In 2016, Armie sought treatment for Bipolar II and Borderline Personality Disorder.
During Armie’s “hospital-shopping”, as they termed it, one psychiatrist became “stiff and hostile” towards them upon learning that they are a lesbian. Another began asking inappropriate questions such as, “why do you like girls?” and “do you feel like a man?”, even though Armie had made clear that being LGBT was not why they were seeking treatment. While they explored visiting a private hospital, the fees were ultimately too costly for a patient in need of monthly visits. On top of that, the psychiatrist assigned to them didn’t display the empathy they were looking for.
Over a period of three years, Armie visited around five different hospitals before finding a psychiatrist who was accepting, non-judgemental, and listened to their needs with respect.
Armie’s experience highlights an uncomfortable problem in mental healthcare in Malaysia today: even when one reaches out for help, the help you receive might be inadequate.
Awareness of and around mental health issues is on the rise in Malaysia. In July, Minister of Health Datuk Seri Dzulkefly Ahmad spoke on the need to talk openly about mental health. In mid-October 2019, as part of the government’s plan to tackle the issue, the minister launched a public education campaign called “Let’s Talk Malaysia”, to be held every October with the aim of eliminating stigma against people with mental health disorders or illnesses. The Ministry of Health was also said to be announcing a National Strategic Action Plan for Mental Health in September, covering the period of 2019 to 2025—though there have yet to be any updates.
Dzulkefly’s comments mirror the current discourse around mental health in Malaysia; namely the focus on reducing stigma. In a typical campaign, the prevalence of mental illness is cited to illustrate the need to reduce stigma, and those who are struggling are called upon to speak up and reach out for help.
These campaigns aim to normalise talk of mental health issues and the need for treatment. But this line of discussion often prescribes an inadequate, one-size-fits-all solution (ie. “seek help”) to a multi-faceted, complex problem.
Contextualising mental health
One concern with anti-stigma campaigns is that they ignore the wide-ranging sociopolitical conditions that give rise to poor mental health in the first place.
In Bridging Barriers: A study on improving access to mental healthcare in Malaysia, research analyst Lim Su Lin highlights that, in 2015, “one in three adult Malaysians were suffering mental health problems and [were] at risk of developing diagnosable mental illnesses.” At the same time, comparing data from 1996 and 2015, she found that this prevalence rate is not equal across different socio-demographic groups.
While the rates increased across all income groups, low-income earners (earning less than RM1000, or US$240, a month) reported the highest prevalence in both years. In another trend, Orang Asli groups reported the highest prevalence of all ethnic groups in 2015, a threefold increase from 1996. Also notable is the significant rise of prevalence in Malays, from 8.1% to 28.2%, and in Indians, from 17.2% to 28.9%.
These data excerpts point to a few social determinants of mental health. They also show that mental health is but another dimension of social inequality.
Mental health is but another dimension of social inequality.
Thus, campaigns that focus solely on encouraging sufferers to seek help exclude marginalised communities, such as low-income groups, indigenous peoples, LGBT people, refugees or undocumented migrants, among many others. These communities not only experience systemic barriers to accessing mental healthcare, but also struggle with unique concerns that leave them more vulnerable to mental illness or poor well-being.
For example, “[i]t’s a no-brainer that [surviving violence] will lead to women experiencing a whole host of different situations such as depression, anxiety, PTSD, all of which need to be addressed,” says Sumitra Visvanathan, Executive Director at the Women’s Aid Organisation (WAO), which provides shelter and support services to women and children who have survived violence and abuse.
Survivors of abusive relationships, usually women, might find temporary respite when they reach out for help, but there’s no guarantee that they’ll be safe from future harm. They might lack the social or economic resources to leave an abusive partner, or feel pressured by sexist cultural norms to stay in a marriage. Those grappling with pre-existing mental illness, Sumitra adds, have an even harder time, as their condition is exacerbated by the violent environment.
Underscoring the link between environmental factors and mental health, LGBTQI persons in Malaysia are at risk of “increased trauma, anxiety and decreased quality of mental well-being due to criminalisation and policies that target [them],” says Thilaga Sulathireh, co-founder of Justice for Sisters. Experiences like Armie’s, where a queer person feels discriminated against or judged even if their reason for reaching out has nothing to do with their sexual orientation, can make accessing help even more challenging.
It also works both ways: while a toxic situation impacts an individual’s mental health, their mental health also factors significantly into their ability to remove themselves from that situation. WAO social workers aim to equip survivors with viable options—such as skill-building programmes, support for job-seeking, childcare, and so on—that allow them to leave an abusive relationship. But Sumitra notes that they’ve begun to realise “you can throw as many opportunities at someone [as possible], but that individual will not be able to take advantage of those opportunities if they are not mentally, psychologically in a situation where they are able to do something about it.”
To situate mental health within a wider sociopolitical context is thus also to recognise this relationship between mental well-being and the navigation of adverse situations.
To situate mental health within a wider sociopolitical context is thus also to recognise this relationship between mental well-being and the navigation of adverse situations. “It’s a cycle,” says Sarah Yung, a lecturer and counsellor at a local university.
Yung has worked with rural and refugee communities. Sharing her experience, she says, “Impoverished individuals who struggle with their practical needs like shelter, work, or a sense of safety and security often don’t have enough capacity to deal with their stressors. They might not have the opportunity or capacity to focus on long-term goals, because right now they are just focused on surviving.”
Mental health as a sociopolitical issue
As someone who lives with Post Traumatic Stress Disorder (PTSD), Sumitra is acutely aware that mental health should always be a priority. Recognising the need to strengthen the internal capacity of domestic violence survivors, WAO has, in recent years, expanded their focus to providing counselling and emotional support programmes. But such efforts are limited by resources, which are almost always in short supply among such organisations.
“Unfortunately, that area of intervention is costly,” Sumitra says. “We are able to move forward with that only if we have the financial support for it.” For this support to be sustained in society over the long-term, concurrent state-level interventions are needed.
But the state itself can perpetuate marginalisation and social inequality. In August, the National Institute of Occupational Safety and Health, in collaboration with the Ministry of Health, announced plans to launch a programme to tackle mental health in the workplace, with modules to raise awareness and provide psychological first aid training for both employers and employees. Such a programme will no doubt benefit some, but it does not address underlying causes of poor well-being, such as the lack of a living wage, abysmal work-life balance, sexual harassment, or forced labour. Recent criticisms that Malaysia undercounts the prevalence of poverty also suggest that the state is hesitant to acknowledge—let alone address—the full needs of those struggling to survive.
In fact, a study by the Health Equity Initiatives (HEI) in 2011, “Human Trafficking, Forced Labour, and Mental Health”, found that 70% of asylum seekers and refugees in Malaysia surveyed suffered symptoms of depression, anxiety, and stress. These symptoms were linked to unemployment and forced labor. For them, accessing healthcare services might not be an option if they are undocumented and left without any legal rights.
What’s clear is that mental health itself is a political issue, and the state is no neutral actor.
What’s clear is that mental health itself is a political issue, and the state is no neutral actor. When it comes to the well-being of LGBT people, for instance, the state continues to sponsor conversion therapy.
“At the moment the government funds rehabilitation therapies, seminars that target parents, counsellors and students that promote the rehabilitation of LGBTIQ persons and other forms of misinformation,” says Thilaga.
“These programs are not evidence- and rights-based and in fact have adverse long term impact on the health and wellbeing of LGBTIQ persons. [They] have to be immediately reviewed and ended.”
Mental health as a community issue
While social and cultural attitudes—the target of multiple anti-stigma campaigns—present barriers to accessing mental healthcare services, there are practical barriers, too: time, financial costs, transportation, long waits within the public healthcare system, among others. Efforts to address mental health and well-being must therefore also find ways to reduce these barriers.
In Yung’s view, providing financial aid for mental healthcare would be a “game-changer”, not only to address the practical barriers to access, but also to send the message that mental health is important.
“What some people don’t realise is that counselling takes a lot of work and effort,” says Louise Tan, a social worker at the WAO who also has experience navigating the Malaysian mental healthcare system. Whether through therapy, physical exercise, medication, or leisure activities, maintaining one’s mental health requires resources, commitment, and time.
To that end, Tan sees mental health as a community issue. She points out that community support contributes to an individual’s capacity to recover from mental illness, and that “community dynamics directly influence mental health outcomes.”
As a non-binary lesbian, Armie has experienced firsthand the power of community support: “[The LGBT community] has been nothing but welcoming to me. It’s been such a stark difference having that acceptance; it has improved my mental health so much.”
In an effort to pay it forward, they’ve co-founded My Happy Pill—a mental health support group that grew out of a Reddit thread—as well as an LGBTQI-only support group. Part of their motivation was realising that there’s currently “no guide” for those dealing with mental illness, and little information on where to turn to for support.
From organising the LGBTQI support group, Armie has seen how having an LGBTQI-only space provides comfort, safety, and understanding for individuals who have been struggling with the double stigma of being LGBTQI and mentally ill. Some participants even accompany each other to the clinic or hospital, which makes the trips less daunting.
In the context of pervasive stigma and discrimination, Thilaga emphasises that mental health providers have the potential of being a source of “life-saving support for LGBTIQ persons so they do not suffer from violence and isolation.”
However, “it is really challenging to find mental health providers who are LGBTIQ-affirming, [and who] respect and understand that LGBTIQ persons’ identities are part of human diversity [and not a medical condition].”
Beyond “mental illness”: promoting national wellbeing
Conversations around mental health have also revolved around the need to improve biomedical interventions and healthcare capacity in Malaysia, such as by addressing the severe shortage of psychiatrists. Others have also pointed to the need to address structural stigma, such as by decriminalising suicide or including mental health in insurance coverage, which could provide much-needed support—or at least not make things worse—in a crisis.
At the same time, mental health initiatives should also include strategies that prevent such crises in the first place.
“I would like to see the Ministry of Health take the lead but also mainstream the criticality of mental health across the government,” says Sumitra. “It’s relevant to the Ministry of Human Resources, to the Ministry of Women, to the Ministry of Treasury and Finance, to the Ministry of Education, to the Ministry of Rural Development, and so on.”
She adds that it’s crucial to normalise concepts of mental well-being among public servants themselves, so that the government can take the lead in demonstrating that mental health isn’t just the realm of people who are “different” or “crazy”.
Mental health initiatives should also include strategies that prevent such crises in the first place.
Reaffirming this, Chan Wen Li, an assistant professor at a private university in Malaysia, notes that suicide prevention must go beyond “conventional medical treatment of mental disorders.” Instead, there needs to be collaboration between policymakers and other stakeholders to create the “best possible conditions for the development of individuals’ mental health and well-being from a young age.”
Several ministries have taken steps to tackle mental health issues, though these might be seen as focused on crisis intervention, rather than prevention. As an initiative by the Malaysian Communications and Multimedia Commission (MCMC), calls to the Befrienders—a 24/7 helpline for the distressed or suicidal—have been free of charge since the beginning of August. The Ministry of Women, Family, and Community Development also has a provision for 24/7 crisis support with their Talian Kasih 15999 hotline. In April, Deputy Minister of Education Teo Nie Ching announced plans to increase the number of counsellors in schools.
Though the forthcoming 2020 national census promises to be more inclusive and sensitive to determinants of well-being, it’s unclear how mental health will actually factor into national priorities. In the recently announced Budget 2020, significant allocations were made for social welfare. But while spending on healthcare has been increased from RM28.7 billion in 2019 to RM30.6 billion the following year, mental healthcare was not specifically mentioned.
While anti-stigma campaigns have an important place in mental health discourse, a catch-all call to “reach out” cannot replace efforts to address what makes the world an inherently hostile, stressful place to live in for many.