Why do some Singaporeans refuse mental health treatment, and can the law compel them for public safety?

SINGAPORE — The image has become familiar among the Singapore public late last year - an individual, clad in female clothes, was captured on video attempting to forcefully open MRT train doors as other commuters stared in disbelief.

The individual, who was eventually charged with being a public nuisance, was found to be a man who was diagnosed with gender dysphoria and bipolar disorder in 2019, and then with adjustment disorder in 2021. Coupled with the revelation from a CNA report that he had defaulted on mental health treatments for years, this raises a pressing question: Why do individuals, evidently in need of mental health treatment, refuse it?

Yahoo Southeast Asia spoke with mental health and legal professionals to delve deeper into this issue. Psychotherapist and counsellor Jon Sim from Holistic Psychotherapy, for one, emphasises the importance of building rapport and trust between the therapist and the individual seeking help.

"The client comes in with a set of goals and expectations; somehow, it's possible that process with an individual therapist doesn't work out well," he told Yahoo Southeast Asia on Wednesday (10 January). He added that clients may drop out due to mismatched expectations, insufficient competence on the therapist's part, or external life events causing distress.

Are support networks the key to encouraging treatment-seeking behaviour?

Sim points out that prevailing attitudes towards mental health in Singapore can still discourage individuals from seeking support. "Even though there's an increasing awareness of mental health, there's still that kind of taboo and societal norm that if you were to come and visit a mental health professional, people don't take it in a positive light," he explains.

Theses challenges deepen among individuals dealing with both bipolar disorder - a mental illness characterised by significant mood swings - and gender dysphoria, which entails a sense of unease due to a misalignment between one's biological sex and gender identity.

Specialising in LGBTQI counselling, Sim notes the complexity of navigating the transgender community's difficulties, emphasising the importance of a supportive network for those grappling with identity issues.

"I feel like the transgender community faces more challenging obstacles because individuals who are gay are just struggling with internal sexual identity. For transgender individuals, they have to figure it out because they perceive themselves as male in a female body or female in a male body," he said.

"Without a supportive network, anxiety and depression issues increase. The more society, family, and friends diminish their hopes of seeing the light, the less positive motivation there is to seek treatment. Who will be there to encourage them, and who will walk the journey with them?"

How untreated mental health impacts families

Claire Leong, a counsellor at Sofia Wellness Clinic, emphasised the importance of considering the safety of both individuals and the public when discussing mental health.

She stated, "The first thing that comes to mind is safety of both the individual as well as the public. I want to be very careful when I talk about this because there is already an existing misconception/stigma that people with mental illness are a danger to themselves or others, which is not inherently true."

In an interview with Yahoo Southeast Asia, Leong pointed out that while not everyone with mental health conditions poses a safety risk, some individuals may exhibit behaviour that jeopardises their own safety or that of others, when coupled with certain propensities.

She also highlighted the unintended consequences of individuals rejecting mental health care, noting, "Sometimes, individuals who decline mental health care also end up hurting their loved ones unintentionally, especially when they are in positions where they are supposed to be caring for other vulnerable individuals (For example, a parent who denies mental health care and, as a result, is unable to provide the best care for their child).

"In fact, a few of the teen and adult clients I see are dealing with the effects of growing up with a parent with untreated mental health issues."

Growing up with an adult facing mental health problems is recognised as contributing to Adverse Childhood Experiences (ACEs). Leong explained that other factors contributing to such experiences include witnessing violence in the home and having a family member attempt or die by suicide.

She stressed the challenges associated with ensuring mental health care for individuals who refuse treatment. "When an individual declines mental health care, it is unlikely that the healthcare system will be able to force the individual into treatment. For example, even an individual admitted into the hospital for being at risk of killing themselves can be discharged at-own-risk by their next-of-kin," she said.

Leong believes that early intervention is one of the best predictors for good treatment outcome. This means that the sooner one seeks mental health care, the more likely they are to get better.

She also emphasised the potential strain on the healthcare system when individuals deny mental health care. "An individual who denies mental health care today might present with much more severe symptoms in the future that would require more intensive treatment to address, and possibly even involve engaging emergency services. This then increases the load on the healthcare system as a whole."

Does refusing mental health treatment play a role in legal considerations?

Looking beyond personal health, the question then arises: Does the refusal to seek mental health treatment impact an individual's legal rights, especially if their actions pose a threat to public safety or breach the law?

Legal expert Peggy Yee, who is the director of PY Legal LLC, explained that a person's refusal of mental health treatment could be a factor taken into account by the court. Yet, she points out that such refusal may not mitigate the offence.

"In fact, does it make the offender more culpable? The offender’s medical condition may be the very reason why he did not or refused to take medication. So it really depends on the facts," she said.

As for the existence of legal frameworks or precedents addressing the obligation of individuals with untreated mental health conditions to seek treatment, Yee explains, "With community-based sentencing, the court can order a mandatory treatment order for the offender to receive appropriate treatment or intervention."

According to SG Courts, community-based sentencing (CBS) was introduced in 2010 to give courts more sentencing choices "for minor offences". This means that courts can consider CBS in appropriate cases instead of traditional sentences like imprisonment or fines.

One type of community-based sentence is the mandatory treatment order (MTO), which directs an offender with certain treatable psychiatric conditions to undergo treatment for a period of no longer than 36 months.

Before an MTO can be considered, the judge will request a report from a psychiatrist at the Institute of Mental Health. The court can only make an MTO if the report confirms the following:

• Having a psychiatric condition which is susceptible to treatment

• Suitable for the treatment.

• Psychiatric condition contributed to the offence.

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