From digging dirt to a degree-how education preserves mental health

From digging dirt to a degree- how education preserves mental health

By : Jason Smith


A milestone

Recently, I received the wonderful news that I’ve been awarded a First-class Honours for my Bachelors degree. Now 27 years old, it’s been a long road, having dropped out of university in 2014. In the intervening years, I faced many setbacks. While my mindset has remained the same, the difference between then and now is the practical experience I’ve gained in putting it to the test.  I’ve had my moments: head in hands at 2 in the morning trying to figure it all out. But my attitude has proven to be a resilient bulwark against the threat of losing my mental health; a threat I’ve been conscious of- being part of a generation of the infamous ‘quarter life crisis’. In the past, my friends have often commented on how surprisingly upbeat I’ve been during the darker moments. I’d like to share a few pillars of that mindset in the context of my life.

My lowest point

From barista, to waiter, to bartender, to zoo guide, to manual labourer, to delivery driver, to plant operator. The list goes on and on. I’ve bounced from job to job, living day to day. Financial struggles have been an ever-present reality. I naively took out more credit than needed for a man my age. The consequences , combined with bad luck and a stubborn refusal to return home reached a climax: The summer of 2018 saw me reluctantly living in my car and cheap hotels when I could afford it. I have a vivid memory of waking up in the morning of my 25th birthday alone. I was laying back in the driver’s seat tucked inside my sleeping bag, peering through the window. For a moment, I laid there contemplating the reality of my situation.

Embrace the struggle

Suffering is an inescapable part of life.  Rather than seeking to avoid it at every turn, I embrace the personal growth it can stimulate. As a result, I resisted the temptation to give up and take refuge in the comfort of my family home four hours away. I was not yet curled up in a cardboard box on the high street. I would just keep calm and carry on with patient persistence. Today I’m a stronger person for doing so.

Patient persistence

While some temporary situations might end up being more temporary than I’d like, an almost Zen- like persistence allows me to prevail in the end.  As it did with the car/hotel situation which lasted 5 months- far longer than I’d originally hoped. The following summer, I slept on an airbed, for what ended up being an entire year, until I could finally afford to buy a proper bed. I woke up on hard ground in the middle of the night due to yet another puncture more times than I care to remember. When I returned to university, I signed on for the 2017/2018 academic year. But it wasn’t until the 2019/2020 year when my financial difficulties  subsided, that I could  sit the year without any major distractions.

Feed the fire

There were many daunting moments, but they couldn’t crush my spirits. Beneath it all (sometimes buried deep!), I had a feeling of almost smug confidence, knowing these times would pass and a bright future lay ahead. I knew it because I still had that fire inside of me. This fuels my optimism and drives me on. The fire that inspires awe and wonder at the great possibilities of life. And that ‘the world is my oyster!’. I always hold on tightly to a positive vision of the future and feed the fire if it starts to flicker, literally in the mirror if necessary – I know that I must always be my biggest cheerleader.

Life can be unfair

Sure, there may well be an unusually large number of factors getting in the way, and things might be horribly unfair.  Life can get tough – working out the most efficient way to spend my last 87p to maximise my caloric intake before going hungry again wasn’t fun. But ultimately, there’s only one question in a given situation that one wants to improve; ‘what am I going to do about it?’. The external factors are a given. I can either wallow in self-pity, frozen in these conditions, or take action, step by step to improve my circumstances.

I’m in control

I was raised by hardworking, entrepreneurial parents who sacrificed a great deal for their children. From running restaurants to selling wine, I witnessed many different businesses growing up. Seeing the world through an entrepreneurial lens, the underlying message was one of self-reliance and independence.  Most importantly, the optimistic idea that the world is a place to be seized upon through one’s  initiative and effort. I carry that spirit close to my heart. When I look forward I don’t think ‘what’s going to happen to me?’, I think: ‘what am I going to make happen?’.

Not a victim

The biggest threat to that optimistic view of the ‘self’ as an autonomous individual with great power over the direction of their life is the opposite idea that we’re all just victims of forces beyond our control. This is a general idea which circulates throughout society. When there seems to be an unlimited supply of obstacles getting in the way, it can be easy to slip into such a paralysing view of the world. Paralysing because we lose the belief in our ability to take life on. We’re a goal-orientated species. Setting and achieving goals is vital to our mental well-being and as such we must always reinforce that strong sense of the autonomous self.

An intellectual journey

In a six-year period in which I’ve lived in 10 different apartments. The only constant has been an enriching intellectual journey which inspired me to return to academia. It’s important for your mental health to develop some skill or interest during difficult times because it provides that vital sense of positive momentum to drive you forward. For me it was my intellectual pursuits. I may have been materially broke, but my mind grew richer as I delved deeper into my intellectual interests. I knew that I was investing in my mind and that one day it would pay dividends.

What next?

When I decided to return to academia, I knew I wanted to study at the very best institution. I inevitably turned my sights toward Oxbridge. Gaining my undergraduate degree is a stepping-stone toward that goal. Now my focus is on preparing my Master’s application. I yearn for the honour of walking through the ancient halls of Oxbridge. If that time comes, those gruelling 12 hour night shifts covered in dirt, lugging bricks for minimum wage as a university dropout, will become all but a faded memory, if not so scarcely believable that it must have been a distant dream from another life. Whatever happens, the fire will keep burning stronger than ever.

Parting thoughts

In hindsight, our problems are often much smaller than they might have seemed at the time. Approaching future obstacles with this in mind makes them more manageable and protects our mental wellbeing. I’m almost embarrassed to say I’ve suffered in any real way – my hurdles are dwarfed by so many others not only in this generation but certainly for generations past. But that thought helps me to stay grounded. Sometimes it’s useful to take a moment to remind ourselves of everything we have to be grateful for. Instead of focusing too much on the negatives, we should start from a place of gratitude and then build on the positives to be the best version of ourselves that we can be.

By Jason Smith

About the author

Jason Smith achieved his Bachelor’s degree as a mature student in 2020. A strong advocate of an interdisciplinary approach to learning, he combined Economics, History, Philosophy and Politics to complete his degree. After completing his Master’s degree, he will embark on a long academic career where he hopes to make a positive and lasting difference to academia and society at large.


All of me: case management in mental health

All of me : case management in mental health

By Heryani Jamaludin



This article is based on my experience in case management in both hospital and community settings in the UK and Malaysia and as senior manager for a non- profit organisation in Singapore. My experience spans from 1997 to 2019.

The problem with the medical model

Only doctors are licensed to diagnose a mental illness. However, the treatment provided by them is not the be all and end all. In fact, a large percentage of patients do not keep their follow up appointments and even more do not take their prescribed medication.  The medical model is where the patient presents with a set of symptoms; the doctor offers a diagnosis and prescribes medication; he may refer the patient to another health care professional for talking therapy. At a follow- up, the doctor monitors the client’s progress or the lack of it.  From the perspective of the medical model, if there is a significant abatement of symptoms then the treatment is a success. If not, the doctor continues the treatment by changing the medication and adjusting the dose.

One step forward, two steps back

Sounds simple enough but in reality, this linear and seemingly perfect treatment is not so.  Recovery is a process.  There are good days and there are bad days.  A patient may make a step towards progress and  slides two steps back. More importantly in treating all types of mental illness one must look at the clients holistically. This is because mental illness affects most if not all aspects of a person’s life. The ramifications of a mental illness go beyond signs and symptoms but also include one’s social, spiritual, work, family and personal development. Let’s consider the following example:

A holistic approach

Paul was an active 24 year- old who had lots of friends, played football regularly and helped out at his church. He worked in an IT company. One day Paul started hearing voices. These voices criticised his actions constantly. He thought that people were spying on him. The voices became so bad that he could not concentrate and eventually lost his job.  He started to talk to himself.  His friends were afraid and stayed away from him. Paul also stopped going to church. Due to his intense anxiety and fear Paul isolated himself in his room and neglected his personal hygiene. Family members who did not understand called him ‘lazy’ and were hostile towards him.  One day, he thrashed his bedroom and became aggressive toward his mother. Fearing for her safety, she called the police. They admitted him to hospital.

From the above example Paul’s onset of schizophrenia cost him his job which would affect his financial status. The illness also impacted on his social life, spirituality and hobby.  His mental illness lowered his self- esteem and put a strain on his family. A doctor who spends an average of ten minutes and is trained to look for signs and symptoms would not have the time to enquire about what’s going on in Paul’s life.  Arguably, addressing other aspects of Paul’s life is beyond his job scope.


While we support the idea that recovery is personal and means different things to different people, there is this universal truth that when you recover from any illness – physical or mental you would want to come back to as near your base line as possible or to what is deemed as “normal” to the person with the illness.

In treating a mental illness, a holistic approach that addresses the other needs of the clients should be at the heart of all service provision. In doing so the beneficiaries can get back on track in an impactful way.  To this end health care professionals will need to work collaboratively with other professionals and the delivery of care has to be effectively customized to meet the needs of the clients.  It is clear that one health care professional cannot address all those needs because no such beast exists. A doctor who adjusts the medication is not a social worker. The social worker is not a priest and cannot fulfil his spiritual needs and the priest is not his employer and so forth.

Case management

Good quality care involves comprehensive case management. It is not just the medical approach but a coordinated and combination of social work, problem solving, carer involvement, life coaching, psycho education, faith- based counselling, education counselling, back to work scheme and so forth. Whatever that is needed to make the client “whole “again.

Good quality case management involves a thorough assessment of the client’s needs by a coordinator.  With the agreement of the patient, she formulates a plan of care and refers him to the necessary agencies. At a case management meeting, each professional’s role is clearly defined: who does what, when, where and how often. This information should be documented and all parties should have a copy. In an ideal world these same people should “talk” to each other and periodically meet to evaluate if the care plan has impacted the clients’ lives. If it has not then interventions must be readjusted. Case management should be needs led, not service led.

 The Challenges

The disparity between what the client wants and what the professionals think he needs poses a challenge. As a Community Psychiatric Nurse (CPN) in the UK, I had to fight demons because what my client wanted was a continent away from what I thought was good for him. Still we have to respect our client’s wishes even though we may not agree with it (as long as it’s not too off the wall), for that is true empowerment. In formulating care plans there needs to be a fair amount of negotiating where both parties must be prepared to compromise for there to be any achievable goals. Nothing is more demoralising when unrealistic goals are set that result in failure to achieve them.  When expectations differed, it was important that I maintained a general positivity and exuded calmness so that our professional relationship could be sustained.

Hit and Miss

As senior manager leading a team of counsellors in Singapore, I found that case management was not formalised. It was very much a hit and miss. Services were fragmented and some services serve only certain geographical areas. Some of my team members were not keen on case management because they did not know what it entailed, they did not have the skills, they did not want to go “that far” or didn’t think it was their role. I’ve dealt with other agencies who referred clients to our organisation because: “He’s been with us for so long” or “I don’t know what to do with him.”

Let’s share

Another hindrance of case management is the reluctance for agencies to share information. I’ve heard of anecdotes where different departments of a single organisation will not share information because they feared the repercussions of breaking PDPA rules. Such rules do exist in the UK but when it came to case management where collaboration was the operative word, information is often shared on a need to know basis.

In Singapore, some agencies worked in silos and many case managers struggle to come to an agreement of when to meet.  I once had to change a meeting four times to accommodate other people’s schedule. If we put case management at the top of our  priority list then meeting once every three months should not be an issue.

Cracking the whip

I’m also speculating that some health care workers think that case management involves them doing all the work and the idea of coordinating everyone and “cracking the whip” is a daunting one. Maybe there is this idea that only social workers can or should be case managers and that counsellors or clinical psychologist cannot case manage. This misconception must be lifted and perceptions corrected if we are to have any hope of introducing effective case management to improve the lives of people with mental illness. In the UK case managers are not confined to one profession. Doctors, social workers and psychiatric nurses like myself could be case managers.

Revolving door

When I was senior manager in 2019, some clients kept relapsing and were readmitted – like a revolving door. Some remained as chaotic as ever or where they reached a plateau, had not moved on.  Others received identical services from different agencies and learned to “play” the system. If this was the status quo in most of the service providers in Singapore, I would not be surprised if  health workers become demoralised and suffer from burn out as they take on more clients and have to manage a huge caseload because their clients rarely got better.


Case Study 1 – a successful story

This is a 50 year- old widow who had 2 children. The reason for referral was a language issue. The client suffered from schizophrenia following her husband’s death.  When she became unwell, she put her children in danger and since then her children were in care. The social worker and I saw Madam Z together. We soon realised that we were doing the same work.  I was about to disengage when Madam Z became unwell and was admitted. I saw Madam Z in hospital and spoke with her nurse. Already we were planning for her discharge.

Working together

When Madam Z became stable, she attended an activity centre  twice a week.  The accompanying occupational therapist observed her safety awareness and social skills. The social worker  liaised with the foster parents to arrange Madam Z’s visit with her children. My role was to help her identify her triggers and explore strategies to cope with stress and build her resilience.  We discussed her delusions, what she felt and how she behaved when she became unwell. We also explored what she wanted us to do when she became unwell again.  The occupational therapist  disengaged after observing that Madam Z could safely take public transport on her own. Madam Z continued to attend the centre. Meanwhile, she had discussed going back to work with the social worker who  found her a job as an assistant. After a couple of months the doctor discharged her.

Continuity of care

Madam Z stopped attending the centre when she started work. I visited her at home to monitor her mood and symptoms until I disengaged months later.  Madam Z continued to work, see her children at the weekends and went to the hospital for her monthly injections.  There was no paperwork among us but we updated each other regularly by email. Our roles were clear and when our services were no longer needed, we disengaged. In doing so we use our resources efficiently. There was no designated coordinator but it was clear that the SW was the main man in Mdm Z’s care.

Psychological safety

In Madam Z’s care – the health professionals were a psychiatric nurse, a staff nurse, a doctor, a social worker, an occupational therapist and the children’s home manager.  Our roles were clear and we did the needful as per our area of expertise. We listened to each other’s input and respected each other’s opinion.  There was psychological safety among us where we could say what we thought without fearing the repercussions. We communicated regularly and shared information.

Case study 2 – a not so successful story

I attended a case management meeting regarding a single mother who had a 5 year- old son.  Sabrina (not her real name)  worked as a cleaner. She became unwell with schizo-affective disorder and put her child in harm’s way.  The Child Protection Unit put her child into care.  The court ordered that she should comply with her care plan if she wanted her child back.

A crowded room

When I attended the meeting there were around fifteen people in the room. There were 3 people from one agency. We planned to meet earlier to discuss the issues before the client arrived.  The client looked well groomed and was articulate. She stated that she felt overwhelmed by the numbers present. Half way through the meeting she stated that she “pushed to a corner” because “you all have my son”. I got the sense that she  stated that she would comply with the plan because she wanted her son back.  She  didn’t believe she had a mental illness.

We’re doing the same thing

My role was to see her every two weeks to monitor her symptoms. She agreed to this. But I was not convinced that she would comply. When I phoned her, she stated  politely that with work, rest and supervised visits with her son she simply did not have the time to see me.  Her reasons were plausible. I was looking for a solution when she told me  she was seeing a psychiatric nurse as an outpatient. If I were to engage, we would be doing very similar work.  Despite this I phoned her three times. The client rejected my services each time.


In my email to the care coordinator I stated that my intervention cannot proceed on the grounds that there was no consent. Furthermore,  there would be a duplication of services. He insisted that I try to engage. I appreciated that he was under pressure but consent is of  utmost importance in what we do. And that alone is not enough. It is also important that we have the goodwill of a client. Case management isn’t just collaboration among professionals but also between clients and professionals. We can obtain consent implicitly and explicit- even under duress. However,  goodwill must come from a willingness from the client to receive help. I updated my report to the team and closed the case at my end.

The role of a case coordinator

  • Assesses the needs of the client holistically
  • Makes the necessary referrals
  • Calls for a meeting
  • Document the decisions made
  • Collates all information given by other agencies
  • Shares this information
  • Calls for evaluation meeting and adjusts care plan accordingly
  • Main point of contact for all updates.

Good Practice

  • Encourage the client to bring someone for support.
  • Keep meetings small.
  • Introduce everyone and their role in the client’s care
  • Encourage frank and honest discussion
  • Discuss disagreement and find resolution at the meeting
  • Ensure everyone’s emails and phone numbers are accurate
  • Go through each point at the end of the meeting – making sure everyone is “onboard”
  • Make sure client has an  opportunity to speak at the end of the meeting
  • Document all information accurately
  • Send out detailed care plan soon after meeting

A good case management coordinator is…

  • The person who has the best rapport with the client
  • Not be afraid to disagree and say so
  • Proactive in being able to anticipate challenges
  • Courageous
  • Au fait with negotiating
  • Flexible
  • A good communicator
  • Respectful
  • Well informed of resources
  • Willing to learn and accept new ideas
  • Creative


It has become abundantly clear that there needs to be some form of leadership here. If case management is mandatory the world will be a better place. A single agency should be taking the lead in producing the following: a standardised template to document the care plan;  a work flow and a comprehensive training package for all sectors. Is it audacious for me to hope that one day everyone will come on board? I hope not. We have Marina Bay Sands and The Jewel.  Surely, we can provide our citizens who have mental health issues with a comprehensive care package. I am forever optimistic.


#case management # resilience #psychological safety #positivity #optimistic #case coordinator #recovery #holistic #calmness #recovery #information sharing

Obsessions, Compulsions, Depression and the Muslim Community

Obsessions, Compulsions, Depression and the Muslim Community: Reflections from the Singapore Mental Health Study 2016

By Sufian Hanafi


Mental illness and Muslims interface in unique circumstances. In the Singapore Mental Health Study (SMHS 2016) completed in 2018, researchers from the Institute of Mental Health (IMH)  found that those of Malay ethnicity have higher odds of OCD (Obsessive Compulsive Disorder). (For the convenience of this article, Malay ethnicity has been taken as representative of the local Muslim community.)

The SMHS went on to state the “higher odds of OCD are difficult to explain and needs further research to elucidate the underlying cause(s)”.

Those familiar with OCD would know that this mental health condition consists of two components – obsessions and compulsions. Persons with OCD may have varying obsessions and compulsions.

According to Dr Elna Yadin, an authority from the International OCD Foundation who visits Singapore occasionally for consults, the  main anxious obsession  of a person with OCD is the desire not to become “a bad person”. As for compulsions, some of its more typical forms involve maintaining cleanliness and acts of washing.

When these dots are connected, it becomes understandable if one tries to hypothesise how OCD interfaces with Muslims.

OCD: An obsession with piety?

Given the  emphasis of Islamic teachings on cleanliness as an indicator of one’s faith , members of the Muslim community may run the risk of turning cleanliness into an unhealthy obsession.

It is indeed important for the Muslim to perform acts of ritual purification such as taking ablution and compulsory baths properly, in order to perfect his acts of worship. However, over-zealousness masked by attempts to attain absolute perfection during such acts of ritual washing may land such a Muslim in a psychological trap and throw him into a spiral of compulsive behaviours.

Such persons then become preoccupied with washing and keep repeating their ablution, sometimes to the point of missing their prayers entirely.

Unfortunately, this is sometimes compounded by extreme fear-mongering about the perils of not taking proper ablution, by unwitting yet well-meaning religious teachers and elders. Anecdotally, it is not uncommon in religious settings to hear about the ‘punishments’ to be suffered by one who is lackadaisical in washing after himself after using the restroom to pass bodily waste.

It is then drilled into the psyche that one’s ritual worship will be invalidated, and that he would be tortured in the grave due to a lack of proper hygiene when using the toilet.

While such teachings are essential, there may be a greater need to mediate such messages when they are delivered on public platforms.

It is true that maintaining cleanliness is part of a Muslim’s faith, and this article does not seek to deny this religious injunction. However, when it is internalised by an unwitting layman without nurturance and guidance, it may become problematic. In striving to perfect one’s faith, such a Muslim may end up obsessing irrationally about cleanliness and miss the higher objectives of the religion instead.

The Need to Prevent OCD in Religious Practice

The SMHS found that OCD has the highest 12-month prevalence among mental disorders at 2.9%. Statistically, this means that for every 50 persons in the street, at least one person would have had a diagnosis of OCD within the past  2 months. In fact, the data for Muslims may be even more startling as Malays have a 12-month prevalence of OCD of 4.3°/o. For data visualisation’s sake, this could mean that at least one out of every 2 5 Malays may be experiencing clinical OCD. Imagine how many persons in any given mosque at a Friday congregation actually suffers from OCD?

Leaders in the community must be concerned about this 25th person, for if he has an existing schema that renders him psychologically more  vulnerable, this person may tum innocent intentions into obsessions, and innocent rituals into compulsions, at the expense of his mental health. It becomes more worrying when one considers that persons with OCD have been shown to delay seeking professional help the longest (II years). Are members of the Muslim community then able to distinguish the difference between ‘piety’ and OCD in their religious practices? Does this indicate that more psycho-education for OCD is needed in the Muslim community?

While these questions fester in our minds, we should also call for a more nuanced delivery of Islamic teachings with regard to ritualistic practices, especially as religious rituals inevitably become associated with the accumulation of ‘merits’ and ‘demerits’ – a significant phenomenon because of its attributed role in determining where one ends up in the afterlife.

Solutions can be found within the vast Islamic scholarship on this matter. Therefore, adopting a moderate approach in Islamic teachings cannot be over emphasised here, accompanied by critical thinking skills to help individual Muslims contextualise and accommodate or adapt their daily rituals accordingly without jeopardising their mental health.


Not far behind OCD in terms of prevalence, is depression. While Malays (again by extension, Muslims) had  the lowest lifetime prevalence of Major Depressive Disorder at 4.9°/o, Malays were still second highest for r 2-month prevalence at 2.9°/o. It must be noted that while not every person who feels depressed receives a diagnosis of major depressive disorder, there are many variants of depressive symptoms which are equally disruptive to daily functioning.

Even without manifesting as a full blown episode of clinical depression, it is possible for one to experience acute stress, adjustment difficulties, grief and complicated grief, or simply one of the many symptoms of depression such as loss of appetite, poor sleep, irritability, low mood, suicidality and so forth. These presentations could eventually lead to depression, or may possibly exist in isolation without ever meeting the clinical criteria for depression.

Although  the rates of prevalence for mental illness for Malays were not flagged in the SMHS, there are still potential risk areas which may be of interest to helping professionals, and the community at large. Specifically, these risk areas pertain to relationship difficulties.

The Relational Dimension of Depression

The causes of depression are multidimensional and the onset of depression may be caused by biological factors, environmental factors, or both. Extrapolating from some of the evidence­ based psychotherapy treatments for depression, we will find that such ‘environmental factors’ which contribute to depression may have developed out of difficult couple and interpersonal relationships.

This poses some questions for the Muslim community because anecdotally, the community is more communal, connected and family-oriented (read: interpersonal relationships) and where the prevalence of marriage and divorce (read: couple relationships) is relatively higher. Certainly, it will be a huge leap to suggest that members of the Muslim community are therefore at higher risk of developing depression. There is simply no data to support such a correlation. Furthermore, despite ranking second highest for 12-month prevalence, Malays still ranked lowest in terms of lifetime prevalence for depression.

One hypothesis is that perhaps somewhere after an acute 12-month period, Malays (and Muslims) find a way to overcome depressive symptoms, or simply ‘manage to get by’. Possibly, this could either be due to the communal and social support that the tight-knit community lends to its members, or in spite of this tight-knit community. The latter might suggest that the Muslim community is resilient and can buttress against chronic depression.

Yet, given the literature on ‘disability days’ due to depression, paired with its

‘economic burden’, it still behooves helping professionals, and the wider community, to be able to detect signs and symptoms of this illness. The social impact of depression is such that one person with depression in the community remains one too many.

Depression, Marriage & Divorce

Another question then lingers: If we cannot definitively conclude that difficult interpersonal relationships lead to depression, can we say the reverse instead? That it is depression that leads to difficult interpersonal relationships? Could this then finally explain the pervasive marital difficulties in the Muslim community, and even in society at large?

These questions run the risk of oversimplifying both depression and couple conflict, yet it seems intuitive to do so. Adopting a systemic mental model, depression may possibly correlate with numerous other contributing factors to couple conflict such as unemployment, financial difficulties, marital/parenting role adjustment, addiction, sexual dysfunction and more.

Systemically, this implies that marriage preparation programmes and divorce counselling programmes in the community may need to include some form of awareness with regard to the impact of mental health on marriage, and  marriage on mental health.

 A not-so-final word

These reflections are a cumulation of the author’s professional practice experiences in the social and mental health sectors, and have been crystallised by the ethnic breakdown of data in the SMHS 2016. The role of mental health cannot be neglected in social and community development.  This can only be achieved with relentless advocacy. Dots of social problems, health problems and their respective solutions keep interconnecting, even as more dots continue to appear in our highly developed society. The impact on the Malay, and Muslim, community is significant. While some of the ideas that have been suggested in this article remain moot for now, it is hoped that they may spark ideas for research and uncover new social and mental health solutions for the future. ⬛


About the Author:

Sufian Hanafi is a  senior  social worker and counsellor who has been providing counselling , psychotherapy and psychoeducation for individuals, couples , families and groups for more than a decade. He has worked in both the health and social services sectors, specifically in outpatient children and adolescent mental health. inpatient and community adult mental health, specialised services and mandatory pre-divorce counselling programmes for inter-ethnic and blended families. He currently runs a private practice, Just Guidance Counselling & Psychotherapy.



This article was first published in “Karyawan” a publication from AMP Singapore in 2019


Dying to be thin- the facts on eating disorders

Dying to be thin – the facts on eating disorders


By Aishah Alattas

Eating disorders are one of the most common mental illnesses. The latest estimates show that around 8% of people suffer from an eating disorder over the course of their lifetime. Despite its high prevalence, eating disorders continue to be among the most under reported, under treated and misunderstood mental illnesses. This occurs on various levels – on the sufferers themselves who may be in denial that their thoughts and behaviours around food and body image are harmful to them; on friends and family who may discount the distress that comes with eating disorder, and lastly on mental health professionals who together with the patient and their caregivers, must overcome  barriers to treating the disorder. Eating disorders can affect anyone at any point in our lives. With more knowledge and understanding, sufferers can recover. They can have a healthy relationship with food, eating and their bodies and live a fulfilling life.

What are eating disorders?

Eating disorders are illnesses where people experience severe disturbances in their eating behaviours. The behaviours relate to their thoughts and emotions. People with eating disorders typically become preoccupied with food and their body weight. Below is a list of types of eating disorders:

  • Anorexia Nervosa

Starvation or extremely restricted eating with the intention of weight loss. May also include excessive exercise.

  • Bulimia Nervosa

Cycles of binge eating and purging which may or may not include a starvation phase. Purging involves behaviours such as self-induced vomiting, abusing laxatives or diuretics and even excessive exercise.

  • Binge Eating Disorder

Binge eating without purging. This disorder is different from the basic overeating which all of us may have experienced over the holidays where we take that extra helping of food. It is characterized by eating a significantly larger amount of food over shorter periods of time than most people would eat under similar circumstances. The person engaging in this behavior then feels guilty, embarrassed and a sense of loss of control.

  • Orthorexia Nervosa

Those who suffer from orthorexia are not focused on losing weight, but are fixated on the ‘purity’ of food. They are extremely selective, only eating foods that they deem to be absolutely healthy. Inevitably, these people eliminate most foods from their diet. Consequently, they become malnourished and may face negative physical and emotional effects.

Common myths and misconceptions


There are many assumptions that come with eating disorders. Many of this assumptions can hinder the recovery process. They can even add  to the physical, emotional and psychological distress that comes with eating disorders. It is important to separate these myths from the facts. In so doing,  we can understand ourselves or those who may be suffering with an eating disorder:

  • Eating disorders are not a lifestyle choice

Eating disorders are more than just being ‘on a diet’. When we want to reach a healthy weight we may benefit from controlling what and how much we eat.  The problem arises when these attempts have lost sight of their goal. This means there is no longer an ideal weight or health target.  The sufferer becomes obsessed with ‘the perfect body’ and will work towards this illusion at all costs.

  • Eating disorders are about more than just food

Eating disorders are complex emotional and psychological disorders that manifest in the form of food and eating. A majority of people with eating disorders also suffer from a mood disorder and low self-esteem. These people see food as an all-powerful tool which he or she can focus on. They do this to gain a sense of control, numb painful emotions or gain approval or acceptance.

  • You cannot tell if someone has an eating disorder based on their weight

This misconception mostly relates to anorexia, where the assumption is that anyone with anorexia must me severely underweight when in fact this is not true all the time. All our bodies work differently and individual health factors, genetics and metabolic rates play a part in determining our weight. Indeed, multiple people with the exactly the same eating and exercise habits can come in many different shapes and sizes and the same applies to those with eating disorders. Instead of assuming that someone is suffering from an eating disorder by looking at their weight, it would be more beneficial to take note of their eating habits and ask them about their thoughts and feeling surrounding food and their bodies.

  • Eating disorders are not ‘female’ disorders

It is true that the majority of those with eating disorders are female, however, the gap between the two genders has been closing and increasingly more males have been diagnosed with eating disorders over time. Unfortunately, for males that suffer with eating disorders, the stigma of these disorders as being ‘female issues’ can further impede help-seeking behaviours and this has been thought to be one of the reasons why males that do present with eating disorders seem to be at the more severe end of the spectrum.

  • Eating disorders are not solely caused by the media

Eating disorders are often over attributed to the media and the ideal portrayal of a slimmer body. While media portrayal is a contributing factor, it is only a small part of a very large picture. Recent years have seen a shift in fashion trends and representation.  The movement that ‘real women have curves’ is heavily promoted. Yet we still see anorexia at the same, if not a higher prevalence.  Another fact to consider  is that the ideal ‘skinny’ body was only promoted in western media. People in  Africa or the Middle East,  consider curvier figures as desirable, yet anorexia and other eating disorders still occur in these areas.

Someone I know has an eating disorder – next steps


Coming to terms with an eating disorder whether it is admitting it to yourself or recognizing it in a loved one is a huge step in itself and is a place that takes courage to arrive at. As with any other mental illness, it is important to seek professional help. Depending on where you are in the world and your circumstances this could be a GP, a psychiatrist, a psychologist or a counsellor in a variety of settings. With the help of these professionals, all parties involved can come up with a plan for the sufferer that takes into account nutritional intervention, psychotherapy and medical and psychiatric monitoring.There is a good chance that this  multidisciplinary approach is able to rectify not only the behaviour but also the morbid thoughts and emotions. With this approach, recovery is possible and the sufferer can live to his or her full potential.

About the Author:

Aishah Alattas has a Master’s in affective disorders . She has extensive experience in working with individuals with mood, anxiety, eating and psychotic disorders and their care givers.

An advocacy in educating the public on mental health, Aishah is keen to reduce the stigma of mental illness at an individual, community and societal level.

She is currently working on expanding the scope on mental health intervention by using theatre and the arts and via digital platforms



20 ways to a better you

 When you are recovering from a mental health condition it is easier if you take one day at time.  Sometimes you can have a difficult day yet on other days life can be easy.  Sometimes things are going to get worse before it gets better.  Below is a list of things you can do to boost your self esteem and overcome depressive thoughts. Some of the things may be challenging but others may be easy and fun.  Try to do the task and don’t be too hard on yourself if you can’t do them. Bottom line is you tried and rest assured the sun will  shine in your corner.



Day 1: Get a notebook and start a journal.  Spend 10 minutes writing down your thoughts and feelings

Day 2: Write 10 things that you like about yourself

Day 3: Pay a compliment to 3 people

Day 4: Phone or email an old friend to connect

Day 5:  Cook a new dish

Day 6: Offer to help someone expecting nothing in return

Day 7: Forgive someone – in person, by phone, by email; if unreachable write your forgiving statement in your journal

Day 8: Compose an affirmation/mantra of 3 to 4 statements about how to maintain your mental well being

Day 9: Clean out your closet/ drawer/ cupboards:  Give away / recycle / throw 5 things that are no longer necessary or useful.

Day 10: Ask someone to have a coffee with you

Day 11: Give someone a small gift

Day12: Watch a funny movie and have a good laugh

Day 13: Learn a new song

Day 14: Write down 20 things you are grateful for

Day 15: Drink 8 glasses of water throughout the day

Day 16: Eat a vegan diet – No milk, cheese, yogurt, butter and definitely no meat!

Day 17: Listen to your favourite music

Day 18: Brisk walk outdoors for 20 minutes

Day 19: Write 5 things that you want to have or achieve

Day 20: Go on You Tube and learn yoga ( for absolute beginners )

What is mental health recovery?

What is mental health recovery?

BY:  Heryani Jamaludin


” Being back to my normal self and being able to do the things that I want to do without difficulty.” – Imah


Recovery from a mental illness is possible. Like a body that is broken the mind also wants to heal.  Just as a person’s experience of  mental illness is unique so is his recovery. For one person recovery means being able to go back to work.  For another recovery means being able to get out of bed.  How one person defines his recovery is as individual as the person who is experiencing the mental illness himself.  Recovery is not only about the reduction of signs and symptoms but more about the restoration of the self. As humans our ‘self’ is not one dimensional but a conglomeration of many aspects of what we are or do that defines us. Additionally recovery is also about building resilience to face the next challenge.

The problem with the medical model


” Before I sit down the doctor already write my prescription” –  Leng


When you see your doctor he listens to your complaints and looks for signs and symptoms. He makes a diagnosis and prescribes medication.  You are referred to another health professional for further treatment. When you report a reduction of signs and symptoms at the next appointment the good doctor will declare you clinically stable. He then offers you another appointment in three months for ‘maintenance’.

This linear model of care seems straightforward but in reality it is never like that. The medical model of recovery is flawed for 2 major reasons: Firstly, the journey to recovery from a mental illness is never  linear because recovery is a process.  A process is a series of steps towards a particular end. The steps may also not necessarily be a step forward but a step back. For example, it is not uncommon for a person who is in  recovery to have a relapse before he gets better.

In the UK 50% of patients do not collect their prescription or take their prescribed medication.

Secondly, mental illness affects many aspects of a person’s life by causing setbacks. These setbacks are not medical in nature and pills cannot resolve them.  A doctor whose area of expertise is in diagnosing and prescribing  does not have the skills to help the person with mental illness overcome the setbacks.  A United Nations report (2017) stated that  approaches that lean towards the medical model are no longer tenable.

The concept of recovery


The recovery model of mental illness looks at the whole person . Mental illness not only affect a person’s physical health but also other aspects of a person’s life. For example, Michael is a young man who hears voices recently. He gets confused and is afraid. Consequently Michael isolates himself and neglects his personal hygiene. Due to his long absence from work his boss sacks him. Subsequently he loses touch with friends. His family members who do not understand, ignore him. Even if medication puts his mind at ease, Michael has to relearn the skills needed to regain some normality in his life. For Michael and many more like him this is very much a personal recovery and not a clinical recovery.

Apart from restoring what mental illness has depleted, recovery is also about building upon what the person with mental illness can do to help himself and learning new skills to manage future setbacks. The focus is on ” what can you do?” Not,  “what’s wrong with you?” This concept puts the person with mental illness very much in the driver’s seat. It puts the responsibility of getting better more on the person with mental illness than on the health professional. This kind of empowerment is powerful and is a tool in itself. In conclusion, recovery is not just about cure but the emphasis is on the client and the approach is strength based.

 What is C.H.I.M.E?


The Scottish Recovery Network asserted that recovery works best when five elements are present in a person’s life. Denoted by the acronym: C.H.I.M.E. they stand for connection, hope, identity, meaning and empowerment. The clip below explains C.H.I.M.E.



The origin of the recovery model


 Dr Mary Ellen Copeland  pictured below suffered an enduring mental illness. She felt frustrated with her doctors who were trying to treat her because she did not get better.  Consequently she invented the Wellness Recovery Action Plan. This was a set of actions plans that helped her with her recovery.  Her method  was so successful that mental health organisations in both the US and the UK have adopted the model it in various forms.



The recovery model is about working collaboratively with your client and respecting his decision even though you may not agree with it . Using recovery language you  help your client identify triggers and explore coping skills to overcome his challenges. Once this is done you may want to help him set some goals to enable him to  live a fulfilling life. Recovery is also faster and more effective when assisted by someone with lived experience. Nothing is more powerful than meeting a person who has gone down that dark road and has come out to the other side.  A peer  who has the experience of a mental health challenge himself is well placed to instill hope and inspire the other person towards recovery and his goals.

How health professionals work with each other?


In the UK the Care Programme Approach is a legal process for people with an enduring mental illness .  This is a care package delivered by a multidisciplinary team. The main objective is to ensure that the client’s needs are met and that there is accountability.  The CPA is more needs led  than it is service led.

In Singapore the formality of a multidisciplinary approach that is holistic is still in its nascent stage. It’s implementation is rather patchy. For the delivery of care to be impactful and holistic the approach must be multidisciplinary where different sectors must ‘talk’ to each other. One organization must take the lead in formulating a workflow, create documentation and provide training across all sectors so that everyone is on board. This holistic and multidisciplinary approach that is full of rigour will render recovery in its true meaning of the word.


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How to stop your intrusive thoughts

How to stop your intrusive thoughts

By: Heryani Jamaludin


In 1992 while living in America, I became pregnant with my second child. A few months later my husband was made redundant. At 7 months pregnant I flew half way across the world to have my baby in Singapore. Three weeks after my C section my family and I resettled in the UK. I stayed with my in-laws temporarily and moved house two more times before we could purchase our own home. Meanwhile my father-in-law passed away after a long struggle with cancer. When my husband found work outside the UK I stayed behind to look after my 2 young children in a small village in the south of England.

When my baby was 5 months old I started to have recurring thoughts about a small incident at my father – in – law’s funeral. These unwanted thoughts had such an emotional charge that every time I picture the incident I  get upset . I would cry. Things got worse when I started to cry for no reason. The thoughts were intrusive and interfered with my daily routine. I could not concentrate on the simplest of tasks and it occupied my mind for most of the day. When my 5 year old son asked me why I was crying I started to panic and feared that I was going mad. I felt scared and exhausted . In desperation I went to see my GP. I thought that he was going to be dismissive of me. Instead my GP listened carefully and referred me to a mental health practitioner.

At the first session the MHP took a history. She reflected to me that in one year I lived in 3 countries – experienced redundancy, birth and death and now caring for my young family without my husband. She instructed me to wear a rubber band on my wrist and to snap that rubber band each time I have the thoughts. She helped me put the incident in perspective so that I wouldn’t load it with negative emotions.
Skeptical about the process but desperate to get better, I tried the technique for 2 weeks and guess what? It worked! I saw the MHP for another session and that was it. The rest of the time I did my own internal work. No pills, no long therapies, just a technique and sorting out of thoughts.

Looking back I’m convinced that my intrusive thoughts came from relentless stress that I had generally managed well but never gave myself enough ” me ” time to regroup. I basically took care of everyone but did not see to my own needs.  The incident  itself wasn’t that traumatising. It was at best a little embarrassing.  Now I would just shrug it off or laugh it off. But at that time due to my stress levels I made it into a very big deal – to such an extent that it affected my mental health.  I have learnt many things since that incident in 1992. One would argue that snapping a rubber band and causing pain – thus associating pain with unwanted thoughts is a mild form of self harm.  For me it wasn’t. The pain if you can call it that was rather mild . As it was self inflicted you can  control how hard you snap that rubber band.  More importantly it worked for me. For those who do not wish to have the rubber band you can snap your fingers or clap your hands to literally snap out of the intrusive thoughts.  But I thought the rubber band technique was the most discreet and would attract little attention if you are in a public place. Please share if you’ve experience something similar.

#thought stopping # mental health practitioner #stress#association

High expressed emotions can cause relapse

Recovery from schizophrenia in early 20th century England- treatment options


Recovery from schizophrenia in 20th century England was very much a ‘hit and miss’.  There was very little understanding about the nature of the illness and its treatment.  Society labelled people who suffered from schizophrenia as “lunatics”.  Wealthy people locked away their mad relatives in an attic room away from  others. Doctors treated patients with insulin or performed frontal lobotomies. This was a procedure that involved a sharp, long needle inserted through the eye to get to the brain.


The origin of expressed emotion – a study by Brown et al

In the 1950’s doctors began prescribing chlorpromazine. Patients became stable and went back to their homes.  It wasn’t  long before these patients relapsed and  returned to hospital. To understand the reasons for these relapses a psychiatrist called George Brown studied over 229 discharged men.  He found that those who lived with their parents and wives were more likely to relapse. Those who lived with other relatives or in lodgings fared better. He found a connection between the carers’ behaviour towards the person with mental illness and the relapses. He termed this as expressed emotion.

Definition of expressed emotion


High expressed emotion or ‘HEE’  are words, actions and attitudes that  carers demonstrate toward the person with mental illness.  An example of a critical comment is a remark on his apparent lack of comiment.  Hostility are words that are harsh or critical; blaming the person for being sick or lazy, spoken in a loud and aggressive manner.

Emotional over involvement is when the carer or relative blames himself for the illness and showing regret and remorse.  In his study, Brown found that patients who returned to their wives or parents soon relapsed and were readmitted. Those who lived with siblings and informal carers did better


Low expressed emotions denoted by ‘LEE’ is emotion that is conveyed by a compassionate, empathetic attitude towards the sufferer. Exercising patience , giving the sufferer plenty of space, speaking in soft tones. Talking to and trying to understand the person suffering from schizophrenia- his hallucinations, delusions and exploring coping strategies so that the sufferer may have fulfilling life play a major role in relapse prevention. A general positive regard by those around him is key to remaining well.


What can you do as a health professional?


Recovery is more effective when you involve carers or family members. You should inform them of the nature of the illness , how the medication works and the importance of compliance. Some families of newly diagnosed people are emotional. They are frightened because they do not understand the illness. Your role of counseling them about positive regard and low expressed emotion requires a good balance of empathy and assertiveness. Invite your client to talk about his voices or his delusion – being careful not to agree or argue with the latter. Find out how these symptoms affect his life and how he copes. Help him with exploring new strategies and setting his own  goals.


#expressed emotions#chlorpromazine#psycho-education#causes of relapse

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Out of the Blue – how to recover from depression

The common cold of mental illness

Depression is known as the common cold of mental illness. It is a treatable disease. Millions of people who suffered from depression have fully recovered.  From prescribed medication to alternative ones like St John’s wort and LSD, from conventional talking therapies to complimentary therapies like mindfulness and yoga, many more have found a combination of ways to manage their depression and live fulfilling lives. If your doctor has diagnosed you with depression there are many things you can do to reclaim your life.

Why do people become depressed?

There are 2 types of depression:

  1. Endogenous depression: There are no triggers as it comes from within.
  2. Reactive depression:  There are triggers that cause the depression. Here are some examples of stressors.
  • Physical illness
  • Sense of loss: death of a loved one, loss of a role in life, loss of job, loss of support
  • Low self esteem
  • Substance misuse/ abuse
  • Inability of cope with stress within the work place, family or society
  • Unresolved trauma
  • Unsolved problems
  • Hereditary

How do depressed people think?

  1. All or nothing thinking: the persons thinks in absolutes – in black and white with no middle ground or grey area. They tend to judge others using general labels. ” I’ll never get a job” ” I’m completely useless”
  2. Awfulising  or catastrophising: the person tends to magnify or exaggerate how awful or unpleasant events can be. He tyically over estimates the chance of failure
  3. Personalising: the person takes responsibility and blames himself for anything unpleasant eventhough it has nothing to do with him

  1. Negative focus: the person focuses on the negatives and usually filters out the positive aspects of events.
  2. Jumping to conclusions: the person interprets events negatively without evidence or definite facts. Predicting the future negatively
  3. Living by fixed rules: the person is most likely a perfectionist, living by fixed rules with little or no flexibility. He has high expectations of people. He regularly uses the word ” should” “ought” ” must” or “can’t”. The more rigid the statement the more disappointed , angry, depressed or guilty he is likely to feel

Keep active

  • Do things that bring you joy
  • Change your environment if possible
  • Exercise regularly

Questions to ask

Only a doctor can diagnose you.  Your doctor may prescribe medication and  suggest other treatment. Make sure  you get as much information as possible from your doctor and other reliable sources.  Below are some questions  you may want to ask:

  1. What is the name of the medication?
  2. How does it work?
  3. When will the effect of the medication kick in?
  4. How long do I have to take the medication for?
  5. What happens if I stop taking the medication?
  6. What are the side effects of the medication?
  7. How can I manage the side effects?
  8. What happens if I want to get pregnant?
  9. I’m taking other medication , will the antidepressant be effective?
  10. I’m breastfeeding , will the medication have any effect?
  11. How long do I need to see the doctor for?
  12. What happens if I want to stop taking the medication?
  13. What happens if the medication does not work?

Sometimes you may need to be in hospital to have a more intensive treatment. It is important that you fully discuss this with your doctor, your carer and those that you care for.  The purpose of being in hospital is to keep you safe. The environment and  health care professionals can help you get better.  Make sure you have a discharge plan to remain well as this is important. Keep your appointments with the health professionals and keep active.

Vicious Cycle

Feeling depressed is a vicious cycle. Your negative thoughts make you feel miserable, lack of confidence and unmotivated. This means you slow down, get tired and become less active. You avoid situations which means you don’t have any positive experience. As a result, your confidence is further reduced. The reduced confidence strengthens your negative thoughts.

To do list

  1. Write down a “to do” list before you sleep because you need a plan for the next day
  2. Mix pleasurable activities with duties and responsibilities
  3. Connect with others; phone a friend to go for a walk with you
  4. Break big tasks into smaller ones.
  5. Be flexible . Do not fret if you are unable to achieve one of the task. Just go to the next one
  6. Increase the frequency of your activity taking it one step at a time.


For more information on how to cope with depression purchase my e-book ” You can be your best ”

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Shut the hell up!- coping with voices

Shut the hell up!- coping with voices

By: Heryani Jamaludin

What are auditory hallucinations?

 This article explains why people hears voices and how to cope. People  generally do not hear voices.  People who suffer from schizophrenia or psychosis hearing human voices is not unusual. The state of hearing voices is called auditory hallucinations and is usually a symptom or one of the symptoms of a psychiatric condition.  These symptoms are also called positive symptoms in the sense that it is something “extra” that the person is experiencing. If a person suffers from schizophrenia and hears voices one would say that he has positive symptoms. If he withdraws and becomes mute then one would say he has negative symptoms.

They come when I’m stressed at work. I would take an extra pill and go to sleep. When I wake up , I feel better.

The nature of auditory hallucinations

Voices may come anytime during the day, the voices may come from inside the head or outside as if someone is speaking to that person. It can be a man, woman or even a child’s voice; the sufferer may know or not know the owner of the voices.  It may be one person talking or a few persons talking to the person with mental illness or talking to each other about that person.

Some voices say funny things and can make the sufferer laugh. Some voices praise the person with the mental illness or say good things. Yet some voices will say random things or even say rude words and make the person feel uncomfortable. 

Voices that talk to each other may make derogatory remarks about or to the person with mental illness.  The voice or voices may also tell the sufferer to do bad things for example:  kill himself or kill others. Auditory hallucination can be entertaining but at other times it can cause a lot of distress to the sufferer.

The effects of auditory hallucinations

A person who hears voices can usually manage his symptoms but constant hearing of voices can be distracting and renders the person who suffers from this symptom unable to concentrate and complete tasks. Constant rude comments or outrageous instructions can make the person be self conscious to the point of being paranoid or have low self esteem.

Sometimes the person with mental illness responds to the voices by talking to it- especially when the voices say nice things, crack jokes  or are just funny. To the casual observer that person is seen talking or laughing to himself.  At the best of times this behaviour when  seen in public  may seem odd but to some it can be unsettling.

Measuring auditory hallucinations

From a therapist’s perspective helping your client talk about his voices will help you understand your client’s symptoms and inform you of future interventions. Make notes of the following: the onset (what time of day ), trigger, frequency, duration, intensity ( loud or soft, how many people)  and the content ( what is being said). It is also important to explore how your client feels about the voices, what do the voices mean to him and how does it impact his lifestyle if at all.

Managing auditory hallucinations

Some antipsychotics prescribed by a doctor for example, risperidone can expunge or reduce the auditory hallucinations and enable the person to live a relatively “peaceful” life.  But some medication have side effects and not everyone is willing to take medication. Below is a list of actions that can be taken to manage hearing voices:

  1. Set aside a specific time of day for you to listen to your voices
  2. Tell the voices : “ Not now . I will listen to you later”
  3. Engage in calming activities: painting, drawing, yoga or  reading ( if you can concentrate)
  4. Talk to someone about your voices and what it means to you
  5. Write down what the voices say
  6. Respond to the voices ( best you do this in private )- Please do not act on the nasty commands
  7. Share your coping strategies with others
  8. Practice meditation or mindfulness 
  9. Take your prescribed medication and discuss with your doctor of its effectiveness
  10. Listen to calming music especially if you want to rest


Auditory hallucinations or hearing voices is a symptom of a psychiatric condition.  It is a common symptom and many people are managing it well.  Many people who  hears voices have got it down to fine art in terms of management either with or without medication. If you are hearing voices talk to a health professional to explore your personal coping strategy.