A total of 7 FGDs were conducted with 38 participants for the study. The participants’ age ranged between 27 and 63 years, were mostly females (84.2%), of Chinese ethnicity (81.6%), and the majority had obtained a post-graduate degree (94.7%; Table 2). All participants had received formal training in varied psychotherapy modalities including cognitive behavioral therapy, positive behavioral management, exposure and response prevention, eye movement desensitization and reprocessing, acceptance and commitment therapy, schema-focused therapy, emotion focused therapy, solution focused brief therapy, psychodynamic therapy, dialectical behavioral therapy, mindfulness-based therapy etc. For the majority of participants, their clientele comprised adults presenting with mental disorders including mood disorders and anxiety disorders. Others worked with children and adolescents with childhood disorders, elderly population with dementia, or individuals who needed life coaching.
Thematic analysis of the qualitative data identified five themes pertaining to psychotherapists’ definition of PMH: (1) acceptance; (2) normal functioning and thriving in life; (3) resilience; (4) positive overall evaluation of life; (5) absence of negative emotions and presence of positive emotion states. Their views on the concept of PMH could be examined from the following three themes: (1) novel and valuable for psychotherapy; (2) reservations with terminology; (3) factors influencing PMH. Figure 1a, b present the coding trees derived from the coding process with the subthemes and themes shown. The following section describes the themes in further details and salient quotes that underscore the essence of the theme are presented.
Definitions of positive mental health
This was a common theme discussed by participants from various FGDs. PMH was defined as having the ability to accept things that happened in life and acknowledging the outcomes that resulted. Acceptance was in relation to not just negative events, but also acceptance of ‘difficult emotions’ and where one is in life.
It’s about accepting where you are in life and… as well as… growing in that journey to acceptance and being at peace with that. – FGD 3
Same way like you were talking about ACT (Acceptance and Commitment Therapy) just now, it’s accepting it, even if they just accept what has happened to them, I think it’s already positive mental health. – FGD 7
In a related note, a participant described PMH as having contentment in life and described how acceptance of situation contributed to contentment.
Positive mental health to me is finding content, which is a bit like peace, whatever the circumstance… a lot of it is perception, how you see certain things, like certain circumstances that you might not be able to control. So I mean modifying or coming to terms with what I can accept and what I can change. I think that helps; gives me contentment and peace. – FGD 6
(2) Normal functioning and thriving in life
For the participants, having PMH was defined as being able to function normally. At the individual level, a functioning person was described as someone leading a balanced and healthy lifestyle, and able to manage stress and not be overwhelmed by it. The idea of optimal functioning pertained to various aspects in life including occupation, relationship with others, and being an active and contributing member of the society.
PMH is not about like the mental condition. It is about, you know, how we make these conditions and maybe other life issues not to interfere with our life. So it’s about living that life, you know, despite all the obstacles and difficulties. – FGD 3
Some participants moved beyond the notion of basic psychosocial functioning to describe PMH in terms of thriving which encompassed the idea of growth.
I wrote it (PMH) as the ability to thrive in very stressful environment [be]cause I think the way I see PMH is not just the absence of mental health issues but [it] is also the ability to kind of progress and really to be able to kind of expand on your own potential. – FGD 4
… they (clients) are kind of bootstrapped. They are self-corrective. They may come to you with a presenting problem, but if you just drop a few hints along the way, a bit of psycho-edu[cation] here, a bit of coaching there, they are able to extrapolate that to other problems independently on their own. So I think that’s also important. It’s not just where you are now, it’s whether you have the capacity to adapt and grow. – FGD 6
In defining PMH, the concept of resilience was frequently brought up by participants and it at times co-occurred alongside the theme on functioning. Yet this is a distinct theme from functioning in that rather than focusing on outcomes, it describes a trait or skillset that promotes wellbeing.
I would see it (PMH) as resilience, the ability to deal with challenges and the ability to function. – FGD 1
Okay for me positive mental health is being able to cope with the demands and challenges of life. So it’s a bit like mental resilience… sometimes you have negative emotions and being able to cope with that or cope with the demands. – FGD 2
Resilience was often described by participants as a trait that would help their clients to ‘bounce back’ from adversities, and also as a coping resource to support normal functioning in spite of challenges. One participant discussed how having emotional resilience can aid distressed clients to self-regulate by learning to not internalize events that occurred around them.
(4) Positive overall evaluation of life
The keywords in this theme were ‘quality of life’, ‘good life’, ‘fulfilled life’ and ‘life satisfaction’. Definitions captured in this theme described the concept of PMH as an all-encompassing, overall evaluation of one’s life that generated a broad sense of wellness or a feeling of ‘good living’.
Good living, like you’re not just alive; but you are living well, so living well… I think it’s defined differently by different people. So to person A living well might be ‘I’m a able to look after my grandkids’, that’s living well… to summarize it’s the person’s own idea of a good life, a good quality of life. – FGD 1
While elaborating the concepts of life fulfillment and the ideal life in the context of PMH, keywords such as ‘goals’, ‘values’, ‘purpose’, ‘meaningful’ and ‘aspirations’ were often mentioned and participants described these as constituents of a ‘good life’.
… a feeling of living a life that is consistent with one’s values… If someone values career, then he is living a life that is working towards that. If my value is family, I’m living a life that allows me to spend time with my family in a way that I consider meaningful. – FGD 5
Positive mental health is leveraging on people’s needs and values to bring them closer to their fulfilment… To me, fulfilment is living their own values, living their lives according to their own values. And being able to meet their needs. – FGD 6
(5) Absence of negative emotions and presence of positive emotion states
This theme relates to the emotional state of an individual and the definitions of PMH encompassed the absence of distress and the presence of positive emotions. PMH was defined as the removal of mental illness symptoms or distress, and also it meant experiencing positive emotions and state such as ‘happiness’, ‘hope’ and ‘joy’.
Freedom in mind, having peace, having calm. And there is no mental illness or distress and managing with difficulties. – FGD 4
I’ve written that firstly, positive mental health is being hopeful and laughing often. – FGD 5
Views on the concept of PMH
(1) Novel and valuable for psychotherapy
For some participants, PMH was a novel concept which could be defined in various ways by different individuals. For one participant, it gave the ‘impression of mindfulness’ which is the ‘third wave of therapy at the moment’, and some participants compared it to positive psychology.
So I think positive mental health is a new change, so it’s like a new science where you hear a lot of people saying that oh it’s important, it’s crucial but the research out there is very limited to back up all this evidence, but we do see the trends of positive mental health is emerging too. – FGD 2
Participants generally agreed on the importance of individuals to have PMH, with one participant stating it as ‘our birth right’, and another participant citing it to be ‘imperative for a healthy society’. A number of participants acknowledged the roles that they could potentially play as psychotherapists in introducing PMH concepts to their clients, as evident from the following quotes:
Like traditionally the way therapy was created was for like to remove disorder. That’s why I think the newer age therapists are saying that we really need to go further where there’s this idea of growth. I think that’s where the newer age therapists try to incorporate it as part of therapy. – FGD 4
I think for me they (PMH-based interventions) definitely have a space in psychotherapy and they help to balance out between always talking about problems as compared to, well, talking about what were you like before all the problems and what would it be like without the problems. So it balances out the conversation a little bit as compared to every time you come in we talk about your difficulties. – FGD 5
Not all participants, however, concurred with the relevance and significance of PMH, particularly in the context of clinical setting and the profile of clientele that they saw.
I think positive psychology is not that much used in our setting maybe because we have quite a lot of patients in quite severe conditions and talking about positive psychology is like… we are at this level and then you are talking about positive psychology. So maybe in our setting, clinical setting, we don’t really talk about positive psychology and I find that it’s more of a marketing thing… like it’s great and we are doing these classes in school and all that but I think there are other things that are more important to be done. – FGD 2
(2) Reservations with the terminology
A number of participants expressed reservations with the term ‘positive’ that was being used, either with respect to ‘positive mental health’ or ‘positive psychology’. To some participants, such usage implied that clients have to strive towards a positive state all the time, which is ‘not natural’ and ‘an impossible setup’ for them, when instead a simple improvement or progression could in fact be thought of as ‘positive’.
Because from clinical psychology background, it’s about treating mental illness. So it’s like if they (clients) can reach a neutral level or it may be back to baseline, then it’s something the patient may know to achieve, so positive means it sounds to me like up there (pointing to higher level). That you know even myself cannot be completely happy all the time. – FGD 3
The word ‘positive’ here is very misleading. And it’s exaggerating people’s expectations… it’s like wherever you are, if things get in anyway slightly better… that’s already positive. It need not necessary be like you have to have ten steps of growth, not really. – FGD 7
Some participants felt that this terminology carries a connotation and dichotomizes mental health either into the positive or negative realm, and that did not accurately reflect the entirety of what mental health should be in their psychotherapy practice.
I guess one of the main core tenets of psychotherapy is to bring flexibility and balance in the ideas or the perspective that we share about ourselves and other people. So I guess with a connotation, where you kind of put ‘positive’ in front of a word, it doesn’t sit really well in a lot of practices that we do encourage in psychotherapy. – FGD 1
When you term it as positive it becomes very dichotomous, very off-putting… when [what] we want to talk is more about adaptability, workability, more neutral rather than there’s a negative or positive connotation. – FGD 1
They suggested alternative terms such as ‘mental wellness’, ‘positive living’, or sticking to words that were used by their clients, for instance ‘better life’ if that was what the client explicitly stated.
(3) Factors influencing PMH
Participants described several factors that could influence PMH and these were broadly classified into three categories: individual level, interpersonal level, and community and social cultural level. At the individual level, it was about clients’ personality and them having basic self-care which included things like exercise, proper sleep hygiene and healthy coping mechanism. For some participants, it was also about the clients having goals and purpose in life that could motivate them and which contribute to better wellbeing.
I think the other is having that sense of meaning and purpose, so feeling that I have meaningful visions, pursuits or meaningful job that I can contribute meaningfully to my system and the society at large. – FGD 3
At the interpersonal level, participants discussed interpersonal relationship with others that could influence PMH. This included support received from family, friends, or a significant other who provided the feeling of being ‘connected’ with others. A couple of participants noted the impact of mismatched values or misaligned expectations in relationships with others could have on the individuals.
But I think the other part is in the relationship with their significant other, the manner of how these values are transmitted or being talked about. Sometimes it can cause a lot of distress when they have different values. That’s where they have a lot of conflicts, especially when mental illness comes into the system which is a new thing, it can actually distraught the whole thing. – FGD 3
In terms of factors at the community level and social cultural level, a number of participants described how addressing stigma could be a step forward in improving PMH. One way to do so could be to reframe the idea of PMH:
But I was just wondering like why can’t PMH be same as growth and development so not assuming that you have a problem, but you just want to be resilient or be with some more resources. – FGD 4
Participants also suggested creating awareness and improving mental health literacy, particularly amongst the youth and within the school setting.
We are so driven by academic literacy that that’s pretty much all we know right, to achieve and strive, achieve and strive. And if we don’t get it then we fail. But there’s no emotional literacy and acceptance in that that is being taught in schools. – FGD 1