Start-up: A more thoughtful approach to mental health

This article first appeared in Enterprise, The Edge Malaysia Weekly, on January 13, 2020 - January 19, 2020.
Start-up: A more thoughtful approach to mental health
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An estimated 264 million people around the world are suffering from depression. In Malaysia, one in three adults are grappling with mental health problems. The problem is so acute that children as young as 10 years old are seeking help for clinical depression.

Despite the alarming statistics, mental health is a highly stigmatised and largely ignored problem in this country, says Joan Low, founder and CEO of ThoughtFull Hub PLT. That is because mental health is often an afterthought.

“We only hear about it after people go through a psychotic episode, where there was a display of violent behaviour or symptoms that caused them to lash out and hurt themselves or others. Or much worse, when they attempt to take their life and succeed,” she points out.

Even those with debilitating issues tend to suppress their symptoms for fear of being labelled weak-willed or accused of over-reacting, until it is too late.

But the stigma aside, there are several key barriers that continue to hinder progress. Many countries — both advanced economies and emerging markets — invest only a fraction of their healthcare budgets on mental health, disproportionately less than the burden of mental disorders, according to the World Health Organization in its Mental Health Atlas 2014 report.

While many governments are still figuring out effective ways to tackle the growing pandemic, Malaysia has yet to even bring awareness to the issue, says Low.

To her though, mental health challenges are more than a systemic program. They are part of a personal story of tribulation and enlightenment that started when a loved one was diagnosed with mental afflictions 20 years ago.

“That was the first time my family learnt about mental illness and it was a total shock to us. Mind you, information on mental health was not as readily available 20 years ago as it is today,” says Low.

“Our loved one was successfully working in the corporate sector. From the outside, our loved one was fit and healthy in all physical aspects - the most unlikely of persons to be struggling with mental health challenges, or so we thought".

"In the beginning, our loved one complained of neck aches, racing thoughts and exhaustion but no one thought anything of this because these symptoms pretty much summed up the life of any ordinary working adult. However, it is difficult to support someone when we do not understand the underlying challenges that one may be facing, she says."

“We ran the gamut [of responses] when it came to dealing with his issue. First, there was denial: How could this happen to our family? Is it a sign of misbehaviour (laziness, reluctance to perform) or something else?

“Then we moved on to despair: There are so many people in this world, why must it be us? Eventually, we learnt that professional help was the option.”

As private care was the only service easily accessible at the point of emergency, the family sought private treatment. “It cost us an arm and a leg… 20 years ago, the average charge for a session with a private practitioner, including medication, was anything from RM400 to RM1,200,” she says.

However, psychotherapy (also known as talk therapy), or talking through issues, was not an option available to them. Not much has changed since, she adds. The approach to mental health (or illness) in Malaysia is still considerably outdated and the cost of treatment beyond the reach of many.

As a result of her family’s struggles in coping with having a loved one suffering from a mental disorder, Low has become attuned to how various societies deal with such issues. This also compelled her to start ThoughtFull in 2018.

Prior to establishing the mission-led enterprise, Low was a private banker at JPMorgan Chase & Co in Hong Kong for six years. That journey began right after her Form Five examinations, when she won a scholarship to do a two-year International Baccalaureate at the United World College in Canada. Then, she received another scholarship to Middlebury College in Vermont, the US, where she completed a four-year degree in international politics and economics.

“I tried a lot of things because it was a liberal arts programme. I lived in Paris for six months during my junior year and Beijing for six months in my third year. This set the foundation for what came after college,” says Low.

She moved to Hong Kong when she got a job at JPMorgan Chase & Co. “I thought I would give finance a try for two years, but I ended up doing that for six years,” she says.

The job gave her access to ultra-high-net-worth clients with investable assets of US$30 million and above. By 27, she was managing a portfolio of more than US$1 billion.


Turning point

But just as Low entered the sixth year of her career, she felt that she had come to a crossroads. If she stayed where she was, the huge sum of money that she was earning would effectively act as “golden handcuffs” and eventually, it would be impossible to leave.

Low went home to figure things out. “I gave myself a three-month break, returning to Malaysia after living abroad for 13 years. That was when I re-centred on or reprioritised a lot of things,” she says.

In those three months, she observed the various degrees of mental health treatments offered. “In Canada, for example, it was very common to go for talk therapy and skills building, which is what they call ‘rehabilitation’, on top of seeing a doctor for medication. This was known as a bio-psycho-social approach to mental illness,” says Low.

According to her, the bio-psycho-social model is based on the assumption that mental health problems are not limited to just one domain of human experience, but influenced by multiple domains of human experience and have biological (medical), psychological (mental) and social/spiritual impact.

“The psychotherapy part is where clinical psychologists and counsellors help you unpack what happened. They try to understand what got you there in the first place — what your triggers were — and teach you how to build coping mechanisms so that you do not react in the same way to the triggers. They also make you aware of the triggers,” says Low.

After all this, the patients are led to a community centre and rehabilitation facilities to help them reintegrate into society.

Low kept a mental checklist of how each country she had lived in dealt with mental illness. When she returned to Malaysia, it dismayed her to realize that little had changed in the mental health landscape over the past 20 years.

“It really broke my heart. In Canada and the US, everyone has a shrink; it is almost like a status symbol. Even in Europe and the more socialist countries — and to a certain extent, Hong Kong — there is a lot of government money for mental health awareness,” says Low.

The deeper she dug, the more complications she unearthed. She came across cases where human resources departments of local companies discouraged their staff from stating that they suffer from a mental disability.

“The problem here is, if you do not put it down, no one will know. And because it [the mental disorder] is an invisible illness, meaning it is not a physical disability, your superiors and colleagues expect you to perform like any normal individual. This does not ensure a fair playing ground,” says Low.

“When you fall short of expectations, you are bullied. They do not understand why you are underperforming and you cannot tell anyone why because no one is supposed to know.”

She wondered if there was something she could do about it. “I was looking for something more impactful to do anyway and I had to make a judgement call. Do I go back to Hong Kong and resume my life? Or do I give up everything and come back here? That in itself was a process because I really wanted my family’s blessing before I did this,” she says.

Low understood that she needed to do a lot more groundwork before attempting to tackle the problem in Malaysia. “I am not a mental health professional. So, how can I start a business based on mental health? This bothered me a lot. But I also knew I could contribute. So, I started by running workshops, co-presented with certified professionals who were clinicians, counsellors, psychologists and government psychiatrists,” she says.

“They helped with the content, design and presentations. I did the programme design. While they knew their content very well, they may not know the best way to deliver it. However, I was trained in sales and my whole career was about getting people to buy.”

Low’s experience as a carer also came in handy. “I have so much practical knowledge because there have been situations that could only be handled with experience, compared with a clinician who does not have first-hand experience,” she says.

“For example, if you are dealing with someone whose behaviour puts you in danger, a clinician may know what to do in the theory. But if you have experience, having lived through such situations, you would understand, through trial and error, how to deal with that situation.

“This is practical knowledge. For example, how do you make sure your stance is not threatening? How about when the person you are trying to help thinks you are going to harm him when all you are trying to do is give him his medication?

“A clinician can tell you all the theories, but we are the ones who prepare the food, ensure that they eat and that their day-to-day care is delivered optimally. These are the things that I think add value.”

These are some of the concerns raised during the workshops and engagement sessions, says Low. “Some people ask us how they can support their family member or friend through mental health issues. Some of the more popular questions are ‘How do I know if someone is going through this?’ and ‘How do I know if I am being supportive and not counterproductive?’

“I was able to share my own experiences because there had been so many of these situations in the last 20 years. It was the right combination — having practical knowledge and partnering professionals.”

The workshops initially ranged from two-hour sessions to full-day events, catering for non-governmental organisations, non-profit entities, social enterprises, corporations, tertiary institutions and schools. “We covered the whole range because I was looking to see if mental health awareness was even needed. It was very good to gain exposure to various demographics,” says Low.

“In the 10 months, we reached out to 1,000 people. We did not do it alone. We mobilised more than 100 volunteers to help with the facilitation and everything else.

“It was truly eye-opening because we ran assessments for depression, anxiety and stress on everyone we reached out to. This assessment was placed as standardised benchmarks to understand where people are because we were targeting ‘normal’ people. We were not preaching to the choir or people who have already been diagnosed.

“From the assessment, we flagged one third as having severe or extremely severe depression, anxiety or stress, or a combination of the three.”

At first, this alarmed the team, says Low. However, on learning that one in three Malaysians go through some form of mental illness at some point in their lives, she realised that her limited findings were credible. “We did not want to start this based on presumptions. We needed to have an open mind to understand what the problems may be and the complexities surrounding these.

“So, after we flagged one third of them, we asked if we could support them in any way and followed up with them. For those who agreed, we went one step further and asked if we could share a bit more information on how we could go about supporting them.”

Initially, she thought the solution was to simply make the information on mental health more available and help match these people with the right kind of help. “We thought this would work because most people do not even know they have a problem. It is not like they can step on a scale and discover that something is wrong,” she says.

“I was not trying to create a marketplace. We were just following the pain. But unwittingly, ThoughtFull started to evolve into a marketplace.”


Reimagining the solutions

But here, Low experienced a setback. She thought she had really helped those people. But when she checked up on them, she discovered that they had hardly made any progress.

“I am glad I was taught to track my clients and follow up with them because when we followed up with the people we had matched with mental health professionals, we realised that they either did not show up for their therapy sessions or did not follow through on them because of cost or time. Or maybe, they felt it was too cumbersome,” says Low.

Again, it all came down to the stigma of mental health.

“Even after we made the appointments, the idea of seeing a counsellor engendered a lot of resistance. First, it may have been a matter of denial because these were all high functioning — in fact, ‘normal’ — people, although they were severely depressed, anxious or had some other mental health issue. But they could still go about doing their jobs. Perhaps they just complained a bit more than usual,” she says.

Not showing up for appointments was also a matter of face. They did not want to be caught seeking psychiatric treatment. Under normal circumstances, people would want to go to whatever was closest to where they lived or worked. But when it came to psychiatric treatment or therapy, it was the opposite.

“If you walk into a Lululemon Athletica outlet, you will not have a problem with being seen or recognised. In fact, you may even take a picture of yourself there and post it on Instagram,” Low points out.

The same could not be said for seeing a therapist or psychiatrist.

Then, there was the matter of cost. According to Low, private therapy sessions cost an average of RM200 an hour. “If a fresh graduate earns RM2,500 a month, the fee is almost 10% of his salary. And for mental illness, you cannot just go once. It is not like taking a pill for a headache. If it is acute, you may have to go once a week. At one point, my family member was going twice a week,” she says.

Accessibility is another issue. Low explains that the traditional set-up of getting help for mental health is not formatted and innovative to suit our current lifestyles. “We are constantly on the move. So, how can we consistently make appointments and show up at the appointed time?”

She wondered why nobody was using technology to address this issue. Surely there was some way to create a platform that could help people get the mental care they needed?

Low went back to the drawing board to formulate a new plan. She decided to maintain the education outreach programmes and start a chat platform, ThoughtFullChat.

“With mental health, you cannot just send a deck over and hope the recipient has internalised the information. I am acutely aware that these engagements can have a negative impact if not done properly. And it is not like you can get a refund or replacement. I cannot give you a new brain or a renewed sense of self if the therapy sessions prove to be detrimental,” says Low.

That is why her company has been quietly testing ThoughtFullChat over the past few months. “By using a mobile chat platform, we connect people who need help with certified professionals such as counsellors, psychologists and psychiatrists. We are not venturing into the medical field — for example, prescribing drugs — yet. The focus is solely on talk therapy,” she says.

Low says this approach has garnered positive feedback as those who need help can work through their issues without having to worry about the stigma and hefty fees. “The more we delved into this ecosystem, the more we realised that this was the best way forward to reach as many people as we could.

“We needed economies of scale. Certified professionals are a whole ecosystem that we had to learn about because there are only 380 psychiatrists in a country with a population of 32 million. There are about 350 psychologists while the rest are counsellors. But not many are active and you do not know the quality of their work or their reach.

“There is a gap between those who are overbooked and professional psychologists and counsellors who are trying to establish themselves and are struggling to make ends meet. Time is money and they cannot scale their time. If they are working nine hours a day, they should be able to fit in nine clients. We believe technology can help them by creating a marketplace.”

ThoughtFullChat connects those with mental health problems to professionals using an asynchronous text messaging platform. “Essentially, they can text their professionals anytime, anywhere. They can then expect their professional to be in touch with them as soon as they can,” says Low.

She created the platform using a subscription model so that the company could reach a wider group at a lower cost. However, as mental health challenges come in varying degrees of severity, asynchronous text messaging may not be suitable for everyone. So, there are processes in place to ensure that ThoughtFullChat is only offered to suitable clients.

There isn’t an app for ThoughtFullChat because the programme is still being tested, says Low. “We have run this in a very controlled manner. We have been tracking the people on it for the last three months. So far, it has been very user-centric because it is the clients who are important right now. They need to feel helped and supported.

“They report to us every week and we ask them questions such as how they would rate their current happiness levels, their ability to cope with stress and handle emotions and their quality of sleep. These are some of the quantifiable factors, but we also ask for a lot of qualitative feedback. So far, they have shown improvement on all fronts.”

She adds that the company has taken stringent measures to ensure that personal data is protected and cybersecurity is well managed. “Data is collected on a consensual basis and securely handled according to the necessary protocols in place.

“My vision for ThoughtFull is to create a world where mental health can be as aspirational as physical health so that people can be empowered to be truly on top of things. I hope to develop a solution, along with the whole ecosystem, that is accessible and affordable.”