The rise of mental health awareness – and the stigma that remains attached to certain conditions
SINGAPORE: It’s been five years since Sabrina Ooi, 30, attempted suicide - and two since she penned a blog post discussing her attempt.
The blog post, published on October 9, 2019 - one day before World Mental Health Day on October 10 - was the first time Sabrina publicly shared about that dark period in her life.
Since that fateful day in 2016, suicide has been decriminalised in Singapore after the committee reviewing the Penal Code acknowledged that treatment, rather than prosecution, was the appropriate response to people who feel they have no choice but to take their own lives.
Sabrina has also co-founded a mental health community, Calm Collective Asia, with two friends during the “circuit breaker” period.
While she’s been called an advocate for mental health, she prefers the term: “Mental health expert by experience”.
“I think this advocacy thing just happened because I’m in my personal journey of processing what I’ve gone through and wanting to help others going through something similar,” she told CNA over the phone.
Occasionally, being open about her anxiety and depression has even led to strangers pouring out their stories to her on social media.
“Whenever I share, I go through a vulnerability hangover. It can be really tiring, but I know that sharing my story is helpful, both to others and for myself in getting clarity about my own story,” she said.
READ: Commentary: When we call people with strange behaviour mentally ill, we reinforce mental health stigma
READ: IN FOCUS: The challenges young people face in seeking mental health help
But Sabrina noted that this candour about anxiety and depression doesn’t always extend to another mental health condition she lives with: Bipolar disorder.
This condition causes extreme and unusual shifts in mood, energy, concentration, and activity levels that affect one’s ability to carry out day-to-day tasks.
“While I've been open with talking about anxiety and depression, I'm still very careful about the term ‘bipolar disorder’ because people tend to freak out and make their own assumptions about the condition,” she said.
“I've had friends completely wash their hands of me. They decided they didn’t really understand it and couldn’t support me in this part of my journey.”
Like Sabrina, 30-year-old Syazwan Rahmad, who is also diagnosed with bipolar disorder, is no stranger to a fear of judgement.
This partly stems from his own “shock” when he got the unexpected diagnosis recently, he explained, as he thought he only had depression.
“I don’t want people to think that I’m crazy. I’m scared they don’t want to be around me because I have a disorder. Till today, I have this thought in my head,” he told CNA.
Syazwan has since disclosed his condition to family, close friends and even to the public in a CNA Insider story that tracked the economic impact of COVID-19 on his dance career. But he admitted that he still struggles with criticism.
“About 20 per cent respond with negative comments about my career and me as a Muslim (when I talk about my mental health). But ultimately, I’m so open because I want people to know it’s okay not to be okay. Be true to who you are and that’s where healing will start,” he said.
SOME CONDITIONS HARDER TO DISCUSS
The COVID-19 pandemic revealed a need for more mental health support, with an increase in people calling in to mental health helplines.
Suicide prevention agency Samaritans of Singapore saw an increase of more than 22 per cent in the number of calls attended to on their 24-hour hotline in March 2020 as compared to that of the same period in 2019.
Likewise, the Singapore Association for Mental Health (SAMH) received an increase in helpline calls by 50 per cent in February and March 2020 compared to the average calls from April 2019 to Jan 2020.
READ: COVID-19: Worries about pandemic see more calls to mental health helplines
READ: Commentary: We still fail to understand that some people are more prone to mental illness
Yet, despite more people seeking help for their mental health over the past year, and the increasing awareness around conditions like anxiety or depression, other conditions remain difficult to disclose, said seven individuals who spoke to CNA.
Some of these conditions are bipolar disorder, obsessive compulsive disorder (OCD), borderline personality disorder (BPD) and schizophrenia.
The traits of people with BPD include a feeling of emptiness, fear of abandonment, intense anger and irritability, unstable emotion, idealising and devaluing people, possible psychosis when stressed, and even binge eating, said Dr Roger Ho, an associate professor and senior consultant at the Department of Psychological Medicine at the National University of Singapore.
He added that there is also the possibility of physical self-harm among those with BPD, which is also known as emotionally unstable personality disorder (EUPD).
“Another symptom we pick up is they will cut themselves. In the emergency department, when you see someone with a lot of scars on their forearm, the patient might have BPD,” he said.
“But society doesn't know much about BPD; they think it’s just depression. The self-laceration is a very unique sign. When you ask someone with BPD why they cut themselves, they usually don't say they want to end their life. They want to experience the emotional pain they’ve had in the past.”
Dr Ho, however, reinforced that while some people might possess the traits of BPD, having a personality disorder is more than just checking off these traits.
“Having a personality disorder means that the traits become so strong that the person has interpersonal problems. These problems affect their life, whether it’s family, work or study,” he said.
READ: Commentary: Schizophrenia, a life increasingly detached from reality
Similarly, the stigma attached to schizophrenia - a psychotic disorder - prevails in Singapore.
According to a 2016 Singapore Mental Health Study released by the Institute of Mental Health (IMH) on May 21, about one-third of the population who have been diagnosed with psychotic disorders had a diagnosis of schizophrenia at some point in their lives. This makes schizophrenia the most common psychotic disorder here.
The results were part of the first nationwide study to examine the prevalence of schizophrenia and other psychotic disorders among those living in Singapore aged 18 and above, their associated factors, and the treatment gap of the disorders.
Despite the prevalence of schizophrenia, public understanding is lacking, with people with the condition being perceived as “dangerous or as individuals incapable of managing themselves”, said Ms Lim Lay Keow, a senior case manager at the Early Psychosis Intervention Programme at the Department of Psychosis in IMH.
“Schizophrenia is still sensationalised by the media. The accessibility to smart phones allow for photo or video taking of a person in distress, subjecting them to be judged online.”
This behaviour, Ms Lim noted, doesn’t just make it difficult for those with schizophrenia to disclose their condition for fear of discrimination. It also results in self-stigmatisation, where the person with schizophrenia finds it difficult to “differentiate themselves from the condition”.
The deeply entrenched stereotypes about schizophrenia also make it harder for the public to understand that schizophrenia is “not a personality flaw but a disease of the brain”, she added.
YOUTH MORE CANDID, BUT STIGMA REMAINS
Even before the pandemic last year, younger people were increasingly open about their mental health on social media, with some talking about therapy sessions or situations where their mental health conditions might flare up.
READ: The Big Read: With youths more open about mental health, it’s time others learn to listen
But Ron Yap, who was diagnosed with OCD three years ago, said this conversation doesn’t translate into less stigma for all conditions.
“While there has been more conversation for disorders like generalised anxiety disorder and depression, there’s still stigma surrounding more uncommon disorders, like OCD,” the 23-year-old said.
“Even though non-sufferers (of anxiety disorders and depression) will never experience the depths of pain and discomfort those conditions cause, they can at least get a rough, if imperfect, idea of what it’s like to suffer, by taking the times in which they experienced anxiety or sadness and amplifying the intensity and duration.”
But with OCD, the 23-year-old said, “It’s harder to fathom how and why someone would wash their hands 50 times to the point of breaking their skin, go to the bathroom 20 times before bed or dwell on a distressing thought for a whole day to the point of paralysis.”
To a non-sufferer, he added, such behaviour is “simply irrational, and even insane, and this impression hinders one’s ability to empathise with the sufferer”.
READ: 'I thought I was going crazy': OCD, an often misunderstood mental health condition
Ron, who runs the Instagram account @mentalhealthceo, believes misconceptions about OCD don’t help, such as that there’s only one type of OCD “exemplified by someone who obsessively washes their hands or clothes over and over again”.
“OCD and its rituals can manifest in countless different forms. I know someone who has to eat their food in a certain order, otherwise they wouldn’t be able to consume the meal at all,” he said.
Although a huge part of Ron’s life involves breaking the stigma around mental health, he still hesitates to disclose some of the “more personal symptoms” of OCD to people around him, such as going to the bathroom multiple times.
“I sometimes mask it by coming up with stories about why I usually spend so much time in the bathroom or through humour, especially when I don’t feel comfortable talking about my OCD in the moment or if I feel like they wouldn’t understand,” he said.
ADDRESSING BLINDSPOTS WITH NUANCE
That said, openness about anxiety or depression doesn’t mean a lack of stigma around these conditions, experts observed.
“From what we’ve observed, some of the challenges faced by those living with mental illness include being labelled as ‘attention seeking’ when they talk about their mental illness, or that they’re ‘overreacting’,” said Ms Jasmine Chang, a clinical psychologist at IMH.
“Even though there’s awareness around mental illnesses, admitting to having a mental illness is actually a different story.”
She added that some of her clients fear that their diagnosis might affect their employment and appraisal, while those serving National Service worry about being negatively evaluated by their peers.
READ: Commentary: Will you hire and retain persons with mental health conditions?
With increased awareness about mental health, more nuance is now needed to take people's understanding to the next level, advised clinical psychologist Ms Chang.
For example, there is a difference between having a couple of bad days and having prolonged periods of bad days that debilitate you and prevent you from doing anything else.
“All of us experience varying levels of sadness and anxiety. While we experience sadness and anxiety in our everyday life, depression and anxiety disorders lead to significant impairment and distress in someone’s life. It affects their ability to go to work, to sleep, and for a sustained period of time,” she said.
Public education about the diagnosis would also help, she added.
“This involves highlighting to people that mental illnesses can be managed with the right treatment and support, and those living with mental illnesses can lead fulfilling and meaningful lives.”
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Besides managing symptoms, Sabrina, who has depression in addition to bipolar disorder, believes it would be better to look deeper at what causes them.
“Usually the triggers stem from your childhood trauma, environmental triggers, and even biological factors. So it’s good that we start talking about anxiety and depression, but we need to take it a step further and understand the root cause,” she said.
And while media campaigns like Beyond the Label aim to change public perception around mental health conditions, some said labels actually help them make light of what they go through.
Sabrina, for example, doesn’t mind that some mental health conditions are more prominent than others, because it helps her “reshape her perspective” on what she’s going through.
“I’ve had people tell me they honestly don’t know what bipolar disorder is. And I realise I have to link it to depression or something more familiar to them for them to understand,” she said.
“So at least the increasing awareness of anxiety and depression has helped me talk about my condition.”
Where to get help: Samaritans of Singapore operates a 24-hour hotline at 1800 221 4444, or you can email pat [at] sos.org.sg. You can also find a list of international helplines here. If someone you know is at immediate risk, call 24-hour emergency medical services.