality, including potential eavesdropping or having others walk in on them. Not only does this make the session extremely disruptive, it can be a huge concern for many considering that mental health concerns are sensitive topics. Clients must make the extra effort to find a suitable place and time for them to speak with their therapists freely and with ease. As such, physical presence in a controlled clinical setting may have the upper hand.

 

Nevertheless, this article in no way aims at undermining the efficacy of tele-health, nor to allude that tele-therapy is ineffective or pointless. Considering the need for physical distancing during the pandemic, telecommunication is undeniably crucial in limiting the spread of the virus. Putting that aside, traditional in-person therapy can have its barriers too, limiting people from attaining the mental health support they need. Individuals with disabilities may find accessibility to be a significant problem at hand, and find it difficult to travel for therapy without having others to rely on. Others include parents who are unable to find suitable childcare options, all while juggling work and mental health care. For those struggling with social anxiety and agoraphobia, it can also be extremely intimidating and overwhelming for them to step out. In fact, some research has shown that virtual and in-person therapy, depending on the treatment goal, can be equally effective. In adults, cognitive behavioural therapy was shown to be similarly effective both in vivo and virtually (Khatri et al., 2014). There is also evidence that youth with anxiety disorders respond positively via telehealth (Khan et al., 2020). Traditional face-to-face therapy and tele-therapy both have their perks, and we acknowledge that it also boils down to individual preferences. If you’re unsure as to which treatment option to opt for, do feel free to contact us.

 

References:

  1. Brenes, G. A., Ingram, C. W., & Danhauer, S. C. (2011). Benefits and Challenges of Conducting Psychotherapy by Telephone. Professional psychology, research and practice, 42(6), 543–549. https://doi.org/10.1037/a0026135 (Accessed 06/09/2021)
  2. Khatri N., Marziali E., Tchernikov I., Shepherd N. Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: A pilot study. Clinical Interventions in Aging. 2014;9:765. (Accessed 09/09/2021)
  3. Khan, A. N., Bilek, E., Tomlinson, R. C., & Becker-Haimes, E. M. (2021). Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19. Cognitive and behavioral practice, 10.1016/j.cbpra.2020.12.002. Advance online publication. https://doi.org/10.1016/j.cbpra.2020.12.002 (Accessed 09/09/2021)
  4. https://www.nataliarachel.com/articles-practitioners/shifting-to-tele-therapy-attuning-without-physical-presence (Accessed 07/09/2021)
What Does Journeying with a Psychiatrist for My Mental Health Issue Look Like?

What Does Journeying with a Psychiatrist for My Mental Health Issue Look Like?

For many people, when they hear the word ‘Psychiatrist’, it would instantly conjure up an image of a doctor prescribing medicine for someone with a mental health condition. This is true to the extent that a psychiatrist is a medical doctor who has undergone training to become a mental health specialist. While prescribing medications are indeed part of the treatment process, what really goes on in between – from the first session to the very end? 

 

On your very first session, your psychiatrist will most likely spend 1-1.5 hours with you to gain a better understanding of what you’re coming in for. Mental health conditions can be a touchy subject for many, and it is understandable that you’d feel hesitant to open up to a complete stranger right away. However, trust that your psychiatrist has your best interests in mind, and will do his/her best to provide optimal treatment. Don’t be afraid of being judged for your symptoms, rest assured that the psychiatrist’s office is a safe and non-judgemental space. The psychiatrist will want to know as much as you’re willing to share, and being honest with your psychiatrist will be extremely helpful for an accurate diagnosis and the development of an effective treatment plan. Just as what you’d expect when you seek a General Practitioner for physical conditions, your psychiatrist would start off by asking broader questions such as, “What brings you here today,” or “How can I help you?” For some individuals, especially if it’s their first time at a psychiatrist’s, open-ended questions like these may be nerve-wracking. You may feel a little overwhelmed, not knowing how to start or where to begin. However, there are no hard and fast rules as to how the session should flow. Simply communicating your symptoms and your concerns would be a great start, and your psychiatrist will guide you through the interview. 

 

Your psychiatrist will also run through a history-taking process, paying special attention to your medical history, family history, your current lifestyle habits and general patterns of sleep. It is important to let your psychiatrist know if you’re on certain medications, as some may have side effects that may fuel certain mental health conditions. Avoid downplaying or dismissing any information related to your physical or mental wellbeing, the clue to an accurate diagnosis may very well lie in the details. As such, going for your first session prepared with a complete list of medications, dosages, and your compliance with them can be very beneficial. Many studies have also shown that genetics play a role in mental health disorders. If you have a family member who suffers from a psychiatric issue, be sure to let your psychiatrist know for him to have a clearer idea of the situation. If need be, your psychiatrist may also ask permission to speak with other family members.

 

Depending on the patient’s circumstance, the psychiatrist may conduct a physical check-up if necessary, or possibly laboratory tests to exclude other possible causes for your condition. These are done to confirm that what you’re experiencing are not due to other medical conditions which may give rise to similar symptoms. Hence, if your psychiatrist asks for these procedures to be carried out, don’t feel too worried! Questionnaires to further assess your symptoms may also be given, so do make sure to answer them as truthfully as possible.

 

Depending on the complexities of your condition, medication options or other forms of treatment may be prescribed. If you are given medications, the psychiatrist would counsel you on how you can tell if the medications are working. Over the course of your recovery journey, take note of how subtle changes to the medications made by your psychiatrist affects you. Do they stabilise or improve your condition, or do they seem to send you on a downward spiral? How have you been feeling since you started taking them? Whatever the outcome, keep your psychiatrist in the know of how you’re coping. In the same vein, it is very important that you do not adjust your medications on your own without seeking professional advice! Patients may get impatient if they’re not seeing the desired change after a while, but constant and unregulated changes can cause undesirable fluctuations, potentially worsening the situation. We need to understand that there could be catastrophic, life-threatening consequences if we do not take them seriously.

 

In general, psychiatrists usually work closely with psychologists and therapists, as some mental health conditions are best treated with both neuropharmacological support and psychotherapy. Thus, your psychiatrist may also refer you for psychotherapy if deemed fit. Depending on the level of care required to address the patient’s symptoms, psychiatrists may recommend treatment programmes if more intensive care is needed. 

 

It is natural to feel nervous or uncomfortable about seeing a psychiatrist, but don’t let these emotions hold you back from getting the help you need. We hope that giving you a better sense of what to expect will help alleviate your concerns, and give you the courage to seek professional help.

 

References:

  1. Psychiatrists and psychiatry. Healthdirect.gov.au. (Accessed 21/05/2021)
  2. What Questions Do Psychiatrists Ask? | PHS San Diego (Accessed 21/05/2021)
  3. What to Expect During Your First Psychiatry Appointment (Accessed 22/05/2021)