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Managing Grief

Managing Grief

There isn’t consensus in the scientific community about whether Kubler-Ross’ five stages of grief is rooted in empiricism. Although much vaunted in popular culture, if you’ve experienced grief and resolved it in your own way, you’ll know that grief is an organic process that is by no means neat or orderly. It’s deeply unique to each individual, and this article is designed to hopefully help you through whatever loss you have experienced in the recent past.

The five stages of grief, which Kubler-Ross first postulated that terminally ill patients experience are: Denial, Anger, Bargaining, Depression and Acceptance. Denial in this context encapsulates a perfectly normal response to a tragedy, and is exactly what you would imagine – it’s simply a refusal to believe that “this bad thing is happening to me”. After reality sets in, and the sobering realisation that the tragedy has occurred is impossible to ignore, Kubler-Ross observed that people often display frustration, which culminates in Anger. Once that Anger has dissipated, people often move on to Bargaining, which is the hope that they can somehow extricate themselves from their dire straits and obtain the balm of a different circumstance. Notwithstanding the success of the earlier bargain, Depression follows, which is self-explanatory. The final stage of Acceptance is the sanguine realisation that nothing will change their situation.

If you are currently going through your own grief and taken a step back to evaluate how you are processing it, you might have noticed some incongruencies between the model and your experience. That’s perfectly natural because there has been some criticism levelled at the Kubler-Ross model in that there is confusion over description and prescription. This means you shouldn’t take it as a rule, no, or feel inadequate or “bad” that you aren’t “properly” grieving. We hope that what follows in this article will provide you with some breathing room to let your grief take its own course, and helps you handle a tragedy with the right tools.

Grief is a loss. It’s your prerogative to define what grief is to you, and even something as banal as losing a cherished item from your childhood can precipitate feelings of loss. So, you shouldn’t wall up these feelings behind what society has proscribed as appropriate. We’re talking about you here, not anyone else. It bears repeating that your grief is unique because of a multitude of factors, for those of you who don’t want to accept that it is your right to give yourself the breadth to grieve – your upbringing, your culture, your faith, your parents, the list is endless. So give pause and slip into your own rhythm of grieving.

To help ensure that you do not slip into the common fallacies that can disrupt your grieving process, we’re going to list some of the pitfalls that ensnare people and prevent therapeutic processing of grief. 

1) If you don’t show an outward display of grief such as crying, you aren’t “sad”

Just like the shortcomings of Kubler-Ross’ model, while crying is seen as a “socially acceptable” way of demonstrating sadness, it isn’t applicable to everyone. You may have been brought up to avoid tears at all costs, perhaps due to tough parenting or some childhood trauma, or you may not wish to “affect” others with your grief. No matter the reason, you should know that physiological responses to grief vary widely depending on your circumstances. Shock, numbness, anger, even hysterical laughter – just about anything is permissible in the initial, very private stages of your grief. 

2) If you don’t “get over it” within an “acceptable timeframe”, you aren’t good enough

Although your family members or people in your community may react to and resolve their grief earlier than you, you need to know that it is by no means healthy to affect the fragility of such a process by introducing the pressures of comparison. Some people simply have better coping-skills than others or are more inured to unhealthy thought processes that hold them back from the therapeutic management of their grief.

3) You feel like you need to “protect” loved ones from your grief, so you turn inwards

We keep emphasizing that grief is individual to everyone – this should tell you that there is no circumscription to how you handle it. Even though it might feel selfish to display your feelings openly because you think less emotionally able loved ones shouldn’t have to deal with your pain, remember that there is nothing shameful about the old adage, “Shared joy is double, shared sorrow is halved”. 

There are some simple coping mechanisms that you can use to help yourself through the process. Although the low mood is a given after the heartache of a tragedy or loss, and you might not feel willing or able to pick yourself up and carry on, remind yourself of the wisdom of eating and sleeping right. Drugs and drink might seem the most accessible ways to insulate yourself from poor mood, but these indulgences, in the long run, are hindrances to sustaining your mental well-being.

If you feel like the person you have lost needs to be remembered, you can do so in the solitude of creative expression, or you can choose to gather loved ones to laugh about cherished memories. If there’s one scenario where laughter in the face of loss is wholly acceptable – here it is! Whether communal or solitary, there are many ways you can raise someone up in loving memory – honouring them and helping yourselves. 

Find solace in your old routines. If you’re hurting after the failure to gain acceptance into a school of your choice, it may help to remember all the things you did well before that gave your life meaning and structure. At the worst of times, it helps to fall back on old patterns if only to hang on to some stability.

Lastly, know that there is a difference between clinical depression and the normal response to grief. You should be aware of critical signs or symptoms in both yourself and your loved ones that may indicate depression. For example, if you notice that your loved one isn’t eating or sleeping properly after a long period of time, or is displaying reckless tendencies such as driving dangerously or overindulgence in addictions, it may be time to seek professional help. Although many people can get through grief without the help of a mental health professional, when it all gets too heavy to handle, you may consider seeking grief therapy. Some of our clinicians are specifically trained in grief therapy, such as Joachim Lee or Winifred Ling.

 


Photo by Claudia Wolff on Unsplash

Mental Health Awareness Panel Discussion feat. Dr Rajesh Jacob & S C Anbarasu

Mental Health Awareness Panel Discussion feat. Dr Rajesh Jacob & S C Anbarasu

On May 16th 2020, Dr Rajesh Jacob, Senior Consultant Psychiatrist & S C Anbarasu, Senior Clinical Psychologist, were invited to be a part of a Public Education Talk: ‘Mental Health Awareness Panel Discussion’ by the ‘Migrant Workers Singapore’  group – a migrant workers community platform.

The discussion touched on a wide range of Mental Health conditions that they are concerned over; explained what they are and how one could cope or be a support.

We encourage you to hit the ‘play’ button to view the video.

 

Mental Health Awareness Panel Discussion

So if you feel anxious, depressed, stressed, or even suicidal? What can you do? Too many people suffer in silence and don’t seek help! Come join a conversation about mental health issues! Our experienced panel will consist of mental health professionals from various disciplines, a Senior Consultant Psychiatrist, Senior Clinical Psychologist from Promises Healthcare Clinic, and an Assistant Head of a Family Service Centre! The panel will be moderated by Casework Manager of SG Accident Help Jevon Ng, an advocate for mental health and wellbeing. Our panel members all have a lived experience of mental health and will be answering questions from the audience.audience participation is encouraged. Please click the link below to join the webinar: https://us02web.zoom.us/j/83397902082Date: Saturday, May 16 2020Time: 4:30 pm – 6:30 pmEvent Categories: Raise Awareness Organizer@Migrant workers Singapore Support by SGcare Physiotherapy Clinic

Posted by Migrant Workers Singapore on Saturday, 16 May 2020

Religion, Spirituality and Psychiatry

Religion, Spirituality and Psychiatry

Written by: Dr Rajesh Jacob, Senior Consultant Psychiatrist, Promises Healthcare

 

The basic characteristics of all religions are similar. There is a firm belief in a higher unseen power who is the supreme master.

 

Religion and Spirituality, Is There A Difference?

Religion Is an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality).

Spirituality is the personal quest for understanding answers to the ultimate questions about life, about meaning, and about the relationship with the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of a community. Spirituality is thus a more inclusive concept than religion.

 

Mental Illness In The Middle Ages

The idea that religion and psychiatry have always been in conflict is still very prevalent. Today, most people believe that in the medieval ages, most mental disorders were considered as witchcraft or demonic possession. People with mental disorders were recognized as different and treated in various ways. Early medicine men, considering such individuals to be possessed by demons, introduced a technique called trephination, which Involved drilling a hole in the head of the individual to let evil spirits out of the body. Many other civilizations independently developed such a procedure. For example, among the remains of the Incas in Peru are skulls with holes and trephination devices. The treatment of mental illness deteriorated in the late Middle Ages and remained poor through the eighteenth century. As the medieval years progressed, insanity became linked to witchcraft and demon possession. Those considered to be possessed with demons were exorcised. This ritual, performed by a priest, would call upon the demon to come out of the individual and to transfer itself into an animal or inanimate object. Both the Greeks and Romans thought that the mentally ill were capable of causing major social problems, as well as harm to themselves. They made provisions for guardians to take care of the insane. Realizing that these people could hurt themselves or others and could destroy life and property, laws were passed that set specific guidelines. Since there were no lunatic asylums, people with mental illness were a family responsibility. The seriously impaired were restrained at home, but others were permitted to wander in the hope that evil spirits might fly out of them.

Certain saints were thought to be more active in the domain of madness. In northern France, the shrines of Saint Mathurin at Larchant and Saint Acairus at Haspres were known for healing. In Flanders, now Belgium, citizens of Geel developed a shrine to Saint Dymphna that became a hospice to house the mentally ill. During the early years of the Middle Ages, the community took care of the mentally ill. Later, hospices, then asylums were developed to house them. London’s Bethlem asylum—better known as Bedlam—was founded in 1247, making it one of the oldest institutions of its kind. The term “bedlam” became associated with chaos, confusion, and poor treatment, which reflected the general attitude toward mental illness at the time. It was only in the nineteenth century that scientists and society began to reconsider deviant behaviour from the perspective of mental illness rather than as a manifestation of evil spirits.

 

Religion And Psychiatry

Persons with mental disorders can sometimes present with symptoms such as hyper-religiosity (manic episodes as part of bipolar disorder) or delusional beliefs such as possessing godly or religious powers. Rates of religious delusions in schizophrenia remain high. These symptoms and signs need to be carefully assessed by mental health professionals. Certain groups in Christianity such as Pentecostal Christians “speak in tongues”, which is not a symptom of mental illness, but an expression of their religious beliefs. “Speaking in tongues” is mentioned in the Bible. 

In the last two decades, rigorous scientific research has been done and published in mainstream medical and psychological journals. David B. Larson, Jeffrey S. Levin and Harold G. Koenig were some of the authors. They have conducted a series of studies looking at the relationship between religious involvement and mental health in mature adults, either living in the community or hospitalized with medical illness. Since then, many other researchers have produced a large body of research that has usually, but not always, shown a positive association between religious involvement and mental health.

According to the Harvard psychologist, Gordon Allport, a person’s religious orientation may be intrinsic and/or extrinsic.

  • Extrinsic Orientation
    Persons with this orientation are disposed to use religion for their own ends. Many find religion useful in a variety of ways – to provide security and solace, sociability and distraction, status and self-justification. 

 

  • Intrinsic Orientation
    Persons with this orientation find their master motive in religion.

    • Other needs, strong as they may be, are regarded as of less ultimate significance, and they are, so far as possible, brought in harmony with the religious beliefs. Having embraced a creed, the individual endeavours to internalize it and follow it fully. Usually, the intrinsic orientation is associated with healthier personality and mental status, while the extrinsic orientation is associated with the opposite. Extrinsic religiosity is associated with dogmatism, prejudice, fear of death, and anxiety, it “does a good job of measuring the sort of religion that gives religion a bad name.
    • Physical health:  Religiousness was related to decreased smoking and alcohol consumption. Religious commitment and participation seemed to affect longevity, as well, especially in men.
    • Suicide rates were consistently found to have a negative correlation with religiosity. In Hinduism, if you take your life prematurely, you have to suffer in the next birth. Most research findings support that religious affiliation, especially participation, lowers the rate of alcohol consumption. Being religious results in more hope and optimism and life satisfaction.

 

Belief Systems, Cognitive Framework

Beliefs and cognitive processes influence how people deal with stress, suffering and life issues.

Religious beliefs can provide support through the following ways: Enhancing acceptance, endurance, and resilience. They generate peace, self-confidence, purpose, forgiveness to the individual’s own failures, and positive self-image. On the other hand, they can sometimes bring guilt, doubts, anxiety and depression through an enhanced self-criticism. ‘Locus of control’ is an expression that arises from the social learning theory and tries to understand why people react in different ways even when facing the same problem. An internal ‘locus of control’ is usually associated with well-being and an external one with depression and anxiety. A religious belief can favour an internal ‘locus of control’ with an impact on mental health.

 

Religious practices

Public and private religious practices can help to maintain mental health and prevent mental diseases. They help to cope with anxiety, fears, frustration, anger, anomie, inferiority feelings, despondency and isolation. The most commonly studied religious practice is meditation. 

It has been reported that it can produce changes in personality, reduce tension and anxiety, diminish self-blame, stabilize emotional ups and downs, and improve self-knowledge. Improvement in panic attacks, generalized anxiety disorder, depression, insomnia, drug use, stress, chronic pain and other health problems have been reported. Follow-up studies have documented the effectiveness of these techniques.

 

Role of the Psychiatrist

During assessment, the psychiatrist should be able to determine whether the religion in the life of his patient is important, has a special meaning and is active or inactive. Four basic areas should be remembered when taking a spiritual history.

  1. Does the patient use religion or spirituality to help cope with illness or is it a source of stress, and how?
  2. Is the patient a member of a supportive spiritual community?
  3. Does the patient have any troubling spiritual question or concerns?
  4. Does the patient have any spiritual beliefs that might influence medical care?

The clinician who truly wishes to consider the bio-psycho-social aspects of a patient needs to assess, understand, and respect his/her religious beliefs, like any other psychosocial dimension.

 


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What is the Lasting Power of Attorney (LPA)?

What is the Lasting Power of Attorney (LPA)?

The idea of becoming mentally incapacitated is often so frightful that most people simply avoid the issue. Discounting the various other ways someone can lose control of their mental faculties, in Singapore, 1 in 10 people above 60 will succumb to dementia and 3.6% of people will suffer from obsessive-compulsive disorder, 1 in 50 people will experience a psychotic episode at some point in their lives, and 1% will suffer from schizophrenia, all conditions that might precipitate the loss of mental faculties. It’s a statistic that we’ve not brought up to alarm you, but simply to help you decide if you have someone in your life you trust to protect your interests, in the realm of your personal welfare, and property and affairs.

You simply have to be above the age of 21, by law in Singapore, to appoint one or more “donees”, who are people you trust “to make decisions on your behalf, in your best interests”. You, as the appointer of your donee(s), are known as the “donor”.

The Ministry of Social and Family Development suggests that it is beneficial to make an LPA as a protective measure against any untoward happenstance as it relates to your mental well-being. It is obviously best to decide what the best permutation for you is while you are capable of making rational decisions on your own behalf. Broadly, your appointed donee(s) will have control over one or both of the following aspects of your life: your personal welfare; and your property and affairs.

The LPA is designed to safeguard your interests, so it grants you the latitude of choice in deciding if: you want a single donee, whose powers are defined in Part IV of the Mental Capacity Act, or multiple donees. In the event that you decide that you would prefer multiple donees, you also have the power to decide if you will allow any one of them to act alone in making a decision on your behalf, or have them come to a consensus on undertaking a decision.

The difference between LPA Form 1 and LPA Form 2 is that LPA Form 2 allows you to appoint more than 2 donees, more than 1 replacement donee, or grant your donee(s) customised powers above the general powers with basic restrictions that donees are granted under LPA Form 1. LPA Form 2 requires the services of a lawyer.

After you have decided what’s best for you, and filling up LPA Form 1, or LPA Form 2, which you can do with the help of a lawyer, there is a “critical safeguard” in place to ensure that the LPA is not made under duress. This means that your LPA form will have to be witnessed and certified by an LPA certificate issuer, which can be:

  1. an Accredited Medical Practitioner;
  2. lawyer; or
  3. registered psychiatrist

As the writer of this article is none of the above, we recommend that you speak to your chosen LPA certificate issuer to fully understand the nuts and bolts of the LPA.

Nobody wishes to have the eventuality of an LPA come to pass, but we hope you will consider that “a stitch in time saves nine”. For Singapore citizens, the LPA Form 1 is free, until 31 August 2020.

Please refer to the MSF’s LPA FAQ for further details.

 


  1. Singapore Mental Health Study, 2016.
  2. Psychosis – Institute of Mental Health. https://www.imh.com.sg/clinical/page.aspx?id=258, accessed 8/6/20
  3. SA Chong, et al. A Risk Reduction Approach for Schizophrenia: The Early Psychosis Intervention Programme, Annals Academy of Medicine, Sep 2004 Vol 33 No. 5.
  4. Photo by Scott Graham on Unsplash
Demystifying Play therapy: Play ought to be taken more seriously

Demystifying Play therapy: Play ought to be taken more seriously

Written by: Dr B. Malavika, Psychological & Educational Therapist

Play is a critical part of a child’s development from birth. It boosts healthy brain development that is conducive for physical, cognitive, and emotional growth. It encourages imagination and creativity, and improves social skills and confidence. It is therefore not surprising that psychologists realised its power and tapped into it as an instrument of healing.

Challenges are a part of life. But in childhood, they can be harsher as children haven’t developed the capability to understand or deal with what they are going through.  In their tender minds, loss or pain could be something as small (to an adult) as a broken favourite toy and range up to a major loss in the forms of death, separation from a loved one,  hospitalization, abuse or other personal/family crises. While some children might manage to some extent by voicing their displeasure or through negative behaviours, others might just suppress their emotions. If the setbacks are beyond the coping skills of the child, the trauma can manifest as psychological or emotional disorders.

Parents often ask how they can know if their child needs counselling.  Some signs could be that the child is being more angry, nervous, defiant, sad, or withdrawn than usual, or than is reasonable. The child could also be showing changes in eating and sleeping patterns, a decrease in school grades or reduced interest in previously favoured activities. When in doubt, it is better to err on the side of caution and seek help.

Play therapy is one of the prominent forms of therapy for children and is practised by a variety of mental health professionals, like counsellors, psychotherapists, clinical psychologists, psychiatrists and social workers. It is an intervention which allows children who are experiencing emotional or behavioural issues to open up their emotions in the safe space of the ‘playroom’.  They are given toys to play with, and the children play as they wish, without feeling interrogated or threatened.  For the children themselves, play (therapy) is familiar and fun and they are thus able to work out their undesirable experiences and resolve their emotional and behavioural difficulties. What materials the child chooses to play with and how they play all have meaning.  The therapist watches their play to get an insight into their emotional or mental health problems. 

Depending on the issues faced by the child and their own training, therapists conduct non-directed or directed play therapy and provide play materials accordingly. Non directed play therapy is free-play and very similar to the free association of adult psychodynamic therapy. While in the latter adult clients are allowed to talk and ventilate to gain insight and resolve their problems, free play with limited conditions and guidelines, allows the child to express their feelings just through their play. Their verbal expression might or might not be as important.

Directed play therapy includes more structure and guidance by the therapist and several techniques are used to purposefully engage the child. These could be engaging in play with the child themselves or suggesting new topics, themes for play. Parents might or might not be included in the sessions. Materials may include art and craft materials, sand and water, clay, dolls, toys, blocks, a family of dolls, miniature figures, animals, musical instruments, puppets and books. While traditionally Play therapy is considered to be beneficial for children ages  3 to 12,  it has been modified and customised by researchers and therapists to help adolescents and adults also, and some mental health practitioners have started including video games as therapeutic tools. Apart from being used at counselling centres, play therapy is also being used at critical-incident settings, such as hospitals and domestic violence shelters to help children deal with deep issues. 

In regular lives, parents can encourage their kids to play indoors and outdoors and especially in nature. Lawrence J. Cohen has created an approach called ‘Playful Parenting’, in which parents are encouraged to connect playfully with their children through silliness, laughter, and roughhousing to enhance relationships and general well being.

Challenges are a part of life. While the purpose of therapy is to solve problems, playing for the sake of fun can prevent them. This can be applied not only for children but for the inner child in every individual to make life happier and more meaningful. As the proverb goes – All work and no play makes Jack a dull boy.

 


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Mental Wellness during  #CBLite – Pushing Through The Phases

Mental Wellness during  #CBLite – Pushing Through The Phases

Written by: Joachim Lee, Senior Psychotherapist, Promises Healthcare

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!


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