Introduction

In the last two decades, there have been several changes to how mental health is approached from a population and clinical perspective. The World Health Organisation defined mental health as “a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (WHO, 2005). This approach has motivated researchers, policymakers, and clinicians to view mental health as a foundation for well-being and optimal functioning of an individual despite having a mental illness or disorder. Salutogenesis, the study of the origins of health, relates to creating, enhancing, and improving health prospectively in order to yield optimal well-being for individuals and society (Antonovsky, 1996). Its foundation lies in focusing on individuals’ resources, understanding their approach toward their problems, and using these resources for betterment (Lindström & Eriksson, 2005). On the other hand, pathogenesis adopts a model of care that emphasizes the origins of disease and retrospectively treating, managing, or avoiding health problems (Antonovsky, 1996). Becker et al. (2010) highlight the importance of enhancing “salutogenic thinking, research, and practices” while acknowledging the equal and complementary role of the two approaches to improving health and well-being.

Elaborating on these co-occurring processes of mental health and illness, a two-continua model of mental health was proposed by Westerhof and Keyes (2010) to show that the absence of mental illness does not equate to presence of mental health and vice versa. Such beneficial mental health resources have since been conceptualised from multiple perspectives, together contributing to the literature on positive mental health (PMH) and well-being. One of the earliest definitions of PMH was proposed by Jahoda (1959) who defined it as the ability of individuals to have: (i) Positive attitudes towards themselves that relate to their self-esteem and positivity; (ii) Self-actualisation and potential to be their best self; (iii) Resistance to stress, seen through how they manage stressful situations; (iv) Personal autonomy relating to their feelings of independence and capacity for self-reliance; (v) Accurate perception of reality that relates to how they view the world around them; and (vi) Adapting to and mastering the environment where they are able to adjust to new situations. Closely related to this positive approach to mental health are other mental health and well-being models, including the self-determination theory that provides a framework for human motivation and personality based on three basic psychological needs of autonomy, competence, and relatedness (Ryan & Deci, 2000), subjective well-being relating to feelings of happiness and life satisfaction (Diener, 1984), psychological well-being represented by six concepts such as self-acceptance and purpose in life (Ryff & Keyes, 1995) and the Positive emotion, Engagement, Relations, Meaning and Achievement (PERMA) model based in positive psychology (Seligman, 2011).

Besides these widely used theories, researchers have also established other frameworks to describe PMH from a public health perspective (Vaingankar et al., 2012) or from a recovery-oriented perspective (Leamy et al., 2011). A previous qualitative study in Singapore obtained perspectives of adults in the general population and found that according to them PMH meant having sound personal growth and autonomy, positive relationships, spiritual beliefs and practices, coping strategies, and interpersonal skills (Vaingankar et al., 2012). These domains of mental health identified in Singapore were found to be associated with better life satisfaction and general functioning in persons with affective disorders (Seow et al., 2016). Using the different theories of mental well-being, a recent review attempted to provide a hierarchical description of PMH and found that PMH can be attained at six levels – physiological (predominance of neurochemicals related to positive emotions), emotional (positive emotions), cognitive (satisfaction in life domains), meta-cognitive (positive evaluation of individual’s life compared to others’/standards), developmental (positive psychological states, for example, autonomy, personal growth, etc.), and social-ecological (having social resources) (Sirgy, 2019). Given the multiple approaches to defining PMH, there is currently no scientific and clinical consensus on what constitutes PMH and mental well-being. However, empirical evidence reviewed over the last 40 years has yielded strong support for improving mental well-being in order to improve health outcomes in clinical and non-clinical populations (van Agteren et al., 2021).

The benefits derived from integrating PMH approaches into other clinical practices, including psychotherapy are also well-documented in the literature. For example, the emphasis on PMH is reflected through the development of novel and emerging psychotherapeutic interventions such as Well-being Therapy (Fava & Ruini, 2003), Salutogenic Talk Therapy (Langeland & Vinje, 2013) and Positive Psychotherapy (Seligman et al., 2006). Integrative and eclectic psychotherapy combining multiple clinical practice interventions has resulted in adopting salutogenic approaches such as mindfulness into traditional psychotherapies (Castonguay et al., 2015). In a study that explored clients’ experiences of receiving positive cognitive behavioural therapy (CBT) compared to traditional CBT for major depressive disorder, it was found that although clients on positive CBT were initially skeptical about trying it, they eventually learned techniques faster and experienced better stimulation and motivation (Geschwind et al., 2020). Another study exploring the experiences of adult survivors of brain injury on a pilot trial of brief positive psychotherapy (PPT) for post-traumatic growth compared to treatment as usual, found that only participants on PPT perceived lifestyle improvements as new possibilities that can enhance their rehabilitation (Karagiorgou et al., 2018). Recent research also suggests that although therapies may not immediately reduce depression or anxiety symptoms, they can increase PMH aspects such as a sense of coherence and personal growth thereby assisting in individuals’ overall recovery (Trompetter et al., 2017; Fulcheri & Carrozzino, 2017). Additionally, mindfulness-based and multi-component positive psychology interventions were found to significantly improve the mental health of clinical and non-clinical samples (van Agteren et al., 2021). This growing body of research thus highlights the need to target and evaluate both, psychopathology and PMH in therapy.

However, as individuals vary widely in their acceptance of and responses to specific treatments, delivering personalised medicine that matches clients’ preferences is vitally important (Cuijpers et al., 2012). To improve PMH and psychological well-being through psychotherapy, practitioners should understand how people with serious mental conditions regard mental well-being as their health outcome. A limitation in adopting PMH approaches in clinical practice is that several frameworks of PMH such as psychological and subjective well-being were predominantly developed in general population samples. It is believed that the needs of people in therapy are more diverse than other patients (Flanagan, 2010) and therefore, they may require more targeted therapeutic approaches to address their PMH needs. For example, CBT interventions target maladaptive thinking patterns, emotional regulation, goal setting, and cognitive reappraisal; ACT interventions focus on creating hope, commitment to change, acceptance over control, and cognitive diffusion and PPI interventions focus on strengths, gratitude, and pleasurable experiences which have been incorporated in clinical interventions (van Agteren et al., 2021). In their systematic review, van Agteren et al. (2021) found that while well-being interventions were more effective in people with severe symptoms, there was a complex relationship between mental distress and well-being that should be explored through understanding the “utility of using common therapies” in the context of different cultures and populations.

One way to explore clinical populations’ understanding, needs, and preferences for mental health is by employing qualitative methods, which are increasingly perceived as valuable in developing health interventions (Stein & Mankowski, 2004). Recognizing the perspectives of clients through our research upholds the principles of the Partners for Change Outcome Management System that recommends obtaining feedback in order to “prioritize what matters to psychotherapy outcome” and “change the conversation from a medical model dominated discourse to a more scientific, relational perspective” (Duncan & Reese, 2015). Flanagan (2010) also highlights the importance of orienting therapy sessions to clients’ needs to increase their effectiveness. In a qualitative study among older adults receiving group art therapy, the recipients said it helped them explore their emotions, thoughts, and memories safely and form social connections with other recipients (Bennington et al., 2016). Similar feedback was received in a survey in The Netherlands where patients with personality disorders who were offered art therapy while on the waitlist for specialist outpatient treatment identified five broad domains of mental health as relevant - symptoms, flexibility, well-being, mindfulness, and adaptive traits such as evaluating, problem-solving and working (Haeyen et al., 2018). Likewise, a study among patients with psychosis in Norway who received music therapy identified four themes relevant to them - freedom, social contact, mental well-being, and symptom reduction (Solli & Rolvsjordb, 2015). Previous research highlights the relevance of symptoms reduction and social dimensions for the mental well-being of therapy recipients and underscores the importance of obtaining the perspectives from newer clients on therapy to meet their therapeutic needs.

Singapore is a multi-ethnic developed economy in the Asia-Pacific region. A review describing mental health services in Singapore found that, in Singapore, while three main therapies are commonly practiced (psychodynamic, cognitive-behavioral, and supportive), other models including interpersonal psychotherapy, solution-focused therapy, gestalt therapy, and narrative therapy, are also used (Kua & Rathi, 2019). The authors caution that since illness behaviour and health-seeking patterns in people with mental illness are often determined by cultural and religious beliefs, “it is important to know what type of therapy fits what type of clients–what works best for them”. However, research in psychotherapy is sparse in Singapore. There are very few studies on the effectiveness of PMH or well-being interventions in Singapore. One of the studies among mental health professionals found that while therapists in Singapore have largely adopted Western therapeutic approaches, they tend to add other elements such as the use of traditional medicine or recommending specific diet to meet the cultural needs of the local population (Foo et al., 2006). To the best of our knowledge, previous research fails to provide insight into patients’ perspectives on PMH approaches to therapy that can enable clinicians to identify and personalize appropriate psychotherapeutic interventions for their clients. Given the advantages of offering therapies that are effective, expansive, and patient-centred, there is a clear need to address this knowledge gap around clients’ perspectives on PMH in Singapore. Using a qualitative design, this study aimed to understand what PMH means to psychotherapy clients in Singapore and how psychotherapy could help them to achieve it.

Methods

The study is reported as recommended by the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).

Epistemological approach

This qualitative study used an interpretative approach as it sought to gain an in-depth understanding of reality constructed from participants’ narratives on PMH while seeking psychotherapy at a psychiatric hospital in Singapore. Semi-structured interviews (SIs) were used to obtain inputs from the clients as they allowed delving deeper into personal experiences and provided privacy and confidentiality to the participants (Yeo et al., 2013).

Setting

The study was conducted at a tertiary psychiatric hospital in Singapore. Singapore is a developed economy with a multi-ethnic population of 5.6 million with a majority belonging to Chinese (74.3%) ethnicity, followed by Malay (13.4%), Indian (9%), and other ethnic groups (3.2%). The study site is the sole tertiary psychiatric care centre in Singapore catering to the largest number of people with serious mental conditions in the country.

Ethical process

Ethical approval was obtained from the relevant Institutional Review Board and written informed consent was obtained from all the participants prior to data collection.

Participants and sampling

Participants were adult Singapore residents (citizens or permanent residents) aged over 21 years who were undergoing psychotherapy for at least six months at the psychiatric hospital. Convenience sampling was employed to recruit individuals who had attended at least two psychotherapy sessions in the past year, who were aged 21 years and above, and capable of providing consent to the study. Psychotherapists employed at the study site were informed of the ongoing study and its procedures and then referred potential participants to the research team. All participants who were approached agreed to participate in the study. Fifteen SIs were conducted once with each participant between January to December 2019 at the hospital or other locations preferred by them, such as cafes or workplaces. The average age of the participants was 33.8 years, ranging from 22 to 55 (Table 1). The majority (n = 12) had depressive and/or anxiety disorders, which is the largest diagnostic group presenting for treatment at the study site. Participants’ experience of psychotherapy ranged from 6 months to 11 years. The participants reported receiving a range of therapies, including cognitive behavioral, schema, acceptance and commitment, psychodynamic, and exposure and response prevention therapy. However, some participants also received eclectic forms of therapy and mindfulness. In the past year before their interviews, participants had received 2–48 therapy sessions; half of them had received at least eight sessions.

Table 1 Profile of study participants
Full size table

Interview procedures

An open-ended interview guide was designed to address key research questions while providing flexibility to allow participants to share new information. The guide was tested among two acquaintances with lived experience of psychological problems and who were not part of the study team. Minor modifications were made to improve the clarity of the prompts. One-to-one SIs were conducted by two female researchers with backgrounds in epidemiology and psychology, and experience in qualitative research. The interviewers first asked general introductory questions to obtain their personal background and encourage participant engagement. Interview questions focused on obtaining examples of people who according to the participants had good/positive mental health, aspects of PMH that are relevant to them, and what they do / how they plan to achieve these. Further prompts were used to better understand each PMH component mentioned during the interviews. The interview guide and relevant prompts are presented in Table 2. The same questions were asked of all participants. Interviews were continued until thematic saturation was achieved which was determined as the point where no new themes emerged from the data (Saunders et al., 2018). For assessing saturation, coding was concurrently performed along with data collection to identify potential themes reflected in the data. The codes and themes were then examined across the different interviews and in the wider context of the original transcripts by three researchers (JAV, SC and ES). Discussions were regularly conducted to understand the collected data and provide evidence of thematic saturation.

Table 2 Interview guide
Full size table

Participants were given adequate time to share their experiences. The SIs lasted for an average of 38 min (29 to 96 min). Interviews were audio-recorded and transcribed verbatim by a researcher while another team member checked them for accuracy.

The research team comprised five health service researchers, two psychiatrists, and two clinical psychologists. Two researchers had extensive prior experience in conducting qualitative research and domain knowledge on mental well-being. Thus, the team had the necessary skills to understand the experiences discussed that enabled effective probing and analysis. Six researchers and nine of the participants were women. The interviewers and coders did not know any of the participants. Thus, prompts and coding were unlikely to be influenced by their mutual experiences. However, the participants were aware that the research team, including the clinical psychologists, were employees at the hospital where they were seeking treatment, and therefore may not have mentioned certain sensitive experiences.

Study team and reflexivity

All authors contributed to the study’s design and provided inputs on the study results and inferences. Seven team members designed the interview guide, which included three psychotherapists (HA, SL, and GT) and four researchers (JAV, RS, SC, ES) with backgrounds in epidemiology, public health, and psychology who also performed coding and analysis. All interviews were conducted by two female researchers (JAV and SC) with experience in conducting qualitative studies. Their backgrounds are in epidemiology and psychology, respectively. The interviewers did not know the participants before the interviews. Interviews were conducted in locations such as cafes, workplaces or public places as per participants’ preferences, ensuring an informal setting for the dialogue. While in public places, interviewers selected a relatively quiet and private corner to conduct the interview. High-quality audio recorders with noise-cancelling features were used to keep the volume of the conversation at a low level and assure the participants of confidentiality. The interviewers were researchers and did not have any clinical experience or role. Nevertheless, they were employed with the mental health institute where the participants were receiving therapy. The participants were also referred by their therapists, who were part of the study team. The therapists were not involved in the coding process and therefore had no direct influence on the coding process or assessment of thematic saturation, thus minimizing insider knowledge bias. However, the thematic analysis results were shared with them periodically to gain a deeper understanding of the experiences of therapy clients (without identifying any participants) and to obtain directions for further data collection, improve probing, and reduce misinterpretations while coding. While the participants were assured that the qualitative data could not be linked to their personal information, some might have modified their views towards more socially desirable responses. Additionally, given that all the participants were in different stages of therapy during their participation, thus, actively experiencing some problems at the time of the interviews, their perspectives could have been influenced by their needs at that point. For example, the theme of euthymia could be reflective of their current needs. The interviewers were, however, well-trained to handle such biases through broad probes that ensured that the participants also talked about achieving PMH via therapy in a general sense. These measures improve trustworthiness in the study results.

Data analysis

Thematic analysis was undertaken for this study (Braun & Clarke, 2006). NVivo 11 was used to code and organize the data. Researchers familiarized themselves by contributing to the interview guide development, transcribing their own interviews, and/or reading through all transcripts. Participants’ statements, ideas, or keywords frequently appearing across the SIs were inductively grouped together to form short codes based on similarity. New codes emerging from earlier interviews were used in reviewing later transcripts. As data collection and initial coding were team-based, simplified definitions were developed for codes using group consensus prior to coding (MacQueen et al., 1998). A bottom-up, primarily inductive approach was adopted by one researcher to identify broad themes, which were then discussed with other coders. The content was assessed for deviant cases during the study to allow modifications to the emerging themes (Pope et al., 2000), however, none was identified. Inductive thematic saturation and adequacy were determined by the repetition of the content and codes, and the non-emergence of new information (Saunders et al., 2018). After the thirteenth interview, no new themes or codes were generated from the interviews. However, two more interviews were conducted to confirm that themes were not missed. Member checking was not performed as transcripts were anonymized and de-identified to safeguard participants’ confidentiality.

Results

Six main themes on the meaning of positive mental health emerged from the data – acceptance, positivity, resilience, purpose in life, social cognition, and euthymia. We describe these themes in greater detail in this section while highlighting participants’ narratives on the areas where and how psychotherapy helped them achieve the respective PMH domains.

Theme 1: Acceptance

For our participants, having PMH meant being able to accept their circumstances, emotions, and condition. Accepting their condition also meant keeping a positive attitude toward their mental health condition and not comparing their situations with others. This was of particular importance in the era of social media for one participant. She said,

Nowadays, social media is such a stressful thing. Everybody wants to be happy on social media. When it’s something sad, you don’t see it. So it’s like a, oh the person is so happy because they post all the happy pictures so you start to compare. So that can be stressful as well…. So when you see like they are so happy all the time, you actually question (yourself)….(but) you have to understand life is not always on a good page, it’s always up and down. – P15.

In the same vein, another participant shared the importance of accepting her emotions.

Positive mental health- I think it’s more like, uh a person is willing to accept she can be happy, upset like, she can feel a whole range of emotion and that is okay. Like she accepts whatever that comes her way – P04.

One participant also equated PMH with accepting whatever comes their way and moving forward in their life as described below in their words.

People who are able to like accept the situation and then move on, who are able to like take things in their stride and then just say “yeah, let’s think of how to get over this and take some action and move on.” – P03.

Two participants narrated how psychoeducation received as part of their therapy helped them understand their condition better and identify the issues they were facing. Gaining a deeper understanding of themselves and knowing that what happened or is happening is not their fault, helped them accept who they are and their circumstances.

Psychotherapy helps someone to understand themselves…like not just the good but also the bad like understand why are they like this in certain situations or times? What they can do about it? And also like how they can accept themselves for it and all. I think through understanding and acceptance, the person can be more positive about it. -P04.

When you (are) feeling blue, and it occurs to you, you may not know why, the root cause of it. It may confuse you so being able to learn it yourself means it’s like learning (about) your condition, understanding yourself, know that it’s not your fault. – P11.

Specifically, two participants mentioned they benefitted through acceptance and commitment therapy (ACT). One of them said,

ACT is acceptance and commitment, right? It helped me to accept certain things like my parents’ are dead, they are not coming back, my situation is like this now…. Then ACT will tell you to accept who you are, you don’t have to be rich or don’t have to be handsome, so you will feel better – P14.

In addition, as a result of being mindfully aware of their emotions without judging them, participants shared how they could finally accept their emotions and do things they wanted to do to move forward. Two participants who practiced mindfulness narrated how it helped them understand and accept their emotions,

Mindfulness is useful for like accepting your feelings because sometimes when you feel a certain way, you just wish that you did not feel that way but the fact is that the feeling is there already and you cannot change it or you cannot make it go away. So, by practising mindfulness, it’s actually a coping strategy to identify how you are feeling and to just accept that it is there – P07.

I feel that mindfulness has contributed in ways that hmm helps me to yeah to take note of the negative thoughts as it comes by, then to do know that it can go off by itself, it wouldn’t stay inside the brain for a long time, yeah, something like that.– P02.

Theme 2: Positivity

According to the study participants, a person with PMH would be able to think positively, possess a positive outlook and use good thoughts to help themselves.

I think person with good positive mental health would be a person who is able to think positively in the face of setbacks in their lives. They, for example, … they know how to like change their negative thoughts you know, they know how to think positively, they know how to avoid all the pitfalls of bad mental health issues… a person who knows how to encourage himself you know …to think good thoughts– P13.

Positive mental health… It can (be) reflected by yourself…having a positive outlook at your own condition and trying to find the better things in life.– P11.

However, one participant also highlighted the relevance of maintaining a pragmatic outlook despite being positive.

I think that it’s always good to maintain a positive outlook in life but also at the same time balance that with a sense of uh pragmatism and a sense of knowing that “ok, I would like to approach these from a positive I guess mindset/mentality. I want the best possible outcome of it.” But at the same time, to also have that measure of groundedness also…knowing that this may not go well; I have to prepare for that kind of eventuality as well. – P05.

Therapy helped with positivity by providing participants with hope and optimism and breaking the chain of negative thinking, as described by two participants.

Sometimes the therapist will show you your blind spots like where you’ve been, where you’ve, like sometimes if you keep thinking a certain persistent negative train of thought, the psychotherapist being an external third person, they can actually see you’re having this negative train of thought. They’re a mirror to show you where you are thinking in a very narrow way. So, they give you different points of view to consider. So, when you have different points of views, then you realize that actually, it’s not as dead-end a situation as you think it is – P07.

I think is like once you seek proper help, their outlook will change… ah…so outlook change it also make a difference in a small way. But every, is baby steps need to be taken -…Some people take about 10 sessions to recover, some people take longer than that. These are like, the method is for them psychotherapy is to help them hmm improve themselves and have a positive outlook on themselves also. – P11.

While most of the participants expressed having persistent negative thoughts during therapy – specifically cognitive behavioural therapy (CBT) in the case of four participants, they were able to identify their negative thoughts personally, stop negative thinking patterns and analyze their thoughts better. One of them said,

CBT helps me to identify my own personal negative thoughts. Then after identifying those negative thoughts, I can use like more positive thoughts to… I can discover more positive thoughts to overlap the negative thoughts and to stop them from keep on coming into my head – P02.

Theme 3: Resilience

According to the participants, persons with PMH are able to bounce back and cope with their problems and emotions quickly, calmly, and in a healthy way. Mental strength, resilience, and the desire to bounce back were deemed relevant while facing adversity.

Positive mental health would seem to be like (when) there will be periods of sadness or there will be periods of happiness, but the person can just bounce back to normal. It’s not like a prolonged state of sadness. I mean there are always ups and downs in life but for me, positive mental health would mean being able to bounce back from down, yeah, and rather quickly in a sense. – P03.

I guess if one does not have resilience, then I guess they would not want to work through or find answers for themselves, whether it’s an answer they would accept or not, that sounds good or not, but having an answer would give you a direction that you can work to(wards). And I think if a person does not have resilience, it’s very hard for them to seek help in the first place. You would need to have a desire to not get stuck in your rut, right. – P12.

Two participants explained how psychotherapy helped them bounce back by equipping them with confidence and building resilience and healthy coping skills in them.

The therapist can maybe help the person to build up confidence like maybe build up confidence in speaking with others, or build up confidence build up his resilience level, like his resilience level against obstacles in life and how to face negative challenges as they come – P02.

When stressful situations come, some of the methods which I learn, I try to put it in play. So whether it works or not, some way it works, some of it, it work but it take a longer duration because it is something new. So for me is a slow building process….Psychotherapy…(helps) find a particular method for coping because each individual is different. Some people take about 10 sessions to recover, some people take longer than that. The method is for them to. help them face adversities and improve themselves. – P11.

Theme 4: Purpose in life

Participants often mentioned a need to be occupied, have goals, and find meaning and purpose in life. Character traits such as being confident, having self-esteem, and being able to motivate themselves to meet their goals and life plans were also briefly mentioned while describing a person with PMH.

(By having goals) you don’t feel so useless. When you have nothing to do at home, it’s easy to get more and more depressed. And then when you go out to work you also get to meet people. Even though your colleagues may not necessarily be your friends, just the fact that there are people to meet, it makes things not so lonely. –P07.

I really think it’s like keeping occupied, doing things that we are interested in. I found it a struggle at home because like it was like really just housework, children. Yeah but like most recently I’ve started picking up my old hobby. And then I guess the sense of, I think it’s like a sense of achievement, the satisfaction that yeah, that feeling that hey, I can still, I can still do something like maybe something not useful, but something that makes me happy, yeah. –P03.

They also shared their own personal plans and how they engaged in meaningful activities to get a sense of achievement and enjoyment.

Actually, I’ve been going for Zumba, K-Pop to you know to exercise. Because I love dancing since young and exercising also help you know. – P05.

Therapy seemed to be particularly useful in improving their goal setting, which might have encouraged them to derive confidence, self-esteem, and meaning in life.

I write my goals on a piece of paper. When I had no goals and nothing to do, it’s like life is nothing much ah. But when I set goals and stuff and everything, it’s like oh yeah I got something to do. Something to work towards. – P08.

One participant shared how his therapist encouraged him to consider engaging in some activities.

I would say she would ask me to keep myself occupied. For example, when I was unemployed, she actually recommended me this so that I could get some money out of it (laughs) also and I have something to do and also to start searching for jobs. But she did recommend jobs that are not so intensive, basically jobs that are more relaxed even though the pay is not high she just recommended me to do something. – P10.

Highlighting the impact of Exposure and Response Prevention (ERP) on her confidence and imparting a sense of being useful, another participant mentioned,

Exposure Prevention that one, they can help me to face my biggest fear in my current state of life. Then after facing those biggest fears, they help me to become a more er… more useful person. Then hmm… after being a more useful person, the ERP also helps me to build up confidence and become a much more confident person, then a much more cheerful person, and a much more hmm… useful person – P02.

Theme 5: Social participation

Having social connections and an awareness of other people’s thoughts and feelings came across as important aspects of PMH for psychotherapy clients. Being open to sharing their problems and seeking help from others required placing trust in the relationships. Participants expressed the relevance of support from people who genuinely cared about their well-being in their recovery and encouraged them when they were down.

I think having good relationship is important. Interpersonal relationship is one thing very useful. I really have experience and I helped a lot of people. Being able to relate (to) one another is very important. It helps you to feel less alone and for depression … having that means not being socially isolated does help for a good mental health. Like I say any human being, ill or not, you should have some good friends or relationships with some friends, boyfriends, husband whatever. I think that is very important for mental health – P14.

When you feel that you haven’t done anything good or achieved anything good then your friends can be there to give you a more objective view of things or like if you are going through a tough time then they just encourage you to go on. So that is something that is very valuable and important. – P07.

Sharing problems also… With friends, friends that understand…, I mean it’s like they understand where you’re coming from. – P08.

Being non-judgemental towards others, being willing to provide help and being considerate to others formed part of the social cognitive process according to the participants.

Once you stabilize yourself, you feel like helping everybody. You can go for the peer support specialist or for ambassador (training), go for proper skillset training and then you can help others also… You also can project positive mental health on yourself and for others so they will not be felt ostracized or by assumptions by the public– P10.

Having PMH also meant contributing to the society, for example, by helping and motivating others or through volunteering or gainful employment, which deepened their sense of awareness and belonging.

Other people’s perceptions would be that they need love, they need support and they need attention but mostly they need, what is that called, care. But real kind of care, not those people who cut them halfway…I feel that for a person to have positive mental health, one needs to have like certain kind of placement in society. He needs to have a position (where) he feels that he or she can contribute to society, then he feels that he can like maybe work or study. Work in a job that he feels he can still contribute to society or study in some courses. – P09.

One participant shared how she and some of her friends felt the need to talk to somebody and share their feelings, yet they were at times unable to open up to their friends and family out of fear of being judged. Due to this need for trusting relationships, they perceived their therapist as a strong support figure. For them, their therapist was someone with whom they could talk about their problems without depending on their social circle. Having someone who could listen to them and the fact that this person was trained and could see their thought patterns, assured the clients of their support.

Therapy, I guess everybody just needs somebody to talk to. But there is a… but there are just, and you cannot just depend on your social circle. And I find that therapy allows me to say things easily that I cannot say to my friends and family for fear of being, of their excessive concern or maybe their judgement – P12.

The participant elaborated further by sharing how therapy had helped her in other ways to relate to other people.

I think learning to recognize that people are not always, people do not have values, they might have very different values that may or may not be better, if there is even a spectrum. But yeah, to be very aware of other people, and that’s how psychotherapy helped me, to be able to relate that to other people, and like “oh, so other people can do this kind of things”, I did not think that that was possible (be)cause I did not see past my own lenses– P12.

According to another participant, her therapist helped in validating the positives in her life, reminded her of her achievements, and made her feel useful.

When I speak with my therapist, they sort of ask me questions to make me remember the things that I have done before, that I have achieved so that I can realize on my own that actually, I’m not as useless as I thought I was so that, in a way that contributes to my self-esteem. They try to reaffirm my worth even if I don’t see it. – P07.

Participants also briefly expressed how personal or family therapy can help them with relationship management and managing the expectations of others, be it in a work environment or their personal relationships.

I think it helps you to manage expectations on relationships. I don’t know how to manage the relationship .It helps you to manage expectations, manage your relationships, somehow it is good. Because… how do I say this ..hmm.. sometimes some people are not mentally ill in that sense but you don’t know how to function in the society. You don’t know how to make friends. I’m a new colleague here, I sit down there, I expect you to talk to me … so you walked in first day everybody must treat you like king? That’s unrealistic expectation. It’s thought process. So I think psychotherapy, sometimes… help to deal with certain things. There are working people who actually come for psychotherapy … They need help to deal with certain things, maybe interpersonal. How they see themselves, how like maybe colleagues don’t like me, that kind of thing. So, it helps. – P14.

I do think that it(therapy) can help with like the relationships (of) the person like familywise or …not just I think personal psychotherapy, but I think psychotherapy comes in other forms like I think family. They can sit down to have a chat and all. . mainly family – P04.

Theme 6: Euthymia

As expected, for our participants PMH was being free of their troubling mood symptoms and having a stable mental state. Being able to feel less sad, depressed, or anxious was expressed by almost all participants as a sign of having PMH.

I myself don’t know what I’m going through. Positively? You know, everybody goes through mental health, whether they seek help a not. hmm. depression can be on a very different level, probably mine is just very high that I cannot control my depression… Really there’s no positive, there’s just really everything is just negative about mental health. I mean, you don’t want to have that. Positively its like- for me it’s whether you can control yourself or not. – P6.

I think positive mental health is simply being able to function without having a spectre of anxiety that looms over you.– P15.

Having the capacity to manage their symptoms better or avoid relapse was of relevance to most of them. For the participants, managing their emotions to achieve PMH also meant having control over their behaviors such as not letting their emotions affect how they behave in certain situations, not being uptight about things, and not isolating themselves. From the perspective of one participant, having PMH meant,

Probably being able to endure a lot of things like from work and maybe from life in general, not have suicidal thoughts and maybe not have panic attacks, just being to function as a normal human being under stress– P10.

I feel that a person with positive mental health is happier, he feels much more cheerful, then less sad, and less depressed … he feels fewer negative thoughts, then he feels that he is more useful, and more worthy of living in society… Then he feels that he can manage his symptoms better. – P02.

Participants narrated some skills they had learned through therapy that helped them manage their moods and emotions. CBT was mentioned by some participants as being effective for them in terms of learning these skills. Therapy also helped them recognize their trigger points and learn attentional retraining and relaxation techniques that helped them modulate their reactions.

Therapy helped me because that teaches me how I should react or how I should behave under the most annoying of circumstances you know. So, I thought that was good. – P13.

Likewise, another participant felt that ERP helped him control symptoms of OCD better and become more positive.

ERP it helps me. I have OCD, then my biggest fears is like falling sick from some illness, or fear of losing my personal belongings … ERP helps me to become more positive person. – P04.

Explaining the contribution of their therapists in helping them achieve PMH, two participants mentioned,

The art therapist helped me to express certain pains or depression or suicidal thought or happiness. They just helped me, what they called it ah, regulate your emotion, which I think makes me feel better than (when) everything’s bottled up and builds up and makes me more… worse –P14.

I feel like my therapist, she actually does a really good job trying to break down the panic attacks and suicidal thoughts in like a more digestible format. So she actually knows how to separate different entities and make me understand it better so I feel that that’s the way I can understand it –P10.

Discussion

This qualitative study aimed to understand psychotherapy clients’ perspectives on the meaning of PMH and ways in which psychotherapy helps achieve it. The study found that persons receiving psychotherapy in Singapore perceived six PMH areas as relevant to them. These were - acceptance of their circumstances and themselves, having positivity, resilience to stress and coping, having a purpose in life, ability for social participation, and euthymia or managing their symptoms well. The PMH domains identified have overlaps with elements within psychological well-being (Ryff & Keyes, 1995), subjective well-being (Diener, 1984) and positive psychology (Seligman et al., 2006) frameworks. For example, self-acceptance, positive relationships with others, and the sense of purpose and meaning in life form key psychological well-being domains, while positive emotion and positive outlook are factored within subjective well-being and positive psychology interventions. Thus,practitioners can consider these PMH models while designing a therapeutic plan for their patients.

In a previous review of qualitative studies exploring psychotherapy clients’ experiences of psychotherapy, four therapeutic areas were identified relating to clients’ insight into their condition, reassurance and relief sought through the relationship with their therapists and knowing what their problem was, problem-solving skills and encouragement (Hodgetts & Wright, 2007). Although these were summarised from the perspective of general experiences of therapy instead of PMH aspects of therapy, there were some similarities with the results obtained in this study. In particular, the benefits derived from having an encouraging and positive relationship with their therapist were evident from the results of the review (Hodgetts & Wright, 2007) and in the narratives of the participants in this study. The results indicate the importance of therapeutic alliance as a cornerstone of the therapeutic relationship, which places relevance on “empathy, congruence, and unconditional positive regard” for the clients’ experiences (Ardito & Rabellino, 2011). This finding is also supported in literature where the therapeutic alliance was associated with well-being, life satisfaction, and flourishing (i.e. functioning well) (Prusiński, 2022). Thus, future PMH approaches to therapy should uphold this foundation and adapt it to meet patients’ needs.

Besides expressing the need to reach the desired functioning in these domains, our study participants also equated PMH with euthymia that was expressed as not feeling depressed or anxious and being free of their troubling symptoms. Similar results were observed in qualitative studies in art therapy recipients with recipients having an emphasis on managing their symptoms well (Bennington et al., 2016; Solli & Rolvsjordb, 2015). It is also shown that being free of unpleasant thoughts is linked to greater emotional stability, thus leading to PMH (Lamers et al., 2012). The theme of euthymia has several links to the CHIME (connectedness; hope and optimism about the future; identity; meaning in life; and empowerment) model that describes five processes in mental health recovery (Leamy et al., 2011). By virtue of their purpose and definition, both relate to the management of distressing symptoms. However, while recovery is the process of getting well, PMH is considered as the resource that makes recovery possible (Browne et al., 2017; Iasiello et al., 2019). The concordance between CHIME and the PMH perspectives of therapy recipients seen in this study, signals advancing knowledge on these constructs and finding the key process involved in improving PMH and aiding recovery.

There is growing evidence on the effectiveness of PMH approaches to psychotherapy in improving mental health outcomes. A systematic review of PMH interventions in psychotherapy found that mindfulness-based interventions were more successful than other interventions such as CBT or ACT in improving symptoms management in recipients of psychological interventions (van Agteren et al., 2021). Such interventions often used meditation or mindfulness-based CBT, stress reduction, or self-compassion, in single or multiple sessions, and included techniques such as “diaphragmatic breathing, mind–body scan and mindful imagery”. Singular or multi-component positive psychology interventions were also found to be equally effective in the metanalysis and more so in patients with severe illness. Examples of interventions associated with improving PMH were positive psychology exercises, constructive response, counting blessings, and savouring (i.e., emotional regulation through mindful evaluation of life experiences) and techniques for optimism, character strengths, gratitude, and pleasurable experiences. In addition, reminiscence interventions that operate by reviewing past experiences and integrating life stories with the retrieval of specific positive memories can improve mental well-being in these individuals (Lamers et al., 2015). Thus, psychotherapists have a range of newer psychological interventions and techniques to address the PMH needs of their clients. This study results can thus, help start a conversation between the therapist and clients to identify appropriate methods in psychotherapy.

An important contribution of this study stems from the knowledge gained on the likely impact of psychotherapy on the components of PMH that were relevant to the recipients. As expected, therapy appeared to contribute to all the components of PMH. We could not specifically explore specific therapeutic approaches in greater detail as some clients had tried multiple therapies throughout their journey; they were receiving eclectic therapy or were unaware of the exact therapy they were receiving. However, few clients specifically mentioned how CBT contributed to improving positivity and euthymia, while ACT uniquely seemed to be effective in bringing about acceptance. Positive psychotherapy (Seligman et al., 2006) which aims to improve engagement, meaning, and positive emotion, works by identifying the strengths of clients and channeling their attention to positive aspects of their lives. This approach has similarities to CBT (Wiltsey Stirman et al., 2010). In addition, CBT also involves deeper discussions of problems and symptoms and helps in providing a more balanced view of a person’s negative experiences. Likewise, ACT encourages people to embrace their thoughts and feelings rather than fighting or feeling guilty about them (Stockton et al., 2019). These processes are mirrored in Well-being therapy (Fava & Ruini, 2003) which has its foundations in theories of psychological well-being, where self-acceptance forms one of the six pillars (Ryff & Keyes, 1995). These reports provide a context for understanding our participants’ experiences and help improve the trustworthiness of our study findings.

A strength of this study is that it highlights an understanding of PMH from the perspective of psychotherapy clients that could be used to design and offer PMH approaches supplement traditional therapy. These could also better explain clients’ preferences and behaviours toward managing their condition. This is one of the first qualitative studies that elicits accounts of psychotherapy clients in a developed Asian country and provides insight into the perspectives of individuals with different clinical and social backgrounds. This study among participants with serious mental conditions provides as yet unavailable and deeper understanding of their thought processes and presents avenues for drawing comparisons with the general population and other clinical samples in the future. A limitation of the study is the possibility of social desirability bias as participants might have presented their views in a more positive light given that referrals were sought from psychotherapists employed at the same organization as the interviewers. Secondly, the study participants were relatively young with the mean age being around 30. Some evidence suggests that both the opinions on mental well-being and psychotherapy preferences vary by age; more young adults are willing to opt for novel or integrative psychotherapies (Mohlman, 2012). We could not explore such diversity in our interviews as most of the clients referred to our study were younger, although we made adequate efforts to include interviewees with heterogeneous socio-demographic backgrounds. Additionally, the study included a relatively small number of participants based on the evidence of thematic saturation and non-emergence of new codes or themes. This approach to relying on the number of codes can result in a poorer interpretation of a phenomenon due to a lack of understanding of the meaning of these codes (Hennink et al., 2017). Future research should try to incorporate more diverse voices, a larger sample of participants including patients without therapy experiences, older clients, and those in the preliminary stages of therapy.

Implications of the study to clinical practice and research

The primary focus on prevention and treatment of mental distress alone over developing and testing PMH-enhancing interventions has been consistently raised as a challenge to investing in PMH approaches in clinical practice which largely targets symptom reduction and management. The study results indicate the need to incorporate techniques to further strengthen the positive dimensions of acceptance, positivity, resilience, purpose in life, and social participation in psychotherapy in order to meet patients’ needs. The in-depth understanding of the concept of PMH gained in this study can help incorporate appropriate PMH strategies in psychotherapy and mental healthcare. Our findings build upon previous research and demonstrate that there are nuances in the meaning of PMH across different populations, thus, providing an empirical basis for examining PMH in people undergoing therapy. For example, in a recent qualitative study conducted in Singapore, psychotherapists defined PMH as constituting acceptance, functioning, resilience, positive life evaluation, and positive emotions (Chang et al., 2022). While psychotherapists perceived ‘optimal’ functionality in various domains of life as a sign of PMH, this theme of functioning was less strongly reflected in the themes of social participation and purpose in life among the therapy recipients in this study. The current results indicate that approaches and communication on therapy goals relevant to functioning should consider their value and meaningfulness to the therapy recipients over aiming for ideal functioning. Both studies, however, suggest that the expected improvements to mental health are not limited to the management of psychopathology but should also include improvements to the psychosocial well-being of individuals. Our results also indicate that management and control of emotions are important outcomes for people in therapy which could serve as a potential pathway to PMH. Psychotherapists may want to consider the extent to which clients endorse PMH beliefs and what they hope to achieve for themselves while developing therapeutic goals. This study also contributes to the limited literature on the possible psychological domains that could be targeted through PMH-enhancing interventions and psychotherapy techniques and can enable planning further research on the effectiveness of such interventions in Singapore.

Further research is needed to understand the role of specific therapies on PMH in greater depth and investigate if certain therapies are more adaptable to integrating well-being approaches. Another area of research is to investigate the effectiveness of novel therapies such as positive psychology or well-being therapy to help practitioners and researchers determine their effectiveness and identify the mechanisms through which such therapies work and complement traditional approaches.

Conclusion

This study identified six key aspects of PMH that are relevant to psychotherapy recipients and offered target areas for PMH approaches in psychotherapy. The study also provided a broad overview of users’ understanding and experiences of how therapy can enable them to achieve PMH goals. By recognizing the unique perspectives of psychotherapy clients on PMH, integrative or complementary therapies can be designed to benefit people with mental health problems more effectively. Understanding recipients’ expectations from psychotherapy can also help in expanding therapeutic goals and techniques in clinical practice.