If you’ve been pottering around the Promises Healthcare’s ‘Our Team’ page, and are new to the world of mental health in that you’re considering making the leap to seeking help from a mental health professional, it’s our hope that this casual guide to demystifying the titles, designations and dizzying abbreviations that adorn each profile will point you in the right direction.
For starters, there’s one thing that each of our mental health professionals have in common. They all possess at minimum a Master’s level certification in their discipline, so you can be assured of all their competencies.
As we’ve shared in a previous article, a psychiatrist is at their core a medical doctor, which certifies them to prescribe neuropharmacological support – i.e., medication.
But of course, psychiatrists more often than not do indeed possess relevant counselling and psychotherapy certifications, because being well-versed in the craft of patient care in the mental health sector does help them delve deeper into the minds and psyches of their clients, and assist them in skilfully and empathetically overcoming boundaries that some clients may consciously or unconsciously put up that stymie the therapeutic process.
Prescribing the most effective neuropharmacological support is buttressed by the psychiatrist’s skill in interpersonal communication, both verbal and non-verbal. Psychiatrists often describe themselves as observers, but it goes without saying that navigating these one-on-one interactions requires input from their side of the desk. While you might think that psychiatrists have reached the peak of the career trajectory of a mental health professional, keep in mind that by no means should you think of a psychiatrist as the fount of all mental health knowledge. Think of the ‘helping’ professions encompassed in the form of a large tree, rooted in a common desire to help people in need and supported by a trunk of science and evidence based knowledge , from which grows different branches representing the many ways in which mental health professionals can help someone in need – certain disciplines are applied more rigorously in helping certain conditions or situations. This is why Promises is described on our page as a multidisciplinary team of mental health professionals. Your treatment plan is provided by our team, and under the shade of our tree, you will be prompted to reach for certain branches – but at the end of the day, it is your choice to pick the leaves which seem most lush to you.
Psychologists differ from psychiatrists in one key authority. They are not medical doctors, and therefore cannot prescribe you medication. You’ll notice that our stable comprises a good number of clinical psychologists – so, what exactly are they, and how can they help you? Clinical psychologists possess doctorate degrees in psychology, and are imbued with the ability to cater to clients who suffer from any number of the discombobulating disarray of mental health conditions which sadly, are still negatively stigmatised in society. Think schizophrenia, bipolar disorder, depression, and their ilk. A clinical psychologist can make a diagnosis for you, if you think you are suffering from a mental health condition. Using the tools in their arsenals which they are trained in, such as psychometric testing, intelligence testing, personality testing, and much more, their diagnoses are firmly rooted in evidence based science. You could then make the logical conclusion that if they deem your condition treatable with medication, they would refer you to a psychiatrist. There’s a lot of symbiosis going on in our clinic!
The difference between Counsellors & Psychotherapists
We’ll deal with counsellors and psychotherapists next, because the two fields are very much intertwined, aligned in some facets, while possessing in granular detail key differences. Counselling and psychotherapy are both broadly concerned with betterment of clients in need, and there is significant overlap in the goals of either mode of therapy. Now, on to the differences, which will help you better distinguish which leaf you’d like to choose. First, there is a temporal difference between the two in both the length of treatment and how far back into your life each mode of therapy delves into in order to solve your current issue.
Counselling, on one hand, tends to favour clients who are more self aware and sensitive to their emotions and thought processes, and need a helping hand in unpacking a recent difficulty or life altering experience that they wish to resolve. This is rather unlike psychotherapy, rooted in a humanistic tradition – some may refer to it as height psychology, a term which gained currency during the time of Abraham Maslow and his espousement of self-actualisation. Psychotherapy, in this sense, takes a long, lingering look at a person’s past, life changing experiences, deep seated traumas and neuroses, or any relevant factors – all to help a client gain mastery of self (self awareness) and challenge them to enact the necessary life changes that lead to self improvement. You might well think of counsellors more as “advisors”, and psychotherapists as the “life guides”. Of course, detract nothing from both disciplines – their practitioners chose their specialities precisely because they fit into their world-views and probably, because they thought that they were good at it!
How do you choose?
Of course, given the array of therapeutic modalities and mental health professionals, we understand that choosing the right leaves can be a bewildering experience. That’s why we feel it’s best that you browse the profiles of our therapists, read their biographies and see which of them you feel most comfortable seeing. In the near future, Promises Healthcare intends to refine and streamline your selection process by having a list of issues or conditions that you are having problem(s) with – your input will then guide you to the mental health professional in our team that is best equipped to deal with your issues. For now, take a deep breath, sit back, read, absorb, think with clarity about what you want to deal with, and pick one to make an appointment with. Choosing the right therapist isn’t a one hit wonder – it takes time and patience, but rest assured that we’ll do our best to help you in that regard.
Written by: Dr Mark Toh, Consultant Clinical Psychologist
It is a reality that we can choose our friends. If at times we find them annoying, we can always choose to make adjustments or even terminate the friendship if needed. But unfortunately, we cannot choose our family members. As such, it can be a challenging and sometimes very difficult situation when family members are emotionally unhealthy and they have not sought help to address their own difficulties.
Instead, by having to live with them as members of the same family, they become a regular source of mental distress. This can pose a particular burden for minors, or those still dependent on the difficult member as the financial source of living, or during the current coronavirus lock-down imposed by the government when family members are confined together. In some cases, especially when violence and harm is a possibility, these unhealthy members can become damaging or dangerous and more drastic action may need to be taken to promote safety.
For the child, this may be confusing if the source of difficulty from parents are due to attempts to parent or from inappropriate control. Or they may have siblings who like being bossy to their siblings. Here are some signs to consider in trying to differentiate healthy from unhealthy behaviours from difficult family members.
They are always blaming you while not accepting their own responsibilities.
Individuals who engage in unhealthy relational behaviours often have difficulty taking ownership for contributing to the problems that emerge between each other during disagreements or conflict. Their need to blame others is usually a defensive response against accepting their own guilt or responsibility for their fault or wrong in the situation.
They are always critical towards you.
Unhealthy family members also often present themselves as critical. This goes beyond a simple discussion to point out about errors if or when you or someone else has made them. But it appears more as a pattern or their habit in regarding you as a target of contempt. Words that undermine your character are often expressed. It is also often expressed regardless of the many accomplishments you may have achieved. It is often an expression of projection that reflects deep resentment or the unfulfilled wishes of the parent on a family member. Sometimes it is a resentment shared between both parents and projected on a child who they have identified as the “scapegoat”. The scapegoat in unhealthy families are usually children who are targeted for blame because the parents need to fault the child to avoid taking ownership of a problem.
They are dismissive of your feelings.
A healthier family is more prone to being encouraging or supportive especially in difficult times. But the unhealthy family member is often unconcerned of your feelings or even your opinion. The extent of their dismissal of you may show up as disagreement with you even if you are right. In severe cases, if you attempted to approach them to resolve a disagreement, they may even resort to convincing you as the problem. In this focus, they could convince you to see that you are the problem rather than to problem-solve in search of a solution that has mutual benefits.
They often make threats.
Physical altercations are not the only signs when the relationship or behaviour is unhealthy. Making threats especially when repeated is often employed as a means of control. This is going beyond anger which is a common feeling within long-term relationships. Anger is a sign when someone feels offended, frustrated or hurt. But the use of threats goes beyond anger to become an instrument of intimidation or domination, and a misuse of power. It is a common behaviour of abusive individuals.
They are controlling.
There is a difference between control from healthy parenting and unhealthy parenting. Healthy parenting is focused on what is in the child’s best interests. When discipline is exercised, it is done to facilitate learning for the child. In unhealthy parenting, control is displayed more because it is primarily attentive to the parents’ wishes and not in the best interests of the child. This is often expressed when the parent becomes forceful and induces fear on the child so that the parent can feel powerful or have his or her way. This control can also be applied between couples or siblings. The family member is expected to take the role of submission in their engagement for the controlling person to be pacified.
Additional signs for concern in this area is suggested by (a) prohibition of personal decision-making that is good for the family member, (b) issues of appropriate concern are denied from being raised for discussion, (c) material resources such as money or food are used to manipulate the family member towards submission, (d) there is direct restrictions into personal choices pertaining to clothes, appearances, spending, friendships, or even use of time, and (e) there is an opposition towards the family member becoming independent, to be separated from the unhealthy individual, or for the family member to be individuated (mature to become their own person) over time. Between couples, a controlling spouse is often violating the boundaries of his or her spouse. It is as if the controlled spouse is not allowed to be free to exercise his or her own choices.
They confuse punishment with discipline.
Discipline is the means to teach someone to abide by a code of conduct, or correction for a child to learn right from wrong. But for the unhealthy individual, punishment or discipline occurs when there is no lesson to be learned. It shows up usually because the person is unhappy for some reason. Their need to lash out is their attempt to vent out their anger or rage even if it becomes hurtful to others, and they feel justified conducting themselves this way. At other times, this punishment is expressed through passive aggressive behaviours when “silent treatment” is employed instead of yelling or shouting. Or the punishing behaviour is excessive and disproportionate to the action or event.
Unhealthy parents take sibling rivalries or ‘misbehaviour’ to the extreme.
This usually occurs when the unhealthy parent is resentful of all his or her children. They may feel that having children (or marriage) have become a personal cost to them because of the responsibilities required for the care of the children. They feel prevented or deprived of their freedom and so the children or family member are to blame. Or this could show up with a parent showing favourites to one child over the others. In the course of sibling rivalry, the unhealthy parents is revealed by (a) blaming one child more severely over the other and consistently, (b) humiliating the scapegoated child, or (c) the unhealthy parent experience the sibling rivalry or conflict as a personal or vindictive act against the parent.
Strategies for Coping with Unhealthy Parents or domineering spouses and/or siblings
It may be a sad reality that parents can consider themselves parents simply because the infant is born following his or her physical birth. But beyond the biology, the emotional maturity, readiness or mental health can often be found lacking in parents to create the healthy conditions for the infant to develop or thrive. Controlling family members who are narcissistic in nature are also more interested in their control than the well-being of others. When family members regularly display the above behaviours, there is a need for concern. Given the potential for mental distress, developmental disruption and suffering, the following strategies may be essential to assist in coping.
Know that you are your own person.
Although you may share some traits or the same family name with your parents, remember that you are not 100% of the same people who raised you. If you recognise that your parents are emotionally unhealthy, understand that you do not need to follow their same values or behavioural patterns. When you realise that you have been hurt by them repeatedly and their use of authority serves their own interests over your needs to develop in a healthy way, be ready to break away from their self-serving values to work towards a healthy development for yourself. Explore to find healthy models of functioning among others to seek their influence over your lives rather than what is practiced at home.
Create space for your own emotions to nurture your own sense of self.
The unhealthy parent, spouse or sibling often do not respect your personal boundaries. They may deny your personal space or your feelings because they are preoccupied with their own. They may not discuss matters out or they may attempt to deny an essential part of who you are. While they deny how you may feel in their relationship with you, this does not mean you cannot acknowledge or express your own feelings by blogging or journalling.
Find supportive relationships elsewhere.
When your family members have made themselves unapproachable, you can turn to others for support instead. Friends, teachers, counsellors, or colleagues are often available to relate to who engage with a healthier appreciation for you. You do not need to go through difficulties alone. So find a support system from those who appreciate you for who you are and who value you in the person you can become.
Understand that your parent, spouse or siblings may have narcissistic tendencies or a self-serving biases so set your expectations low in conversations with them.
Unhealthy parents, spouses or siblings highlight the need to understand mental illness. Having to engage family members who have already discounted you, or hold you in contempt is often more reflective of them than of you. For this reason, understanding if they have a narcissistic or anti-social personality or tendencies is useful to recognise their biases. You may wish to have deep, meaningful or respectful conversations with them. But since this is not possible for those who are narcissistic or anti-social in nature, keeping exchanges brief and light is best to minimise stress or conflict.
Be prepared to employ diversion tactics in conversation.
Being diversionary may not be appreciated in social circles. But if your family member is controlling or looking for conflict, having a mutually respectful conversation may not be possible. As such, their attempts to dominate or argue can be diverted. For example, if they choose to criticise your choice about what you bought, you can note their comment while affirming your choice. Then this can be followed up by you changing the topic. This may allow you to have some control while you may be under attacked.
Recognise the traits that make you an easy prey.
For some, the need to dominate can be influenced by their perception that you have difficulty standing up for yourself. Their view that you are unable to be firm in protecting yourself may appear as an invitation to them to bully or dominate. Learning to stand your ground will help to establish yourself as deserving of respect.
Expect their angry response but do not surrender to it.
Your attempts to hold your ground or establish personal boundaries may be seen as a threat to the controlling parent or spouse. They see it as a challenge to their need to dominate or control. As such, anger can be employed as their weapon. It is important to not be paralysed by the person and to remember that you still have power. This power may not be accepted by them but you have power nevertheless. You can continue to pursue what is clearly in your best interests despite the threats and anger they express. Choosing the right timing to pursue your interests with them may be required. Or being able to refer to the credibility of someone else with authority on the subject may be helpful to borrow these views to help you to hold your position.
Aim to be self-sufficient and independent.
The need to establish your healthy sense of self and personal integrity is important. Your own mental health depends on it. In the face of parents or family members who are clearly focused against your best interests in pursuit of their own interests, you can set goals to be financially independent in order to become autonomous with what is needed to establish your own integrity and identity. Unhealthy parents often employ money as a means of keeping the child dependent. As such, learning to budget and be self-financing will help to establish your independence from them.
Do not accept abusive behaviour and the effects of it.
Recognising the signs of mistreatment from abusive parents, spouses or siblings should allow you to feel the anger you have reason to feel. Often these people may also engage in seduction or manipulation to downplay their dysfunction and hide their mistreatment of you. Being able to recognise their self-serving bias and the potential damage that this can create is important to not allow them to justify it. If their mistreatment is justified, it is more likely that you could minimise the damage and practice it yourself.
If the abuse is persistent or violent, be prepared to get help and seek shelter and protection outside the family.
This is hard to do for children but the sad reality is that some parents are poorly prepared to parent or they are mentally ill when they decided to have children. It is a sad and tragic reality that children have died from neglect, abuse or mistreatment while in the hands of their parents or caregivers. Children have been starved, exploited, tortured in the hands of violent, mentally ill parents. This has also occurred between couples as indicated by one spouse being regularly abused by another. Abuse can be physical, emotional and/or sexual, and they can happen between couples and on children within a marital or family system. If only one parent is aggressive or violent, the other parent has to be prepared to seek shelter to protect themselves or their children. If in the case of one parent being violent and the other parent ignores the child being abused, the children need to be protected from both parents.
This article is a call to alert those who may be suffering within families. Tragically, there are hidden dangers that vulnerable family members may be exposed to. They may already be suffering in subtle or obvious ways at the hands of unhealthy, abusive or emotionally damaging family members. Our collective concern for the weak calls out for us to be sensitive to when this danger is present within our community to protect the vulnerable among us.
Faubion, D. (2020, Apr). Toxic family dynamics: the signs and how to cope with them.
Chen, C. (2015, Feb 25). What to do when the toxic people in your life are (unfortunately) your parents. The Huffington Post.
Streep, P. (2016, Dec 14). 8 strategies for dealing with the toxic people in your life. Psychology Today.
Thorpe, J. (2015, Sep 18). 7 tips for dealing with toxic parents. Bustle.
Anger is a response most of us have when we feel our territory is being threatened. This is a primitive reaction from our days as cavemen (and cavewomen) when a wild animal was nearby! This reaction has not quite been removed by modern civilisation. When something threatens our security, the brain responds to it with a fight or flight reaction. The body releases adrenaline which causes changes in the body. The heart pumps faster, breathing gets faster, blood gets diverted to the legs and arms so we can run or fight back. The blood flow to the reasoning part of the brain is lessened so that thinking becomes difficult. Nowadays there are no saber tooth tigers coming out to attack us which require us to fight or flee. However the body’s response to a threat remains the same and, unless we find ways to discharge the energy or change our perceptions, the fight response will persist.
Powerless!! That’s the situation most people find themselves in at the moment during this Covid-19 Pandemic Circuit Breaker. From the home maker, who has to see her family all day long to the child who wants to have his friends over; teenagers who are restricted in their activities with peers to husbands who have to adjust to being at home with no break! Cabin fever is setting in and many are not coping well. Add to that mix an addiction that is running rampant in the household and you have a powder keg ready to blow!!!
What can family members do at this time to stay sane and not get embroiled in another power struggle or argument with the addict in the house. Anger that luxury during normal times is just magnified as all of us are forced to Stay Home. A simple request turns into a huge event; an innocent comment gets misinterpreted; and even demonstrations of concern become fuel for accusations of being manipulative or controlling. What to do??
Most family members of addicts or dysfunctional families (most of us can attest to being in this category), have resorted for a while now to manage, manoeuvre, save or guilt trip. This comes from a place of love and fear. However having time apart has always been a great diffuser of tension. Now faced with a Stay Home situation things can get stressful. Once free to go out, meet friends, go to the gym and pursue our life goals, we find ourselves having to don a mask and stay six feet away from each other, with frequent temperature checks thrown in! Yes we know it’s for our own good but just how do we go about removing that sense of irritation or frustration?? What’s wrong with me? I never used to get SO upset?? Being stuck at home we ‘step on the toes’ of others or they inadvertently step on ours.
So here are some possible ways to cope…..
1. Walk away and discharge the energy
Going for a walk, or a run and getting away from the source or trigger for our anger is one option. Moving away and giving vent to the energy is what we need to do. Digging in the garden, washing dishes, scrubbing the bathroom tiles or polishing the furniture is a great outlet for this energy. Shredding newspaper is another excellent technique. After which you could turn the strips into Papier Mache pulp and create an art project. One woman wrote that she would pull out weeds and imagine she was pulling out her husband’s hair! This is called Detaching.
2. Practice Deep Breathing and Self soothing
This taking in of deep breaths, helps bring more oxygen into the body and to the brain. Especially important is the frontal cortex where our reasoning happens. Improved brain function helps restore some calmer thinking. Follow this up with doing something good for yourself such as listening to some music you like, dancing, playing a game on your phone, doing a craft or even having a nap. Seld care is important when you have to deal with a loved one suffering from an addiction. We often say, “Put on your own oxygen mask before you attend to others.”
3. How Important Is It?
Ask yourself this question. After walking away and breathing for a bit, consider how the event figures in the larger scheme of things. Does this event require action right now or can it wait? Do I need to say what’s on my mind right now or can I pause and say it later. Often I ask myself these questions- Does it need to be said? Does it need to be said by me? Does it need to be said by me now?? By the time ive asked myself these questions, my good sense would have returned and I can leave it for another time.
4. Respond not react
After calming down, consider a way to communicate which is kind and thoughtful. Say what you mean, mean what you say, but don’t say it mean. I’ve heard this said by someone- “Try to say it in ten words or less!” Haha! Most of us have communication patterns that escalate tension! So, try this for a change.
Another great tool is the acronym – T.H.I.N.K. Before I speak I need to THINK.
Is what I’m saying Thoughtful, Honest, Intelligent, Necessary or Kind. If not take a piece of Masking tape and place it nearby. This helps as a reminder to keep my mouth shut.
When all else fails, go talk to someone you trust and let it out. A friend in need is a friend indeed. Or seek one of many support groups or counsellors to help you cope. Whatever the case, we are all in this together! So don’t suffer alone. There are many helplines and people available to support you such as the ones listed below.
If you’re considering seeking help from a mental health professional / psychiatrist, there’s a pretty good chance that you’ve realised there’s help out there that can assist you with whatever concern you have on your mind. Your mind may be in disarray, but remind yourself that whatever stigma against seeking mental help may exist in your mind, it’s there because of your lived experiences – created by the culture you live within. There’s absolutely nothing wrong with wanting to get better, or better yourself, and to feel constrained by some vague idea of what it means to be “a man” or “a strong woman” is unwarranted.
If you’re fearful of revealing your innermost thoughts and feelings to a stranger (by virtue of it being your first visit), keep in mind that your psychiatrist is first and foremost a doctor, bound by the Hippocratic oath, and second, believes in the value of offering a non-judgmental listening ear through their training and moral code. If that doesn’t comfort you, you should be aware of legal constraints that exist in your favour to protect the information that you share with them. Notwithstanding of course, if there is reason to believe you intend to injuriously harm yourself or another.
Because of the anxiety that may roil your thoughts, it may do you well the night before to sit in silent contemplation and pen down the reasons or thoughts you intend to divulge. Having a concrete list to bring into your psychiatrist’s office will help you ground yourself and serve as a reminder that you’re there for good reason – to get help. Nothing to be ashamed of, nothing to hide, nothing to unconsciously lose behind a preponderance of mistrust or other self-serving attitudes. Your psychiatrist’s office is a safe space.
If you feel that all this is a hard ask, consider bringing along someone whom you trust and knows you well, with your best interests in mind. They can serve as a calming influence that soothes your inner turmoil. Furthermore, they might be able to helpfully point out if there are discrepancies between what you tell your psychiatrist and the truth of the matter.
When you step into your psychiatrist’s office for the first time, you will most likely be greeted with an open-ended question such as “How may I help you today?”, or “What’s been bothering you?”. It’s normal to feel overwhelmed by the variegated ways you can choose to answer their greeting, especially if you have issues with how you are perceived by others. But remember, this is their way of getting to know you, especially since they have nary a clue of why you may have decided to make good on your appointment.
Because of the time constraints on your visit (your psychiatrist’s office is a place of business after all), you can expect them to try their best to elicit responses through a line of inquiry that their best judgment will allow them to evaluate and cohere into an accurate as possible diagnosis of your mental condition, if you are indeed suffering from one. No psychiatrist is a soothsayer or mind-reader, and you should be aware that the help you receive will very much be preponderant both the truthfulness of your responses and the skill of your psychiatrist, who is also trained in reading cues and tells that they feel will help them make a diagnosis.
As your visit comes to a close, based on the personal proclivities of your psychiatrist, you can expect a number of permutations to happen. They may prescribe you medication, if they feel confident in their diagnosis. They may point you towards psychotherapy or counselling (the difference between the two we will delve into in another post), they may prescribe both the former and the latter, or they may hold off on either if they feel that they cannot in good conscience do so.
Of course, it is very much your right to evaluate for yourself if the synergy between your initial choice for a psychiatrist is optimal for you. If you feel comfortable with them, do feel encouraged to continue on course, or if not, seek out another psychiatrist per a trusted friend’s recommendation, or look online for one that seems more promising in terms of a potential therapeutic alliance.
Ultimately, don’t forget that your psychiatrist has your best interests in mind. They are committed to formulate a treatment plan for you that runs parallel to your values and is in line with your goals.
Promises Healthcare is committed to providing mental health services to those in need, and has realigned how we provide these services in light of the current COVID-19 pandemic. Not only do we practice strict social distancing in the clinic, we have a new teleconsultation service up and running. This may be a blessing for those who are not yet comfortable with in person visits. Simply visit our main website and visit our teleconsultations page.
Alternate services of help are also provided by the Ministry of Health & National Council of Social Services in the public health and non-profit sector respectively. The Minister for Health has also written in response to a question regarding the use of Medisave for mental health therapy and counselling treatment: “No Singaporean will be denied access to necessary and appropriate healthcare because of an inability to pay.”
The 2nd Singapore Mental Health Study (SMHS) which began in 2016 (reported in December 2018) was initiated by the Institute of Mental Health (IMH) in collaboration with the Ministry of Health (MOH) and Nanyang Technological University (NTU). The study focused only on those 18 years old and above. The findings show that 13.9% or 1 in 7 Singaporeans have experienced a mood (major or bipolar depression), anxiety (obsessive compulsive disorder and generalised anxiety disorder) or alcohol use disorder (alcohol abuse and alcohol dependence) in their lifetime. These are the top 3 mental disorders in Singapore among the conditions assessed in the study. The study also reported that more than three-quarters of those with a mental disorder in their lifetime did not seek professional help. In the first SMHS study in 2010, the lifetime prevalence rate of mental disorders in the Singapore population was 12% or 1 in 8 persons.
In a 2012 publication on Depression by the Ministry of Health, it was reported that depression affects between 2.5% to 18% of youth*. Depression among youths in Singapore is considered common. But it is a serious mental health symptom because of it what it reflects of children’s experiences in their environment. In particular, it is a serious reflection of what they may experience in the family or relational environment. If not adequately treated, the depressed child is likely to bring their depression into adulthood. This means that the emotionally wounded or damaged child is likely to carry their wounds forward as adults. This is a likely scenario because it is estimated that an initial episode of depression increases the likelihood of a second episode by 50%. A second major episode of depression increases the likelihood of a 3rd episode of depression by 75%. A third major episode of depression increases the likelihood of a 4th episode by 100%. Not surprisingly, depression has been found to affect brain structures and functioning. It is this recurrent tendency of depression that the suicide risk often increases over time within the same individual with a history of depression.
The risk of depression in childhood needs to be a major consideration for all those concerned with the development of children. Depression among children is a serious health problem because it can impair the emotional development of the child. It can seriously affect identity formation which is foundational to how the emerging adolescent learns to relate to themselves, to others and to the world at large. Later as adults, depression can impair psycho-social as well as occupational functioning. Depression is associated with significant morbidity and mortality. Also, depression can be triggered by, or lead to, other mental health conditions such as substance abuse, anxiety, schizophrenia or personality disorders.
Signs to watch for in children who may be depressed:
Continuous feelings of sadness and hopelessness
Irritability or anger
Increased sensitivity to rejection
Changes in appetite — either increased or decreased
Changes in sleep — sleeplessness or excessive sleep
Vocal outbursts or crying
Fatigue and low energy
Physical complaints such as stomachaches, headaches that do not respond to treatment
Reduced ability to function during events and activities at home or with friends, in school, extracurricular activities, and in other hobbies or interests
Feelings of worthlessness or guilt
Impaired thinking or concentration
Thoughts of death or suicide
Not all depressed children display these symptoms. They are more likely to display different symptoms at different times at different settings. When depression is significant, there are often noticeable changes in social activities, loss of interest in school and poor academic performance, or a change in appearance.
The young child is most vulnerable to depression due to the quality of relationships with his or her caregivers. This vulnerability increases when the family environment is also accompanied by marital conflict, abuse, violence, illness and/or low socioeconomic status. However, it is in the quality of relationships with caregivers that is crucial because of what it can offer as a buffer or protection from other external events or causes. Therefore, the mental health of children begins with thoughtful parents who genuinely understand and care about their child’s emotional needs and development.
Parenting Practices that promote Good Mental Health in Children:
1. Love your child unconditionally
A genuine attitude to decide in the best interests of your child, and not in the parent’s convenience. Children thrive under certain physical and emotional conditions. The long-term view is needed. Parenting must understand the healthy outcome effective parenting can produce. This helps to plan to optimise the emotional development of the child. Loving well in the best interests of the child provides the best head start towards orienting the child to relate to themselves and others in a healthy way. Children’s need to establish a healthy identity, to uncover and stretch their potential, and learn to self-actualise will require parents to stretch their own emotional ‘ceiling.’ This means parents who desire to raise emotionally healthy children have to face their own insecurities so as not to impose them on their own children. Parenting with the best interests of the child will often be at the inconvenience of parents especially if parents do not appreciate the value of nurturing relationships which children thrive on.
Loving your child well answers the deep longing for the child to later ask, “Am I worthwhile?” The need for children to recognise their own personal importance, value and worth prepares them to find that their later life will amount to significance. The child at risk of depression commonly struggle with this sense of self regard. Loving the child unconditionally is not based on the social or academic performance that society may hold out for children. Instead, mistakes are accepted as a natural part of their learning. If the parents placed their importance on their children only in reaching their own ambitions, or social or academic accomplishments, these indicate conditional expectations for them to find approval or acceptance. The will view their worth based on what they do instead of who they are.
2. Ensure safe and secure physical and emotional surroundings
Secure attachment, which is offering an ongoing, consistent, soothing, accepting presence to the infant is the important beginning in the parent-child relationship that helps the infant to learn to feel safe and secure in the world. This is a foundational need for positive mental health in infants and children and later adulthood. Emotional safety from the secure bond offered by a secure parent helps young children to trust the caregiver and to experience their world as safe and predictable. Through this quality of care, a child is encouraged to first accept themselves as as lovable, as important. It also prepares them next to want to explore their world as they mature physically. This means parents who wish the best for their children have to prepare them to become independent over time.
Punitive, harsh or neglectful parents, especially when physical punishment is employed, leads to children questioning their worth or value and increases the risk for later depression. Parents who frequently employ shame, threats, insults or convey other derogatory messages to their children tend to raise a child who view themselves as defective. This is particularly damaging to children. Indeed, the DSM-V lists the sense of hopelessness or worthlessness as a common symptom of depression. Children can be raised to view themselves as defective, and that their life as meaningless.
Promoting a safe emotional environment emphasises listening and empathy as skills, and being age-appropriate supportive as an attitude. Being emotionally present and listening well will foster the child’s wish to share their experiences. It builds on the bond already started from providing a secure attachment. It encourages children to view the parent and other people as a safe resource they can count on later if needed. It answers the important question that children ask, “Is it OK to be me?” This also fosters familiarity with emotional intimacy that better prepare children for friendships and significant relationships later. Familiarity with close and supportive relationships also mean that the child is less likely to isolate themselves socially when they face problems later on. It is a wise parent who value interactional activities with their young children early on rather than let them become overly attached to computer games and the internet to amuse themselves. Excessive computer use at the detriment of other activities has been linked to increased loneliness, poor social development and depression.
3. Nurture Self-confidence and High Self-esteem
Self-confidence is most easily found when children grow up feeling loved unconditionally.
The foundation provided when the child feels loved should be supported by the child’s search for mastery in the world when they are ready to explore. Starting with simple activities, their need for autonomy and mastery over their environment allows them to gain confidence over the tasks they wish to take on. It is important for parents to support this rather than to over-protect them from exploration. Parents who are over-protective of their children and anxious about possible mishaps will find it difficult to foster the autonomy and independence their children need. To build their self-confidence and nurture high self-esteem, parents should be ready to praise their children’s exploratory efforts, be honest with them about their own mistakes, participate in the children’s activities, encourage them in activities where their interests match their ambitions and allow them to be tested by the tasks they take on.
The child’s ability to overcome, which allows them to be exposed to the frustrations and disappointments along the way, is something they have to face as well. Children should be encouraged to enjoy the process in the process of becoming. Learning to face their own frustrations, disappointments and failures will also serve to build self-confidence. Avoiding frustrations or disappointments or learning through determined effort and even failure tends to undermine self-confidence. The opportunities for children to grow through tasks and responsibilities is the beginning from which they can discover and establish their personal power and resilience.
Looking for ways to nurture your child’s self-confidence and develop high esteem answers the child need to know “Can I do it?” It requires that parents focus on building strength or resilience through the children’s autonomy –their learning to exercise control over their environment– rather than emphasize ease or comfort through avoidance.
4. Promote opportunities to Play with other children and self
Play is an integral part of emotional development of children. It is the primary means in which children learn to explore, to discover themselves in their world, and socially to cooperate, take turns and help in friendships. Studies have even suggested that inadequate play time for preschool children lead to more disruptive behaviour. Besides social interactions, play allows for the development of emotional awareness and fosters empathy where children learn about their own emotions as well as the emotions of others. Play also allows children to enjoy the process of becoming one self. This is important in a goal-oriented world that emphasises only winning or success or grades. Indeed they can discover the truth that frustrations and disappointments are often the price we all pay to achieve success. In so doing, play allows children to learn how to emotionally regulate their feelings when they are presented with opportunities to learn to express thoughts, feeling and behaviours in socially appropriate ways.
Play is an important part of the child’s need to learn and experiment. Participation in play individually or in a group is an integral part of this learning process. Parents who are open to social interactions offer their children important advantages because they can facilitate their children’s emotional regulation and social learning when they play with their children on a regular basis. Children are more likely to enjoy other people contact when they already enjoy warm relationships with and have fun with their parents. TV or computer use should be monitored so that children are encouraged to engage more in active learning through participation. Computer games designers have made it easier for children, especially children who are neglected or are alone a lot, to be addicted to computer games. Excessive computer use has been found to be linked to depression in children.
Play offers the opportunity to address the questions that children ask, “Am I OK and is it good to be me?
5. Provide appropriate guidance and discipline
While children need to explore, develop new skills and become more independent and responsible, they also need to learn that certain behaviours are not acceptable. They need to be offered guidance and discipline that is fair and consistent from the family unit. They tend to take these social rules to their school and eventually to the workplace. Expectations may be expressed firmly but they need to be kind and realistic. Again, children learn best within encouraging and nurturing relationships. Parents need to be aware of their own maturity and growth and emotional status as they seek to help their children develop self-control, self-discipline or become kind. Their children cannot be expected to growth in those areas which parents have not grown themselves.
Explain “why” the child is being disciplined and the consequences of their actions. Criticism should be focused on the behaviour and not the person. Threats, nagging and the use of threats should be avoided. The power that the parent wields should emphasise guidance and instruction in the best interests of the child that allow for children to learn from their mistakes. Those parents who practice excessive domination or coercion should understand that it is not helpful in the long run if children are forced to accept a place of surrender in order for them to survive in the relationship. They need to be encouraged to exercise their own power when appropriate. What has been described as authoritarian parenting, characterised by high demands with poor feedback or nurturance has also been found associated with a higher incidence of depression in children. This is in sharp contrast to authoritative parenting which is characterised by high demands accompanied by responsiveness to the child’s emotional needs. This approach is found to produce children who are responsible, they can regulate themselves, they can make good decisions on their own, and they are respectful to others and to rules.
Parenting is primarily a personal and emotional project in raising one’s children. It is foundationally an emotional process to secure the child before a young child eventually matures to believe in themselves. This is crucial before they begin to actively learn to navigate themselves in an increasingly complex world. It is widely understood as a parent’s most important life task since the emotional outcome show up in emotionally healthy or unhealthy individuals even before adulthood beckons. There is an emotional ‘birthing’ process where the Self of a child arrives at a healthy place in their identity formation. Or the opposite will happen. Quality parenting in this ‘birthing’ process create the foundation in which the next generation of children find the basis for their own survival, happiness and fulfilment. As such, parents learning to parent with optimal outcomes will do well to emotionally mature and be healthy themselves so that their children have the best chance to establish themselves in a healthy place in preparation to thrive in life.
The Ministry of Health, Depression: MOH Clinical Practice Guidelines, 2011.
Woo BSC, Chang WC, Fung DSS, Koh JBK, Leong JSF, Kee CHY, et al. Development and validation of a depression scale for Asian adolescents. J Adolesc. 2004 Dec; 27(6):677-89.
Woo BSC, Ng TP, Fung DSS, Chan YH, Lee YP, Koh JBK, et al. Emotional and behavioral problems in Singaporean children based on parent, teacher and child reports. Singapore Med J. 2007 Dec; 48(12):1100-6.
I am a self-confessed introvert. And I’m also an addict.
I was recently cajoled into attending a Psychodrama session. I’d heard things about it – years earlier, my then significant other lauded the raw emotional exploration her sessions afforded her. I encouraged her, it was good for her. Personally though, I found the idea of a group session’s ability to evoke genuine emotion alien. It was the antithesis of who I was.
I had never enjoyed group sessions. I hated them. The introvert in me screamed (silently) in indignation at being forced into a room with my peers, lorded over by therapists who would extol the heaven-sent power of vulnerability, hanging it over the heads of us sullen detainees. They would espouse connectedness with others, openness. To me, these were just unattainable states of being that I could never actualise. The years wore on, and I plodded along, entwined with my precious, thorny, addictions. Prison, pricey rehabs abroad. I took care to never bring my real self along to the banal group therapies – I merely presented them with an alter-ego. Faking it to get along. Or “faking it to make it”, in the parlance of addicts like myself who would say or do anything to achieve a discharge.
I was living an entirely unremarkable life, losing friends and embarrassing myself.
Then, I experienced a seismic shift in circumstances. To represent it as merely ‘mandated’ would be to deny gravity to what had happened. I had run afoul of the law again, and paid my penance with a 9 month long “drug rehab”. I got out, and three months later I was a year clean. Still, I wasn’t happy. I had done no soul searching, nor had I even begun to scratch the surface of my addiction, always lurking in the shadows. Of course, a large part of my reticence towards accepting sincere nudges in the direction of help could be attributed to personal and moral failings. But why was I the person that I was? That’s when I decided to attend a psychodrama workshop at the urgings of my boss, a sweet girl whose genuine concern had initially confounded me. Why did I acquiesce? To understand myself, I guess. So, I went in with an open mind.
Psychodrama is about exploring internal conflicts, by acting out emotions and interpersonal interactions. I wasn’t inclined to be the center of attention just yet, so I left other enthusiastic participants to play the protagonists. The director, a bubbly personality whose sharp wit was tempered by insightful, genuine empathy, herded a roomful of clueless attendees with a deft hand, schooling us in psychodrama’s basic concepts. I made myself small in the corner and watched as our director doubled volunteers, acting out scenes from their lives, giving voice to their unconscious. Revelatory perspicacity was the order of these moments. I watched as they were mirrored, experiencing themselves from the outside, drawing from a nonjudgmental pool of collective consciousness. I watched as roles reversed – mothers became their daughters, and wives their husbands. All of them seemed edified, comforted, even. Misty eyes and rivulet strewn faces, sighing into closures when none previously seemed possible. There was a woman pained by a frightful trauma, her repressed malefaction she seemed so sure she had committed driving her to seek expiation from whom had ceased to be able to give her any. From the outside looking in, I was sure her wound was self-inflicted – we all knew this, but one’s own guilt is deeply personal, often insidious. As her situation percolated in my mind, so did my own guilt. I hadn’t wept when I learned of my father’s and sister’s departures, I hadn’t wept at their funerals, I hadn’t wept at their memorials. I hadn’t needed to, because I had my addiction. Now, without the pernicious warmth of substances, these losses became some therapeutic cynosure of a starting point. I had begun to understand myself, through others. The cynic in me finally realised why, across addiction recovery literature, syllabuses are almost invariably characterised by the motif of benefits accrued by group therapy. I think it owes something to the collective experience of humanity, that no matter your guilt or your shame, there are people out there who have lived congruent experiences. It may seem cloying and mawkish for me to say that no-one is truly alone, but it’s true.